Speaker 1: Hi. My name is Molly, and in March of twenty fifteen,
Speaker 1: I was thirty six weeks pregnant with my first child.
Speaker 1: For the most part, my pregnancy had been uneventful, except
Speaker 1: for a visit to labor and Delivery in mid February
Speaker 1: with some pain that they determined at the time to
Speaker 1: be just gas. So on the afternoon of March sixteenth,
Speaker 1: when I started to feel similar pain again, I just
Speaker 1: put it off as being gased and did all the
Speaker 1: recommended things to treat the pain, but over the course
Speaker 1: of a few hours, the pain got progressively worse. At
Speaker 1: around six pm on the evening of March sixteenth, I
Speaker 1: decided I would take a bath to see if warm
Speaker 1: water would help, and once I got out, I could
Speaker 1: barely walk, and I then decided that this was definitely
Speaker 1: not gas pain. When I got to the hospital, because
Speaker 1: I was thirty six weeks pregnant, they really just focused
Speaker 1: on me being in pre term labor, but the biggest
Speaker 1: issue being that the pain I was having was getting
Speaker 1: progressively worse and was constant, which contractions aren't. At about
Speaker 1: two hours in, a doctor mentioned that what I was
Speaker 1: experiencing might be round ligaman pain and they were probably
Speaker 1: going to send me home with some exercises. Thank god
Speaker 1: they didn't. To the span of a few hours, I
Speaker 1: had an ultrasound done as well as an MRI. Is
Speaker 1: a doctor's thought I could possibly have appendicitis, but when
Speaker 1: you're pregnant, the appendix is often hidden because of your baby,
Speaker 1: so standard tests don't allow you to see the appendix.
Speaker 1: Prior to going into the MRI machine. They gave me morphine,
Speaker 1: which still didn't touch the pain, and having to lay
Speaker 1: in the MRI machine for over forty minutes not being
Speaker 1: able to move was one of the worst things I've
Speaker 1: ever experienced. Unsurprisingly, the MRI and ultrasound didn't show anything. Finally,
Speaker 1: after six hours, around midnight on the seventeenth of March,
Speaker 1: they decided to admit me to the hospital, still not
Speaker 1: knowing what was going on. As the hours went on,
Speaker 1: my white blood cell count continued to rise, I developed
Speaker 1: a fever, and I was losing amniotic fluid. So finally,
Speaker 1: after sixteen hours of being an excruciating pain, they decided
Speaker 1: that they had to do an emergency C section to
Speaker 1: figure out what was going on. I remember getting the
Speaker 1: epidural and it being the greatest thing. Ever, because I
Speaker 1: could no longer feel the pain in my stomach as
Speaker 1: they cut me open. The one thing I can remember
Speaker 1: is that I'm saying, there's puss and her stomach called
Speaker 1: the other surgical team. Minutes later, they delivered my daughter, Madeline,
Speaker 1: at twelve thirty four on Saint Patrick's Day. After they
Speaker 1: delivered my daughter, the ob team swapped out with a
Speaker 1: general surgical team, and for a brief moment, they considered
Speaker 1: keeping me awake since I had an epidural, but thankfully
Speaker 1: my husband stepped in and said, put her under now.
Speaker 1: Once they put me under, it was found that my
Speaker 1: appendix had ruptured and I had peratinitis in my intestines.
Speaker 1: For the next three days, I was on ivy antibiotics,
Speaker 1: but my white blood cell count was continuing to rise
Speaker 1: and I was still running a fever and it looked awful. Thankfully,
Speaker 1: after three days, my white blood cell count finally dropped.
Speaker 1: At this point, my doctors confessed to me how concerned
Speaker 1: they were getting about me. I stayed almost a week
Speaker 1: in the hospital recovering from appendicitis in my c section,
Speaker 1: and I was very popular on the floor because most
Speaker 1: of the doctors had never seen a case like this.
Speaker 1: It took me weeks to fully recover, and I was
Speaker 1: seeing a doctor twice a week for over a month
Speaker 1: because of constant issues I was having. My daughter spent
Speaker 1: two days in the special care unit receiving IVY antibiotics,
Speaker 1: but overall was really healthy considering what she had been through.
Speaker 1: While this was all going on, I was so focused
Speaker 1: on my pain, recovering and my daughter that I really
Speaker 1: didn't think about the implications of what had happened to
Speaker 1: me until I started your research and realized how dangerous
Speaker 1: the situation was and how it could have ended so
Speaker 1: differently for both me and my daughter. Thankfully, we were
Speaker 1: both okay afterwards and having discussions with my doctor, they
Speaker 1: think that my appendix started to be inflamed when I
Speaker 1: went to labor and delivery in February of twenty fifteen.
Speaker 1: They also had a theory that my daughter was kicking
Speaker 1: my appendix and that may have caused it to become
Speaker 1: inflamed in rupture. Lastly, during those agonizing sixteen hours prior
Speaker 1: to having my daughter, we had an amazing nurse who
Speaker 1: knew what I was experiencing wasn't labor pain or around
Speaker 1: ligament pain. And advocated for me and stay with us
Speaker 1: the entire time, even when she was off her shift,
Speaker 1: to make sure that we were okay. I will never
Speaker 1: forget her and the other nurses he took care of me.
Speaker 2: Thank you.
Speaker 3: Oh my gosh, that sounds terrifying, absolutely awful. I can't. Oh,
Speaker 3: I can't imagine. Yeah, thank you so much for be
Speaker 3: being willing to relive that experience and share that with
Speaker 3: all of us that I can't. Yeah, I don't have words.
