Ep 160 Appendicitis: Don’t know what you’ve got til it’s gone?

For decades, it seemed like the appendix would go the way of 8-track players, pagers, and the phonograph. Outdated, obsolete, not worth keeping around. Surgeons performed appendectomies like it was spring cleaning - when in doubt, cut it out. But then the tides began to turn as medicine started to question the long-held belief that the appendix is a defunct organ (on a good day) or a ticking time bomb (on a very bad one). In this episode, we trace the story of the appendix from its earliest descriptions to the latest advancements in treatment of appendicitis. If you’ve ever wondered whether the appendix actually serves any function and what that function might be, then this is the episode for you!

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Episode Transcript

Speaker 1 (00:00):
Hi. My name is Molly, and in March of twenty fifteen,
I was thirty six weeks pregnant with my first child.
For the most part, my pregnancy had been uneventful, except
for a visit to labor and Delivery in mid February
with some pain that they determined at the time to
be just gas. So on the afternoon of March sixteenth,
when I started to feel similar pain again, I just
put it off as being gased and did all the

(00:21):
recommended things to treat the pain, but over the course
of a few hours, the pain got progressively worse. At
around six pm on the evening of March sixteenth, I
decided I would take a bath to see if warm
water would help, and once I got out, I could
barely walk, and I then decided that this was definitely
not gas pain. When I got to the hospital, because
I was thirty six weeks pregnant, they really just focused

(00:41):
on me being in pre term labor, but the biggest
issue being that the pain I was having was getting
progressively worse and was constant, which contractions aren't. At about
two hours in, a doctor mentioned that what I was
experiencing might be round ligaman pain and they were probably
going to send me home with some exercises. Thank god
they didn't. To the span of a few hours, I
had an ultrasound done as well as an MRI. Is

(01:03):
a doctor's thought I could possibly have appendicitis, but when
you're pregnant, the appendix is often hidden because of your baby,
so standard tests don't allow you to see the appendix.
Prior to going into the MRI machine. They gave me morphine,
which still didn't touch the pain, and having to lay
in the MRI machine for over forty minutes not being
able to move was one of the worst things I've
ever experienced. Unsurprisingly, the MRI and ultrasound didn't show anything. Finally,

(01:28):
after six hours, around midnight on the seventeenth of March,
they decided to admit me to the hospital, still not
knowing what was going on. As the hours went on,
my white blood cell count continued to rise, I developed
a fever, and I was losing amniotic fluid. So finally,
after sixteen hours of being an excruciating pain, they decided
that they had to do an emergency C section to

(01:49):
figure out what was going on. I remember getting the
epidural and it being the greatest thing. Ever, because I
could no longer feel the pain in my stomach as
they cut me open. The one thing I can remember
is that I'm saying, there's puss and her stomach called
the other surgical team. Minutes later, they delivered my daughter, Madeline,
at twelve thirty four on Saint Patrick's Day. After they

(02:11):
delivered my daughter, the ob team swapped out with a
general surgical team, and for a brief moment, they considered
keeping me awake since I had an epidural, but thankfully
my husband stepped in and said, put her under now.
Once they put me under, it was found that my
appendix had ruptured and I had peratinitis in my intestines.
For the next three days, I was on ivy antibiotics,
but my white blood cell count was continuing to rise

(02:33):
and I was still running a fever and it looked awful. Thankfully,
after three days, my white blood cell count finally dropped.
At this point, my doctors confessed to me how concerned
they were getting about me. I stayed almost a week
in the hospital recovering from appendicitis in my c section,
and I was very popular on the floor because most
of the doctors had never seen a case like this.

(02:55):
It took me weeks to fully recover, and I was
seeing a doctor twice a week for over a month
because of constant issues I was having. My daughter spent
two days in the special care unit receiving IVY antibiotics,
but overall was really healthy considering what she had been through.
While this was all going on, I was so focused
on my pain, recovering and my daughter that I really
didn't think about the implications of what had happened to

(03:17):
me until I started your research and realized how dangerous
the situation was and how it could have ended so
differently for both me and my daughter. Thankfully, we were
both okay afterwards and having discussions with my doctor, they
think that my appendix started to be inflamed when I
went to labor and delivery in February of twenty fifteen.
They also had a theory that my daughter was kicking

(03:38):
my appendix and that may have caused it to become
inflamed in rupture. Lastly, during those agonizing sixteen hours prior
to having my daughter, we had an amazing nurse who
knew what I was experiencing wasn't labor pain or around
ligament pain. And advocated for me and stay with us
the entire time, even when she was off her shift,
to make sure that we were okay. I will never

(03:59):
forget her and the other nurses he took care of me.

Speaker 2 (04:02):
Thank you.

Speaker 3 (04:48):
Oh my gosh, that sounds terrifying, absolutely awful. I can't. Oh,
I can't imagine. Yeah, thank you so much for be
being willing to relive that experience and share that with
all of us that I can't. Yeah, I don't have words.

Speaker 4 (05:07):
No, Yeah, thank you, thank you. It must have been
really terrifying, So thank you for sharing.

Speaker 3 (05:13):
Hi. I'm Aaron Welsh and I'm Erin Alman Updike, and
this is this podcast Will Kill You.

Speaker 4 (05:18):
And today we're talking appendicitis. Yeah, yeah, this.

Speaker 3 (05:22):
Is kind of an oddball one for us. I feel like.

Speaker 4 (05:24):
It isn't It isn't I feel yeah, you're right, don't know.
I feel like that about a lot of our episodes recently,
where I'm like, are there rules anymore?

Speaker 3 (05:33):
I don't think so, No, we make the rules are
and this is our podcast?

Speaker 4 (05:37):
True, but kind of I think there's I'm excited to
learn history things don't know it, and there's pathology there
for sure, So.

Speaker 3 (05:49):
I mean, one of my biggest touch points is Madeline.
I think I talk about Matline that was always drawn
to that for some reason. Probably I was a spooky
little kid. But yeah, doesn't.

Speaker 4 (06:03):
Everyone love Madeline like it's it's a classic?

Speaker 3 (06:06):
Yeah?

Speaker 1 (06:06):
I know?

Speaker 3 (06:07):
But okay, were there multiple Madeline books or just Madeline?

Speaker 4 (06:11):
I only know Madeline, but I don't know.

Speaker 3 (06:14):
Oh my gosh, Okay. For the longest time, I thought
it was all I don't know. I thought that was
just like story number one in a Madeline series.

Speaker 4 (06:22):
I don't know. I've only read that one. Matt me too.

Speaker 3 (06:25):
Yeah, okay, so I guess it feels like there must be.

Speaker 4 (06:29):
We are gonna have to google it after.

Speaker 3 (06:30):
This, someone is going to reach out and be like, wow, Wow,
your Madeline knowledge is really poor, very poor. One out
of five stars.

Speaker 4 (06:40):
Thank you, dear. You know what. It's good though, it is.
It's going to be a great episode. But before we
get into any of it, it's quarantiny time.

Speaker 3 (06:48):
It is, Aaron, what are we drinking this week?

Speaker 4 (06:52):
We're drinking waiting for the rupture, not the rapture.

Speaker 3 (06:57):
Gosha. I'm pleased with myself on this song should.

Speaker 4 (07:00):
Be It's a good one. I would hope that we
don't ever actually wait for the rupture. But it's a
good quarantini name.

Speaker 3 (07:07):
No, it's a great name, if I do say so myself.
And it's a great quarantine as well. It's got some
delicious ingredients. Essentially, what you've got here is a French
seventy five, which is gin and champagne. Subtract the champagne,
add some sparkling cider for a little bit of a
fall winter vibes, some iced lemon spices, you know, delish.

Speaker 4 (07:30):
We'll post the full recipe if you need it on
our website, this podcast okay dot com and our social
media for both the Quarantini and the non alcoholic plus
sy parita.

Speaker 3 (07:41):
They're there. They're there website. We've got some great stuff
on that website. You know, we just revamped it, well
just now it's been months, because two and a half
months ago we revamped.

Speaker 4 (07:53):
It by the time this comes out, but it's great.
Check it out.

