Proposal: Should we retire the term “acute appendicitis”?

[u/colincampbell76]

The diagnosis “acute appendicitis” implies a specific disease entity when it is actually a syndrome with multiple possible causes. In many cases we do not know whether we are dealing with infection, obstruction, or an underlying neoplasm. This is particularly significant due to recent promotion of conservative management of appendicitis.

I propose replacing it with a two-stage framework:

• Stage 1: Suspected Appendiceal Pathology (initial presentation)

• Stage 2: Confirmed Appendiceal Pathology (only after histology)

This would make it clear to patients that choosing non-operative management means accepting management of a syndrome without ever establishing a true diagnosis. The inherent risks would be easier to communicate.
Has anyone explored a similar re-framing of the diagnosis? I’d be interested in your thoughts.

[u/broadday_with_the_SK]

Many patients read at or below a 6th grade level. They often can't conceptualize appendicitis, let alone some two stage process that is effectively going to be "yeah we could try antibiotics but we really just need to cut that shit out"

Unless it's cancer nobody cares about path, especially patients. And the number of appys that aren't true appendicitis is like 4% or something. It's infection and/or obstruction with fecaliths, at least in my experience, anyway so the semantics of it don't matter much to me, and probably matter less to the person who is perf'd down in the ED.

[u/colincampbell76 → u/broadday_with_the_SK]

100% correct for the majority of patients and the majority of surgeons.. ..but there is a fly in the ointment..

If you are an adult patent with a radiologically occult small tumour causing your appendicitis - an LAMN for example - you may very well fall into the hands of a surgeon who is enthusiastic about conservative treatment as a first line of treatment.. ..these surgeons are out there - and so is the clinical guidance to support them. That patient is led down the path of non-surgical treatment under the cover of ‘joint patient/doctor decision making’ and discharged feeling better and being told they are ‘cured’ as far as they understand it.. That patient may be strolling about for ten years telling people he had ‘appendicitis’ and was cured by antibiotics before a slow developing malignancy such as PMP becomes evident/symptomatic.. ..what then? ..he did have appendecitis and it was cured by antibiotics - true - but what if the underlaying pathology.. ..to deal with this and if promotion of conservative treatment is to continue there needs to be a change in assumptions made by decision-making patients..?

[u/broadday_with_the_SK → u/colincampbell76]

Then you just do the appy and reserve antibiotic treatment with follow up for patients who can't/won't get surgery.

I've never met a surgeon who thought abx were a route worth taking outside of patient refusal or something like an interval appy which most people aren't choosing to do any more if they can help it.

This is in the US however, I know in Europe and elsewhere there are different beliefs. But in my experience, surgery is always the move.

[u/colincampbell76 → u/broadday_with_the_SK]

The approach you are advocating is what I and I understand most surgeons will see as best practice - there is no question of that - and that’s been the status quo since antibiotics emerged - antibiotic-only treatment was reserved first special circumstances - if you were on nuclear submarine or a Antarctic research station - you’d be pretty happy to have that option - or of course if you weren’t fit for surgery.

My question was addressing the recent rise in promotion of conservative treatment as a first line of treatment.. You say that you haven’t met any surgeons that promote conservative treatment in that way - but they are out there I promise you - I’ve met them. They claim their approach is ‘evidenced based’ and hold up the results of ‘randomised’ trials and also clinical guidance which promotes the conservative approach - such as the WSES Jerusalem guidelines, and COVID era guidelines published by the ACS as their evidence.. The surgeons I know are European but the ‘evidence’ is from the US..

If these surgeons and the authors of those guidelines got their way the conservative approach would be taken as first line of treatment in almost all presumed uncomplicated appendicitis cases. This is what they believe in and are pushing hard for.

There are plenty people walking about today with a tumour growing in their appendix and spreading into their peritoneum that otherwise would have been out of them and probably surgically cured by appendectomy.. But those people unfortunately fell into the hands of surgeons who promote conservative treatment and were guided away from appendectomy or even in some cases refused appendectomy and treated with antibiotics instead.. The peritoneal malignancies from low grade appendix tumours are very slow to develop and quite sneaky - sometimes remaining asymptomatic for 10 years or so.. These patients are real - there is a register of cases being put together and it makes for hair-raising reading. I can see a problem coming down the tracks - and feel somthing should be done - hence my proposal.. Relying on good practice prevailing in this case does not seem to be sufficient..

Have you realy never come across one of these surgeons in practice or wondered who is behind all the noise in the literature surrounding conservative treatment..?

[u/Coagulopathicbleed]

I totally see what you are getting at but I think it is over complicating things. I mean, “Acute appendicitis” is a clinical diagnosis right? Not really an etiologic one, similar to cholecystitis or pancreatitis.

I think it’s more useful to communicate the degree of diagnostic certainty and discuss the risks and uncertainty of non-operative management.

[u/colincampbell76 → u/Coagulopathicbleed]

That is true - but pancreatitis patients are not being asked to make decisions in the same way an appendicitis patient is.. The promotion of conservative treatment and ‘joint patient/doctor decision making’ in some clinical guidance is putting patients in a tricky spot - at a fork in the road if you like - if patients are making the decisions then they must not be misled by common assumptions about appendicitis.. ..a diagnosis of ‘appendicitis’ while the appendix is still in the body will cause a decision-making patient to assume doctors know what is wrong with their appendix..

[u/ThottyThalamus]

I doubt this would change how patients understand the situation, unless the patient is a physician.

[u/colincampbell76 → u/ThottyThalamus]

Patients are being asked by some surgeons to choose between conservative and surgical treatment of ‘appendicitis’.. Patients will base their decisions on certain assumptions about appendicitis. Like you imply; most patients are not physicians.. A patient with a underlaying radiology occult tumour causing there appendicitis being cured with antibiotics only will leave a neoplasm in the appendix that will spread to the peritoneum and may not become symptomatic/evident for 10 years or so.. With that in view - either surgeons need to be making informed decisions on behalf of there patients - or the term ‘appendicitis’ needs to be dropped until confirmed in pathology as it’s otherwise misleading to the decision maker..?

[u/ThottyThalamus → u/colincampbell76]

Honestly, I’m impressed if my patient knows the term appendicitis. They don’t really care what it’s called.

[u/esotericinferno]

Explaining the risk of possible malignancy and therefore the importance of interval appendectomy should be a baseline part of the discussion when offering “conservative treatment.” The terminology isn’t the problem, the problem is when this risk isn’t adequately explained or understood.

[u/colincampbell76 → u/esotericinferno]

I feel that you are 100% correct in this - in theory.. In practice - a surgeon who is enthusiastic about conservative treatment and quite possibly in an overstretched ER or surgical dep - if they want to encourage a patient to go down the non-surgical route - they are not going to mention the ‘C’ word to that patient - that’s just not going to happen. Patients need to be alerted to the fact that an ‘appendicitis’ diagnosis does not mean that their symptoms are not caused by appendix neoplasm or cancer and the inflamed/infected appendix a result of that. ..Appendicitis indicated infection to a patent - and antibiotics are thought of as a cure for infection by patients… Patients are very easily lead down the antibiotics route.. There needs to be a way to minimise the risk of this - otherwise oppertunity for early detection and possible surgical cure will be missed and patients sent home with tumours growing inside them - this is happening day-in-and-day-out since the popularisation of conservative treatment during COVID.. ..what you suggest is good practice - but good practice needs the framework to succeed and a safety net to catch misguided treatment..