Speaker 4: No, Yeah, thank you, thank you. It must have been
Speaker 4: really terrifying, So thank you for sharing.
Speaker 3: Hi. I'm Aaron Welsh and I'm Erin Alman Updike, and
Speaker 3: this is this podcast Will Kill You.
Speaker 4: And today we're talking appendicitis. Yeah, yeah, this.
Speaker 3: Is kind of an oddball one for us. I feel like.
Speaker 4: It isn't It isn't I feel yeah, you're right, don't know.
Speaker 4: I feel like that about a lot of our episodes recently,
Speaker 4: where I'm like, are there rules anymore?
Speaker 3: I don't think so, No, we make the rules are
Speaker 3: and this is our podcast?
Speaker 4: True, but kind of I think there's I'm excited to
Speaker 4: learn history things don't know it, and there's pathology there
Speaker 4: for sure, So.
Speaker 3: I mean, one of my biggest touch points is Madeline.
Speaker 3: I think I talk about Matline that was always drawn
Speaker 3: to that for some reason. Probably I was a spooky
Speaker 3: little kid. But yeah, doesn't.
Speaker 4: Everyone love Madeline like it's it's a classic?
Speaker 3: Yeah?
Speaker 1: I know?
Speaker 3: But okay, were there multiple Madeline books or just Madeline?
Speaker 4: I only know Madeline, but I don't know.
Speaker 3: Oh my gosh, Okay. For the longest time, I thought
Speaker 3: it was all I don't know. I thought that was
Speaker 3: just like story number one in a Madeline series.
Speaker 4: I don't know. I've only read that one. Matt me too.
Speaker 3: Yeah, okay, so I guess it feels like there must be.
Speaker 4: We are gonna have to google it after.
Speaker 3: This, someone is going to reach out and be like, wow, Wow,
Speaker 3: your Madeline knowledge is really poor, very poor. One out
Speaker 3: of five stars.
Speaker 4: Thank you, dear. You know what. It's good though, it is.
Speaker 4: It's going to be a great episode. But before we
Speaker 4: get into any of it, it's quarantiny time.
Speaker 3: It is, Aaron, what are we drinking this week?
Speaker 4: We're drinking waiting for the rupture, not the rapture.
Speaker 3: Gosha. I'm pleased with myself on this song should.
Speaker 4: Be It's a good one. I would hope that we
Speaker 4: don't ever actually wait for the rupture. But it's a
Speaker 4: good quarantini name.
Speaker 3: No, it's a great name, if I do say so myself.
Speaker 3: And it's a great quarantine as well. It's got some
Speaker 3: delicious ingredients. Essentially, what you've got here is a French
Speaker 3: seventy five, which is gin and champagne. Subtract the champagne,
Speaker 3: add some sparkling cider for a little bit of a
Speaker 3: fall winter vibes, some iced lemon spices, you know, delish.
Speaker 4: We'll post the full recipe if you need it on
Speaker 4: our website, this podcast okay dot com and our social
Speaker 4: media for both the Quarantini and the non alcoholic plus
Speaker 4: sy parita.
Speaker 3: They're there. They're there website. We've got some great stuff
Speaker 3: on that website. You know, we just revamped it, well
Speaker 3: just now it's been months, because two and a half
Speaker 3: months ago we revamped.
Speaker 4: It by the time this comes out, but it's great.
Speaker 4: Check it out.
Speaker 3: It is great. It's got things like transcripts. It's got
Speaker 3: links to our bookshop dot org affiliate account, our Goodreads list,
Speaker 3: it's got links to merch some pretty sweet stuff going
Speaker 3: on there. It's got links to our Patreon. It's got
Speaker 3: links to oh music by Bloodmobile. It has got sources
Speaker 3: for each and every one of our episodes, have a
Speaker 3: little section about the errands. There's a submit your first
Speaker 3: hand account form. There's areas where you can contact us.
Speaker 3: Let's say you want to request an episode. Let's say
Speaker 3: you want to see if we will come and do
Speaker 3: a workshop or give a talk boom contact us form
Speaker 3: and other stuff.
Speaker 4: And yeah, we also have our promo page listed where
Speaker 4: you can find the promo codes that we cite in
Speaker 4: all of the ads from all of the time, all
Speaker 4: the active ones. You can find them. Go to our website,
Speaker 4: click extras and savings. You can find it there.
Speaker 3: And you know, we're just gonna shout it out again.
Speaker 3: If you like the show, please rate, review, subscribe, make
Speaker 3: sure that you're subscribed on whatever podcast or you use.
Speaker 3: It really helps us out a lot, So it does.
Speaker 4: Yeah, thank you.
Speaker 3: Thanks.
Speaker 4: Well, should we get started.
Speaker 3: Let's do it. Let's take a quick break and then begin.