Speaker 3 (07:58):
It is great. It's got things like transcripts. It's got
links to our bookshop dot org affiliate account, our Goodreads list,
it's got links to merch some pretty sweet stuff going
on there. It's got links to our Patreon. It's got
links to oh music by Bloodmobile. It has got sources
for each and every one of our episodes, have a

(08:19):
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hand account form. There's areas where you can contact us.
Let's say you want to request an episode. Let's say
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Speaker 4 (08:35):
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you can find the promo codes that we cite in
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Speaker 3 (08:51):
And you know, we're just gonna shout it out again.
If you like the show, please rate, review, subscribe, make
sure that you're subscribed on whatever podcast or you use.
It really helps us out a lot, So it does.

Speaker 4 (09:04):
Yeah, thank you.

Speaker 3 (09:05):
Thanks.

Speaker 4 (09:06):
Well, should we get started.

Speaker 3 (09:08):
Let's do it. Let's take a quick break and then begin.

Speaker 4 (09:34):
There is this kind of very textbook description of appendicitis,
and I'm going to tell you how it goes. It
starts with usually kind of a vague pain and abdominal
pain around the belly button, kind of like in the
center of the belly, around your belly button, and it
tends to go along with like, I'm not really feeling

(09:54):
hungry because my stomach doesn't feel good. I don't want
to eat anything, and then it might press to feeling
actually nauseous, like feeling like you're gonna throw up, and
then maybe some vomiting, and then that pain will start
to move and it moves from around the belly button
down into the right lower quadrant kind of mirror your

(10:15):
right hip bone, like the part that sticks out, and
then you'll get a fever. And this tends to kind
of progress usually over about like a twenty four hour period,
Like it's not a super sudden onset, but it's not
like prolonged. That's the classic description. And this classic description

(10:35):
is not the only way that appendicitis can present by
any means, but it is the classic description because it
does happen, and it happens pretty frequently. It's very common
that this kind of series of events is how appendicitis
starts and presents. I can very vividly remember having a

(10:56):
patient describe their like course of symptoms that brought them
to the emergency room exactly liked this, and I looked
at them and I was like, well, you described the
textbook description of a pendicitis.

Speaker 3 (11:09):
Are you an actor right here? Like this?

Speaker 4 (11:12):
Is this a real patient encounter? And then when you're
in the emergency room and the person examining you starts
to do their exam and they touch your stomach. Sure enough,
very often people have pain in this kind of text
book area. And that point. There's a point, it's called
mcburney's point. It's like two thirds of the way between

(11:36):
your belly button and that sticky, oudy part of your
hip bone, which is called your anterior superior iliac crest.
So it's like a little bit closer to your hip
bone than your belly button. Along this like diagonal line
between your belly button and that hip bone, you can
put your finger there, and that tends to be the
most tender spot. It hurts really bad if you smush
down there. There's a few other signs that you can see.

(12:00):
Maybe someone doesn't have pain exactly right there, but they
might If you smush down on the left side of
their belly, it might hurt on that right side. That's
a sign that there might be appendicitis, and then there
are a lot of other things, like the way that
you move somebody's hip or leg that might tell you
how far down into the pelvis, how extensive that infection
might be. So when somebody comes into the hospital, to

(12:24):
the emergency room or even an urgent care reading that
textbook description, almost certainly, like over ninety percent of the
time people get diagnosed correctly with appendicitis. And it's possible
based on those textbook descriptions that diagnosis can happen with
just that story alone. But today, because it's available at

(12:48):
least in most of the high income countries in the world,
we have access to technology to confirm this diagnosis. So
most of the time when people come in with symptoms
like this, there's going to be some kind of imaging
that's either a CT scan or an ultrasound if you
need to avoid radiation, to make totally sure that what
we see is actually appendicitis. And that becomes even more

(13:11):
important when people don't read the textbooks, aka, when your
bodies present with appendicitis differently than what that classic description is, right.

Speaker 3 (13:21):
And what are some of the ways that it doesn't
present with that classic description.

Speaker 4 (13:25):
One of the ways that it gets missed the most
is when somebody is having constipation, and so they're maybe
not having because sometimes you get diarrhea with appendicitis. When
people are having constipation and appendicitis, it's more likely to
get missed for one reason or another. You might not
have a fever. You might not have a fever yet

(13:46):
you might have pain, but it's a little bit more nonspecific.
Someone might think, and this is where things get very subjective,
and we'll talk more about this later, but people might think, well,
your pain doesn't seem that severe. So there's a lot
of different ways you may or may not have that
nausea or vomiting. You might have a lot of vomiting,
you might have no vomiting. So like, there is a

(14:08):
huge range. But so when those symptoms might not exactly
match what we think of as appendicitis, maybe the point
where you have pain seems to be a little off
from what I expect for appendicitis, whatever it is, then
these kinds of imaging studies become even more important. And
the truth is that there's also a lot of other
pathologies that can mimic appendicitis, even if it seems like

(14:30):
a textbook description right, something like an ovary intrsion, a
cyst rupture, an ectopic pregnancy. There's something called mesenteric lymphatinitis
that looks almost identical to appendicitis clinically, but then on
imaging is going to look really different, So there's other
stuff that it could be. So imaging and then blood
work are going to kind of help the overall picture

(14:52):
of making sure that we're correctly diagnosing somebody with appendicitis.

Speaker 3 (14:56):
What do you see in the blood?

Speaker 4 (14:58):
You might see an elevated whye blood cell count because
you have an infection going on, and then you would
expect usually not to see other things like your liver
being out of whack, because that might make you think
it's something else that's going on. You always have to
check if somebody has a uterus to make sure that
there's not a pregnancy, because a then it could be
an ectopic pregnancy, and b then you might change the

(15:21):
type of imaging that you're going to do to avoid radiation.
So that's the kinds of things that you're looking for
in blood work. There's not anything that's like, ooh, this
blood work means appendicitis. There's no like specific blood work
and Arin, I think you'll talk. I'm sure about how
people used to deal with appendicitis back in the day.
I can't wait, but a little spoiler for most people,

(15:43):
because it wasn't that long ago that the standard of
care was to cut somebody open with a big old
incision and then cut that appendix out and then stitch
you back up. And that is called an open appendectomy.
And that is what Madeline had. Ah, that's why she
had a big old scar, and everyone was like, I
want my appendix out too.

Speaker 3 (16:04):
Yep, I did as well. Yeah, before I knew more appendixes.

Speaker 4 (16:10):
So open appendectomy was the standard of care for a
long time until the advent of what's called laparoscopic appendectomy,
which is instead of one giant cut, they use really
a couple of really really small cuts, and then these
instruments on long sticks and a camera that they can
put inside of your belly to look at your appendix
and all of your other organs, and then if needed,

(16:33):
take the appendix out through these teeny tiny holes. And
this is a lot better because it's a faster recovery,
there's less trauma to the muscles of the abdominal wall,
there's less pain, postoperatively. It's like, everything is better if
you can do a laparoscopic procedure. But it's still surgery, right,
It's still cut this thing out because it's causing problems. Today,

(16:55):
in the year twenty twenty four, people are starting to
come around to this wild idea. And I say start
because the literature goes back quite a ways.

Speaker 3 (17:02):
Yeah, to like the fifties at least.

Speaker 4 (17:04):
I think, Oh, that's even further than I realized I
knew of it, like to the early two thousand, but
like it's been an accepted practice I think since like
the mid two thousands, but still is not that common
that you maybe don't have to cut it out and
maybe can just use antibiotics to treat it.

Speaker 3 (17:26):
But is there there's like a higher relapse rate or
whatever it would be called, like a higher recurrence rate
of appendicitis? Right?

Speaker 4 (17:33):
There is there a lot. Let's talk about it. Okay, okay,
So let's talk first about what is actually going on
in your appendix. What is appendicitis really like? Now we
know what it looks like and most of the time
you're going to need surgery to get it out. So
what's going on? And that might tell us when it
might be a good idea to not do surgery or

(17:53):
do surgery based on what's going on.

Speaker 3 (17:56):
Oh it, it's good.

