Appendix: An Organ with Main-Character Energy.

Meet the tiny organ evolution couldn’t quite delete.

Your appendix mostly minds its own business—until one day it sparks a full-blown abdominal crisis. In our new episode of Not Another Medical Podcast, James, Brodie, and Josh unpack:

➡️ How appendicitis actually starts and why the pain “moves”

➡️ Why 1 in 12 of us will get it

➡️ When to stop “waiting it out” and head to the ER 🚑

➡️ Whether antibiotics can ever replace surgery

➡️ And what the appendix might really be for: a leftover evolutionary glitch… or a microbiome bunker and immune outpost that stuck around for a reason.

Episode Transcript

(00:11):
And tell yourself it'll just pass.
But then the pain moves.
It moves from the middle of the belly to the right lower side.
Suddenly every bump on the road hurts, standing hurts, breathing hurts, and you're thinking, okay, maybe this isn't just tacos.
That's the appendix for you.

(00:33):
The body's quietest roommate spends his entire time doing nothing.
Then one night it decides to start a house fire, and here's a kicker.
Happens to one in 12 of us.
Most of the time, the only warning is a whisper of pain that turns into a scream.
Today we're talking about appendicitis, why it happens, how to spot it before it bursts, and what your options are once it does. 12 00:01:16,587.102696371 --> 00:01:20,855.462090435 and opinions expressed in this podcast are those of the hosts and guests do not reflect the official policies or positions of any affiliated institutions or organizations. 13 00:01:21,72.128757102 --> 00:01:25,472.128757102 This podcast is for informational, educational, and entertainment purposes only, and it is not intended to provide medical advice, diagnosis, or treatment. 14 00:01:25,755.462090435 --> 00:01:34,197.654504966 Listeners should consult their own healthcare professionals for any medical concerns, I'm Brodie. 15 00:01:34,217.654504966 --> 00:01:34,517.654504966 Nolan. 16 00:01:34,517.654504966 --> 00:01:35,477.654504966 I'm an emergency doctor. 17 00:01:35,753.336323147 --> 00:01:37,583.336323147 I am Josh Levitts Internal Medicine. 18 00:01:37,836.427232238 --> 00:01:39,846.427232238 And I'm James Jung, a general surgeon. 19 00:01:40,296.42723224 --> 00:01:43,266.42723224 This is not another medical podcast. 20 00:01:44,876.75971208 --> 00:01:54,206.75971208 Last week, um, you probably can't see, but, uh, which may, may or may not mean anything to you guys, um, was in Toronto, playing at Massey Hall. 21 00:01:54,400.2665148 --> 00:01:55,975.2665148 from the eighties and it was amazing. 22 00:01:56,216.75971208 --> 00:02:04,177.75971208 Yeah, no, Thundercat is an amazing bassist and hip hop Oh, and Grammy award winner, um, from cool. 23 00:02:04,346.75971208 --> 00:02:04,586.75971208 album. 24 00:02:05,276.75971208 --> 00:02:07,316.75971208 he was in, uh, in Toronto at uh, Massey Hall. 25 00:02:07,316.75971208 --> 00:02:14,246.75971208 So went to go see and, halfway through set, uh, I mean unfortunately there's actually a medical emergency in the crowd. 26 00:02:14,246.75971208 --> 00:02:15,512.75971208 So I mean, people very Yikes. 27 00:02:16,826.75971208 --> 00:02:17,876.75971208 Thundercat again, smaller venue. 28 00:02:17,876.75971208 --> 00:02:19,196.75971208 He saw everything stop the show. 29 00:02:19,342.75971208 --> 00:02:19,632.75971208 Yeah. 30 00:02:19,637.75971208 --> 00:02:19,897.75971208 Yeah. 31 00:02:20,66.75971208 --> 00:02:22,16.75971208 and so then I was doing my due diligence. 32 00:02:22,16.75971208 --> 00:02:26,516.75971208 I was off, off to the side, like not on the main, uh, the main floor. 33 00:02:26,786.75971208 --> 00:02:28,796.75971208 Um, but then there's the overhead. 34 00:02:28,946.75971208 --> 00:02:30,296.75971208 Is there a doctor? Right. 35 00:02:31,256.75971208 --> 00:02:43,226.75971208 Gave it the obligatory five or 10 seconds, and then the second call came out and you better believe I like jumped over the barricade and like waddled my way through the crowd to check it out. 36 00:02:43,226.75971208 --> 00:02:47,822.75971208 And yeah, sure enough, some, some guy just, just passed out, so we helped him Oh, well. 37 00:02:47,966.75971208 --> 00:02:48,352.75971208 until the Wow. 38 00:02:48,666.75971208 --> 00:02:51,532.75971208 the paramedics got there and And you return to work. 39 00:02:52,825.2665148 --> 00:02:54,506.75971208 Brodie, to enjoy the concert. 40 00:02:54,506.75971208 --> 00:03:00,686.75971208 Missed like two songs, unfortunately, but, uh give you, did they give you an upgrade or something? oh, definitely not. 41 00:03:00,716.75971208 --> 00:03:01,201.75971208 No, no, no. 42 00:03:01,206.75971208 --> 00:03:01,556.75971208 That's okay. 43 00:03:01,556.75971208 --> 00:03:01,796.75971208 Yeah. 44 00:03:02,275.2665148 --> 00:03:03,952.75971208 Yeah, that's very well. 45 00:03:04,5.2665148 --> 00:03:05,545.2665148 Don't do this for the, uh, for the fame. 46 00:03:06,502.75971208 --> 00:03:08,722.75971208 Anyways, I so that was my excitement for the week. 47 00:03:08,722.75971208 --> 00:03:12,172.75971208 An amazing concert and a, a very minor call to duty. 48 00:03:12,261.2665148 --> 00:03:16,281.2665148 want, uh, I want the, I want the slow-mo video of you jumping over that barricade. 49 00:03:16,671.2665148 --> 00:03:17,511.2665148 Someone's got it. 50 00:03:19,78.75971208 --> 00:03:19,368.75971208 Yeah. 51 00:03:19,593.75971208 --> 00:03:20,703.75971208 Flick your hair. 52 00:03:20,722.75971208 --> 00:03:21,501.2665148 yeah, Yeah. 53 00:03:21,831.2665148 --> 00:03:23,361.2665148 Put some good music behind it. 54 00:03:23,361.2665148 --> 00:03:24,81.2665148 It'll be awesome. 55 00:03:24,303.75971208 --> 00:03:26,103.75971208 Like pull out your stethoscope midway. 56 00:03:28,222.75971208 --> 00:03:33,813.75971208 Why, did you bring this to a concert? It just doesn't make It's like, I, I knew this would happen. 57 00:03:34,42.75971208 --> 00:03:34,492.75971208 off. 58 00:03:34,732.75971208 --> 00:03:35,932.75971208 It's a weird flex man. 59 00:03:36,806.2665148 --> 00:03:38,661.2665148 uh, that's awesome. 60 00:03:38,943.75971208 --> 00:03:39,963.75971208 Oh, that's hilarious. 61 00:03:40,203.75971208 --> 00:03:40,768.75971208 Oh, that's awesome. 62 00:03:41,61.2665148 --> 00:03:42,831.2665148 uh, you were across the world. 63 00:03:42,891.2665148 --> 00:03:46,358.75971208 How was that? Oh yeah, I was, uh, yeah, I can't believe it was just last week. 64 00:03:46,358.75971208 --> 00:03:52,418.75971208 But, uh, yeah, I was in Singapore, uh, for, for about a week, first time there. 65 00:03:52,518.75971208 --> 00:03:56,228.75971208 I was very impressed with the country, you know, very, clean. 66 00:03:57,98.75971208 --> 00:04:01,628.75971208 I also heard that, uh, if you litter, like you could get like a big fine. 67 00:04:01,868.75971208 --> 00:04:08,168.75971208 They're very strict with littering or, or drinking or eating in public transportation. 68 00:04:08,498.75971208 --> 00:04:12,998.75971208 Um, so it's, it's like complete opposite of New York, Subway. 69 00:04:13,721.2665148 --> 00:04:14,51.2665148 Yeah. 70 00:04:14,558.75971208 --> 00:04:16,238.75971208 So, Or if yeah. 71 00:04:16,238.75971208 --> 00:04:16,688.75971208 So. 72 00:04:16,721.2665148 --> 00:04:18,281.2665148 if you're not littering, people are angry. 73 00:04:18,843.75971208 --> 00:04:19,133.75971208 Yeah. 74 00:04:19,138.75971208 --> 00:04:19,418.75971208 Yeah. 75 00:04:19,418.75971208 --> 00:04:21,437.75971208 It's like, why aren't you literary? Yeah. 76 00:04:21,758.75971208 --> 00:04:26,378.75971208 Why are you keeping garbage in your pocket? subway? Yeah. 77 00:04:26,378.75971208 --> 00:04:34,388.75971208 It was actually kind of interesting 'cause like, on the way back, the transfer was at JFK and then there were, you know, of course delays, overnight delays. 78 00:04:34,658.75971208 --> 00:04:38,198.75971208 And so I had to like, find the hotel and take the subway to a hotel. 79 00:04:38,588.75971208 --> 00:04:45,488.75971208 And of course, like there was somebody who's like, you know, yelling and screaming at the subway, like, you know, with like, cockroaches everywhere. 80 00:04:45,488.75971208 --> 00:04:50,198.75971208 So it was a stark difference between the New York subway and, and the streets of Singapore. 81 00:04:50,528.75971208 --> 00:04:53,583.75971208 Um, but yeah, yelling and screaming, that's right. 82 00:04:54,43.75971208 --> 00:04:54,623.75971208 It was me. 83 00:04:55,793.75971208 --> 00:04:56,383.75971208 Screw you. 84 00:04:56,943.75971208 --> 00:04:57,623.75971208 American Airlines. 85 00:04:59,832.75971208 --> 00:05:05,865.2665148 Um, how about you, Josh? Did you do anything? Uh I went to Vegas. 86 00:05:05,865.2665148 --> 00:05:07,992.75971208 I went the other, the, the other oh, yeah. 87 00:05:08,22.75971208 --> 00:05:08,652.75971208 I saw that. 88 00:05:08,712.75971208 --> 00:05:11,895.2665148 Uh, you saw, I saw that you went to the health conference, right? Yeah. 89 00:05:11,895.2665148 --> 00:05:12,705.2665148 HLTH. 90 00:05:12,705.2665148 --> 00:05:14,955.2665148 It was, uh, a big shout out to HLTH. 91 00:05:15,15.2665148 --> 00:05:17,295.2665148 Um, it was a innovation in medicine conference. 92 00:05:17,295.2665148 --> 00:05:17,865.2665148 It was huge. 93 00:05:17,865.2665148 --> 00:05:20,25.2665148 I think it was like 50 or 55,000 people. 94 00:05:20,567.75971208 --> 00:05:20,987.75971208 Mm-hmm. 95 00:05:21,15.2665148 --> 00:05:26,85.2665148 all about, uh, most mostly AI in medicine with some longevity discussions in there. 96 00:05:26,415.2665148 --> 00:05:27,252.75971208 Um, and some other Mm-hmm. 97 00:05:27,255.2665148 --> 00:05:27,825.2665148 cool stuff. 98 00:05:27,885.2665148 --> 00:05:28,455.2665148 It was amazing. 99 00:05:28,815.2665148 --> 00:05:31,875.2665148 It is so, uh, fascinating to see what is out there already. 100 00:05:32,212.75971208 --> 00:05:40,707.75971208 they, they don't call it health, like, it's like called HLTH, I thought it was, uh, um, HLTH. 101 00:05:40,875.2665148 --> 00:05:42,45.2665148 actually think they call it health. 102 00:05:42,45.2665148 --> 00:05:43,65.2665148 I think it's HLTH. 103 00:05:43,257.75971208 --> 00:05:43,437.75971208 Hmm. 104 00:05:43,990.2665148 --> 00:05:45,280.2665148 Oh, well that's disappointing. 105 00:05:45,940.2665148 --> 00:05:48,340.2665148 It's like, you know, misuse of that acronym. 106 00:05:48,732.77331752 --> 00:05:51,162.77331752 Well, I think, I don't think you could just call yourself health. 107 00:05:52,997.77331752 --> 00:05:54,434.2665148 Like not? some letters. 108 00:05:54,434.2665148 --> 00:05:55,634.2665148 No, it'll know the difference. 109 00:05:55,634.2665148 --> 00:05:56,84.2665148 It's fine. 110 00:05:56,894.2665148 --> 00:05:59,609.2665148 Are you an acronym, are you not? Hmm. 111 00:06:00,972.77331752 --> 00:06:03,132.77331752 Uh, it Yeah, discussion there. 