Speaker 4: There is this kind of very textbook description of appendicitis,
Speaker 4: and I'm going to tell you how it goes. It
Speaker 4: starts with usually kind of a vague pain and abdominal
Speaker 4: pain around the belly button, kind of like in the
Speaker 4: center of the belly, around your belly button, and it
Speaker 4: tends to go along with like, I'm not really feeling
Speaker 4: hungry because my stomach doesn't feel good. I don't want
Speaker 4: to eat anything, and then it might press to feeling
Speaker 4: actually nauseous, like feeling like you're gonna throw up, and
Speaker 4: then maybe some vomiting, and then that pain will start
Speaker 4: to move and it moves from around the belly button
Speaker 4: down into the right lower quadrant kind of mirror your
Speaker 4: right hip bone, like the part that sticks out, and
Speaker 4: then you'll get a fever. And this tends to kind
Speaker 4: of progress usually over about like a twenty four hour period,
Speaker 4: Like it's not a super sudden onset, but it's not
Speaker 4: like prolonged. That's the classic description. And this classic description
Speaker 4: is not the only way that appendicitis can present by
Speaker 4: any means, but it is the classic description because it
Speaker 4: does happen, and it happens pretty frequently. It's very common
Speaker 4: that this kind of series of events is how appendicitis
Speaker 4: starts and presents. I can very vividly remember having a
Speaker 4: patient describe their like course of symptoms that brought them
Speaker 4: to the emergency room exactly liked this, and I looked
Speaker 4: at them and I was like, well, you described the
Speaker 4: textbook description of a pendicitis.
Speaker 3: Are you an actor right here? Like this?
Speaker 4: Is this a real patient encounter? And then when you're
Speaker 4: in the emergency room and the person examining you starts
Speaker 4: to do their exam and they touch your stomach. Sure enough,
Speaker 4: very often people have pain in this kind of text
Speaker 4: book area. And that point. There's a point, it's called
Speaker 4: mcburney's point. It's like two thirds of the way between
Speaker 4: your belly button and that sticky, oudy part of your
Speaker 4: hip bone, which is called your anterior superior iliac crest.
Speaker 4: So it's like a little bit closer to your hip
Speaker 4: bone than your belly button. Along this like diagonal line
Speaker 4: between your belly button and that hip bone, you can
Speaker 4: put your finger there, and that tends to be the
Speaker 4: most tender spot. It hurts really bad if you smush
Speaker 4: down there. There's a few other signs that you can see.
Speaker 4: Maybe someone doesn't have pain exactly right there, but they
Speaker 4: might If you smush down on the left side of
Speaker 4: their belly, it might hurt on that right side. That's
Speaker 4: a sign that there might be appendicitis, and then there
Speaker 4: are a lot of other things, like the way that
Speaker 4: you move somebody's hip or leg that might tell you
Speaker 4: how far down into the pelvis, how extensive that infection
Speaker 4: might be. So when somebody comes into the hospital, to
Speaker 4: the emergency room or even an urgent care reading that
Speaker 4: textbook description, almost certainly, like over ninety percent of the
Speaker 4: time people get diagnosed correctly with appendicitis. And it's possible
Speaker 4: based on those textbook descriptions that diagnosis can happen with
Speaker 4: just that story alone. But today, because it's available at
Speaker 4: least in most of the high income countries in the world,
Speaker 4: we have access to technology to confirm this diagnosis. So
Speaker 4: most of the time when people come in with symptoms
Speaker 4: like this, there's going to be some kind of imaging
Speaker 4: that's either a CT scan or an ultrasound if you
Speaker 4: need to avoid radiation, to make totally sure that what
Speaker 4: we see is actually appendicitis. And that becomes even more
Speaker 4: important when people don't read the textbooks, aka, when your
Speaker 4: bodies present with appendicitis differently than what that classic description is, right.
Speaker 3: And what are some of the ways that it doesn't
Speaker 3: present with that classic description.
Speaker 4: One of the ways that it gets missed the most
Speaker 4: is when somebody is having constipation, and so they're maybe
Speaker 4: not having because sometimes you get diarrhea with appendicitis. When
Speaker 4: people are having constipation and appendicitis, it's more likely to
Speaker 4: get missed for one reason or another. You might not
Speaker 4: have a fever. You might not have a fever yet
Speaker 4: you might have pain, but it's a little bit more nonspecific.
Speaker 4: Someone might think, and this is where things get very subjective,
Speaker 4: and we'll talk more about this later, but people might think, well,
Speaker 4: your pain doesn't seem that severe. So there's a lot
Speaker 4: of different ways you may or may not have that
Speaker 4: nausea or vomiting. You might have a lot of vomiting,
Speaker 4: you might have no vomiting. So like, there is a
Speaker 4: huge range. But so when those symptoms might not exactly
Speaker 4: match what we think of as appendicitis, maybe the point
Speaker 4: where you have pain seems to be a little off
Speaker 4: from what I expect for appendicitis, whatever it is, then
Speaker 4: these kinds of imaging studies become even more important. And
Speaker 4: the truth is that there's also a lot of other
Speaker 4: pathologies that can mimic appendicitis, even if it seems like
Speaker 4: a textbook description right, something like an ovary intrsion, a
Speaker 4: cyst rupture, an ectopic pregnancy. There's something called mesenteric lymphatinitis
Speaker 4: that looks almost identical to appendicitis clinically, but then on
Speaker 4: imaging is going to look really different, So there's other
Speaker 4: stuff that it could be. So imaging and then blood
Speaker 4: work are going to kind of help the overall picture
Speaker 4: of making sure that we're correctly diagnosing somebody with appendicitis.
Speaker 3: What do you see in the blood?
Speaker 4: You might see an elevated whye blood cell count because
Speaker 4: you have an infection going on, and then you would
Speaker 4: expect usually not to see other things like your liver
Speaker 4: being out of whack, because that might make you think
Speaker 4: it's something else that's going on. You always have to
Speaker 4: check if somebody has a uterus to make sure that
Speaker 4: there's not a pregnancy, because a then it could be
Speaker 4: an ectopic pregnancy, and b then you might change the
Speaker 4: type of imaging that you're going to do to avoid radiation.
