Generally treated as a medical emergency, appendicitis can leave a person doubled over in agony.

The most common symptom is abdominal pain, explains Dr. Martin Zielinski, a surgeon trained in critical care and trauma at Mayo Clinic in Rochester, Minnesota. A dull discomfort typically starts around the belly button before moving to the lower right part of a person’s abdomen, where it turns into a sharp pain. Nausea and vomiting often follow from inflammation of the appendix, a tubular, inches-long sac located where the small and large intestine meet, with an unknown function and a reputation for disrupting lives. “A patient’s not hungry, can’t eat, [experiences] fevers, chills — those would all be very common signs [of appendicitis],” Zielinski says.

Understandably, anyone experiencing appendicitis might think he or she is in no condition to consider different treatment options, particularly if preoccupied by concerns the infection will inevitably lead to perforation, or a burst appendix. New research, however, suggests the majority of the roughly 300,000 Americans who suffer appendicitis annually don’t need to undergo surgery and could be treated with antibiotics. The research looked only at patients with uncomplicated appendicitis, such as patients who did not have a burst appendix, abscess or tumor, as confirmed by a CT scan.

Experts disagree on whether enough evidence exists to move away from the current standard of practice to treat appendicitis, namely to surgically remove the appendix, in such straightforward cases. But most agree that research shows patients with uncomplicated appendicitis can safely take the time to consider all their treatment options, including drugs alone — which treat the source of the infection causing inflammation in the appendix — or delaying an operation.

At the belly of it all, the study published in the Journal of the American Medical Association last month found that 73 percent of patients with uncomplicated appendicitis who were treated with antibiotics alone did not need surgery within the study’s one-year follow-up period. Neither, researchers reported, did those who needed an appendectomy during the follow-up period face significant complications, like developing an intra-abdominal abscess, as a result of delaying surgery. In addition to complicated cases, the study excluded certain groups of patients, including women who were pregnant.

“We now know that uncomplicated acute appendectomy is not a surgical emergency,” Dr. Paulina Salminen, the study’s lead author and a surgeon at Turku University Hospital in Finland, wrote in an email. “There has already been some shifting of attitudes and also practice of both surgeons and patients — some patients already ask for antibiotic therapy.” What’s more, an editorial accompanying the JAMA study asserted: “The time has come to consider abandoning routine appendectomy for patients with uncomplicated appendicitis.”

Still, questions remain, and most experts agree that more study is needed if — and before — the long-held standard of care, to operate, is likely to change.

One hang-up, Zielinski cited: The researchers were not able to definitively prove that antibiotics weren’t inferior to surgery. Researchers noted that they fell short of an anticipated 75 percent success rate for antibiotic therapy, given that 27 percent of patients ultimately required surgery in the year after initially being diagnosed with appendicitis and treated with drugs alone.

Moreover, Zielinski says that even researchers’ preset expectations for success and failure, had they been met, would have fallen short of the higher success rate for appendectomy, or appendix removal surgery, routinely performed to treat appendicitis at Mayo. “Our default is almost always to offer an operation,” he says, adding that approach remains unchanged following the research. “In the patient population that this trial is talking about, our standard of practice is not to do antibiotics, but to do an appendectomy.”

Perhaps the biggest and most obvious benefit of surgery is that when the appendix is removed, so too is the source of the appendicitis. With drugs, appendicitis can recur. An appendectomy, on the other hand, has a roughly 99 percent success rate. As with any operation, however, it’s not without risk.

“There’s about a 4 to 5 percent chance of a wound infection,” Zielinski says. “Certainly, there’s complications as far as bleeding, abscess formation, and over the long term, you can develop a hernia at the port site. All of those complications, though, are on the order of 1 percent or so, in general. So they’re pretty low.”

Complication rates are higher for open surgery — the method that was studied, in part, to generalize results to places in the world where minimally invasive laparoscopic surgical equipment is less readily available. In the U.S., patients who have their appendix removed, including at major medical centers like Mayo, typically undergo minimally invasive surgery, Zielinski says. This is done by going through small holes in the patient’s abdomen.