112 00:06:03,310.2665148 --> 00:06:03,640.2665148 yeah. 113 00:06:03,645.2665148 --> 00:06:04,39.2665148 I mean, go. 114 00:06:04,385.2665148 --> 00:06:16,510.2665148 it's like, uh, S-A-I-D-I thought it was called usaid, uh, just like really bad use of the acronym, you know? Yeah, the, oh, No, it's, is they call it U-S-A-I-D. 115 00:06:16,769.2665148 --> 00:06:17,369.2665148 to say it. 116 00:06:17,440.2665148 --> 00:06:20,410.2665148 Yeah, it's just like HLTH. 117 00:06:20,680.2665148 --> 00:06:23,260.2665148 I thought it was called health, but I. 118 00:06:23,592.77331752 --> 00:06:23,892.77331752 All right. 119 00:06:24,253.77331752 --> 00:06:25,3.77331752 Alright. 120 00:06:25,453.77331752 --> 00:06:27,887.77331752 Yes, great topic. 121 00:06:28,363.77331752 --> 00:06:29,23.77331752 yes. 122 00:06:29,87.77331752 --> 00:06:29,567.77331752 today. 123 00:06:30,557.77331752 --> 00:06:32,57.77331752 like, man, surprise. 124 00:06:32,57.77331752 --> 00:06:33,968.77331752 We haven't done it yet, I agree. 125 00:06:35,91.28012024 --> 00:06:36,377.77331752 Brodie us a little bit. 126 00:06:36,492.77331752 --> 00:06:38,352.77331752 Uh oh, why do you think Uhhuh. 127 00:06:39,691.28012024 --> 00:06:40,231.28012024 I like that. 128 00:06:40,231.28012024 --> 00:06:40,741.28012024 I agree. 129 00:06:41,687.77331752 --> 00:06:50,27.77331752 Yeah, so, I mean, I don't want to, I don't wanna steal James that because I'm curious why he chose it, but for me, what I love about appendicitis is it something that everyone knows about? I see. 130 00:06:50,818.77331752 --> 00:06:51,238.77331752 Mm-hmm. 131 00:06:51,647.77331752 --> 00:07:03,47.77331752 Um, and some people are very worried about when they come to the hospital and, and thinking about it, but it's also a disease that can be very hard to diagnose because it doesn't always present in the classic symptoms, which of which I'm sure we'll talk about today. 132 00:07:03,227.77331752 --> 00:07:09,857.77331752 So it's common and it can present in all sorts of weird different ways, um, and affects everyone. 133 00:07:09,857.77331752 --> 00:07:10,307.77331752 I love it. 134 00:07:10,457.77331752 --> 00:07:10,787.77331752 I love it. 135 00:07:11,743.77331752 --> 00:07:13,513.77331752 Yeah, I, I, I agree with that. 136 00:07:13,513.77331752 --> 00:07:34,933.77331752 And you know, it, it, it's interesting because, you know, when this entity comes to the surgeon, you know, it's a known entity, right? The, the mystery of diagnosis is already gone, right? So I thought this was like a topic that I think Brodie, you'll have a lot to say and your experiences, uh, in this. 137 00:07:35,473.77331752 --> 00:07:54,13.77331752 And also it's something, I mean, you know, we'll talk about this a little bit more, but, you know, I have a young son, he's a 3-year-old, and, in few years he's kind of a, kind of be at the prime age and you know, like teenage boy, uh, who is the most frequently affected by appendicitis. 138 00:07:54,253.77331752 --> 00:08:01,183.77331752 Uh, so, you know, uh, you know, I think this is something that, uh, would be interesting to review and. 139 00:08:02,68.77331752 --> 00:08:11,848.77331752 You know, as a surgeon, you know, one of the first procedures that you kind of, you know, get to learn more and be proficient at is appendectomy. 140 00:08:11,848.77331752 --> 00:08:25,648.77331752 So this was obviously a very special disease, um, if you're a surgical trainee and, and, you know, nowadays there's a bit of a debate about how to treat appendicitis. 141 00:08:25,828.77331752 --> 00:08:30,658.77331752 Um, so I think, you know, there'll be a little bit of interesting conversation around that. 142 00:08:30,658.77331752 --> 00:08:33,241.28012024 So overall, I think it's a, Mm-hmm. 143 00:08:33,328.77331752 --> 00:08:33,568.77331752 right. 144 00:08:33,628.77331752 --> 00:08:34,18.77331752 Overall. 145 00:08:34,18.77331752 --> 00:08:37,18.77331752 I think this is a great little controversy. 146 00:08:37,18.77331752 --> 00:08:37,528.77331752 That's right. 147 00:08:37,831.28012024 --> 00:08:40,81.28012024 this, this podcast has been a bit too agreeable. 148 00:08:40,81.28012024 --> 00:08:41,521.28012024 We gotta, we gotta start fighting. 149 00:08:41,581.28012024 --> 00:08:41,821.28012024 Yeah. 150 00:08:42,358.77331752 --> 00:08:42,868.77331752 That's right. 151 00:08:42,868.77331752 --> 00:08:43,408.77331752 That's right. 152 00:08:43,408.77331752 --> 00:08:45,238.77331752 So, James, why. 153 00:08:45,301.28012024 --> 00:08:50,71.28012024 you, do you and the other surgeons ever sit around being like, I remember my first appendix. 154 00:08:50,251.28012024 --> 00:08:56,191.28012024 I remember taking it out and all the joy it brought me and I knew right then I wanted to be a general surgeon. 155 00:08:56,281.28012024 --> 00:08:57,931.28012024 Is that what you guys do? I assume it is. 156 00:08:59,498.77331752 --> 00:09:18,13.77331752 Uh, uh, I mean, we don't publicly, you know, talk about that, but I mean, but inevitably, a lot of the times the first quote unquote solo procedure, like, you know, yeah, of course there's gonna be your attending surgeon kind of breathing on your neck, you know, on every move and cri criticizing every move. 157 00:09:18,43.77331752 --> 00:09:18,727.77331752 But, sterile. 158 00:09:19,471.28012024 --> 00:09:22,621.28012024 No, actually Don't you guys wear masks? Yeah. 159 00:09:23,537.77331752 --> 00:09:23,657.77331752 a. 160 00:09:28,513.77331752 --> 00:09:34,693.77331752 uh, but, you know, uh, usually it's the appendic, uh, appendectomy that is like one of the first procedures. 161 00:09:34,693.77331752 --> 00:09:44,143.77331752 So certainly, you know, it's a procedure they, we remember the most as like, oh, this was the first thing that I did as a, as a surgical trainee. 162 00:09:44,143.77331752 --> 00:09:44,473.77331752 So, yeah. 163 00:09:46,322.77331752 --> 00:09:56,417.77331752 So James, I want to pick up on something that you started off with again, kind of bringing back to, you know, you having a son and getting older and, you know, we'd already talked about it being a very prevalent disease. 164 00:09:56,417.77331752 --> 00:09:59,117.77331752 Like it happens, you know, uh, quite often. 165 00:09:59,177.77331752 --> 00:10:11,23.77331752 Um, and I, I know you love, I know you love numbers, so I know you've got some things for it, but can you run through just a little bit of like, how often are we seeing this? Like, who's getting it, Yeah. 166 00:10:11,23.77331752 --> 00:10:11,83.77331752 Yeah. 167 00:10:11,477.77331752 --> 00:10:16,693.77331752 you know, is there something like a lifetime risk for people? Like just how common is appendicitis? Yeah. 168 00:10:16,753.77331752 --> 00:10:23,233.77331752 Uh, it, it's a very common, uh, gi uh, infectious, inflammatory disease. 169 00:10:23,238.77331752 --> 00:10:28,963.77331752 It, it occurs in about one in 12, um, individuals over their lifetime. 170 00:10:29,623.77331752 --> 00:10:32,413.77331752 Uh, so that's roughly about, yeah, that's, that's huge. 171 00:10:32,413.77331752 --> 00:10:35,383.77331752 That's almost like a, you know, 10% or 8%. 172 00:10:35,522.77331752 --> 00:10:35,942.77331752 Wow. 173 00:10:36,13.77331752 --> 00:10:36,883.77331752 a huge number. 174 00:10:37,328.77331752 --> 00:10:56,438.77331752 Uh, when we think about when it occurs in one's lifetime, usually it's in your early years, so adolescents, teenagers, so, and, you know, early twenties, uh, that's when it's the, the highest, it's about 250 to 300 per a hundred thousand per year. 175 00:10:56,888.77331752 --> 00:11:12,548.77331752 Uh, and then it kind of slopes down a bit, you know, traditionally, you know, when I was training, we learned about kind of the bimodal distribution where the, uh, um, the incidence peaks up again at later stages, like in the, in their sixties or seventies. 176 00:11:12,578.77331752 --> 00:11:15,308.77331752 But now it's not that anymore. 177 00:11:15,548.77331752 --> 00:11:20,678.77331752 Um, you know, now it's kind of the decrease of the prevalence. 178 00:11:20,678.77331752 --> 00:11:33,338.77331752 You know, as you know, people get older, so highest peak at tens, the teens and twenties, and then it decreases over the time, and men are more likely to get it, about 40% more likely than female. 179 00:11:34,706.28012024 --> 00:11:35,502.77331752 Okay, So. 180 00:11:36,197.77331752 --> 00:11:37,37.77331752 almost in the clear. 181 00:11:37,831.28012024 --> 00:11:38,671.28012024 I'm in the clear. 182 00:11:38,851.28012024 --> 00:11:39,271.28012024 I'm good. 183 00:11:39,271.28012024 --> 00:11:39,781.28012024 I'm out. 184 00:11:40,937.77331752 --> 00:11:41,297.77331752 Yeah. 185 00:11:41,563.77331752 --> 00:11:41,743.77331752 Yeah. 186 00:11:42,73.77331752 --> 00:11:42,433.77331752 Josh. 187 00:11:42,433.77331752 --> 00:11:42,583.77331752 Josh. 188 00:11:42,767.77331752 --> 00:11:42,977.77331752 Yeah. 189 00:11:43,543.77331752 --> 00:11:44,173.77331752 Josh is good. 190 00:11:44,177.77331752 --> 00:11:45,707.77331752 right lower quad pain is his hip. 191 00:11:46,81.28012024 --> 00:11:50,161.28012024 it's, it's, I know we're laughing, but this is very true. 192 00:11:52,277.77331752 --> 00:11:54,647.77331752 That come, that truly comes from a place of caring buddy. 193 00:11:54,647.77331752 --> 00:11:55,538.77331752 Just That's right. 194 00:11:55,921.28012024 --> 00:11:56,551.28012024 don't lie to me. 195 00:11:57,991.28012024 --> 00:12:02,298.77331752 Um, do you, uh, do you guys have your appendix still? I think Yeah. 196 00:12:02,311.28012024 --> 00:12:03,227.77331752 personal with the Ooh. 197 00:12:03,287.77331752 --> 00:12:05,387.77331752 This, be this, be getting real personal. 198 00:12:05,417.77331752 --> 00:12:06,252.77331752 Yes, I am. 199 00:12:06,572.77331752 --> 00:12:07,292.77331752 I am intact. 200 00:12:07,381.28012024 --> 00:12:08,371.28012024 Yeah, me too. 201 00:12:10,63.77331752 --> 00:12:11,263.77331752 I still have my appendix. 202 00:12:12,283.77331752 --> 00:12:19,843.77331752 Yeah, we, we, we only need, uh, you know, nine more people to get a, get a one person who has head appendix out. 203 00:12:20,127.77331752 --> 00:12:30,40.2665148 Uh, James, why young people? Why do young people get it more? Do we know Yeah, so when you're younger, you have more, um, uh, immune cells. 204 00:12:30,70.2665148 --> 00:12:44,410.2665148 So in this area, in the small bowels, uh, like distal small bowels, so distal meaning the last, uh, areas of the small bowels, like small intestines, and then in the colon, the first part of the colon, as well as the appendix. 205 00:12:45,115.2665148 --> 00:12:48,265.2665148 It's really packed with a lot of the lymphoid tissue. 206 00:12:48,595.2665148 --> 00:12:53,525.2665148 So think of it like, uh, uh, a tonsil, for, for the gut. 207 00:12:53,765.2665148 --> 00:13:00,125.2665148 So when you're young, you have, you know, bigger tonsils and then they get smaller over the time. 208 00:13:00,485.2665148 --> 00:13:10,475.2665148 Similarly, you know, when you're younger, you have more lymphoid tissues in those areas of the gut, including the appendix when you're younger and then they get smaller. 