Speaker 4: So that's the kinds of things that you're looking for
Speaker 4: in blood work. There's not anything that's like, ooh, this
Speaker 4: blood work means appendicitis. There's no like specific blood work
Speaker 4: and Arin, I think you'll talk. I'm sure about how
Speaker 4: people used to deal with appendicitis back in the day.
Speaker 4: I can't wait, but a little spoiler for most people,
Speaker 4: because it wasn't that long ago that the standard of
Speaker 4: care was to cut somebody open with a big old
Speaker 4: incision and then cut that appendix out and then stitch
Speaker 4: you back up. And that is called an open appendectomy.
Speaker 4: And that is what Madeline had. Ah, that's why she
Speaker 4: had a big old scar, and everyone was like, I
Speaker 4: want my appendix out too.
Speaker 3: Yep, I did as well. Yeah, before I knew more appendixes.
Speaker 4: So open appendectomy was the standard of care for a
Speaker 4: long time until the advent of what's called laparoscopic appendectomy,
Speaker 4: which is instead of one giant cut, they use really
Speaker 4: a couple of really really small cuts, and then these
Speaker 4: instruments on long sticks and a camera that they can
Speaker 4: put inside of your belly to look at your appendix
Speaker 4: and all of your other organs, and then if needed,
Speaker 4: take the appendix out through these teeny tiny holes. And
Speaker 4: this is a lot better because it's a faster recovery,
Speaker 4: there's less trauma to the muscles of the abdominal wall,
Speaker 4: there's less pain, postoperatively. It's like, everything is better if
Speaker 4: you can do a laparoscopic procedure. But it's still surgery, right,
Speaker 4: It's still cut this thing out because it's causing problems. Today,
Speaker 4: in the year twenty twenty four, people are starting to
Speaker 4: come around to this wild idea. And I say start
Speaker 4: because the literature goes back quite a ways.
Speaker 3: Yeah, to like the fifties at least.
Speaker 4: I think, Oh, that's even further than I realized I
Speaker 4: knew of it, like to the early two thousand, but
Speaker 4: like it's been an accepted practice I think since like
Speaker 4: the mid two thousands, but still is not that common
Speaker 4: that you maybe don't have to cut it out and
Speaker 4: maybe can just use antibiotics to treat it.
Speaker 3: But is there there's like a higher relapse rate or
Speaker 3: whatever it would be called, like a higher recurrence rate
Speaker 3: of appendicitis? Right?
Speaker 4: There is there a lot. Let's talk about it. Okay, okay,
Speaker 4: So let's talk first about what is actually going on
Speaker 4: in your appendix. What is appendicitis really like? Now we
Speaker 4: know what it looks like and most of the time
Speaker 4: you're going to need surgery to get it out. So
Speaker 4: what's going on? And that might tell us when it
Speaker 4: might be a good idea to not do surgery or
Speaker 4: do surgery based on what's going on.
Speaker 3: Oh it, it's good.
Speaker 4: So in humans, Aaron, I remember you asking me this
Speaker 4: while we were before we recorded, and I was like,
Speaker 4: had to look all this up because why are there
Speaker 4: so many different names for the appendix. Yeah, in humans
Speaker 4: it's called the vermiform appendix because it looks like a
Speaker 4: little worm vermous like a worm. Yeah, it's a little
Speaker 4: out pouching. Basically, your appendix is this little like out pouching,
Speaker 4: this little like finger of tissue that comes off of
Speaker 4: the very first part of your colum or your secum,
Speaker 4: or your large intestine. It has a lot of names.
Speaker 4: And I don't remember, Aaron, which episode it was relatively
Speaker 4: recently that you were like, can you tell me all
Speaker 4: the parts of your intestines? Do you remember that?
Speaker 3: I think it was neurovirus.
Speaker 4: Neurovirus, Okay, So as a refresher, your small intestine is
Speaker 4: what's connected to your stomach, and that is what wriggles
Speaker 4: its way back and forth in the center of your abdomen,
Speaker 4: and it ends in the right lower quadrant of your belly,
Speaker 4: and there's a valve that connects your small intestine to
Speaker 4: your large intestine, and right next to just kind of
Speaker 4: right underneath, like down south, closer to your feet. I
Speaker 4: guess of where your small intestine connects to your large intestine.
Speaker 4: That is where this little extra bit sticks out that
Speaker 4: looks like an anemone tentacle. It's very small. It's like
Speaker 4: one to three millimeters in internal diameter, so really small,
Speaker 4: smaller than your pinky finger, and it sticks off of
Speaker 4: the bottom of your large intestine. Your poop is going
Speaker 4: to go through your small intestine and then swoosh up
Speaker 4: your large intestine and then eventually all the way out
Speaker 4: until you poop it out. Okay, So this little finger
Speaker 4: of an appendix can get clogged, and there's a few
Speaker 4: different ways that it can get clogged. Sometimes it gets
Speaker 4: clogged with poop, and when it gets clogged with a
Speaker 4: chunk of poop, that chunk is called an appendico lith
Speaker 4: or a FeCO lith, a little hard poopball. But sometimes
Speaker 4: it can get clogged with other stuff. It could get
Speaker 4: clogged with a tumor, either a benign two or a
Speaker 4: cancerous tumor. It can get clogged with an overgrowth of
Speaker 4: lymphoid tissue that is like our immune tissue, which there's
Speaker 4: a lot of in our appendix, that can kind of overgrow.
Speaker 4: And that can happen just on its own because you
Speaker 4: just have immune tissue growing, or it can happen because
Speaker 4: that tissue is responding to an infection, or sometimes it
Speaker 4: can get clogged with other things like just a little
Speaker 4: chunk of calcium, whatever it is. Anytime in our bodies,
Speaker 4: a small tube that's connected to a bigger tube gets clogged,
Speaker 4: you have stagnation of stuff, and that is a perfect
Speaker 4: medium for bacteria to grow and.