Speaker 4 (17:59):
So in humans, Aaron, I remember you asking me this
while we were before we recorded, and I was like,
had to look all this up because why are there
so many different names for the appendix. Yeah, in humans
it's called the vermiform appendix because it looks like a
little worm vermous like a worm. Yeah, it's a little
out pouching. Basically, your appendix is this little like out pouching,

(18:20):
this little like finger of tissue that comes off of
the very first part of your colum or your secum,
or your large intestine. It has a lot of names.
And I don't remember, Aaron, which episode it was relatively
recently that you were like, can you tell me all
the parts of your intestines? Do you remember that?

Speaker 3 (18:36):
I think it was neurovirus.

Speaker 4 (18:37):
Neurovirus, Okay, So as a refresher, your small intestine is
what's connected to your stomach, and that is what wriggles
its way back and forth in the center of your abdomen,
and it ends in the right lower quadrant of your belly,
and there's a valve that connects your small intestine to
your large intestine, and right next to just kind of

(18:58):
right underneath, like down south, closer to your feet. I
guess of where your small intestine connects to your large intestine.
That is where this little extra bit sticks out that
looks like an anemone tentacle. It's very small. It's like
one to three millimeters in internal diameter, so really small,
smaller than your pinky finger, and it sticks off of

(19:21):
the bottom of your large intestine. Your poop is going
to go through your small intestine and then swoosh up
your large intestine and then eventually all the way out
until you poop it out. Okay, So this little finger
of an appendix can get clogged, and there's a few
different ways that it can get clogged. Sometimes it gets

(19:43):
clogged with poop, and when it gets clogged with a
chunk of poop, that chunk is called an appendico lith
or a FeCO lith, a little hard poopball. But sometimes
it can get clogged with other stuff. It could get
clogged with a tumor, either a benign two or a
cancerous tumor. It can get clogged with an overgrowth of

(20:05):
lymphoid tissue that is like our immune tissue, which there's
a lot of in our appendix, that can kind of overgrow.
And that can happen just on its own because you
just have immune tissue growing, or it can happen because
that tissue is responding to an infection, or sometimes it

(20:26):
can get clogged with other things like just a little
chunk of calcium, whatever it is. Anytime in our bodies,
a small tube that's connected to a bigger tube gets clogged,
you have stagnation of stuff, and that is a perfect
medium for bacteria to grow and.

Speaker 3 (20:44):
Thrive like a stagnant pond.

Speaker 4 (20:47):
Exactly like a stagnant pond. And so that is what
happens in our appendix. When you get appendicitis you have
something that causes this tube that should be like open
to communicate with your large intestine get clogged and blocked off,
and then bacteria start to grow and multiply. As that happens,
it triggers inflammation, because that's what a bacterial infection does.

(21:10):
It triggers inflammation, and that inflammation causes swelling, and when
you have swelling in a really small space, that ends
up cutting off the blood supply. To the walls of
that appendix, like to the tissue, and then eventually, because
the blood supply is cut off, the tissue of the
walls of the appendix starts to die and then it's

(21:32):
weak because it's dead tissue, so then it can perforate,
and that's what causes a perforated appendix. And then all
that infected stuff, the bacteria, the inflammation, the white blood cells,
the pus, it explodes out of your appendix, and a
couple of things can happen. If that happens, If just
a little part of the wall gets a hole in it,

(21:53):
like a small hole, then the fluid might come out
and get trapped, and that is what forms an absce Okay,
or sometimes the whole appendix can rupture and then it's
not contained and then all of that infected fluid can
kind of go throughout your whole abdomen. And that's what's
called peritonitis, which is very serious. That's definitely an emergency.

(22:15):
Does that make sense, I mean, that's essentially appendicitis. That's
that is what causes it.

Speaker 3 (22:36):
Okay, So at what point, like what's happening when your
belly button hurts versus when that pain moves to the
lower right quadrant, and then like when does surgery? When
is surgery indicated? When is it not indicated? You know, like,
what's going on?

Speaker 4 (22:52):
Oh, such a good question. These are fun questions. Okay,
So what's happening when it's going from your belly button
pain down to your right lower quadrant. I don't one
hundred that know the answer to this question. I don't
know if the answer to this question has been like,
I don't know. I didn't read any papers that directly
answer this question. I am going to answer this question
based on my knowledge of our anatomy, and I could

(23:14):
be wrong about this, But in your guts in general,
you don't have direct nervous sensory nerves that go to
your guts, like to your small and large intestine, there's
no sensory innervation there. So a lot of times what
can happen in your guts when you're having pain is
that your brain doesn't actually know exactly how to interpret

(23:36):
the signals of where that pain is coming from, because
all of the sensory nerves are in like the wall
of your abdomen. So if there's pain in one spot,
sometimes your brain is like, ah, there's pain here, and
so then you're like, this is where the pain is.
Because your brain doesn't quite know exactly where that sensory
input's coming from.

Speaker 3 (23:53):
Why does it move?

Speaker 4 (23:54):
The thought is that once that inflammation, as it starts
to get more severe, then your brain can localize it
more because there's more of that inflammation just touching in
that one area. Okay, that's my best explanation. I don't
know if it's a perfect one.

Speaker 3 (24:08):
What's going on with referred pain?

Speaker 4 (24:12):
Ooh? I love referred pain. I mean I don't love
referred pain, but I love so. Referred pain means that
you have inflammation or something that's going on that should
be causing pain, that's triggering pain in one area, but
the pain that you feel is coming in a different area.
And that's because our nerves travel together. So the nerves

(24:34):
that innervate certain parts of say your diaphragm and some
of your abdomen, also innervate places like your shoulder, and
so sometimes when you have pain in certain parts of
your abdomen, you might actually feel it in your shoulder.
And so that's what referred pain is. It's essentially like
nerves that travel together. Your brain doesn't know how to
interpret that signal, and so it goes to the place

(24:55):
that it thinks that the pain is and it's like, hey,
your shoulder hurts when actually it's your spleen or something
like that.

Speaker 3 (25:00):
Got it. Yeah, I've always been curious why that works.

Speaker 4 (25:04):
Our brain is so interesting and weird. So yeah, so
that's why we kind of get pain where it might
start more generalized and then move as that infection gets
more severe. The second question that you asked is like,
then when would you need to surgize versus not surgerize,
and how all of that. So let's talk a little
more about that. So appendicitis starts well before an appendix ruptures.

(25:29):
Before an appendix ruptures, it's called uncomplicated appendicitis. So if
you have these symptoms, if you have this imaging where
we look at a CT scanner, we're like, yep, your
appendix is inflamed, the walls are thick, it's angry. We
can see inflammation, all these things, but it's not ruptured.
That's uncomplicated appendicitis. Once it's ruptured, it's considered complicated. Most

(25:53):
of the studies that look at whether or not you
can use antibiotics only to treat appendicitie or for uncomplicated appendicitis,
So uncomplicated unruptured appendicitis in a lot of cases can
be safely treated without surgery, just with the use of antibiotics.
So in this uncomplicated case, a lot of a lot

(26:16):
of different studies have looked at whether or not you
can safely cure somebody's appendicitis without using surgery, and you
can in a lot of cases. In fact, some people
even treat complicated infections if there's an abscess, like one
pocket of fluid outside of the appendix where it's ruptured,

(26:37):
but it's not all over your whole belly. Sometimes you
can then drain that fluid, like stick a tube in it,
drain out all that gunk, and then do antibiotics on
top of that, and you can cure the infection without
needing to do surgery right away. There's some downsides to this, though.
First you have to use pretty broad spectrum antibiotics, because

(26:59):
this is usually an infection that's not just one bacteria.
It's a bunch of different types of bacteria, and there's
not really a way for us to know which bacteria
because there's so many that live in your guts. Which
is the one that's causing yours versus your friends appendicitis.

Speaker 3 (27:12):
And so this appendicitis, if it's caused by an infection,
not a fecallyth it's like, is it opportunistic bacteria that
like normally reside in your gut?