209 00:13:10,805.2665148 --> 00:13:22,745.2665148 Those lymphoid tissues get bigger and bigger and inflamed, uh, activated, and that it closes the lumen of the appendix, and you're more likely to have appendicitis because of that. 210 00:13:23,492.77331752 --> 00:13:23,782.77331752 Cool. 211 00:13:24,129.2665148 --> 00:13:24,279.2665148 Yeah. 212 00:13:24,279.2665148 --> 00:13:25,34.2665148 So, you know. 213 00:13:25,834.2665148 --> 00:13:37,424.2665148 Brodie, um, I'd love to get your experience thoughts on, or, you know, hear about your experience of seeing these patients who may have appendicitis. 214 00:13:37,784.2665148 --> 00:13:45,109.2665148 You know, you see them, you know, first time these patients come through, healthcare is usually through emergency room because they're usually in severe pain. 215 00:13:45,249.2665148 --> 00:13:47,924.2665148 So tell us more about how they typically present. 216 00:13:49,128.2665148 --> 00:14:01,338.2665148 Yeah, so I mean the, the, the textbook example is really, it starts off with a, a vague, dull abdominal pain, maybe kind of cramping often around like the belly button type of area. 217 00:14:02,58.2665148 --> 00:14:07,98.2665148 that phase tends to last for sometimes hours, sometimes half a day, sometimes a day. 218 00:14:07,98.2665148 --> 00:14:13,38.2665148 And it's just kind of, it's like just, you know, it, is it gas? Is it bloating? It's not, it's not very clear and it's not that severe. 219 00:14:13,368.2665148 --> 00:14:24,738.2665148 Um, but then us usually with over a, again, a course of a, of, of half a day or so, um, it starts to become quite localized and it tends to be localized in what we just consider, like the right lower quadrant. 220 00:14:24,768.2665148 --> 00:14:29,178.2665148 Um, so kind of, you know, towards like, like the, the pelvic kind of type region anyways. 221 00:14:29,178.2665148 --> 00:14:30,618.2665148 And then it becomes really sharp. 222 00:14:30,618.2665148 --> 00:14:33,648.2665148 So now it's, now it's on the dull pain, it's very sharp. 223 00:14:33,768.2665148 --> 00:14:37,578.2665148 And then we start, we start to see other associated. 224 00:14:38,428.2665148 --> 00:14:39,28.2665148 Symptoms with it. 225 00:14:39,28.2665148 --> 00:14:40,468.2665148 So they get a loss of appetite. 226 00:14:40,498.2665148 --> 00:14:44,608.2665148 They might have nausea, they might have a fever or a low grade fever. 227 00:14:44,968.2665148 --> 00:14:53,368.2665148 And then the, the, the sharpness of that pain gets worse with things like laughing, coughing, uh, walking, if you're in a car when you go over a bump. 228 00:14:53,368.2665148 --> 00:14:57,178.2665148 Like all those things where you have a kind of more irritation of the abdominal wall. 229 00:14:57,418.2665148 --> 00:15:02,809.2665148 Um, that's, I would say the, the majority of people, or at least if you read a textbook for what Mm-hmm. 230 00:15:02,998.2665148 --> 00:15:05,8.2665148 I have had people that like come and look. 231 00:15:05,8.2665148 --> 00:15:06,748.2665148 They have kidney stones, there's appendicitis. 232 00:15:06,748.2665148 --> 00:15:10,978.2665148 It looks like they have a, they've got urinary symptoms and it looks like they're having a urinary tract infection. 233 00:15:10,978.2665148 --> 00:15:12,28.2665148 And it's appendicitis. 234 00:15:12,28.2665148 --> 00:15:12,838.2665148 Like it really is. 235 00:15:12,838.2665148 --> 00:15:17,234.2665148 Um, yeah, it, it, it, it can Yeah. 236 00:15:17,458.2665148 --> 00:15:18,854.2665148 sorts of different ways, which is Yeah. 237 00:15:18,884.2665148 --> 00:15:19,154.2665148 Co. 238 00:15:19,184.2665148 --> 00:15:21,44.2665148 Common theme in our podcast. 239 00:15:21,44.2665148 --> 00:15:25,234.2665148 You know, there are textbook, findings, and then there are what we see in real life. 240 00:15:25,294.2665148 --> 00:15:32,196.77331752 Right? I was gonna say, one of my, one of my preceptors said to me, the most common presentation is an uncommon presentation of a common problem. 241 00:15:32,766.77331752 --> 00:15:33,798.2665148 And I remember yeah. 242 00:15:33,876.77331752 --> 00:15:34,86.77331752 me. 243 00:15:35,723.2665148 --> 00:15:36,53.2665148 Yeah. 244 00:15:36,334.2665148 --> 00:15:36,934.2665148 That's a good one. 245 00:15:37,253.2665148 --> 00:15:41,243.2665148 it is way better if you're presenting in a nice, normal way, so we can all like, oh yeah. 246 00:15:41,243.2665148 --> 00:15:42,844.2665148 This is very Right away. 247 00:15:42,844.2665148 --> 00:15:43,234.2665148 Yeah. 248 00:15:43,324.2665148 --> 00:15:43,774.2665148 Yeah. 249 00:15:43,806.77331752 --> 00:15:44,436.77331752 Read. 250 00:15:44,783.2665148 --> 00:15:47,44.2665148 is when you are not presenting in that Mm-hmm. 251 00:15:47,123.2665148 --> 00:15:50,644.2665148 then it, it takes, it often does take people longer to get Right. 252 00:15:50,854.2665148 --> 00:15:52,204.2665148 There could be some delays. 253 00:15:52,626.77331752 --> 00:15:53,513.2665148 read a Yeah. 254 00:15:53,513.2665148 --> 00:15:55,163.2665148 So Read a is on you. 255 00:15:55,326.77331752 --> 00:15:59,854.2665148 present, uh, have to say these days, yeah. 256 00:16:00,546.77331752 --> 00:16:02,344.2665148 a I'm digressing a little bit. 257 00:16:02,404.2665148 --> 00:16:02,764.2665148 Yeah. 258 00:16:02,826.77331752 --> 00:16:21,168.2665148 a Uh, told me to stop blaming the patient, so, uh, I'm digressing a little bit, but you know, these days a lot of the patients have read these textbook outcomes, you know, whether through, you know, uh, a generative AI chat bot or whatever, right? So Mm-hmm. 259 00:16:21,274.2665148 --> 00:16:24,664.2665148 kind of like list off like, oh, I have this, I have this. 260 00:16:24,664.2665148 --> 00:16:26,464.2665148 I, I don't have this, I don't have this. 261 00:16:26,464.2665148 --> 00:16:26,644.2665148 Right. 262 00:16:26,644.2665148 --> 00:16:31,444.2665148 So it's, uh, they're, they're quite, uh, it's almost like they went to medical school these days. 263 00:16:31,853.2665148 --> 00:16:43,733.2665148 Yeah, I, and I will say for those that are presenting classically, it's like, you know, just kind of seeing them touching their belly and they kind of like, especially if they've done a bit of reading, we both kinda look at each other and they're kind like, probably appendicitis. 264 00:16:43,738.2665148 --> 00:16:44,548.2665148 And they're like, I know. 265 00:16:45,454.2665148 --> 00:16:45,634.2665148 Mm-hmm. 266 00:16:45,708.2665148 --> 00:16:49,463.2665148 know, so it is not a, it's not a big surprise for a lot of people too often. 267 00:16:49,553.2665148 --> 00:16:49,913.2665148 Yeah. 268 00:16:50,243.2665148 --> 00:16:50,453.2665148 Yeah. 269 00:16:51,634.2665148 --> 00:17:07,534.2665148 What might be interesting is, and James you're probably better, um, able to speak about this, but you know, again, there's really these two phases per pain that's the generalized ache around the belly button, and then it becomes just kind of focal pain right? Over top of where the appendix is in the right lower quadrant. 270 00:17:07,594.2665148 --> 00:17:11,670.2665148 Like what's, what's the reason behind that? Like, what's, what's happening with Yeah. 271 00:17:12,334.2665148 --> 00:17:12,364.2665148 I. 272 00:17:12,960.2665148 --> 00:17:13,80.2665148 Yeah. 273 00:17:13,80.2665148 --> 00:17:27,310.2665148 So we talked a bit about, innervation or the nervous system, uh, in previous episodes as well, but there are some, there are kind of two different, you know, in here, two different types of nervous systems. 274 00:17:27,310.2665148 --> 00:17:28,840.2665148 So one is the visceral nerve. 275 00:17:28,840.2665148 --> 00:17:32,140.2665148 So when I think about visceral nerve, I think about inner layers. 276 00:17:32,140.2665148 --> 00:17:37,0.2665148 So, you know, this is where, uh, the pain that is in the, the gut. 277 00:17:37,605.2665148 --> 00:17:54,465.2665148 Um, so there's an inflammation of the appendix and that inflammation will cause irritation in the visceral nerve, but the visceral nerve doesn't pinpoint exactly to where that area is, or we don't have the perception of where that exactly is location wide. 278 00:17:54,795.2665148 --> 00:18:00,75.2665148 So it does have that more dull general, you know, sensation of discomfort. 279 00:18:00,615.2665148 --> 00:18:09,725.2665148 But then when that inflamed appendix touches the peritoneum, and that is in the inner layer of the, our abdominal wall. 280 00:18:10,25.2665148 --> 00:18:18,665.2665148 So if we think of, you know, our abdomen as a room, the appendix is there and it's touching the ceiling of the, the room. 281 00:18:18,945.2665148 --> 00:18:20,505.2665148 And the nervous system. 282 00:18:20,505.2665148 --> 00:18:24,845.2665148 There has a, has a better under perception of the location of that area. 283 00:18:25,145.2665148 --> 00:18:25,565.2665148 Gotcha. 284 00:18:25,595.2665148 --> 00:18:33,755.2665148 And Hmm is what makes medicine a bit difficult in that it is so rare we have something that actually focuses on the area that it's happening. 285 00:18:34,25.2665148 --> 00:18:34,906.7597121 We have mm-hmm. 286 00:18:35,75.2665148 --> 00:18:44,195.2665148 pain where the diaphragm area can show up in the shoulder, or pain here can be very diffuse at first, and it does make diagnosis of these and many other issues hard. 287 00:18:44,345.2665148 --> 00:18:46,475.2665148 And that's just for patients and people listening. 288 00:18:46,685.2665148 --> 00:18:50,726.7597121 That's why doctors are often, we, we don't know because things Yeah. 289 00:18:51,95.2665148 --> 00:18:53,405.2665148 exactly where they are and how they're supposed to. 290 00:18:54,426.7597121 --> 00:18:54,756.7597121 Yeah. 291 00:18:54,906.7597121 --> 00:19:04,776.7597121 And the other thing that I want to pick up on what you said there, James, was, you know, it, the, the, that inflammation, that stretch of the appendix, you know, a lot of people will kind of say, I just thought it was gas. 292 00:19:04,812.7597121 --> 00:19:05,232.7597121 Mm-hmm. 293 00:19:05,346.7597121 --> 00:19:05,796.7597121 cramps. 294 00:19:06,36.7597121 --> 00:19:13,416.7597121 But it makes sense because that's exactly the nerves and stimulation they're having as, as when they have gas in their bowels, a bit dilated or de descend from that. 295 00:19:13,416.7597121 --> 00:19:19,712.7597121 So it does often feel like gas or like a bit of like, like a belly ache sort of Mm-hmm. 296 00:19:19,801.7597121 --> 00:19:24,557.7597121 it, it actually is the exact same nerves that are causing that The visceral sensations. 297 00:19:24,557.7597121 --> 00:19:24,677.7597121 Yeah. 298 00:19:25,535.2665148 --> 00:19:26,106.7597121 Do you yeah. 299 00:19:26,195.2665148 --> 00:19:36,611.4885418 you guys wanna talk for a minute about the kind of less common presentations or the atypical presentations about what we could see? It, I always think of the really young and the really old, Mm-hmm. 300 00:19:36,840.4885418 --> 00:19:40,770.4885418 of that is just the, I think the challenges and sometimes localizing so often with kids. 301 00:19:41,3.9953445 --> 00:19:42,123.9953445 what do you consider? Really old. 302 00:19:44,553.9953445 --> 00:19:45,43.9953445 Careful. 