Doc: Surgery best option for ruptured appendix
Dear Dr. Roach: A co-worker of mine recently had a ruptured appendix. The doctors did not remove it, but instead gave him heavy doses of antibiotics for three weeks. I thought they had to remove it. What is going on?
Dear D.M.: Surgery remains the preferred therapy for acute appendicitis, the inflammation of the appendix of the large intestine. Nonoperative management can be used in people with uncomplicated appendicitis — which might be valuable for some, especially people with a history of surgical complications. However, 27 percent of people assigned to antibiotics needed surgery, anyway.
Importantly, people with a ruptured appendix have been excluded from most of these studies (rupture is considered a complication). I did find a study in children comparing antibiotics with surgery for ruptured appendix, but the surgery group had significantly better outcomes.
I am not sure why your co-worker received antibiotics for a ruptured appendix. There may be a time when we will be better able to identify who can safely be treated with antibiotics and who needs surgery, but for now, most surgeons still recommend surgery. It is a safe procedure for the vast majority of patients with acute appendicitis.
Dear Dr. Roach: I’m a Type 1 diabetic who was diagnosed with common variable immunodeficiency. Can you tell me about this, and whether it might be related to my diabetes?
Dear J.B.: Common variable immunodeficiency is, despite its name, not a common condition. It does, indeed, cause immune deficiency and increased susceptibility to infection and malignancies. Further, the condition may be so mild as to go unnoticed in some people, while others have recurrent infections or inflammatory conditions. The hallmark of the syndrome is a very low level of immunoglobulins (antibodies) in the blood. Although usually present at birth, most are diagnosed between ages 20 and 45. Thus, there often is a long delay in diagnosis.
Because CVID is not one disease but many, there are many manifestations of this condition. However, recurring infections, especially pneumonias or sinus infections, should prompt a clinician to consider testing for this condition.
There is evidence that inflammatory bowel disease and Type 1 and Type 2 diabetes may be associated with CVID. I have read an unpublished study that showed up to 25 percent of both types of diabetics may have undiagnosed CVID. Diabetics can get recurrent infections and have elevated cancer incidence. Often, the diabetes may be blamed for what is actually an immune-system disease. Treatment with intravenous immunoglobulin may be lifesaving in serious infections. I also have read that this treatment may make blood sugar sporadically drop in an unpredictable fashion.
Dr. Roach Writes: After a recent column from a reader having difficulty tolerating vitamin D by mouth, several readers wrote in to recommend vitamin D spray. Vitamin D can be absorbed directly through the lining of the mouth, also known as buccal mucosa. This might be a good option for people who have stomach issues when taking vitamin D in pill form.
Email questions to ToYourGoodHealth@med.cornell.edu.