Speaker 3: Thrive like a stagnant pond.
Speaker 4: Exactly like a stagnant pond. And so that is what
Speaker 4: happens in our appendix. When you get appendicitis you have
Speaker 4: something that causes this tube that should be like open
Speaker 4: to communicate with your large intestine get clogged and blocked off,
Speaker 4: and then bacteria start to grow and multiply. As that happens,
Speaker 4: it triggers inflammation, because that's what a bacterial infection does.
Speaker 4: It triggers inflammation, and that inflammation causes swelling, and when
Speaker 4: you have swelling in a really small space, that ends
Speaker 4: up cutting off the blood supply. To the walls of
Speaker 4: that appendix, like to the tissue, and then eventually, because
Speaker 4: the blood supply is cut off, the tissue of the
Speaker 4: walls of the appendix starts to die and then it's
Speaker 4: weak because it's dead tissue, so then it can perforate,
Speaker 4: and that's what causes a perforated appendix. And then all
Speaker 4: that infected stuff, the bacteria, the inflammation, the white blood cells,
Speaker 4: the pus, it explodes out of your appendix, and a
Speaker 4: couple of things can happen. If that happens, If just
Speaker 4: a little part of the wall gets a hole in it,
Speaker 4: like a small hole, then the fluid might come out
Speaker 4: and get trapped, and that is what forms an absce Okay,
Speaker 4: or sometimes the whole appendix can rupture and then it's
Speaker 4: not contained and then all of that infected fluid can
Speaker 4: kind of go throughout your whole abdomen. And that's what's
Speaker 4: called peritonitis, which is very serious. That's definitely an emergency.
Speaker 4: Does that make sense, I mean, that's essentially appendicitis. That's
Speaker 4: that is what causes it.
Speaker 3: Okay, So at what point, like what's happening when your
Speaker 3: belly button hurts versus when that pain moves to the
Speaker 3: lower right quadrant, and then like when does surgery? When
Speaker 3: is surgery indicated? When is it not indicated? You know, like,
Speaker 3: what's going on?
Speaker 4: Oh, such a good question. These are fun questions. Okay,
Speaker 4: So what's happening when it's going from your belly button
Speaker 4: pain down to your right lower quadrant. I don't one
Speaker 4: hundred that know the answer to this question. I don't
Speaker 4: know if the answer to this question has been like,
Speaker 4: I don't know. I didn't read any papers that directly
Speaker 4: answer this question. I am going to answer this question
Speaker 4: based on my knowledge of our anatomy, and I could
Speaker 4: be wrong about this, But in your guts in general,
Speaker 4: you don't have direct nervous sensory nerves that go to
Speaker 4: your guts, like to your small and large intestine, there's
Speaker 4: no sensory innervation there. So a lot of times what
Speaker 4: can happen in your guts when you're having pain is
Speaker 4: that your brain doesn't actually know exactly how to interpret
Speaker 4: the signals of where that pain is coming from, because
Speaker 4: all of the sensory nerves are in like the wall
Speaker 4: of your abdomen. So if there's pain in one spot,
Speaker 4: sometimes your brain is like, ah, there's pain here, and
Speaker 4: so then you're like, this is where the pain is.
Speaker 4: Because your brain doesn't quite know exactly where that sensory
Speaker 4: input's coming from.
Speaker 3: Why does it move?
Speaker 4: The thought is that once that inflammation, as it starts
Speaker 4: to get more severe, then your brain can localize it
Speaker 4: more because there's more of that inflammation just touching in
Speaker 4: that one area. Okay, that's my best explanation. I don't
Speaker 4: know if it's a perfect one.
Speaker 3: What's going on with referred pain?
Speaker 4: Ooh? I love referred pain. I mean I don't love
Speaker 4: referred pain, but I love so. Referred pain means that
Speaker 4: you have inflammation or something that's going on that should
Speaker 4: be causing pain, that's triggering pain in one area, but
Speaker 4: the pain that you feel is coming in a different area.
Speaker 4: And that's because our nerves travel together. So the nerves
Speaker 4: that innervate certain parts of say your diaphragm and some
Speaker 4: of your abdomen, also innervate places like your shoulder, and
Speaker 4: so sometimes when you have pain in certain parts of
Speaker 4: your abdomen, you might actually feel it in your shoulder.
Speaker 4: And so that's what referred pain is. It's essentially like
Speaker 4: nerves that travel together. Your brain doesn't know how to
Speaker 4: interpret that signal, and so it goes to the place
Speaker 4: that it thinks that the pain is and it's like, hey,
Speaker 4: your shoulder hurts when actually it's your spleen or something
Speaker 4: like that.
Speaker 3: Got it. Yeah, I've always been curious why that works.
Speaker 4: Our brain is so interesting and weird. So yeah, so
Speaker 4: that's why we kind of get pain where it might
Speaker 4: start more generalized and then move as that infection gets
Speaker 4: more severe. The second question that you asked is like,
Speaker 4: then when would you need to surgize versus not surgerize,
Speaker 4: and how all of that. So let's talk a little
Speaker 4: more about that. So appendicitis starts well before an appendix ruptures.
Speaker 4: Before an appendix ruptures, it's called uncomplicated appendicitis. So if
Speaker 4: you have these symptoms, if you have this imaging where
Speaker 4: we look at a CT scanner, we're like, yep, your
Speaker 4: appendix is inflamed, the walls are thick, it's angry. We
Speaker 4: can see inflammation, all these things, but it's not ruptured.