303 00:19:45,116.4885418 --> 00:19:45,656.4885418 Josh. 304 00:19:45,793.9953445 --> 00:19:46,283.9953445 Careful. 305 00:19:47,400.4885418 --> 00:19:49,110.4885418 older, older than me. 306 00:19:52,545.4885418 --> 00:19:56,520.4885418 I, I won't give an exact age to it because we know that everyone is, is different. 307 00:19:56,520.4885418 --> 00:19:59,980.4885418 But to that, I think the reason for both as kids and as adults. 308 00:20:00,250.4885418 --> 00:20:03,850.4885418 Older adults, it could be hard sometimes to, uh, to. 309 00:20:04,570.4885418 --> 00:20:06,280.4885418 Communicate where your pain is. 310 00:20:06,310.4885418 --> 00:20:07,270.4885418 'cause you're also like, this is you. 311 00:20:07,270.4885418 --> 00:20:08,860.4885418 I don't really know, just my belly hurts. 312 00:20:08,991.4885418 --> 00:20:09,411.4885418 Mm-hmm. 313 00:20:09,460.4885418 --> 00:20:12,760.4885418 might present with other symptoms then, right? They've got vomiting. 314 00:20:12,820.4885418 --> 00:20:17,230.4885418 Maybe it's, they're refusing to walk because it hurts to, to walk as we talked about beforehand. 315 00:20:17,230.4885418 --> 00:20:21,130.4885418 Especially when the lining of the abdomen and the peritoneum starts to get inflamed. 316 00:20:21,190.4885418 --> 00:20:23,440.4885418 They might just be more lethargic, kind of fevers. 317 00:20:23,710.4885418 --> 00:20:30,231.4885418 So you do have to look for it a little bit more in, in some of those populations, especially people that are, you know, unable to speak Mm-hmm. 318 00:20:30,850.4885418 --> 00:20:32,710.4885418 Um, I also think about pregnant patients. 319 00:20:32,710.4885418 --> 00:20:37,150.4885418 Again, you've, especially if you are quite far along in your pregnancy, that just displaces everything. 320 00:20:37,150.4885418 --> 00:20:43,60.4885418 So your uterus takes up a whole lot of, a lot of space there with your baby, and that pushes your appendix around. 321 00:20:43,60.4885418 --> 00:20:45,421.4885418 So sometimes like they present with back pain Mm-hmm. 322 00:20:45,520.4885418 --> 00:20:50,770.4885418 almost look more like a kidney stone, uh, type of presentation or like higher up in the back. 323 00:20:50,830.4885418 --> 00:20:53,260.4885418 Um, that's just because things get moved around when it's in there. 324 00:20:53,650.4885418 --> 00:21:18,321.4885418 Um, uh, yeah, those would be some of the, like I said, the, the populations I think of, Yeah, if you've got any well, the, just to kind of comment more on the kids with appendicitis, so when, when we rotated through Children's Hospital, we get a lot of these, you know, uh, consultations about appendicitis in kids, and you could almost like with high accuracy. 325 00:21:18,666.4885418 --> 00:21:26,286.4885418 Guess who actually has appendicitis and who doesn't, even before the imaging, just by how the kid is behaving. 326 00:21:26,706.4885418 --> 00:21:32,286.4885418 So the kid with the appendicitis will be like silent, like, you know, does not wanna move. 327 00:21:32,676.4885418 --> 00:21:42,966.4885418 Uh, you know, uh, whereas the kid who doesn't have appendicitis will be speaking to you and say, oh, like my tummy, you know, or like, oh, I think I, you know, blah, blah, blah. 328 00:21:42,966.4885418 --> 00:21:43,956.4885418 Or like walking around. 329 00:21:44,376.4885418 --> 00:21:48,756.4885418 Uh, that almost certainly, you know, does not, you know, we don't see appendicitis. 330 00:21:48,756.4885418 --> 00:21:53,896.4885418 Whereas the kid who, um, has appendicitis just like, doesn't want to move. 331 00:21:54,596.4885418 --> 00:21:59,666.4885418 And, and one of the big tests is like you shake the bed of the, the kid. 332 00:21:59,816.4885418 --> 00:22:02,936.4885418 I mean, we don't do that on purpose, but it's kind of early. 333 00:22:02,970.4885418 --> 00:22:03,270.4885418 shake. 334 00:22:03,990.4885418 --> 00:22:05,220.4885418 Don't shake the kid. 335 00:22:05,636.4885418 --> 00:22:06,476.4885418 Don't shake the kid. 336 00:22:06,690.4885418 --> 00:22:07,380.4885418 the children. 337 00:22:07,526.4885418 --> 00:22:07,766.4885418 Yeah. 338 00:22:08,468.9953445 --> 00:22:08,958.9953445 Come on. 339 00:22:09,630.4885418 --> 00:22:10,590.4885418 Shake the bed. 340 00:22:11,486.4885418 --> 00:22:17,426.4885418 Shake the bed or, or just tap the bed a little bit and then the kid will be like jumping out for, you know, with pain. 341 00:22:17,876.4885418 --> 00:22:25,526.4885418 Uh, so, you know, not to be mean to the, to the kid, but it's a good sign that this, whether this patient has appendicitis or not. 342 00:22:25,766.4885418 --> 00:22:26,156.4885418 Josh. 343 00:22:26,308.9953445 --> 00:22:29,878.9953445 you, and you just gave me a, uh, another parenting tip on how to keep my kid quiet. 344 00:22:30,238.9953445 --> 00:22:32,66.4885418 Uh, just Yeah. 345 00:22:32,66.4885418 --> 00:22:33,983.9953445 Just, app appendicitis. 346 00:22:35,936.4885418 --> 00:22:38,186.4885418 shake the bed with the appendicitis. 347 00:22:38,265.4885418 --> 00:22:44,25.4885418 that sign came from like a very clumsy surgeon who was just like constantly bumping into bed. 348 00:22:44,186.4885418 --> 00:22:44,576.4885418 Yeah. 349 00:22:44,715.4885418 --> 00:22:47,745.4885418 huh? This one probably has it like, yeah. 350 00:22:48,705.4885418 --> 00:22:52,335.4885418 It was like, who was the first person that like really went on to shake that bed? I don't know. 351 00:22:53,115.4885418 --> 00:22:54,885.4885418 Anyways, kudos to whoever it was. 352 00:22:55,176.4885418 --> 00:23:06,592.981739 Right, so maybe, maybe it's an unfair question, but when should people go to the emerge? Like what kind of symptoms would say go to the Emerge even if you don't know if it's appendicitis? Totally. 353 00:23:06,597.981739 --> 00:23:14,362.981739 And, and I think again, a, a common theme of the podcast is like, anytime you're worried, you should probably go and see someone because we have the benefits of blood work. 354 00:23:14,392.981739 --> 00:23:16,162.981739 And really for this, you need advanced imaging. 355 00:23:16,162.981739 --> 00:23:19,632.981739 So it's usually an ultrasound, sometimes a CT scan, to figure this out. 356 00:23:19,632.981739 --> 00:23:24,402.981739 So for me, like worsening pain, abdominal pain and fever is always a red flag. 357 00:23:24,632.981739 --> 00:23:29,702.981739 You know, a pain that's, that has signs of that, like irritation of the peritoneum. 358 00:23:29,702.981739 --> 00:23:32,247.981739 This is pain with coughing, with walking with movement. 359 00:23:32,707.981739 --> 00:23:35,462.981739 Um, you know, those are all things that I get really worried about. 360 00:23:35,762.981739 --> 00:23:40,408.981739 And it's important because, you know, for appendicitis, like timing matters, right? Like Mm-hmm. 361 00:23:40,712.981739 --> 00:23:47,12.981739 you can get diagnosis, sooner you can get treatment, it really does put you at risk for things if you, uh, have delays to your care. 362 00:23:47,293.981739 --> 00:23:47,413.981739 Mm-hmm. 363 00:23:47,582.981739 --> 00:23:49,772.981739 and James, I'm sure you'll, you'll kind of dive into that. 364 00:23:49,777.981739 --> 00:23:49,887.981739 Um. 365 00:23:50,282.981739 --> 00:23:52,573.981739 So that's a good time to, Yeah. 366 00:23:52,592.981739 --> 00:23:54,572.981739 What, um, what's actually happening. 367 00:23:54,572.981739 --> 00:23:57,902.981739 So like, Yeah, in appendicitis and Yeah. 368 00:23:58,112.981739 --> 00:24:02,833.981739 What are you seeing? So appendix is a, is like a cul-de-sac. 369 00:24:02,863.981739 --> 00:24:06,643.981739 It's a blind and uh, uh, pouch. 370 00:24:06,643.981739 --> 00:24:15,43.981739 So I actually, when I speak to patients about it, off of the cecum, which is a first part of the colon, there's a little pinky. 371 00:24:15,373.981739 --> 00:24:17,933.981739 Finger that's just projecting out of that cecum. 372 00:24:17,953.981739 --> 00:24:19,663.981739 So that is the appendix. 373 00:24:20,533.981739 --> 00:24:21,673.981739 Yeah, it's a cute little thing. 374 00:24:21,787.981739 --> 00:24:26,443.981739 of Uh, most of the times when it's not angry, um, it's narrow. 375 00:24:26,443.981739 --> 00:24:28,843.981739 It's, uh, blinded the pouch. 376 00:24:29,173.981739 --> 00:24:49,513.981739 Uh, and as we talked about before, whether if you're a kid, you know, you have a lot of lymphoid tissue and that lumen lumen is the in inside, you know, uh, area, uh, is narrowed even further because of the thickened, uh, lymphoid tissue or there's a poop ball. 377 00:24:50,128.981739 --> 00:24:54,478.981739 It's called append lift, but really it's a poopoo ball that just gets lodged. 378 00:24:54,568.981739 --> 00:25:04,48.981739 Poopoo ball just gets lodged in there, in that opening, and it just blocks the fluid that's produced in the appendix from draining. 379 00:25:04,348.981739 --> 00:25:13,258.981739 And what occurs when there's blockage, there's distension, of the appendix, uh, and there's a bacterial overgrowth. 380 00:25:13,678.981739 --> 00:25:30,748.981739 Uh, and as the appendix becomes more bloated and bloated, the blood supply to that gets stretched and it becomes ischemic or starve of oxygen and blood and it, the tissue dies off and becomes necrotic and then it creates hole. 381 00:25:31,348.981739 --> 00:25:41,818.981739 Uh, and that hole will exude all the bacterial overgrowth or poop and that makes you, uh, unwell and septic or, you know, feeling quite sick. 382 00:25:42,58.981739 --> 00:25:44,518.981739 So that's kind of the effect of what's happening. 383 00:25:44,931.4885418 --> 00:25:50,608.981739 and where, where does all that stuff go? Once it starts leaking out? Just to the abdominal cavity. 384 00:25:50,758.981739 --> 00:25:57,298.981739 Uh, but it, it's not that it will just freely go everywhere, uh, often not. 385 00:25:57,568.981739 --> 00:26:05,848.981739 Um, but it forms sort of the abscess, so kind of the purulent pus and it kind of gets walled off. 386 00:26:06,298.981739 --> 00:26:10,618.981739 Um, and, you know, body does amazing thing to stop this infection. 387 00:26:10,618.981739 --> 00:26:24,878.981739 So it just walls off everything with all the neutrophils, you know, all the, all of our immune police cells, uh, will kind of go there and try to wall that off, but that does become, source of infection and source of sickness. 388 00:26:24,998.981739 --> 00:26:26,708.981739 And that's, that's what happens. 389 00:26:26,891.4885418 --> 00:26:31,481.4885418 There are so many good visuals for upcoming, uh, live action comic. 390 00:26:31,751.4885418 --> 00:26:32,798.981739 Yeah, That's right. 391 00:26:32,831.4885418 --> 00:26:33,728.981739 yeah, Hey, bro. 392 00:26:33,728.981739 --> 00:26:37,133.981739 You talked a bit about the timing, uh, so maybe, you know Yeah. 393 00:26:39,642.981739 --> 00:26:45,743.981739 Yeah, I, I mean, um, with that, you know, so you talked about the risk for, Perforation. 394 00:26:45,813.981739 --> 00:26:46,103.981739 Yeah. 395 00:26:46,152.981739 --> 00:26:49,182.981739 you get this increasing swelling and, and stuff in there. 