Speaker 4 (27:21):
Arian? I love your question. So all appendicitis is an infection. Okay,
all appendicitis is an infection. But you said, is it
a fecal eth or is it not? The first trigger
to that appendix getting clogged could be a chunk of something,
or it could be some other reason, whether it's an

(27:42):
infection or non infection that causes your tissue to hypertrophy. Right,
And what we see in all of these cases, the
bacteria that are growing are just the kind that live
in your guts. So yeah, they're mostly opportunistic infection, right,
They're just able to multiply because of that clog. But
what we see is that if people have appendicitis caused

(28:04):
by a fecal lith caused by a chunk of pooh
that's stuck there, they are less likely to do well
with antibiotics alone.

Speaker 1 (28:12):
Uh.

Speaker 4 (28:12):
Why, Well, because that chunk isn't going anywhere. Okay, And
so that chunk not only is causing like a constant blockage,
it's also causing a blockage that's reducing blood flow. We
think maybe, and that's part of why the antibiotics are
not able to get in as well to the appendix
to treat that infection. But it also means that that

(28:35):
fecalth is still going to be there, right, So then
even if you can get that infection under control, it's
still going to be there and you're not going to
be able to get rid of it unless you take
it out. If you have appendicitis where there's no fecal
lith and there's just a hypertrophy of tissue that's caused
by an infection, you treat that infection, you fix that problem,

(28:56):
and the appendix is no longer clogged.

Speaker 3 (28:58):
Are there risk factors or appendicitis broadly or fecal lith appendicitis?
Like what are the risk factors? Not?

Speaker 4 (29:07):
Yeah, great question, I don't know. I don't think we know.
Like who is likely to get it versus not get it?
You mean I don't know, Yeah, we don't know. People
who are assigned male at birth are more likely to
get appendicitis than people who's assigned female.

Speaker 3 (29:21):
The opposite of gallbladder stuff, right, but.

Speaker 4 (29:25):
We don't know, like why why is that? And it's
not like a very significant I think it's like an
eight percent lifetime risk versus six percent lifetime risk, So
it's not like huge, super meaningful. Yeah yeah, but yeah,
and like and it's older people who tend to get
appendicitis from fecaliths, younger people who tend to get it
not from a fecalith, which kind of just makes sense.

(29:47):
I think of it at least as like you've had
more time for poop to get hard. I don't know
if that's it. But this is also really important because
you said Aaron earlier, like what about recurrence and things
like that, and that is the biggest if there is
a sort of downside to this antibiotics only or antibiotics
first approach, is that failure rates tend to be relatively low,

(30:12):
like eight to twelve percent of people if you try
and treat them with only antibiotics end up getting sicker
during that time period and needing surgery. And usually if
that happens, they are sicker and that appendix is ruptured
or closer to rupture. And it's like a more serious
infection than maybe if you had treated it before by
doing surgery rather than antibiotics. In many cases, that's when

(30:35):
there was actually a fecalith there, right, So a lot
of that initial failure rate is when there was a
poop ball that was causing the initial appendicitis.

Speaker 3 (30:43):
And so that wouldn't show up on imaging necessarily. Sometimes
it does.

Speaker 4 (30:46):
Forty percent of people with appendicitis on CT scan have
a fecal myth, But I don't know if that means
that forty percent of people are having appendicitis caused by
that or if definitely there are sometimes that you might
not see it even if it's there.

Speaker 3 (31:02):
Who are you not capturing?

Speaker 4 (31:03):
Right? Also, just like some people have fecalists without having appendicitis,
that's a thing too, yep. Like incidentally you can find
it like four percent of the time, huh, I know, right.
But then there's also even if you can treat that
infection initially, then there is a concern is it going
to happen again? You had appendicitis once? Are you at
risk for having appendicitis again? If we don't take that

(31:25):
appendix out And the answer is that yes, recurrence can happen,
and depending on the study, depending on the timeframe that
they looked at. Most studies are short and only look
at like one year rates of recurrence. A couple studies
have looked up to like five years out, and if
you look up to like five years out, the recurrence
rates can be as high as forty percent. So what

(31:46):
this means is that there really is a choice that
people can make. And by people, I mean everyone who
is involved in this decision. The person who's stick with appendicitis,
that person's family, the physician who is treating them in
the emergency room, the surgeon who may or may not
be needed to do a surgery. Everyone is involved in

(32:07):
the decision. Do we do surgery right now or do
we not do surgery right now? If we don't do
surgery now, do we do it later because we want
to prevent this recurrence? But do we wait until we've
treated the infection? Right? And so that is kind of
like what it stands right now in terms of what
is the kind of standard of care. There's not a

(32:29):
perfect answer. Can you treat appendicitis with antibiotics alone, yes?
Can you treat it with first line surgery? Yes? Is
there a perfect answer, No, there is not. There are
significantly higher rates of complications in almost all cases, and
that means things like reoperations, wound infections, incisional hernias, small

(32:52):
bowel obstructions, like major complications by doing surgery compared to
antibiotics alone in a lot of the studies, And the
only studies that seem to show more complications for antibiotics
only in uncomplicated appendicitis is if people had one of
those Pooh chunks, then they were more likely to get

(33:13):
more sick, including maybe have deeper infection or sepsis, by
not doing surgery right away.

Speaker 3 (33:20):
But when it comes to antibiotics versus surgery for appendicitis,
the downsides of surgery are connected solely to the surgery
itself and complications arising from that. Or are there also
downsides to not having your appendix? Period?

Speaker 4 (33:37):
What a fun question. We don't know. Are there downsides
to not having your appendix? We don't know, Aaron, Like,
how do we not know?

Speaker 3 (33:45):
We've had literally, like so many decades, hundreds of years
to figure this out.

Speaker 4 (33:50):
So I was going to talk about this later, but
there's some really interesting data now on like the association
between your appendix and things like ulst of colitis.

Speaker 3 (33:59):
Uh huh.

Speaker 4 (33:59):
And it actually seems that like in some small cases,
like if you got your appendix out because you had appendicitis,
and if you got your appendix out before you were
a certain age, then having your appendix out might actually
be protective against all sort of colitis. Fascinating, right, weird,
it's not that is not what I have studies that

(34:20):
you can read more because it's not that straightforward. But yeah,
so what happens if you live without your appendix? Is
there any complications other than surgical complications? Not that like
we know of no, okay, and so there Really it
used to be the case that, like I remember working
with an obgui n right, So she did like pelvic
surgeries on uteruses, and I remember being in a surgery

(34:45):
with her where she showed me she was like, hey,
look this is this person's appendix. Back in my day
when I trained, we would take this out almost every time.
If you see an appendix, just take it out because
then they are never going to get appendicitis. And that
was like standard of care way back when.

Speaker 3 (34:58):
Yeah, a lot like tanso, a lot like tonsils. So
much like tonsils.

Speaker 4 (35:03):
Yeah, yeah, but yeah, are there downsides to it aside
from obviously surgical complications? I don't know. I don't have
an answer to that, right, Yeah, so interesting, So interesting, dude.
So Aaron, tell me about the appendix.

Speaker 3 (35:21):
H yeah, I will do the best that I can
right after this break. What do long term residents of

(35:50):
an Antarctica settlement most astronauts and Stephen Colbert have in common?

Speaker 4 (35:59):
I'm appendix?

Speaker 3 (36:00):
Yeah, you guessed it.

Speaker 4 (36:03):
Wait wait, wait wait most astronauts, hold on, I have
so many questions.

Speaker 3 (36:06):
Uh huh uh huh. Do they do it prophylactically some
of the time? Yeah? Wow, okay, let's yeah. All of
these people I just listed no longer have their appendix.
In late twenty twenty three, Stephen Colbert developed appendicitis, and
actually he taped a couple of shows before going to
the hospital where they had found that his appendix had

(36:27):
already ruptured. Fortunately he made a full recovery. NASA strongly
recommends that astronauts have their appendix and gallbladder removed before
venturing into the stars, and many have done so, and
people who moved to VLS Astraeas, which is a long
term settlement in Antarctica, they have to have their appendix

(36:48):
out before moving in. Kids.