Speaker 4: That's uncomplicated appendicitis. Once it's ruptured, it's considered complicated. Most
Speaker 4: of the studies that look at whether or not you
Speaker 4: can use antibiotics only to treat appendicitie or for uncomplicated appendicitis,
Speaker 4: So uncomplicated unruptured appendicitis in a lot of cases can
Speaker 4: be safely treated without surgery, just with the use of antibiotics.
Speaker 4: So in this uncomplicated case, a lot of a lot
Speaker 4: of different studies have looked at whether or not you
Speaker 4: can safely cure somebody's appendicitis without using surgery, and you
Speaker 4: can in a lot of cases. In fact, some people
Speaker 4: even treat complicated infections if there's an abscess, like one
Speaker 4: pocket of fluid outside of the appendix where it's ruptured,
Speaker 4: but it's not all over your whole belly. Sometimes you
Speaker 4: can then drain that fluid, like stick a tube in it,
Speaker 4: drain out all that gunk, and then do antibiotics on
Speaker 4: top of that, and you can cure the infection without
Speaker 4: needing to do surgery right away. There's some downsides to this, though.
Speaker 4: First you have to use pretty broad spectrum antibiotics, because
Speaker 4: this is usually an infection that's not just one bacteria.
Speaker 4: It's a bunch of different types of bacteria, and there's
Speaker 4: not really a way for us to know which bacteria
Speaker 4: because there's so many that live in your guts. Which
Speaker 4: is the one that's causing yours versus your friends appendicitis.
Speaker 3: And so this appendicitis, if it's caused by an infection,
Speaker 3: not a fecallyth it's like, is it opportunistic bacteria that
Speaker 3: like normally reside in your gut?
Speaker 4: Arian? I love your question. So all appendicitis is an infection. Okay,
Speaker 4: all appendicitis is an infection. But you said, is it
Speaker 4: a fecal eth or is it not? The first trigger
Speaker 4: to that appendix getting clogged could be a chunk of something,
Speaker 4: or it could be some other reason, whether it's an
Speaker 4: infection or non infection that causes your tissue to hypertrophy. Right,
Speaker 4: And what we see in all of these cases, the
Speaker 4: bacteria that are growing are just the kind that live
Speaker 4: in your guts. So yeah, they're mostly opportunistic infection, right,
Speaker 4: They're just able to multiply because of that clog. But
Speaker 4: what we see is that if people have appendicitis caused
Speaker 4: by a fecal lith caused by a chunk of pooh
Speaker 4: that's stuck there, they are less likely to do well
Speaker 4: with antibiotics alone.
Speaker 1: Uh.
Speaker 4: Why, Well, because that chunk isn't going anywhere. Okay, And
Speaker 4: so that chunk not only is causing like a constant blockage,
Speaker 4: it's also causing a blockage that's reducing blood flow. We
Speaker 4: think maybe, and that's part of why the antibiotics are
Speaker 4: not able to get in as well to the appendix
Speaker 4: to treat that infection. But it also means that that
Speaker 4: fecalth is still going to be there, right, So then
Speaker 4: even if you can get that infection under control, it's
Speaker 4: still going to be there and you're not going to
Speaker 4: be able to get rid of it unless you take
Speaker 4: it out. If you have appendicitis where there's no fecal
Speaker 4: lith and there's just a hypertrophy of tissue that's caused
Speaker 4: by an infection, you treat that infection, you fix that problem,
Speaker 4: and the appendix is no longer clogged.
Speaker 3: Are there risk factors or appendicitis broadly or fecal lith appendicitis?
Speaker 3: Like what are the risk factors? Not?
Speaker 4: Yeah, great question, I don't know. I don't think we know.
Speaker 4: Like who is likely to get it versus not get it?
Speaker 4: You mean I don't know, Yeah, we don't know. People
Speaker 4: who are assigned male at birth are more likely to
Speaker 4: get appendicitis than people who's assigned female.
Speaker 3: The opposite of gallbladder stuff, right, but.
Speaker 4: We don't know, like why why is that? And it's
Speaker 4: not like a very significant I think it's like an
Speaker 4: eight percent lifetime risk versus six percent lifetime risk, So
Speaker 4: it's not like huge, super meaningful. Yeah yeah, but yeah,
Speaker 4: and like and it's older people who tend to get
Speaker 4: appendicitis from fecaliths, younger people who tend to get it
Speaker 4: not from a fecalith, which kind of just makes sense.
Speaker 4: I think of it at least as like you've had
Speaker 4: more time for poop to get hard. I don't know
Speaker 4: if that's it. But this is also really important because
Speaker 4: you said Aaron earlier, like what about recurrence and things
Speaker 4: like that, and that is the biggest if there is
Speaker 4: a sort of downside to this antibiotics only or antibiotics
Speaker 4: first approach, is that failure rates tend to be relatively low,
Speaker 4: like eight to twelve percent of people if you try
Speaker 4: and treat them with only antibiotics end up getting sicker
Speaker 4: during that time period and needing surgery. And usually if
Speaker 4: that happens, they are sicker and that appendix is ruptured
Speaker 4: or closer to rupture. And it's like a more serious
Speaker 4: infection than maybe if you had treated it before by
Speaker 4: doing surgery rather than antibiotics. In many cases, that's when
Speaker 4: there was actually a fecalith there, right, So a lot
Speaker 4: of that initial failure rate is when there was a
Speaker 4: poop ball that was causing the initial appendicitis.