396 00:26:49,272.981739 --> 00:26:54,553.981739 Like what, what are the timelines that you see? Like, you know how someone comes in, Uhhuh. 397 00:26:54,672.981739 --> 00:27:14,648.981739 appendicitis, we need to do some, some workup and stuff, but like, what, what does that risk of, Yeah, so, look so because the process is somehow sequential, uh, that there's blockage, obstruction and then distension, and then necrosis and then whole, the longer you wait, the more likely you're gonna have perforation. 398 00:27:14,708.981739 --> 00:27:22,508.981739 The perforation is bit of a, it's a before and after perforation, in a way, in append the world of appendicitis, and we'll talk about that a little bit later. 399 00:27:22,508.981739 --> 00:27:28,148.981739 But before perforation treatment is simpler, after perforation treatment is more complex. 400 00:27:28,478.981739 --> 00:27:29,712.981739 So, Fair. 401 00:27:29,948.981739 --> 00:27:34,28.981739 uh, so the risk of perforation is about, or less than 10%. 402 00:27:34,628.981739 --> 00:27:46,598.981739 If, um, within 24 hours of the start of the symptom, that risk of perforation goes above 40% after 48 to 72 hours of symptoms start. 403 00:27:46,838.981739 --> 00:27:54,368.981739 So the longer you wait, uh, the higher chance of perforation and the worse, uh, consequences of this disease. 404 00:27:56,231.4885418 --> 00:27:56,801.4885418 Wild. 405 00:27:57,581.4885418 --> 00:28:04,871.4885418 Um, now, uh, I wanna, I wanna sideline to a question that we've all had and we've all asked, then we will get into diagnosis and all that after. 406 00:28:04,871.4885418 --> 00:28:05,813.981739 But Mm-hmm. 407 00:28:05,981.4885418 --> 00:28:06,281.4885418 one. 408 00:28:06,821.4885418 --> 00:28:14,21.4885418 Why the hell do we have an appendix? does it do and do we need it? And I think things have changed over the years. 409 00:28:14,21.4885418 --> 00:28:16,691.4885418 'cause I remember med school, it was always like, we don't even need the appendix. 410 00:28:16,691.4885418 --> 00:28:18,533.981739 Why don't we just take it out on everybody? Yeah. 411 00:28:18,653.981739 --> 00:28:20,693.981739 That's why they called it appendix. 412 00:28:21,161.4885418 --> 00:28:21,461.4885418 yeah. 413 00:28:21,671.4885418 --> 00:28:22,301.4885418 There you go. 414 00:28:23,243.981739 --> 00:28:23,513.981739 Yeah. 415 00:28:23,513.981739 --> 00:28:30,983.981739 So, um, I mean, I've, uh, you know, as you know, we, we went through medical training together. 416 00:28:30,983.981739 --> 00:28:43,643.981739 You know, we learned that this is just useless, uh, vestige from, for some reason it kind of stayed, it kind of fought off the Darwinian evolution, uh, to stay with us. 417 00:28:43,883.981739 --> 00:28:44,123.981739 Um. 418 00:28:45,278.981739 --> 00:28:48,968.981739 And they, you know, Darwin himself actually proposed that. 419 00:28:48,968.981739 --> 00:28:57,908.981739 It's a kind of the shrunken remnant of a, uh, a larger cecum that sometimes we see in cattles or, you know, Harbor VREs. 420 00:28:58,121.4885418 --> 00:29:03,122.981739 Oh, Um, Are we about to disprove Darwin? Are we gonna be even Oh no. 421 00:29:03,638.981739 --> 00:29:08,48.981739 oh, well, well there's the, this is where the controversy comes in. 422 00:29:08,796.4885418 --> 00:29:09,86.4885418 Okay. 423 00:29:09,176.4885418 --> 00:29:10,88.981739 Sorry to Yeah. 424 00:29:11,528.981739 --> 00:29:27,818.981739 Uh, but I think there's a, a new view, I mean, hasn't been completely proven, but there's some emerging evidence that, you know, and we talked about this lymphoid tissue, uh, that, you know, appendix, when you look at it microscopically has a lot of lymphoid tissue. 425 00:29:28,178.981739 --> 00:29:43,428.981739 Uh, and this is part of this, that gut associated lymphoid tissue, uh, area where it plays a big immune roles, uh, and certainly, uh, uh, it has a role in, in microbiome reservoir. 426 00:29:43,428.981739 --> 00:29:45,468.981739 It has a role in mucosal defense. 427 00:29:45,468.981739 --> 00:29:48,978.981739 So mucosa is the inner lining of the gut. 428 00:29:49,308.981739 --> 00:30:07,998.981739 So, you know, that's where, um, our gut sees or interacts with outer environment, right? So whatever you eat, consume that, you know, bacteria that you consume through mouth or you know, through anus, uh, that comes in contact with the inner lining of the gut. 429 00:30:08,508.981739 --> 00:30:20,548.981739 And we believe that the reason we don't get sick all the time is because there, is this, you know, immune police, that surveillance has a surveillance system, uh, of the gut. 430 00:30:20,548.981739 --> 00:30:23,608.981739 And, you know, appendix is one part of this. 431 00:30:23,818.981739 --> 00:30:28,558.981739 Uh, it may not be the, it's not the key part of it, but it plays a role. 432 00:30:28,948.981739 --> 00:30:32,218.981739 Uh, and that's why uh, when we look at. 433 00:30:32,788.981739 --> 00:30:36,928.981739 Anatomy of over 500 mammalian species. 434 00:30:36,958.981739 --> 00:30:50,848.981739 That appendix continues to kind of stay, uh, continues to be there for a lot of, a lot of the, the species, uh, even though, um, you know, once they appear on, on the species. 435 00:30:50,998.981739 --> 00:30:58,198.981739 So it does have maybe some survival benefit, uh, to have the appendix, although it's not true for humans now. 436 00:30:59,192.981739 --> 00:31:05,792.981739 it may not be like the, the leftover remnant, but actually a survival benefit as opposed to slowly getting rid of it over time. 437 00:31:05,848.981739 --> 00:31:19,871.4885418 Yeah, I mean, it, it may be, uh, a leftover remnant, but it just plays a, a, a, you know, it plays, um, maybe not, you know, potentially survival benefit, but it's not a disadvantage, Mm. 438 00:31:20,308.981739 --> 00:31:21,208.981739 to having this. 439 00:31:21,238.981739 --> 00:31:21,538.981739 Right. 440 00:31:21,538.981739 --> 00:31:26,776.4885418 So I think, um, maybe not wrong, but there might be, yeah, Yeah. 441 00:31:26,878.981739 --> 00:31:27,178.981739 more. 442 00:31:27,178.981739 --> 00:31:27,478.981739 Yeah. 443 00:31:27,976.4885418 --> 00:31:29,57.981739 and the appendix that. 444 00:31:29,116.4885418 --> 00:31:30,76.4885418 better PR guy. 445 00:31:30,176.4885418 --> 00:31:31,582.981739 Um, guys, I Oh man. 446 00:31:31,616.4885418 --> 00:31:40,3.981739 uh, controversial theory in that the appendix and the gallbladder are still around, uh, because general surgeons need jobs and without them Yeah. 447 00:31:40,8.981739 --> 00:31:40,238.981739 Yeah. 448 00:31:40,856.4885418 --> 00:31:42,866.4885418 I know it's controversial, but I think it's correct. 449 00:31:43,273.981739 --> 00:31:45,282.981739 yeah, That's you know, state. 450 00:31:45,282.981739 --> 00:31:49,688.981739 Uh, human evolution, you know, centers around surgeons. 451 00:31:51,67.981739 --> 00:31:51,357.981739 yeah. 452 00:31:53,682.981739 --> 00:31:58,208.981739 It's the god that James is, he makes sure that he always has a work lined Yeah. 453 00:31:58,208.981739 --> 00:32:00,158.981739 So it's all about us. 454 00:32:00,192.981739 --> 00:32:06,282.981739 maybe to maybe just to, to confirm what I think you were kind of saying gently there before. 455 00:32:06,402.981739 --> 00:32:12,878.981739 So the appendix might play a role in some of these things, but can also have their appendix taken out Yes. 456 00:32:12,942.981739 --> 00:32:16,842.981739 appendix taken out for a Yes, and live perfectly fine. 457 00:32:16,868.981739 --> 00:32:17,378.981739 that's right. 458 00:32:17,438.981739 --> 00:32:20,618.981739 Yeah, real big changes to, at the end of the day that's right. 459 00:32:20,768.981739 --> 00:32:21,248.981739 Yeah. 460 00:32:21,488.981739 --> 00:32:22,688.981739 I think that's the important thing. 461 00:32:22,991.4885418 --> 00:32:24,731.4885418 there are other things that are doing the same job. 462 00:32:24,881.4885418 --> 00:32:25,901.4885418 There's some redundancy. 463 00:32:25,958.981739 --> 00:32:26,228.981739 right. 464 00:32:26,258.981739 --> 00:32:27,578.981739 Yeah, so, exactly. 465 00:32:27,578.981739 --> 00:32:28,298.981739 That's exactly it. 466 00:32:28,361.4885418 --> 00:32:28,601.4885418 Cool. 467 00:32:29,591.4885418 --> 00:32:30,971.4885418 let's get into the cool stuff. 468 00:32:31,691.4885418 --> 00:32:34,181.4885418 come into the emerge, you think you might have appendicitis. 469 00:32:34,571.4885418 --> 00:32:35,567.981739 How do we Mm-hmm. 470 00:32:35,591.4885418 --> 00:32:37,151.4885418 it? Because that's the, that's the fun stuff. 471 00:32:37,151.4885418 --> 00:32:38,231.4885418 That's what patients wanna know. 472 00:32:38,981.4885418 --> 00:32:40,242.981739 are you guys doing? Yeah. 473 00:32:40,842.981739 --> 00:32:41,52.981739 Yeah. 474 00:32:41,52.981739 --> 00:32:46,152.981739 And there's all sorts of different, like physical exam findings and you look at vital signs and they have a fever. 475 00:32:46,152.981739 --> 00:32:58,302.981739 Is the heart rate elevated and there's different scores that have been developed to predict your likelihood? Um, that being said, I'll be honest, for me, I work in a place that I have ultrasound imaging and CT scan imaging available. 476 00:32:58,302.981739 --> 00:32:59,772.981739 And I think that the. 477 00:33:00,747.981739 --> 00:33:04,33.981739 The, the potential of this is missed for badness Mm-hmm. 478 00:33:04,47.981739 --> 00:33:04,557.981739 high. 479 00:33:04,613.981739 --> 00:33:05,33.981739 Mm-hmm. 480 00:33:05,337.981739 --> 00:33:14,517.981739 if I have anyone that has any sort of persistent reproducible pain, when I press down on the right lower quadrant, I'm moving on to imaging. 481 00:33:14,577.981739 --> 00:33:19,977.981739 Um, yes, you can look for things like in elevation in their white blood cell count on, on blood work, which is again, more. 482 00:33:20,847.981739 --> 00:33:23,683.981739 Systemic signs for infection and inflammation, Mm-hmm. 483 00:33:23,697.981739 --> 00:33:24,687.981739 that's not perfect. 484 00:33:24,747.981739 --> 00:33:26,397.981739 There's no physical exam finding. 485 00:33:26,397.981739 --> 00:33:27,57.981739 That's perfect. 486 00:33:27,57.981739 --> 00:33:31,347.981739 And it's a, it's a common, a common thing that presents in, in a bunch of uncommon ways. 487 00:33:31,347.981739 --> 00:33:38,253.981739 So, um, I think a lot of the time, anyone that, that has reproducible, tenderness down there, Yeah. 488 00:33:38,367.981739 --> 00:33:38,877.981739 imaging. 489 00:33:39,43.981739 --> 00:33:39,333.981739 Yeah. 490 00:33:39,957.981739 --> 00:33:45,27.981739 and then for us, the imaging decisions, um, there, there's kind of the, the pros and cons to each. 491 00:33:45,27.981739 --> 00:33:46,993.981739 There's ultrasound and CT scan, Mm-hmm. 492 00:33:47,397.981739 --> 00:33:53,187.981739 is nice because it, um, it's, um, there's no radiation I guess is really the, the biggest key. 493 00:33:53,187.981739 --> 00:34:03,627.981739 So especially with people that are younger, um, you know, it, it avoids that radiation, that longitudinal, maybe increased cancer risk or things like that, that you might have with a bunch of CT scans over your life. 494 00:34:03,783.981739 --> 00:34:04,203.981739 Mm-hmm. 495 00:34:04,617.981739 --> 00:34:05,512.981739 to ultrasound is that. 496 00:34:06,512.981739 --> 00:34:09,2.981739 It, it doesn't always show the appendix, so it's not uncommon. 