Speaker 4 (36:50):
Included is that because of the one story it probably Yeah,
I love this story so much.

Speaker 3 (36:57):
You don't have to wait that long. It's telling it
right here. So in nineteen sixty one, a Soviet physician
named Leonid Rogasov was stationed in Antarctica, and at one
point in time he recognized the signs and symptoms of
appendicitis in himself, and he proceeded to operate on himself.

(37:17):
On himself quote, on the morning of April twenty ninth,
nineteen sixty one, I did not feel well. The symptoms
noted were weakness, general malaise, later nausea. Within a few hours,
pain arose in the upper portion of the abdomen, which
soon shifted to the right lower quadrant. Body temperature rose
to thirty seven point four degrees celsius. It was clearly

(37:40):
a case of appendicitis end quote. Over the next day,
things got worse and worse. Vomiting became more frequent, his
fever got worse, the pain grew more intense, and with
a blizzard, moving in help from another station became impossible. Quote.
The only solution was to operate on myself. End quote.

(38:01):
Can you imagine now, Rogazov injected a zero point five
percent novacane solution into his abdomen, and while his co
workers held a mirror and retractors, he made an incision
and cut out his appendix. Quote. Sometimes I had to
work entirely by feel end quote. Just by feel, I

(38:23):
would be a disaster at that. I don't know what
things feel like in my abdomen. I'm not a doctor, but.

Speaker 4 (38:31):
Yep. And he was a surgeon, right, he.

Speaker 3 (38:33):
Was, I think later became a surgeon. I think at
the time, I remember he was just like he was
a general practitioner. Oh wow, okay, yeah, uh And by
midnight the operation was complete and within a few weeks
he was back to normal.

Speaker 4 (38:48):
Wow.

Speaker 3 (38:48):
But things could have gone very poorly, which is no
doubt part of the reason for the no appendix policy
at this at the settlement in Antarctica via Las Astreas.
But I just had to tell that story, yeah, because
it's it's one of and the pictures are incredible. He's
just like, his abdomen is open, and he's I.

Speaker 4 (39:09):
Just it's one of the most ridiculous stories. Uh yeah, yep, I'm.

Speaker 3 (39:15):
It's not the only instance of self appendectomy.

Speaker 4 (39:17):
I know.

Speaker 3 (39:18):
Yeah, it's the only one I'm going to tell today,
So just give you a little something to google later.

Speaker 4 (39:24):
Do you remember, I don't remember how much of the
show what's the show with the Scottish Highlanders? Outlander?

Speaker 3 (39:32):
Outlander?

Speaker 4 (39:33):
How much of that did you watch?

Speaker 3 (39:35):
Oh?

Speaker 4 (39:36):
Several seasons because they made it to America. She does
that to herself? She doesn't, doesn't. Isn't an appendect tomy
on herself.

Speaker 3 (39:42):
That she's I don't remember, but I wouldn't put it
past her after the growing penicillin on bread. Yeah, Like.

Speaker 4 (39:50):
I'm pretty sure that's what it is.

Speaker 3 (39:52):
Yeah, anyways, anyways, but I mean, I think that, like
what this reading about the appendix left me was this
feeling that the appendix seems like an agent of chaos,
disrupting plans at the very least, and causing life threatening
injuries in more extreme cases. If we can take it
out with seemingly no ill effect or no apparent ill effect,

(40:15):
why the heck do we have it? Anyway? Shouldn't we
all just get our appendixes out? That was the leading vibe,
like you said, Erin about the organ for much of
the twentieth century, just cut it out until the tune
began to change as researchers realized that what had for
so long been labeled a vestigial organ might actually perform

(40:36):
some very important functions. So let's trace how our understanding
of this weird little organ evolved over the centuries. It begins,
of course, in ancient Egypt. Technically speaking, it begins when
humans first evolved in appendix and developed appendicitis, which we
undoubtedly have had for millennia. But an early piece of
physical evidence of appendicitis comes from an Egyptian mummy from

(40:58):
the first few centuries see who had right lower quadrant adhesions,
suggesting a past episode of appendicitis. And while the appendix
doesn't seem to get a mention in ancient anatomical texts,
appendicitis does make an appearance, with Galen in the second
century describing lower right quadrant pain that at the time

(41:19):
was treated with either draining the abscess that formed or
letting the patient die quote unquote a peaceful death, oh dear,
from the sepsis that ultimately developed. Okay, peaceful as I
think in the eye of the beholder, probably in that instance, yep.
Over the next thousand years, or so, no doubt, people

(41:39):
continued to get ill and die from appendicitis, but the
labeling of human dissection as sacrilegious kept people from identifying
where exactly the trouble was coming from. Like, you have
this pain, but what's causing it? We don't know because
we can't cut into your body. Yeah, And if people
did perform dissections, it was on animal and most animals

(42:01):
outside of primates and the wombat, don't have the same
looking appendix in humans, they don't have the vermiform appendix.

Speaker 4 (42:08):
This is the second time we've talked about wombats in
like two weeks.

Speaker 3 (42:12):
Wombats are all the rage. Their poop is cube cubular.
Maybe that helps contribute to theilar air the fecalith I
don't know. In any case, it wasn't until the fifteenth
and sixteenth centuries, when dissection was back on the menu,
that Anatomus identified and described the appendix, somewhat sloppily and

(42:33):
with no clear idea of what its purpose was. Da
Vinci illustrated the appendix in fourteen ninety two, but it
didn't get published until a couple hundred years later. Andreas
Vesalius also drew the appendix, but called it the secum,
which led to decades of confusion over terminology and the
link between the organ and the condition, like is this

(42:55):
actually what is this condition caused? By?

Speaker 1 (42:58):
Right?

Speaker 4 (42:58):
Got it?

Speaker 3 (43:00):
Passion was one term used to describe what was probably appendicitis.
I love using passion today by iliac is feeling very
and advice for patients experiencing this type of passion was
to manage it with big bouts of blood letting enemas

(43:23):
that cooled or gave you diarrhea. You know, a cooling
enema or a diarrhea enema, opiates, and something called warm
animal compresses. I don't.

Speaker 4 (43:34):
I don't know know what that is. Maybe it's just
putting a warm animal on you.

Speaker 3 (43:38):
Oh my god, just snuggle with your pup. Okay, I
do that every day.

Speaker 4 (43:43):
It feels like it's something different, I don't.

Speaker 3 (43:45):
I think it's maybe a little more gruesome than just
a cuddle sash.

Speaker 4 (43:49):
Yeah.

Speaker 3 (43:50):
Perforated appendixes leading to absesses also made appearances in medical texts,
and the first appendectomy followed one such perforation. By the way,
appendixes is the plural for appendix, like the human organ,
but appendices is the plural for like an appendix, like
a book appendix. Oh isn't that fascinating?

Speaker 4 (44:11):
That is fascinating. Yeah.

Speaker 3 (44:13):
I learned that in a great YouTube video by Patrick Kelly,
who has an incredible channel of YouTube videos on like
the history of medicine. Definitely check it out. I watched
this video on appendicitis, loved it. Great, great stuff. And
that's where I learned about appendixes because I heard it
and I was like, I'm pretty sure it's appendices, and
he's like, no, it's not. So it's great. Anyway. In

(44:35):
seventeen thirty five, Claudius Amiand treated an eleven year old
boy for his hernia, and in the process he found
a fecal fistula to the scrotum, caused by a pin
that the boy had ingested that had perforated his appendix.

Speaker 4 (44:50):
Oh my gosh, I really know, awful, awful.

Speaker 3 (44:54):
And so this guy, Claudius Amyon, took the appendix out,
and from what I can tell, I actually found it
hard to kind of piece together what happened afterwards. The
child survived the surgery, like I went back to find
the paper. But other cases of opportunistic apendectomies, like the
surgeon took out the appendix during another procedure, but the
appendix was not the initial target. These continued throughout the

(45:16):
seventeen hundreds and into the eighteen hundreds, but people still
weren't really making the connection between this organ which was
occasionally described as black or swollen or gangrenous, and the
abdominal pain associated interesting.