Speaker 3: And so that wouldn't show up on imaging necessarily. Sometimes
Speaker 3: it does.
Speaker 4: Forty percent of people with appendicitis on CT scan have
Speaker 4: a fecal myth, But I don't know if that means
Speaker 4: that forty percent of people are having appendicitis caused by
Speaker 4: that or if definitely there are sometimes that you might
Speaker 4: not see it even if it's there.
Speaker 3: Who are you not capturing?
Speaker 4: Right? Also, just like some people have fecalists without having appendicitis,
Speaker 4: that's a thing too, yep. Like incidentally you can find
Speaker 4: it like four percent of the time, huh, I know, right.
Speaker 4: But then there's also even if you can treat that
Speaker 4: infection initially, then there is a concern is it going
Speaker 4: to happen again? You had appendicitis once? Are you at
Speaker 4: risk for having appendicitis again? If we don't take that
Speaker 4: appendix out And the answer is that yes, recurrence can happen,
Speaker 4: and depending on the study, depending on the timeframe that
Speaker 4: they looked at. Most studies are short and only look
Speaker 4: at like one year rates of recurrence. A couple studies
Speaker 4: have looked up to like five years out, and if
Speaker 4: you look up to like five years out, the recurrence
Speaker 4: rates can be as high as forty percent. So what
Speaker 4: this means is that there really is a choice that
Speaker 4: people can make. And by people, I mean everyone who
Speaker 4: is involved in this decision. The person who's stick with appendicitis,
Speaker 4: that person's family, the physician who is treating them in
Speaker 4: the emergency room, the surgeon who may or may not
Speaker 4: be needed to do a surgery. Everyone is involved in
Speaker 4: the decision. Do we do surgery right now or do
Speaker 4: we not do surgery right now? If we don't do
Speaker 4: surgery now, do we do it later because we want
Speaker 4: to prevent this recurrence? But do we wait until we've
Speaker 4: treated the infection? Right? And so that is kind of
Speaker 4: like what it stands right now in terms of what
Speaker 4: is the kind of standard of care. There's not a
Speaker 4: perfect answer. Can you treat appendicitis with antibiotics alone, yes?
Speaker 4: Can you treat it with first line surgery? Yes? Is
Speaker 4: there a perfect answer, No, there is not. There are
Speaker 4: significantly higher rates of complications in almost all cases, and
Speaker 4: that means things like reoperations, wound infections, incisional hernias, small
Speaker 4: bowel obstructions, like major complications by doing surgery compared to
Speaker 4: antibiotics alone in a lot of the studies, And the
Speaker 4: only studies that seem to show more complications for antibiotics
Speaker 4: only in uncomplicated appendicitis is if people had one of
Speaker 4: those Pooh chunks, then they were more likely to get
Speaker 4: more sick, including maybe have deeper infection or sepsis, by
Speaker 4: not doing surgery right away.
Speaker 3: But when it comes to antibiotics versus surgery for appendicitis,
Speaker 3: the downsides of surgery are connected solely to the surgery
Speaker 3: itself and complications arising from that. Or are there also
Speaker 3: downsides to not having your appendix? Period?
Speaker 4: What a fun question. We don't know. Are there downsides
Speaker 4: to not having your appendix? We don't know, Aaron, Like,
Speaker 4: how do we not know?
Speaker 3: We've had literally, like so many decades, hundreds of years
Speaker 3: to figure this out.
Speaker 4: So I was going to talk about this later, but
Speaker 4: there's some really interesting data now on like the association
Speaker 4: between your appendix and things like ulst of colitis.
Speaker 3: Uh huh.
Speaker 4: And it actually seems that like in some small cases,
Speaker 4: like if you got your appendix out because you had appendicitis,
Speaker 4: and if you got your appendix out before you were
Speaker 4: a certain age, then having your appendix out might actually
Speaker 4: be protective against all sort of colitis. Fascinating, right, weird,
Speaker 4: it's not that is not what I have studies that
Speaker 4: you can read more because it's not that straightforward. But yeah,
Speaker 4: so what happens if you live without your appendix? Is
Speaker 4: there any complications other than surgical complications? Not that like
Speaker 4: we know of no, okay, and so there Really it
Speaker 4: used to be the case that, like I remember working
Speaker 4: with an obgui n right, So she did like pelvic
Speaker 4: surgeries on uteruses, and I remember being in a surgery
Speaker 4: with her where she showed me she was like, hey,
Speaker 4: look this is this person's appendix. Back in my day
Speaker 4: when I trained, we would take this out almost every time.
Speaker 4: If you see an appendix, just take it out because
Speaker 4: then they are never going to get appendicitis. And that
Speaker 4: was like standard of care way back when.
Speaker 3: Yeah, a lot like tanso, a lot like tonsils. So
Speaker 3: much like tonsils.
Speaker 4: Yeah, yeah, but yeah, are there downsides to it aside
Speaker 4: from obviously surgical complications? I don't know. I don't have
Speaker 4: an answer to that, right, Yeah, so interesting, So interesting, dude.
Speaker 4: So Aaron, tell me about the appendix.
Speaker 3: H yeah, I will do the best that I can
Speaker 3: right after this break. What do long term residents of
Speaker 3: an Antarctica settlement most astronauts and Stephen Colbert have in common?
Speaker 4: I'm appendix?
Speaker 3: Yeah, you guessed it.
Speaker 4: Wait wait, wait wait most astronauts, hold on, I have
Speaker 4: so many questions.