497 00:34:09,2.981739 --> 00:34:11,72.981739 Sometimes we'll do the ultrasound first. 498 00:34:11,72.981739 --> 00:34:14,762.981739 You can't find the appendix, and then we have to go on to doing a CT scan afterwards. 499 00:34:14,822.981739 --> 00:34:19,562.981739 Um, a CT scan, you know, um, is a bit more expensive from a cost perspective. 500 00:34:19,622.981739 --> 00:34:25,562.981739 Um, there's some radiation exposure that happens, but usually has a pretty good chance for picking up appendicitis. 501 00:34:25,567.981739 --> 00:34:33,268.981739 Um, so that's, that's typically my go-to ultrasound If, um, if they're young, uh, not a lot of other risk factors or things Yeah. 502 00:34:33,542.981739 --> 00:34:53,348.981739 about in my differential, um, but if they are of an older age, I'm worried about maybe things that might be more like a cancer or bowel obstruction or other things like that, then I might move on to doing, um, a CT scan first, You guys may or may not know this, but, uh, we all work in kind of resource, um, rich Rich. 503 00:34:53,546.4885418 --> 00:34:54,68.981739 We Yeah. 504 00:34:54,386.4885418 --> 00:34:55,622.981739 we have the if that's true. 505 00:34:55,706.4885418 --> 00:34:56,276.4885418 we want. 506 00:34:56,696.4885418 --> 00:35:03,536.4885418 Um, do you know if you're in a rural area, you don't have imaging, you kind of present, maybe, maybe not appendicitis. 507 00:35:04,136.4885418 --> 00:35:12,908.981739 James, do you know, like, are, are they going to surgery pretty early? Are they shipping to a bigger center? What's happening? Yeah, so, um. 508 00:35:12,908.981739 --> 00:35:21,878.981739 So I, I think for that precise reason, and because, you know, the, the CT scan wasn't as widely available back in the days. 509 00:35:22,328.981739 --> 00:35:26,18.981739 You know, we really depended on these kind of scores. 510 00:35:26,18.981739 --> 00:35:31,538.981739 One that we learned about a lot and still some to some degree use in practice. 511 00:35:31,538.981739 --> 00:35:33,98.981739 It's called the Alvarado score. 512 00:35:33,458.981739 --> 00:35:47,48.981739 Uh, so if there are few symptoms, like, you know, the pain pattern that we talked about, or if really the patient doesn't want to eat even though they're hungry, uh, if they're having nausea, vomiting, or fever, and that. 513 00:35:47,513.981739 --> 00:35:50,153.981739 Tenderness in the right lower quadrant, right lower quadrant. 514 00:35:50,363.981739 --> 00:36:04,733.981739 If you draw an imaginary line between your belly button and the bony prominence of your hip on the right side, and that kind of, uh, midway or a little bit more to the bony prominence, that's where we are talking about the right lower quadrant or McBurney's point. 515 00:36:05,153.981739 --> 00:36:09,563.981739 Uh, and the physical examination we do are centered around that area. 516 00:36:09,563.981739 --> 00:36:19,913.981739 So if there's a tenderness, we call it peritonitis, where it's quite, you know, tender and the patient when I press will wanna punch me, you know, those are kind of the signs. 517 00:36:19,943.981739 --> 00:36:36,113.981739 Uh, not because of what I've said, or, uh, you know, those are kinda the signs that Yeah, you know, that will put, you know, that will tell us that there's a high likelihood of appendicitis even before ultrasound, uh, and ct. 518 00:36:36,953.981739 --> 00:36:44,183.981739 The other kind of factor is that if it's a young otherwise healthy man and you have all these. 519 00:36:44,858.981739 --> 00:37:02,378.981739 History examination finding, let's say in low resource or medium resource rich, uh, resource setting that does not, or if the patient does not want to pay for ultrasound or a CT scan, I think that's a high likelihood that this is the appendicitis just given the, the prevalence that we know. 520 00:37:02,708.981739 --> 00:37:27,488.981739 Versus if it's a female of certain age, we do have to make sure it's not other things like, you know, ectopic pregnancy or, you know, or any ovarian, cysts, torsion or things like that, that, you know, there are a lot of gynecologic, there are a lot of other things that could present similarly, uh, that if we missed, that would be detrimental. 521 00:37:27,488.981739 --> 00:37:29,88.981739 So I would. 522 00:37:30,53.981739 --> 00:37:43,493.981739 You know, I would be more careful if I'm in a rural area with LCT scan and ultrasound wasn't really working of going straight to the operating room for female, uh, versus for men. 523 00:37:43,493.981739 --> 00:37:46,733.981739 I think there's a higher chance that this is appendicitis. 524 00:37:47,486.4885418 --> 00:37:47,846.4885418 Gotcha. 525 00:37:48,157.981739 --> 00:37:50,996.4885418 Yeah, part of our practices that we don't know as much about. 526 00:37:50,996.4885418 --> 00:37:54,83.981739 'cause again, Yeah, we're, we have whatever we yeah. 527 00:37:54,83.981739 --> 00:37:58,13.981739 We always have CT scan, ultrasound, everything. 528 00:37:58,731.4885418 --> 00:37:58,951.4885418 Yep. 529 00:37:59,107.981739 --> 00:37:59,397.981739 yeah. 530 00:38:00,432.981739 --> 00:38:04,272.981739 So, James, with that, let's say someone is confirmed with appendicitis. 531 00:38:04,272.981739 --> 00:38:06,192.981739 They either have an ultrasound or CT scan. 532 00:38:06,222.981739 --> 00:38:10,782.981739 What's, uh, you talked about some different, you know, uh, to take the operating room or not. 533 00:38:10,812.981739 --> 00:38:16,812.981739 Like, what's, what are you doing? What are your options? Once, once you've been told, Hey, you've got appendicitis. 534 00:38:17,663.981739 --> 00:38:18,953.981739 there are a few ways to think about it. 535 00:38:18,953.981739 --> 00:38:22,403.981739 So, uh, first of all, the treatment option one is surgery. 536 00:38:22,583.981739 --> 00:38:24,203.981739 I think that's the mainstay. 537 00:38:24,773.981739 --> 00:38:25,973.981739 I'm gonna state it up front. 538 00:38:26,216.4885418 --> 00:38:27,266.4885418 you always say that. 539 00:38:27,266.4885418 --> 00:38:27,836.4885418 Okay. 540 00:38:29,6.4885418 --> 00:38:29,726.4885418 Come on. 541 00:38:29,802.981739 --> 00:38:31,657.981739 Got a Well, You can cut something. 542 00:38:31,913.981739 --> 00:38:35,693.981739 well, if you listen to our hemorrhoid episode, I said It's no surgery. 543 00:38:35,786.4885418 --> 00:38:36,832.981739 You're you're absolutely Oh, fair. 544 00:38:37,73.981739 --> 00:38:38,183.981739 I said the rubber band. 545 00:38:38,371.4885418 --> 00:38:38,591.4885418 Yep. 546 00:38:39,471.4885418 --> 00:38:40,791.4885418 I stand corrected appropriately. 547 00:38:41,783.981739 --> 00:38:42,113.981739 Yeah. 548 00:38:42,143.981739 --> 00:38:43,133.981739 So surgery. 549 00:38:43,598.981739 --> 00:38:44,918.981739 Is the mainstay. 550 00:38:44,978.981739 --> 00:38:47,708.981739 So surgery these days mean minimally invasive. 551 00:38:48,68.981739 --> 00:38:51,938.981739 If we do it laparoscopically, it usually involves three little incisions. 552 00:38:52,328.981739 --> 00:39:00,908.981739 Now there are more and more minimally invasive techniques like single port, uh, appendectomy, where you do it all within one port. 553 00:39:00,908.981739 --> 00:39:03,158.981739 So one just small incision. 554 00:39:03,608.981739 --> 00:39:07,88.981739 Uh, either way they're all very small, uh, incisions. 555 00:39:07,958.981739 --> 00:39:14,348.981739 Uh, it does take general anesthesia, uh, but it takes about, you know, less than an hour to do the operation. 556 00:39:14,738.981739 --> 00:39:18,8.981739 Um, really quite safe operation. 557 00:39:18,8.981739 --> 00:39:20,198.981739 Overall, very low complication rates. 558 00:39:20,198.981739 --> 00:39:22,988.981739 And the benefit is it's one and done. 559 00:39:23,168.981739 --> 00:39:27,698.981739 You know, appendix is not gonna grow again just because you pruned it. 560 00:39:29,648.981739 --> 00:39:30,987.981739 It's sounds like a challenge. 561 00:39:32,438.981739 --> 00:39:34,368.981739 so, I mean, unless like they. 562 00:39:34,407.981739 --> 00:39:35,233.981739 over Yeah. 563 00:39:35,293.981739 --> 00:39:40,341.4885418 Uh, unless they left like a huge appendic stump left, Mm-hmm. 564 00:39:40,363.981739 --> 00:39:45,343.981739 maybe you could have stump appendicitis and we've, you know, seen reports of that. 565 00:39:45,403.981739 --> 00:39:52,603.981739 Um, but if the surgeons had had taken out the appendix appropriately, then there's no chance of this coming back. 566 00:39:52,603.981739 --> 00:39:54,343.981739 So those are the advantages. 567 00:39:54,673.981739 --> 00:39:59,833.981739 And often patients stay in the hospital for one day or less than one day if they're well and go home. 568 00:39:59,833.981739 --> 00:40:00,133.981739 So. 569 00:40:00,818.981739 --> 00:40:08,708.981739 You know, you could come into the emergency room at night and get the surgery in the morning and go home at the next night. 570 00:40:08,738.981739 --> 00:40:24,458.981739 So that's kind of the, the, the way, the second, and this has always been around as an alternative way to treatment, and there's been a lot of, uh, uh, randomized controlled trials to compare to surgery is using antibiotics. 571 00:40:24,458.981739 --> 00:40:37,538.981739 So you start, I mean, the patients who are diagnosed with, uh, appendicitis will all get IV antibiotics to start the treatment, but in this cohort, they're advocating for. 572 00:40:38,33.981739 --> 00:40:40,703.981739 Just antibiotics only as a treatment. 573 00:40:41,183.981739 --> 00:40:49,553.981739 Uh, so instead of having surgery, uh, and this we reserve for patients who have something called the uncomplicated appendicitis. 574 00:40:49,763.981739 --> 00:40:53,453.981739 So there's uncomplicated appendicitis versus complicated appendicitis. 575 00:40:53,533.981739 --> 00:41:07,393.981739 Complicated appendicitis is appendicitis that has perforated or that has abscess, that has fluid around the, uh, uncomplicated are those ones who have inflammation dilation, but none of those perforations or anything like that. 576 00:41:07,903.981739 --> 00:41:16,123.981739 And another key factor that we use to select for patients for antibiotics only is that they need to have that. 577 00:41:16,663.981739 --> 00:41:19,573.981739 They, they should not have that football that I talked about. 578 00:41:19,573.981739 --> 00:41:24,463.981739 So no, appendic if you have football, you know, we recommend surgery. 