Dr. Roach: Surgeon to determine which patients need immediate surgery

Keith Roach

Dear Dr. Roach: My daughter was diagnosed with a fecalith after a day of pain and nausea. The expert opinion on her report was that an appendectomy was not required at this time. If a flare-up and pain do not recur, would an elective appendectomy be a wise choice given this first instance of symptoms? If pain and flare-ups become chronic, I assume an appendectomy would be the best choice.

— A.T.

Dr. Keith Roach

Dear A.T.: The vermiform (meaning “worm-like”) appendix (from the Latin term meaning “hang upon”) is a vestigial organ, a remnant of an internal structure that’s disappeared with evolution. It sits at the near end of the large intestine, right where the small intestine connects. Inflammation of the appendix — appendicitis — is one of the more popular reasons for emergency surgery. Oftentimes, the inflammation starts in the appendix because of an obstruction, which can be caused by a fecalith, which is a small and hard ball of stool of just the right size to block the end of the appendix.

Recently, there has been a trend away from sending all people with appendicitis to immediate surgery. Ninety percent of people treated with antibiotics can avoid surgery; however, of those with a fecalith, about 70% recovered without surgery within 90 days. The remaining 30% required surgery before 90 days, and half required surgery within four years. A different study compared antibiotics with just observation, and there was not a significant benefit to the antibiotics.

Some experts are concerned that the risk of a complicated appendicitis (especially a ruptured appendix) is higher in those with a fecalith, and that the CT scan used to make the diagnosis cannot always make the diagnosis with accuracy. For that reason, it remains the expert opinion of the surgeon as to who should be treated with immediate surgery and who can be safely managed with antibiotics or observation.

In a young, healthy person, most of the risk is in the first 90 days, so if she has not had trouble in the first three months, elective surgery would generally not be recommended. The whole reason to treat nonoperatively in most people is to help them avoid surgery.

Dear Dr. Roach: Does turmeric work to treat arthritis?

— W.

Dear W.: Many small studies have shown benefit in people with osteoarthritis of the knee to reduce pain. In a well-done trial comparing the active ingredient in turmeric (curcumin) to placebo, both groups had significant reductions in pain, but the turmeric extract group had better pain reduction. There was not an improvement in the physical functioning, such as walking speed or ability to climb stairs. There were fewer adverse events in the turmeric extract group than the placebo group.

There is moderate evidence that turmeric extracts improve pain in people with osteoarthritis of the knee. I would emphasize that exercise remains an important therapy at both reducing pain and improving function. Unfortunately, there are no medical treatments known to reverse or even slow down the progressive damage of osteoarthritis.

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