Speaker 4 (45:31):
Yeah, you would think, I mean, especially in the age
of humors, something I know, black and gangrenous. That seems
like bad humor.

Speaker 3 (45:39):
I don't know whether it was just like the frequency.
It's not like people were performing surgeries left and right
in the seventeen hundreds.

Speaker 4 (45:45):
That makes sense, Yeah, yeah, how interesting, and.

Speaker 3 (45:48):
Two major developments in the eighteen hundreds eventually paved the
way for physicians to point the finger of blame towards
the appendix and his role in right lower quadrant pain
sometimes leading to death, athesia and antiseptics. Anesthesia and antiseptics
meant people were more willing to undergo surgery, and surgeons
more willing to perform them, since surgery was no longer

(46:10):
as much of a death sentence as it had been
in previous centuries. And glossing over a lot of old
white dude names and most of the nineteenth century. More
surgeries meant more opportunities to observe the appendix in its
natural habitat inflamed, uninflamed, ruptured, gangrenous, perforated, just all the
different flavors, like the spectrum of what the appendix can

(46:34):
look like, right, and so getting more of that information
would allow them to kind of make more classifications on
when is it what is a healthy looking appendix versus
what is not a healthy looking appendix, And eventually physicians
and surgeons began to see the appendix as a surgical
target in itself, not taken out just because you happened
to be elbow deep in someone's intestines and you think,

(46:54):
may as well kill two birds with one stone. Kind
of a thing, but a reason to cut to begin with.
In eighteen eighty six, Reginald Herbert Fitz, a pathologist, first
introduced the term appendicitis and proposed that at any sign
of lower right quadrant pain, that appendix has got to go.
Just a year later, Thomas Morton performed the first appendectomy

(47:18):
solely for appendectomy's sake, and the patient recovered. Another of
his patients, however, did not dying from stepsis soon after surgery,
which made Morton go is this really the right call? Like,
do we really need to be doing this? In response
to Morton's hesitancy, one doctor Chapman replied, quote, A true

(47:38):
vermiform appendix is found only in six animals man, gorilla, chimpanzee,
orange gibbon, and wombat. There can be no doubt therefore,
that the sekl appendix is one of those parts of
the human body having no particular function of significance, being
of use only in animals. In the human being, it
ought to be removed with no bad effect whatsoever. So

(48:00):
that I thoroughly agree with doctor Morton and what he
has to say regarding the opening of the abdomen and
taking out the appendix. It seems to me that the
human being is better off without the appendix than with it,
for it is nothing but a trap to catch cherry
stones and other foreign bodies.

Speaker 4 (48:16):
End quote. Okay, I have so many thoughts. First of all,
everyone's always picking on things like cherry pits. First of all,
who's eating cherry pits? But also why the fact that
it's only in existence in some animals does that make
it not functional in humans? Like most animals don't have

(48:36):
opposable thumbs, and I think we can all respect that
they're really important.

Speaker 3 (48:41):
I think it is like human superiority. So it's like,
we don't need this, animals have this, Why the heck
would we need it? Aaron, I'm not saying it's logical.

Speaker 4 (48:50):
It's so illogical because it's also like, well, only a
few have it, So why did it evolve? In the
they didn't evolution?

Speaker 3 (48:57):
But still, well, I think this was this was evolution.
This is post Darwin. But Darwin himself was like in
eighteen seventy one wrote quote, with respect to the alimentary canal,
I have met with an account of only a single rudiment,
namely the vermiform appendage of the sekum. Not only is
it useless, but it is sometimes the cause of death.

(49:18):
End quote. And so okay, I can see in some
regard if you are when people get appendicitis and it's
not treated or it's not removed, which would have been
the case in much of the eighteen hundreds, you think,
what is this thing that exists that kills us? If

(49:39):
it gets bad? And if we take it out and
someone survives the surgery, they survive it's not like your heart.
It's not like your liver, right, like you can recover
with no Effecteah.

Speaker 4 (49:50):
So it's also probably because it's so small and little,
like how could it be important? Right? You think there's
some sizism going on.

Speaker 3 (50:00):
No doubt, no doubt. But yeah, I think it was
also like, you know, a handful of animals have it.
We have it, but we can remove it easily with
no problem, and we're better than animals. Maybe it's like
all of these different things together, my guess is weird. Yeah,
and so Darwin's hypothesis was that it once served a

(50:21):
function in early humans, but as diet shifted from leaves
to fruits, it was no longer necessary. This was again
furthered by or like underlined by the fact that people
who had their APPENICX taken out seemed to recover fine,
and then that pattern encouraged further appendectomy because it was
like might as well, no big deal.

Speaker 4 (50:40):
Yeah. Well, also like appendectomy versus death, it's an easy choice.

Speaker 3 (50:44):
It's an easy choice. Yeah. A few famous appendectomy cases
further popularized the procedure. The most headlined worthy one was
that of King Edward the seventh, the firstborn son of
Queen Victoria. After the Queen's death in nineteen oh one,
Edward was set to the throne on June twenty sixth
and like coronation, but on the fourteenth of June, twelve

(51:06):
days before, he began to develop severe abdominal pains, was
diagnosed with likely appendicitis. He tried to delay the surgery
and be like, we gotta do the coronation first, but
then ended up having to delay the coronation to have
the surgery. For the first few decades of the twentieth century,
appendectomies were like ton selectomies, right, like we said, just

(51:27):
get them out, it's fine, no need, no need. But
unlike ton selectomies, people started to ring the alarm bell
or like pump the brakes a bit earlier for the appendix,
like let's just take a pause. Maybe we could use
the appendix From a nineteen thirty one paper quote the
diagnosis of chronic appendicitis must be made only after the

(51:48):
history has been very carefully taken and thorough exclusion has
been made of the numerous conditions simulating appendicitis. The day
of indiscriminate appendectomy has passed and quote, but has it
Some researchers think perhaps not. The introduction of antibiotics in
the nineteen forties and the use of laparoscopic surgery in

(52:10):
the nineteen eighties further lowered the threshold for appendectomy. But
in the last few decades some people have questioned whether
some cases of appendicitis could be instead treated with antibiotics
rather than with the knife, like we talked about, And
part of that questioning springs from the mystery of the
appendix itself. What causes appendicitis? Does the appendix serve a purpose?

(52:34):
If so, what is that purpose? And is it important
enough to try to preserve the appendix when we can.
Darwin's dismissal of the appendix in the eighteen seventies stuck
around like a bad habit for about one hundred years
or so, although a few people had their doubts for
much longer, like a researcher named Barry, who reported in
nineteen hundred that the human appendix contains lots of lymphoid

(52:57):
tissue Gault Gault.

Speaker 4 (53:00):
Got associated lymphoid tissue.

Speaker 3 (53:02):
Uh huh, and so Barry suggested that the appendix might
play some sort of immune role, or like Sir William McEwen,
who wrote in nineteen oh four, quote, is this body
of ours so very imperfect that we require to submit
it to the numerous rectifications which are sometimes recommended to
be carried out after it comes into the world. When

(53:22):
a child is born into this country, some consider it
necessary that he be circumcised. A few years later, the
tonsils are removed. This is followed by the removal of
the pharyngial tonsil a few years later. The appendix becomes
an ever increasing terror, which is only a laid when
that organ has been placed in a glass jar. The
majority of mankind seems to do very well with the appendix.

(53:44):
It gives rise to no annoyance in them, for it is,
after all a small percentage of the community that becomes
the victims of appendicitis? Is the appendix really a useless organ?

Speaker 1 (53:55):
End?

Speaker 4 (53:55):
Quote? I really love that quote? Aeric.

Speaker 3 (53:57):
Isn't that funny?

Speaker 4 (53:58):
It's really good?

Speaker 3 (54:00):
Why are we.

Speaker 4 (54:01):
Doing so much cutting?

Speaker 3 (54:02):
Yeah? And that question, which was posed in nineteen oh four,
would only get a solid answer one hundred years later.
In the early two thousands, researchers at Duke University discovered
that hiding within the appendix was a little concentrated cluster
of beneficial bacteria mediated by the host's own immune system.