579 00:41:24,553.981739 --> 00:41:27,673.981739 No football, Yeah, you have a, yeah. 580 00:41:27,763.981739 --> 00:41:28,273.981739 Yeah. 581 00:41:28,273.981739 --> 00:41:33,283.981739 So football is a, is a really important deciding factor, uh, in this. 582 00:41:33,493.981739 --> 00:41:50,293.981739 So there's antibiotics only approach where if the patient and the providers have decided that this is what they want to do, that instead of having an operation, they'll get IV antibiotics and then transition to oral antibiotics for usually about seven to 10 days. 583 00:41:50,503.981739 --> 00:41:54,523.981739 What, um, what percentage of those people will go on to have an appendectomy? I. 584 00:41:54,566.4749363 --> 00:41:55,256.4749363 Yeah. 585 00:41:55,280.4749363 --> 00:41:55,700.4749363 Mm-hmm. 586 00:41:56,36.4749363 --> 00:42:01,856.4749363 that's the important downside of, uh, antibiotics. 587 00:42:02,196.4749363 --> 00:42:06,546.4749363 There's one big trial that was published in New England, journal of Medicine called CODA Trial. 588 00:42:06,856.4749363 --> 00:42:16,386.4749363 It involved 1500 uh, patients and about 70% avoided surgery at 90 days, like since the initiation. 589 00:42:16,386.4749363 --> 00:42:22,776.4749363 So that means like three out of 10 ended up having surgery, uh, in that time period. 590 00:42:23,16.4749363 --> 00:42:27,498.981739 And most of them within acutely, within 30 days Gotcha. 591 00:42:27,646.4749363 --> 00:42:28,816.4749363 while on the antibiotic treatment. 592 00:42:28,836.4749363 --> 00:42:46,566.4749363 So you do have that failure of the treatment that leads to another treatment to take over, and that to me is the reason I advocate mostly for patients who are healthy enough to have surgery, to have surgery because. 593 00:42:47,331.4749363 --> 00:42:56,901.4749363 You know, it's not the, while you are on this treatment with antibiotics, you're staying in the hospital for a few more days than if you are to have surgery. 594 00:42:57,531.4749363 --> 00:43:06,741.4749363 Uh, and you have to kind of live in a fear that this may reoccur and you have to come back to the emergency room if you're home already. 595 00:43:07,101.4749363 --> 00:43:12,141.4749363 Uh, and you, you worry whether there'll be a perforation or not, which will be more consequential. 596 00:43:12,561.4749363 --> 00:43:31,431.4749363 So, so these kind of, and, and, and then there are meta-analysis which are just pooling of like more all of the randomized control trial data that have demonstrated that, uh, you know, that 30% failure or transition to surgery still holds. 597 00:43:31,431.4749363 --> 00:43:35,241.4749363 It's about 20%, uh, in a lot of these studies when you pull them together. 598 00:43:35,631.4749363 --> 00:43:43,671.4749363 So this is a real, you know, um, percentage of people who do end up need another treatment. 599 00:43:44,183.981739 --> 00:43:44,513.981739 Mm. 600 00:43:45,263.981739 --> 00:43:48,36.4749363 And 30, IE surgery? 30% is Yeah. 601 00:43:48,53.981739 --> 00:43:50,46.4749363 medical world, Yes. 602 00:43:50,260.4749363 --> 00:43:56,466.4749363 Yeah, so Like if it only, if your treatment only works 70%, like seven outta 10 times, that's not a great treatment. 603 00:43:56,828.981739 --> 00:43:57,68.981739 Yeah. 604 00:43:57,275.4749363 --> 00:43:57,565.4749363 yeah. 605 00:43:57,818.981739 --> 00:43:58,28.981739 Yeah. 606 00:43:58,990.4749363 --> 00:44:02,256.4749363 Unless you're a hitter at baseball, then you're like Yeah. 607 00:44:02,286.4749363 --> 00:44:04,536.4749363 You're like best of the league. 608 00:44:04,536.4749363 --> 00:44:04,956.4749363 Yeah. 609 00:44:04,988.981739 --> 00:44:05,438.981739 Yeah. 610 00:44:05,678.981739 --> 00:44:11,468.981739 Also, when you, uh, when you said poop ball, I was literally just about to eat my daughter's Halloween smarties. 611 00:44:11,918.981739 --> 00:44:13,28.981739 And you said poopoo ball. 612 00:44:13,28.981739 --> 00:44:16,658.981739 And I just put it down 'cause it's, uh, it's, it's too close. 613 00:44:17,16.4749363 --> 00:44:18,696.4749363 You don't want to have appendicitis. 614 00:44:21,250.4749363 --> 00:44:23,410.4749363 so it sounds like surgeons are still safe. 615 00:44:23,410.4749363 --> 00:44:29,766.4749363 You're not being totally out of a job for IV antibiotics for, uh, for appendicitis Yeah. 616 00:44:29,766.4749363 --> 00:44:33,516.4749363 Uh, yet, unless they come up with a new IV antibodies. 617 00:44:33,576.4749363 --> 00:44:38,606.4749363 No, I, I, I think, surgery is really the mainstay for this disease. 618 00:44:40,196.4749363 --> 00:44:46,556.4749363 Um, especially as surgery becomes more minimally invasive, which they have become. 619 00:44:46,616.4749363 --> 00:44:46,946.4749363 Right. 620 00:44:47,306.4749363 --> 00:44:54,236.4749363 So, you know, back in the days when it was open surgery, you know, you need to stay in the hospital for like five, six days. 621 00:44:54,356.4749363 --> 00:45:06,86.4749363 I mean, it's not that long usually, but let's say three to four days after surgery and the full recovery is even longer versus, you know, you have 70% of success being completely off of this. 622 00:45:06,506.4749363 --> 00:45:10,346.4749363 Uh, with just antibiotics only stay in the hospital for two to three days. 623 00:45:11,126.4749363 --> 00:45:19,506.4749363 Maybe there is a role for antibiotics, but I think more and more, you know, surgery is becoming, more beneficial. 624 00:45:21,130.4749363 --> 00:45:21,400.4749363 Yeah. 625 00:45:21,730.4749363 --> 00:45:25,296.4749363 And j you talked about kind of complicated appendicitis, but I'm Yeah. 626 00:45:26,20.4749363 --> 00:45:30,880.4749363 you know, for patients that, um, haven't deleted that presentation, the, you know, there is a perforation. 627 00:45:30,880.4749363 --> 00:45:32,410.4749363 It's a much more complicated surgery. 628 00:45:32,410.4749363 --> 00:45:35,920.4749363 It's a longer time in hospital, but then also carries all the other risks. 629 00:45:35,920.4749363 --> 00:45:40,240.4749363 You have bacteria and post in the abdomen that can get into the bloodstream. 630 00:45:40,240.4749363 --> 00:45:44,846.4749363 You can get sepsis and you, you know, organ failure and some Yeah. 631 00:45:45,70.4749363 --> 00:45:46,30.4749363 right from appendicitis. 632 00:45:46,30.4749363 --> 00:45:47,920.4749363 Like, it's still like, although we, you know. 633 00:45:48,10.4749363 --> 00:45:49,646.4749363 We talk about it's common and it's yeah. 634 00:45:49,750.4749363 --> 00:45:51,850.4749363 home in a day like the, the, the miss. 635 00:45:51,850.4749363 --> 00:45:58,701.4749363 If it's not diagnosed or you don't get those antibiotics or surgery, again, this can be something that people can die You could get quite unwell. 636 00:45:58,701.4749363 --> 00:45:59,151.4749363 Yeah. 637 00:45:59,260.4749363 --> 00:45:59,830.4749363 present early. 638 00:45:59,991.4749363 --> 00:46:00,261.4749363 Yeah. 639 00:46:00,261.4749363 --> 00:46:07,431.4749363 And you could fall off the, you know, the physiologic reserve and then you could, you know, especially if you have underlying diseases. 640 00:46:07,791.4749363 --> 00:46:08,721.4749363 Uh, so that's important. 641 00:46:08,781.4749363 --> 00:46:19,431.4749363 If it's complicated appendicitis, you know, you, depending on where you are and depending on the number of days, and depending on CT scan findings, you may not get an operation as well. 642 00:46:19,641.4749363 --> 00:46:23,181.4749363 Or you may be treated alternatively with like, drain and things like that. 643 00:46:23,181.4749363 --> 00:46:27,21.4749363 Cool it down and then, um, and then operation down the road. 644 00:46:27,351.4749363 --> 00:46:29,91.4749363 Uh, but it's not gonna be antibiotics. 645 00:46:29,91.4749363 --> 00:46:34,71.4749363 Only if it, if it's a, a, a case of complicated appendicitis. 646 00:46:34,870.4749363 --> 00:46:35,50.4749363 Yeah. 647 00:46:35,80.4749363 --> 00:46:42,220.4749363 That's the other fascinating thing about the body too, is I've had it where like patients have walled off this abscess, and they're not small necessarily. 648 00:46:42,220.4749363 --> 00:46:43,870.4749363 Sometimes they are, sometimes they're not. 649 00:46:44,26.4749363 --> 00:46:44,316.4749363 Yeah. 650 00:46:44,440.4749363 --> 00:46:54,586.4749363 then it's just like, it's just this giant area of pus that's just like Yeah, off from everything yeah, and they're not like super, super sick and they're just have this vague abdominal pain yeah. 651 00:46:54,760.4749363 --> 00:47:01,191.4749363 Um, but yeah, again, the, the being, uh, being faced with appendicitis Absolutely. 652 00:47:01,191.4749363 --> 00:47:09,861.4749363 E even, uh, uh, appendix surgery in setting like complicated appendicitis can be, humbling, can be technically challenging. 653 00:47:10,341.4749363 --> 00:47:16,641.4749363 You know, when there's an abscess like that, it's like cement, uh, it's very hard. 654 00:47:17,61.4749363 --> 00:47:18,466.4749363 Uh, it's hard to know what is. 655 00:47:19,791.4749363 --> 00:47:26,331.4749363 GI tract and what is pus in that area? Everything, all the gi tract becomes very fryable. 656 00:47:26,691.4749363 --> 00:47:28,341.4749363 Everything you touch just bleeds. 657 00:47:28,401.4749363 --> 00:47:31,371.4749363 Uh, so it could be very humbling, uh, operation. 658 00:47:31,371.4749363 --> 00:47:36,471.4749363 So for that reason and can carry high perioperative complication rates. 659 00:47:36,741.4749363 --> 00:48:02,451.4749363 So for that reason, if it's been there for a while, abscess, um, perforation occurred, you know, four or five days ago, uh, and so forth, and the patient is not having severe septic shock, uh, then, you know, we, we would try to drain it, get the, the badness out antibiotics, and then get them better from, uh, from, uh, with that approach. 660 00:48:02,968.981739 --> 00:48:03,48.981739 Hmm. 661 00:48:03,233.981739 --> 00:48:09,653.981739 And I, and I don't know numbers James, but I'm guessing the majority of these do really well post-op, have a great recovery. 662 00:48:09,773.981739 --> 00:48:12,981.4749363 Don't even know they had it three Uncomplicated. 663 00:48:12,981.4749363 --> 00:48:13,461.4749363 Yeah. 664 00:48:13,581.4749363 --> 00:48:16,341.4749363 Uh, appendix, uh, appendectomy? Yes, it's, uh. 665 00:48:16,403.981739 --> 00:48:16,523.981739 them. 666 00:48:16,523.981739 --> 00:48:16,823.981739 Yeah. 667 00:48:17,166.4749363 --> 00:48:19,596.4749363 Yeah, the vast majority do quite well. 668 00:48:19,626.4749363 --> 00:48:20,976.4749363 Complicated rates are quite low. 669 00:48:21,533.981739 --> 00:48:21,893.981739 Cool. 670 00:48:22,553.981739 --> 00:48:27,966.4749363 guys, uh, looking at, looking at the time, I, I think we go to our favorite, our Yeah. 671 00:48:28,913.981739 --> 00:48:31,133.981739 new-ish section of this. 672 00:48:31,133.981739 --> 00:48:32,243.981739 The myth busting. 673 00:48:32,243.981739 --> 00:48:33,23.981739 Sec myth. 674 00:48:34,43.981739 --> 00:48:35,875.4749363 Myth We still need some theme music. 