“As appendectomy has been the standard care for over a century, and there are strong beliefs and also attitudes to overcome. I am sure that changing the current standard of care will take more quality research and time,” Salminen says.

The latest study in JAMA focused on adults ages 18 to 60; more research is planned, including in children. In the meantime, Zielinski — who echoed other experts in calling the latest research looking at treatment of antibiotics versus surgery for appendicitis the most compelling to date — says discussion of antibiotics as a treatment option is already part of protocol at Mayo. That goes for adults and children, who are even more likely to suffer appendicitis.

“We have actually used antibiotics for kids, to treat appendicitis, for a long time,” says Dr. Christopher Moir, a pediatric surgeon at Mayo Clinic Children’s Center in Rochester. “When we meet parents and their children in the emergency room, we discuss antibiotics upfront as a treatment option.” Still, he notes, surgery remains the standard of care at the medical center for children, too.

And contrary to the latest study that focused on using drugs in more straightforward cases of appendicitis, both he and Zielinski say they often consider treatment with antibiotics for more complicated cases because it can be difficult to operate in those circumstances.

“The interesting thing is that we have used antibiotics to treat appendicitis for the very worst cases. These are children who come in with a ruptured appendix with an abscess, and we treat them with antibiotics and they get better,” Moir says of pediatric patients who’d had appendicitis for more than seven days with an abscess.

What drives the use of drugs alone in these cases? “Knowing that surgery was more harmful,” he says. “On some of the worst cases, where the kids are actually doing OK, if you go in and operate, everything is all stuck together, you get a lot of bleeding and you can actually damage the intestine around the area, and the child can actually have a longer recovery time from operating in that circumstance. People can still die from that actually.”

While appendectomy is generally considered a safe and highly effective procedure, Moir says long gone are the days when it was considered the only treatment for appendicitis. “You used to just operate. But we know in certain cases the operation can be associated with a lot of complications, and therefore you want to have [an] alternative,” he says.

“Every surgeon should be willing to not operate, and should be willing to discuss the options of antibiotics or a lesser intervention such as a drainage — putting a needle in and draining the pus,” he says. At Mayo, as a matter of routine, pediatric patients with appendicitis are given antibiotics, he notes, even if doctors plan to operate.

For parents trying to discern the best treatment for their kids, and where drugs might fit in, he advises asking: “Would my child do just as well or better with antibiotics?” Along with potential treatment benefits and harms, inquire specifically about success and failure rates.

Studies evaluating antibiotic treatment of appendicitis put the failure rate somewhere between 11 and 30 percent, depending on severity and factors such as white blood cell count, Moir says.

Regarding recovery time, Moir says for an uncomplicated appendicitis treated with laparoscopic appendectomy, a patient can expect a one-day hospital stay, even leaving the hospital the same day in some cases. “Use of antibiotics will get you out of the hospital at the earliest in two days,” he says. On the flip side: “You don’t have surgery, so you could theoretically get back to sports maybe a little bit faster.” He says kids who undergo laparoscopic appendectomy can typically return to sports in a week.

Finally, while the recent adult-focused appendicitis treatment study named CT scans the best method to discern if a patient has uncomplicated appendicitis, Moir says it’s not necessary to expose most kids with the condition to radiation, which can run the risk of causing cancer.

“We have moved away [almost] entirely from doing CT scans. CT scans are now reserved for complicated appendicitis with abscesses. Otherwise children only get ultrasounds,” he says. “We believe ultrasound in kids approaches the accuracy of CT scanning, in the right hands.” Young children are most vulnerable to radiation risk. But researchers are also looking at the use of low-radiation CT scans to cut cancer risk for adult appendicitis patients, while still being able to use the imaging information to help guide treatment decisions.

Experts stress that patients young and old who develop appendicitis — in particular, the large majority who learn their case is uncomplicated — have treatment options that extend beyond surgery, and should make sure to fully understand and discuss those before deciding how to proceed.

For many, Salminen emphasizes, the therapy with drugs alone approach is viable: “Antibiotics are a safe first-line treatment.”

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Should I Have My Appendix Removed? originally appeared on usnews.com