HERE’S WHY KEEPING YOUR APPENDIX MAY BE VITAL

APPeNDICITIS is notoriously difficult to diagnose — particularly if a patient is unable to see a doctor face-toface — which may help explain why surgery to remove the appendix is the most common emergency operation in the UK, with 50,000 procedures carried out in england alone every year.

But now, there is evidence to suggest that antibiotics in some cases may be a better option — helping to retain an organ thought to play a role in our immunity.

The appendix is a finger-like pouch that hangs off the large intestine, around 3½ in (8.8 cm) long. Appendicitis, which refers to an inflamed appendix, is normally caused by bacteria, or viruses from the bowel collecting in it.

delAy in getting right diAgnosis

ARoUND 7 per cent of people will develop appendicitis in their lifetime. Risk factors include constipation, your age (it’s most common between the ages of six and 50) and sex (it’s slightly more common in men, although women are more likely to have their appendix removed because of concerns that it may cause scarring and infertility).

While what causes these risk factors is not clear, it’s known that as we get older, the opening to the appendix tends to close, making infection less likely.

The problem with diagnosing it is that the symptoms (see box, bottom left) are also associated with a wide range of other conditions, such as an upset tummy, irritable bowel, urinary tract infection, pregnancy and some cancers — and not everyone with appendicitis experiences the same symptoms.

So it can take more than one visit to the gP or A&e to get an accurate diagnosis, says Barry Paraskeva, a consultant surgeon at Imperial College Healthcare NHS Trust in London.

‘There are lots of things that mimic appendicitis, and most people who go to A&e with tummy ache will not have a diagnosis when they leave,’ he says.

Remote consultations make it even harder to diagnose patients, he warns.

‘There are tell-tale signs an experienced doctor will pick up when they see a patient face-toface with appendicitis — a certain odour to their breath, flush of the cheeks and how they move and hold their bodies,’ says Mr Paraskeva. ‘You can’t pick that up via video or on the phone.’

Professor Jeremy Sanderson, a consultant gastroenterologist at guy’s and St Thomas’ Hospitals NHS Foundation Trust in London, agrees: ‘If the patient is a young person and they are tender in the lower right side of the abdomen, appendicitis can be relatively easy to diagnose,’ he says. But in older patients, it is not so straightforward as symptoms are linked to a range of other conditions.

‘The lack of face-to-face assessments is letting people down. In gastroenterology, we are now doing 50 per cent of assessments on the phone.

‘This can work absolutely perfectly but you can’t do an examination of someone’s tummy or look for the signs of inflammation, which are essential for diagnosing appendicitis, so it is difficult to diagnose remotely.’

CAses worse during loCkdown

LoCKDoWN appears to have led to more severe cases of appendicitis, with a higher rate of complications among those admitted to hospital, according to a study of 1,200 patients in 21 hospitals, published by Dutch researchers in the journal BMC emergency Medicine in May.

But another study, published in March, suggested that overall there were significantly fewer cases of appendicitis treated in hospital. The reasons aren’t clear, said the U.S. researchers, writing in the journal Annals of Surgery open, but could include patients being misdiagnosed with Covid-19 (which can also cause gastric symptoms) or, in some cases, the appendicitis simply clearing up on its own. This suggests that in the U.S., at least, the condition may be ‘over-treated’ with surgery, the researchers said.

For more than a century, the standard treatment for an inflamed appendix has been surgery to remove it to prevent it bursting — a condition

called peritonitis, which can be fatal in up to 20 per cent of cases. However, the conventional wisdom is now being questioned after a raft of studies over the past ten years have shown treating uncomplicated appendicitis with a course of antibiotics can be effective.

AntiBiotiCs Cut need For surgery

IN 2012, the BMJ published a review of four trials involving 900 patients with uncomplicated appendicitis, 430 of whom had surgery while the rest were treated with antibiotics. Almost two-thirds (63 per cent) were successfully treated with antibiotics (meaning the problem did not return), avoiding complications of surgery, such as infection.

Dileep Lobo, a professor of gastrointestinal surgery at Nottingham University, who carried out the review, says patients with suspected early appendicitis should first be treated with antibiotics and monitored. If there is no improvement after 48 hours, they should then have surgery.

‘This approach could reduce the numbers requiring surgery by two-thirds and cut the rate of complications by almost a third,’ he

says. During the initial wave of Covid, when surgeries were halted, antibiotics were more widely used to treat appendicitis out of necessity, and seemed to be largely successful.

A uK study of 500 patients with appendicitis during Covid, published in the journal Techniques in Coloproctology earlier this year, found that 54 per cent were initially treated with antibiotics and only 10 per cent of these patients went on to need surgery.

‘There was a concern that we would see patients coming back with appendix problems after being treated with antibiotics,’ says Professor Sanderson. ‘But we didn’t see a wave of returning people. it raises the question whether appendicitis could be a self-limiting condition and more widely treated with antibiotics.’

WHY ARE PATIENTS NOT SCANNED?

AnOTHer concern is that because appendix patients are not routinely scanned, many may be having their appendix removed unnecessarily. Only 15 per cent of women and 23 per cent of men in the uK with suspected appendicitis receive a CT scan. in countries such as the u.S., almost all patients undergo scans before having surgery, while in the uK, whether or not you have a scan is down to the doctor and whether a scan is available.

This means that if appendicitis is suspected, surgery may go ahead without a confirmed diagnosis in order to prevent complications. But it means healthy appendixes are removed, too.

A study in 2019, published in the British Journal of Surgery, found that 28 per cent of women and 12 per cent of men in the uK who undergo surgery for suspected appendicitis end up having a normal appendix removed.

REMOVING IT LINKED TO GUT INFECTION

KeePing your appendix has benefits. For decades, it has been dismissed as a redundant organ, but new studies suggest it plays a key role in our gut microbiome, the colony of bacteria in our gut that has been shown to have a direct effect on our immunity.

research in 2017 by Dr Heather Smith, a professor of anatomy at Midwestern

university in the u.S., suggested that the appendix may serve as a reservoir for beneficial gut bacteria. She found that lymphatic tissue in it can stimulate growth of some types of beneficial bacteria, so the appendix may be able to ‘repopulate’ the gut with good bacteria wiped out by an infection.

Studies have shown that people who have had their appendix removed are more likely to suffer from gut infections such as C. difficile, which can be fatal.

removal of the appendix is also linked to a three-fold increase in the risk of developing Parkinson’s disease, which has strong associations with a protein in the gut, according to an analysis of 62 million records in 2019 by u.S. scientists.

‘While we know that the body functions fine without the appendix, the conventional wisdom that it is a redundant organ is misplaced,’ says Professor Sanderson.

With prevention better than cure, Mr Paraskeva offers the following advice on how to reduce the risk of appendicitis: ‘eat plenty of fibre to prevent constipation and keep well hydrated — everyone can be better at that,’ he says.

RACHEL ELLIS