(54:24):
Biofilms like this exist throughout many mammals and testines, and
they play a role in keeping the bad bacteria from
taking over and helping with digestion of nutrients. But what
happens when you get food poisoning or something just kind
of like cleans out your entire gut, taking all the
good bacteria in these biofilms along with it. That's where

(54:45):
the appendix comes into play.

Speaker 2 (54:47):
Huh.

Speaker 3 (54:47):
Researchers think that the appendix acts as a quote unquote
safe house for good gut bacteria, so that when about
of diarrheal illness wipes out the good microbes living in
your intestines, they can be recolonized buy the bacteria from
your appendix.

Speaker 4 (55:02):
I love that idea, Aaron.

Speaker 3 (55:04):
Isn't that really cool?

Speaker 4 (55:06):
Have they? Can? I ask questions?

Speaker 3 (55:09):
Sure? Yeah?

Speaker 4 (55:10):
Have they? Because I know I was looking at some
papers that looked at like whether there's a shift in
your microbiome after an appendectomy and things like that, and
it seemed like it was minor. Yeah, So then have
they looked at like following an appendectomy, following a diarrheal illness.
Is there a shift that is for the worst if
you've had an appendectmy versus not or things like that.

Speaker 3 (55:31):
I wish I knew the answer to that. The only
so there is some evidence of this in terms of
like post appendectomy and seedediff infection. As we know from
our seadiff episode from a million years ago. People who
have like a seadiff infection, the bacteria just like colonize
the entire intestinal tract and make it really difficult for

(55:53):
any other commensal or like your your good bacteria to
recolonize in your gut, and it's just like it's bad news, right,
And so there have been studies that show that people
who have had their appendix taken out have higher rates
of sea diff infection, Okay, And so it's thought that
the appendix helps to initiate an immune response after exposure

(56:13):
to seed diff as like one of these things, Yeah,
got bacteria that we'll just take all over.

Speaker 4 (56:19):
I will also say that in the studies that have
looked at antibio, because antibiotic use is one of the
major risk factors for sea diff infection, there does not
seem to be an increase in sea diff infection after
antibiotics for appendicitis. So if you're using antibiotics insteadive surgery,
there's not an increased risk in seed iff.

Speaker 3 (56:36):
So that's very interesting. Yeah, there you go. And so
Darwin I think got this one wrong, right. The appendix
certainly does serve a purpose. Is that purpose essential to
life or health? No, but it does play a role,
which begs the question, well, why don't all animals have them?

(56:59):
So early I mentioned that alongside humans, we have just
a few other species that have these worm like vermiform appendixes,
But as it turns out, many other animal species have
what is functionally classified as an appendix, even if it
doesn't have the same worm look to it. Marsupials, primates,

(57:21):
and gliers, which is a new word for me. It
means rodents and lagomorphs like rabbits, compires all have species
within those groups that have an appendix, and researchers estimate
that the appendix has evolved independently at least twenty nine
times in mammals.

Speaker 4 (57:38):
Nine Okay, that alone, I feel like tells you that
there's some functionality going on.

Speaker 3 (57:43):
Uh huh, and it's been lost twelve times, right, So
like the balance is definitely in the favor of this
being having evolved multiple times, suggesting this strongly suggests that
this organ this appendix has been pretty important in evolutionary history.
But does its serve the same purpose in these different species?

(58:03):
Not necessarily, And there doesn't seem to be a strong pattern.
And who has an appendix and who doesn't? Like is
it influenced by diet, by environmental factors, by habitat, by
other aspects of ecology, by life history characteristics. We don't
yet know. There's even variation within a species. So in
certain primate species, some individuals have an appendix and others don't.

Speaker 4 (58:26):
Stop it?

Speaker 3 (58:27):
What right? Yeah, I don't know. In general, people think
that in humans and other primates and maybe some rodents,
the appendix serves this immunological function, like helping to protect
us from invading pathogenic gut bacteria and sort of recolonizing
when we do get a GI infection. In marsupials, it
might just be that the appendix acts as kind of

(58:49):
like the more developed sekum found in other animals, and
in lagomorphs like rabbits, it might trap sand like.

Speaker 4 (59:00):
Oh, my dolar needs.

Speaker 3 (59:06):
Maybe that's why I'm involved in humans, maybe just for
toddlers for toddlers, but yeah, I mean, it seems like
we don't fully know why the appendix, like, what purpose
the appendix serves in these different animal species or groups,
and is it the same, is it different? Why do
some organisms have it and others don't? And there might not

(59:26):
be one thing driving the evolution of the appendix across
all these animal species. But that being said, until recently,
most research has focused on human appendixes, and other animals
have largely been ignored. And so it might be that
we get more clarity on that in the years to come,
as we hopefully will for the causes of appendicitis and

(59:49):
being able to better manage like treatment and weighing the
scales in the favor of antibiotics or surgery. But speaking
of the years to come, what else this might be
on the horizon for appendix research? Can you hit me
with some global appendicitis numbers?

Speaker 2 (01:00:05):
Oh?

Speaker 4 (01:00:06):
I would love to try right after this break. Some

(01:00:35):
of the papers that I read, a lot of the
papers actually cite that acute appendicitis is the most common
abdominal surgical emergency in the world with an incident. This
is an incidence that I think is based on US numbers,
but I don't actually know. But the incidence is estimated
at ninety six to one hundred cases per one hundred

(01:00:59):
thousand adult Okay, which is pretty high. So this is
like thousands, hundreds of thousands of people in the US,
millions of people across the globe that get appendicitis every year.
The incidence, at least in the US tends to be
the highest in teens, so like age ten to nineteen

(01:01:19):
is tends to be the highest incidents, but plenty of
young adults and older adults also get appendicitis. You can
get it at any age. It is pretty rare to
get it under age ten, and I don't have a
good answer as to why that is. My best guess
is like less lymphoid tissue in there. Maybe it hasn't
grown enough. I have no idea.

Speaker 3 (01:01:39):
Yeah, filled with sand still from.

Speaker 4 (01:01:41):
Yeah, you can still get that mesentery loom. You're actually
really funny. You can still get mesentary lymphatinitis, which is
a separate entity but is like when just like lymph
tissue causes inflammation and pain in that area without actually
causing dwelling and infection in the appendix, So maybe it's

(01:02:03):
something to do with like, I don't know, I don't
have an answer, but and I said, it's also slightly
more common in those assigned male at birth compared to
those assigned female at birth. But it's also the case.
And what I want to focus on a little bit
in terms of our statistics is that accurate diagnosis is
really important, right because this is something that can very

(01:02:25):
easily go from treatable to emergency, to sepsis to life threatening.
Accurate diagnosis is very tightly linked to outcomes. So having
a delay in your diagnosis or the incorrect diagnosis the
first time that you present to care results in worse
outcomes perforation, more severe infection, potentially death, and unfortunately and unsurprisingly,

(01:02:49):
it is very predictable what the risk factors are that
contribute to delayed diagnosis. Things like race and ethnicity are
significant contributors to delays in diagnosis. So studies have found
that especially in kids, Black children are less likely to
get opioid pain medication compared to white children who present
with appendicitis. Black children and Asian children in some studies

(01:03:14):
are more likely to have appendicial rupture compared to white children,
which could be a contribution of difficulties and access to
care as well as delays in diagnosis. Uh huh, And
there wasn't a lot of data that I found. At
least it might be out there on populations like the
Hispanic or Latino populations, but I would guess that, especially

(01:03:34):
in this country, there are huge racial and ethnic discrepancies
there as well in terms of access to care. In
terms of delayed diagnosis, sex also plays a role people
as on female at birth both adults and children are
more likely to have a delayed or misdiagnosis of appendicitis
and socioeconomic status itself, at least as measured by insurance type.