675 00:48:35,963.981739 --> 00:48:36,876.4749363 don't, Yeah. 676 00:48:36,923.981739 --> 00:48:38,485.4749363 and we We get air horn. 677 00:48:38,603.981739 --> 00:48:40,345.4749363 need a catchy name You gotta get amped up. 678 00:48:40,373.981739 --> 00:48:41,515.4749363 We need a catchy Yeah. 679 00:48:42,415.4749363 --> 00:48:45,263.981739 Maybe it be like MTH what's up. 680 00:48:46,193.981739 --> 00:48:47,305.4749363 Oh, I instead of health. 681 00:48:48,878.981739 --> 00:48:50,93.981739 That is incredible. 682 00:48:51,713.981739 --> 00:48:52,883.981739 MTH it is. 683 00:48:54,306.4749363 --> 00:48:56,316.4749363 M-T-H-M-T-H. 684 00:48:57,383.981739 --> 00:48:57,713.981739 Oh right. 685 00:48:57,743.981739 --> 00:49:01,103.981739 Well, you know what, I'm just gonna start with the first myth 'cause we kind of already talked about it. 686 00:49:02,123.981739 --> 00:49:05,813.981739 but the myth that, you know, I had pain, the pain's gone now, so I'm fine. 687 00:49:05,813.981739 --> 00:49:06,833.981739 I don't need to see anybody. 688 00:49:07,673.981739 --> 00:49:10,296.4749363 What do you think about that, James? Yeah. 689 00:49:10,296.4749363 --> 00:49:10,356.4749363 So. 690 00:49:11,91.4749363 --> 00:49:18,501.4749363 Uh, there may be a brief period of time in which you had severe pain, and then the pain dissipates a little bit. 691 00:49:19,41.4749363 --> 00:49:25,41.4749363 Uh, and sometimes that gives people relief and that, oh, this has all gone away. 692 00:49:25,641.4749363 --> 00:49:30,501.4749363 But sometimes that could actually be, uh, a time when perforation occurs. 693 00:49:30,921.4749363 --> 00:49:41,273.981739 Uh, so if you've had severe pain, uh, fever, all these red flags that we talked about, you should go to the emergency room, get checked out, Gotcha. 694 00:49:41,273.981739 --> 00:49:42,203.981739 So don't trust your body. 695 00:49:42,443.981739 --> 00:49:42,893.981739 I like that. 696 00:49:44,421.4749363 --> 00:49:47,661.4749363 trust your body, but, uh, don't trust the myth. 697 00:49:48,383.981739 --> 00:49:48,983.981739 There you go. 698 00:49:49,150.4749363 --> 00:49:49,720.4749363 There we go. 699 00:49:49,900.4749363 --> 00:49:50,140.4749363 Nice. 700 00:49:50,530.4749363 --> 00:49:50,800.4749363 Yeah. 701 00:49:51,640.4749363 --> 00:49:51,850.4749363 Yeah. 702 00:49:52,180.4749363 --> 00:49:56,680.4749363 Um, I mean, the other thing, Jamie, talk about the appendix and has being blocked from stuff. 703 00:49:56,680.4749363 --> 00:50:07,11.4749363 So Uh, home remedies? Can you, can you massage your poop ball out? Can you, can you poop out your poop ball? Drink it, drink it out, like just a lot yeah. 704 00:50:07,660.4749363 --> 00:50:13,86.4749363 Are there any like, oh, you know, home methods Yeah. 705 00:50:13,146.4749363 --> 00:50:13,476.4749363 Yes. 706 00:50:13,536.4749363 --> 00:50:20,76.4749363 You know, some people, you know, think whether they could kind of massage like that area to get the poop ball out. 707 00:50:20,556.4749363 --> 00:50:27,996.4749363 Unfortunately, there hasn't been any, you know, home remedy that's shown to be effective in treating appendicitis. 708 00:50:28,206.4749363 --> 00:50:34,206.4749363 It's really just bad luck, you know, with this poop ball just happens to be in the wrong place, wrong time, just like gallbladder. 709 00:50:34,476.4749363 --> 00:50:42,396.4749363 Uh, gallstone happened to be at the wrong, you know, place, wrong time, you know, blocking that, um, that little narrow lumen. 710 00:50:42,966.4749363 --> 00:50:46,626.4749363 Um, really, um, it's unlikely. 711 00:50:47,106.4749363 --> 00:50:51,336.4749363 Um, but sometimes that poopoo ball can kind of dislodge on its own. 712 00:50:51,846.4749363 --> 00:51:01,26.4749363 And it's not because you've done massage or kombucha, uh, or, or go lightly. 713 00:51:01,866.4749363 --> 00:51:02,136.4749363 Yeah. 714 00:51:02,376.4749363 --> 00:51:04,956.4749363 It, it's just that, it's just the bad luck. 715 00:51:06,160.4749363 --> 00:51:06,520.4749363 There. 716 00:51:06,610.4749363 --> 00:51:07,0.4749363 There. 717 00:51:07,118.981739 --> 00:51:08,78.981739 I do enjoy kombucha. 718 00:51:08,78.981739 --> 00:51:08,108.981739 I. 719 00:51:09,111.4749363 --> 00:51:09,191.4749363 Hmm. 720 00:51:09,968.981739 --> 00:51:11,48.981739 Mm-hmm. 721 00:51:11,376.4749363 --> 00:51:12,456.4749363 Yeah, very. 722 00:51:12,456.4749363 --> 00:51:13,716.4749363 Um, very good. 723 00:51:17,595.4749363 --> 00:51:17,815.4749363 Oh. 724 00:51:18,131.4749363 --> 00:51:19,176.4749363 I, I have nothing for that. 725 00:51:20,198.981739 --> 00:51:22,926.4749363 This is what happens at the end of the podcast, isn't it Yeah, that's right. 726 00:51:23,48.981739 --> 00:51:25,778.981739 We all The, done We all slow down. 727 00:51:25,956.4749363 --> 00:51:27,666.4749363 the, the energy is not there. 728 00:51:29,288.981739 --> 00:51:32,318.981739 um, last myth, we, we've already kind of answered this one. 729 00:51:32,318.981739 --> 00:51:36,38.981739 Appendicitis always causes pain on the right side, lower part of the belly. 730 00:51:36,398.981739 --> 00:51:38,661.4749363 And I think I can, uh, I'll just Yeah. 731 00:51:39,38.981739 --> 00:51:39,781.4749363 No, we Yeah. 732 00:51:39,848.981739 --> 00:51:47,168.981739 some atypical presentations, um, depending on who you are and what age you are and what other, medical things going on. 733 00:51:47,288.981739 --> 00:51:48,511.4749363 So Yeah. 734 00:51:48,698.981739 --> 00:51:50,558.981739 the classic presentation, but not the only one. 735 00:51:51,720.4749363 --> 00:51:52,10.4749363 Nice. 736 00:51:52,435.4749363 --> 00:51:52,765.4749363 Nice. 737 00:51:53,78.981739 --> 00:51:53,965.4749363 I just All right. 738 00:51:53,965.4749363 --> 00:51:57,548.981739 I think that the internist of the group who does not see appendicitis ever. 739 00:51:57,548.981739 --> 00:51:58,478.981739 Like, I can't even imagine. 740 00:51:58,778.981739 --> 00:52:01,688.981739 Remember the last time I saw it, I had to pretend I know something about it. 741 00:52:02,845.4749363 --> 00:52:02,965.4749363 nice. 742 00:52:03,126.4749363 --> 00:52:04,926.4749363 Well, that was a good myth busting, Josh. 743 00:52:04,926.4749363 --> 00:52:05,946.4749363 I'm very Thank of you. 744 00:52:06,353.981739 --> 00:52:06,773.981739 Thank you. 745 00:52:07,30.4749363 --> 00:52:07,320.4749363 Yeah. 746 00:52:07,373.981739 --> 00:52:08,153.981739 stop talking now. 747 00:52:12,475.4749363 --> 00:52:12,805.4749363 All right. 748 00:52:12,805.4749363 --> 00:52:20,151.4749363 Should we, should we take it home? The appendix or, Do you, do you yeah. 749 00:52:20,183.981739 --> 00:52:21,923.981739 patients after you take it out? You give it to them. 750 00:52:21,923.981739 --> 00:52:23,33.981739 You're like, take this home. 751 00:52:23,991.4749363 --> 00:52:24,201.4749363 Yeah. 752 00:52:24,201.4749363 --> 00:52:26,451.4749363 Actually some people ask, like, ask for things like that. 753 00:52:26,451.4749363 --> 00:52:30,891.4749363 Like, oh, can I get the gallstones? Uh, unfortunately we send it to the pathologist. 754 00:52:31,191.4749363 --> 00:52:35,331.4749363 Uh, and we would have to ask the pathologist what they do with that. 755 00:52:35,391.4749363 --> 00:52:37,431.4749363 I think they, the And too, yeah. 756 00:52:37,431.4749363 --> 00:52:38,841.4749363 I tell 'em to call the pathologist. 757 00:52:41,211.4749363 --> 00:52:42,201.4749363 Go to the dark room. 758 00:52:42,220.4749363 --> 00:52:43,791.4749363 there on Yeah, go to the dark room. 759 00:52:44,890.4749363 --> 00:52:51,651.4749363 Which also, what did they do with it? We said, I, I I'm, things yeah, I'm, I'm sure there's some protocol. 760 00:52:51,910.4749363 --> 00:52:53,301.4749363 curious, what, guys, we're Yeah. 761 00:52:53,301.4749363 --> 00:52:54,160.4749363 We need, do all. 762 00:52:54,173.981739 --> 00:52:55,133.981739 We're going tangential. 763 00:52:55,133.981739 --> 00:52:57,353.981739 Let's bring yeah, Focus. 764 00:53:00,951.4749363 --> 00:53:01,341.4749363 Alright. 765 00:53:01,615.4749363 --> 00:53:01,855.4749363 all right. 766 00:53:01,855.4749363 --> 00:53:02,935.4749363 I'm, I'm calling first. 767 00:53:02,935.4749363 --> 00:53:03,115.4749363 Okay. 768 00:53:03,115.4749363 --> 00:53:04,915.4749363 So, uh, my take home message. 769 00:53:04,975.4749363 --> 00:53:11,905.4749363 Um, appendicitis is common again, one in 12 people that is insane for your overall lifetime risk. 770 00:53:11,905.4749363 --> 00:53:14,335.4749363 So, um, it's common. 771 00:53:14,875.4749363 --> 00:53:15,955.4749363 Listen to your belly. 772 00:53:16,195.4749363 --> 00:53:25,978.981739 Uh, it's, it's something that, you know, you should be up there thinking about, uh, and if you're having an abdominal pain, especially if it's starting to localize in the right lower quadrant, come to the emerge Yep. 773 00:53:26,455.4749363 --> 00:53:28,931.4749363 or whatever your appropriate healthcare Mm-hmm. 774 00:53:28,945.4749363 --> 00:53:29,65.4749363 be. 775 00:53:29,873.981739 --> 00:53:33,953.981739 And I think just to follow that on the, uh, take home messages, uh, timing matters. 776 00:53:33,953.981739 --> 00:53:36,893.981739 So don't just wait to see if things disappear. 777 00:53:36,893.981739 --> 00:53:37,746.4749363 If it's getting Mm-hmm. 778 00:53:37,943.981739 --> 00:53:41,408.981739 you want to get the to, to the emerge or, or wherever you're going as soon as possible. 779 00:53:41,693.981739 --> 00:53:45,113.981739 The longer you wait, the bigger chance of, uh, poor outcomes. 780 00:53:46,86.4749363 --> 00:53:46,536.4749363 Yeah. 781 00:53:47,286.4749363 --> 00:53:56,586.4749363 And last point is while antibiotics can be effective to about 70% of the time and select. 782 00:53:56,976.4749363 --> 00:53:57,786.4749363 Patient groups. 783 00:53:58,206.4749363 --> 00:54:05,46.4749363 The mainstay treatment is minimally invasive appendectomy or surgery to take the appendix out. 784 00:54:05,856.4749363 --> 00:54:10,776.4749363 These are, uh, very safe, very effective surgery. 785 00:54:11,136.4749363 --> 00:54:14,48.981739 Uh, so don't be too afraid Yep. 786 00:54:14,198.981739 --> 00:54:17,648.981739 And it keeps food on James' plate, so can't forget that one. 787 00:54:19,596.4749363 --> 00:54:23,67.9681336 James, that was such a Uh, So much thanks man. 788 00:54:23,166.4749363 --> 00:54:23,616.4749363 important. 789 00:54:24,783.9681336 --> 00:54:25,113.9681336 Great. 790 00:54:25,113.9681336 --> 00:54:25,323.9681336 Yeah. 791 00:54:25,443.9681336 --> 00:54:26,193.9681336 Great topic. 792 00:54:26,283.9681336 --> 00:54:26,613.9681336 Yeah. 793 00:54:26,823.9681336 --> 00:54:33,543.9681336 This is great to share this with, with you and, uh, you know, great, uh, input from, uh, both of you, especially Josh. 794 00:54:34,716.4749363 --> 00:54:35,46.4749363 Thank you. 795 00:54:36,36.4749363 --> 00:54:36,576.4749363 the boost. 796 00:54:36,966.4749363 --> 00:54:39,426.4749363 All right, boys, we'll see you on the next episode. 797 00:54:39,607.9681336 --> 00:54:40,477.9681336 Thanks guys. 798 00:54:40,503.9681336 --> 00:54:40,893.9681336 Alright. 799 00:54:40,893.9681336 --> 00:54:41,343.9681336 See ya. 800 00:54:41,763.9681336 --> 00:54:42,363.9681336 Great talk. 801 00:54:42,547.9681336 --> 00:54:42,997.9681336 See you.