(01:03:55):
So in the US, people with private insurance tend to
be of higher income to those on public insurance, and
people on public insurance are more likely to have a
pendicial rupture than people on private insurance. So this is
a huge issue of equity and discrepancies in access to care.
In social determines of health, it's multifactorial. It's not just

(01:04:17):
not being believed and not being diagnosed correctly or taken
seriously in the emergency room, but that is part of it.
It's also not having access to an emergency room close
to where you live or whatever. Like, there's a lot
of different things that play into it layers. Yeah, I
think that in terms of one of the like where
does the research go? There's like there's so much erin

(01:04:39):
But I think one of the things that is going
to be really interesting to watch in real time, like
we are living this right now, is like, are these
tides really shifting fully towards a non operative approach? And
if so, how do we accomplish that? What more data
do we need to know? Who is going to do

(01:05:00):
really well with antibiotics alone? What are the criteria that
we're using to come up with the best antibiotic regimen,
because right now, there's not like a standard like, well,
if you're going to do only antibiotics, here's your standard
of care, right, And where do we go from here?
Because the incidence of reoccurrence of appendicitis is not trivial, right,

(01:05:23):
It's like fifteen to forty percent depending on the study.
So then my question is does the appendix go the
way of the gallbladder where ideally, if you have cholisistitis,
which is infection because your gallboughder gets clogged, the same
way that your appendic gets clogged. Ideally you treat it
with antibiotics first and then do surgery later when there's

(01:05:47):
not an active, really bad infection. Because the thing that's
not kind of mentioned in a lot of this is
doing surgery on an abdomen that's actively infected is a
lot harder than doing surgery on an abdomen that's not infected,
because infection comes with a lot of other stuff. It
comes with a lot of inflammation, which means that you

(01:06:08):
have a more likely risk of things like adhesions and
complications later on. So if you can do a surgery
when things are not angry and infected, that's better. But
is it necessary in the case of appendicitis or is
it not? I don't know, Aaron.

Speaker 3 (01:06:23):
It's interesting, And then like, what are there instances where
people who are treated with antibiotics. It's like, for sure,
a case of appendicitis are treated with antibiotics and then
the appendix proceeds to rupture. Does that happen?

Speaker 1 (01:06:37):
Oh?

Speaker 4 (01:06:38):
Yeah, like the like the antibotics just don't work, right, Yeah, absolutely,
that happens to twelve percent of the time.

Speaker 3 (01:06:44):
Yeah, okay, So like it's yeah, I do think that
that is really interesting where it's like, ideally, let's schedule
this surgery, let's pencil it in, but what are the
risks associated with that? And those risks can be severe, right,
not just high risk, but like high risk outcomes, like
the risk the outcomes are really bad.

Speaker 4 (01:07:03):
I guyes, yeah, exactly, yeah. And then there's also the
risks of surgery which are not trivial and especially depending
on the person, what their other risk factors are, et cetera,
et cetera. Like it's it is not a straightforward thing,
and that is why I think there is still such
a I won't say debate, but just like what is
the right answer right now? There isn't one right And

(01:07:23):
so we've talked a lot on this podcast about how
medicine moves slowly, and I think that this is something
like the treatment of appendicitis with antibiotics is something that
has been picking up more and more steam, but there's
still a lot of open questions as to what the
safest and best way is to do that. And so
it's going to vary a lot where you are, which
er you show up to, who's working, what your particular

(01:07:45):
case looks like. To know, like what is the best
possible outcome, and sometimes we can't possibly know that. But
the more data that we have, the better of a
prediction that we can have on what the quote unquote
best option is, which is it's really interesting. I think
that part of that will also have to go along
with more information on what the heck does this appendix

(01:08:06):
do right? And how bad is it to take it out?
I mean, we take out gallblotters all the time. We
take out appendixes all the time. We take out You
can take out a spleen. You can take out so
many your whole colon. You can do it all and
live without these organs. But should we?

Speaker 3 (01:08:22):
It depends right? Yeah? Number one, I have two thoughts.
One is the thought. One is a question, let's do
an episode on gallbladders, because yes, I want to know
a lot more I know, yep about call blotters for
personal reasons, but also purely curious academic reasons.

Speaker 4 (01:08:40):
Personal and professional reasons exactly.

Speaker 3 (01:08:43):
And number two, why does a pendicitis make you vomit?
Is it the pain?

Speaker 4 (01:08:48):
That's a good question. I have no idea. Is it
the pain? Is it also just that like you have
inflammation in your guts? Overall? And so your response to
that is.

Speaker 3 (01:08:56):
Like, well, but why do you vomit rather than have
diarrhea or something you can't havesly can have diarrhea. You
could just be both. Okay, Yeah, I feel like I
don't as commonly read about the diarrhea part of appendicitis,
and mostly hear about the vomiting.

Speaker 4 (01:09:09):
You can have diarrhea, you can have constipation, and sometimes
that can make it harder for somebody to diagnose it
pinpoint as appendicitis, because you're right, the classic description doesn't
include diarrhea or conversation, right.

Speaker 3 (01:09:23):
And I'm sure that like part of what's contributing to
all the confusion is that people hold very strong opinions
about what is the right course of action to be
done well.

Speaker 4 (01:09:33):
And it's also like we're talking about surgery versus non surgery,
and if you're a surgeon you're going to have a
different opinion about that than if you are not a surgeon, too, write.

Speaker 3 (01:09:43):
Like or if you're the patient and you're like, I
want surgery because I don't want to have to have
this happen again and have to run to the er.

Speaker 4 (01:09:50):
And that's why it's such like at this point, and
I think probably from this point forward it is and
will be an individualized decision. It's not, it shouldn't be.
That is more and more the way that me is
moving right is it's like there is not a one
size fits all approach because everyone is also going to
have a different risk tolerance for surgery and for not surgery.
Like there's so many, oh, so many. I could keep going,

(01:10:13):
but if you want to just learn more instead of
hearing us blatd on, We've got sources for you.

Speaker 3 (01:10:19):
We do. I have a few different sources here. So
again I want to shout out that video on YouTube
by Patrick Kelly titled what Happened to Appendectomies? Great channel,
overall great video. Loved it. And then if you would
like to learn more about the history of appendicitis and appendectomies,

(01:10:39):
there is several papers. One I liked called Historic Phases
of Appendicitis from like nineteen thirty one. It's a little
bit old, but kind of fun. And then for the
paper that discussed the function of the appendix, there's a
paper from two thousand and seven titled biofilms in the
large bowel suggests an apparent function of the human vermiform
appendix Bolinger at all, give it, give it all to us.

Speaker 4 (01:11:02):
In the title, I had a few papers, a bunch
of reviews. There was one from JAMMA twenty twenty one
titled Diagnosis and Management of Acute Appendicitis in Adults a review.
There was several reviews of the use of antibiotics versus
surgery for appendicitis, which are really interesting, both in adults
and in kids. So there's a couple different papers there.

(01:11:25):
And then there's more that one where I briefly mentioned
the connection between the appendix and alsative colitis. That was
from a Nature Reviews in gastra Entrology paper from twenty
twenty three titled the appendix and alsative colitis an Unsolved Connection.
So there's a bunch there. You can find the list
of sources from this episode and all of our episodes

(01:11:46):
on our website This Podcast will Kill You dot Com
under the episodes tab.

Speaker 3 (01:11:50):
Thank you again, Mollie so much for sharing that story
with us. Just thank you.

Speaker 4 (01:11:57):
Yeah.

Speaker 3 (01:11:57):
Thank you also to Bloodmobile for providing the music for
this episode and all of our episodes.

Speaker 4 (01:12:03):
Thank you to Tom Bryfogel and Leanna Scolacci for the
incredible audio.

Speaker 3 (01:12:07):
Mixing thank you to everyone at exactly Right, and.

Speaker 4 (01:12:09):
Thank you to you listeners. We hope you enjoyed this episode.
Do you still have your appendix? A lot of you
have written in saying that you, in fact no longer
have your appendix? Have your lives changed at all since
having it out? I actually never asked them on that question. Curious.

Speaker 3 (01:12:24):
Yeah, and a huge thank you, as always to our
fantastic patrons. We appreciate your support. It truly does mean
the world to us.

Speaker 4 (01:12:32):
Thank you, thank you, thank you. Well.

Speaker 3 (01:12:35):
Until next time, wash your hands.

Speaker 4 (01:12:37):
You feel for the animals. M