Speaker 3: Uh huh uh huh. Do they do it prophylactically some
Speaker 3: of the time? Yeah? Wow, okay, let's yeah. All of
Speaker 3: these people I just listed no longer have their appendix.
Speaker 3: In late twenty twenty three, Stephen Colbert developed appendicitis, and
Speaker 3: actually he taped a couple of shows before going to
Speaker 3: the hospital where they had found that his appendix had
Speaker 3: already ruptured. Fortunately he made a full recovery. NASA strongly
Speaker 3: recommends that astronauts have their appendix and gallbladder removed before
Speaker 3: venturing into the stars, and many have done so, and
Speaker 3: people who moved to VLS Astraeas, which is a long
Speaker 3: term settlement in Antarctica, they have to have their appendix
Speaker 3: out before moving in. Kids.
Speaker 4: Included is that because of the one story it probably Yeah,
Speaker 4: I love this story so much.
Speaker 3: You don't have to wait that long. It's telling it
Speaker 3: right here. So in nineteen sixty one, a Soviet physician
Speaker 3: named Leonid Rogasov was stationed in Antarctica, and at one
Speaker 3: point in time he recognized the signs and symptoms of
Speaker 3: appendicitis in himself, and he proceeded to operate on himself.
Speaker 3: On himself quote, on the morning of April twenty ninth,
Speaker 3: nineteen sixty one, I did not feel well. The symptoms
Speaker 3: noted were weakness, general malaise, later nausea. Within a few hours,
Speaker 3: pain arose in the upper portion of the abdomen, which
Speaker 3: soon shifted to the right lower quadrant. Body temperature rose
Speaker 3: to thirty seven point four degrees celsius. It was clearly
Speaker 3: a case of appendicitis end quote. Over the next day,
Speaker 3: things got worse and worse. Vomiting became more frequent, his
Speaker 3: fever got worse, the pain grew more intense, and with
Speaker 3: a blizzard, moving in help from another station became impossible. Quote.
Speaker 3: The only solution was to operate on myself. End quote.
Speaker 3: Can you imagine now, Rogazov injected a zero point five
Speaker 3: percent novacane solution into his abdomen, and while his co
Speaker 3: workers held a mirror and retractors, he made an incision
Speaker 3: and cut out his appendix. Quote. Sometimes I had to
Speaker 3: work entirely by feel end quote. Just by feel, I
Speaker 3: would be a disaster at that. I don't know what
Speaker 3: things feel like in my abdomen. I'm not a doctor, but.
Speaker 4: Yep. And he was a surgeon, right, he.
Speaker 3: Was, I think later became a surgeon. I think at
Speaker 3: the time, I remember he was just like he was
Speaker 3: a general practitioner. Oh wow, okay, yeah, uh And by
Speaker 3: midnight the operation was complete and within a few weeks
Speaker 3: he was back to normal.
Speaker 4: Wow.
Speaker 3: But things could have gone very poorly, which is no
Speaker 3: doubt part of the reason for the no appendix policy
Speaker 3: at this at the settlement in Antarctica via Las Astreas.
Speaker 3: But I just had to tell that story, yeah, because
Speaker 3: it's it's one of and the pictures are incredible. He's
Speaker 3: just like, his abdomen is open, and he's I.
Speaker 4: Just it's one of the most ridiculous stories. Uh yeah, yep, I'm.
Speaker 3: It's not the only instance of self appendectomy.
Speaker 4: I know.
Speaker 3: Yeah, it's the only one I'm going to tell today,
Speaker 3: So just give you a little something to google later.
Speaker 4: Do you remember, I don't remember how much of the
Speaker 4: show what's the show with the Scottish Highlanders? Outlander?
Speaker 3: Outlander?
Speaker 4: How much of that did you watch?
Speaker 3: Oh?
Speaker 4: Several seasons because they made it to America. She does
Speaker 4: that to herself? She doesn't, doesn't. Isn't an appendect tomy
Speaker 4: on herself.
Speaker 3: That she's I don't remember, but I wouldn't put it
Speaker 3: past her after the growing penicillin on bread. Yeah, Like.
Speaker 4: I'm pretty sure that's what it is.
Speaker 3: Yeah, anyways, anyways, but I mean, I think that, like
Speaker 3: what this reading about the appendix left me was this
Speaker 3: feeling that the appendix seems like an agent of chaos,
Speaker 3: disrupting plans at the very least, and causing life threatening
Speaker 3: injuries in more extreme cases. If we can take it
Speaker 3: out with seemingly no ill effect or no apparent ill effect,
Speaker 3: why the heck do we have it? Anyway? Shouldn't we
Speaker 3: all just get our appendixes out? That was the leading vibe,
Speaker 3: like you said, Erin about the organ for much of
Speaker 3: the twentieth century, just cut it out until the tune
Speaker 3: began to change as researchers realized that what had for
Speaker 3: so long been labeled a vestigial organ might actually perform
Speaker 3: some very important functions. So let's trace how our understanding
Speaker 3: of this weird little organ evolved over the centuries. It begins,
Speaker 3: of course, in ancient Egypt. Technically speaking, it begins when
Speaker 3: humans first evolved in appendix and developed appendicitis, which we
Speaker 3: undoubtedly have had for millennia. But an early piece of
Speaker 3: physical evidence of appendicitis comes from an Egyptian mummy from
Speaker 3: the first few centuries see who had right lower quadrant adhesions,
Speaker 3: suggesting a past episode of appendicitis. And while the appendix
Speaker 3: doesn't seem to get a mention in ancient anatomical texts,
Speaker 3: appendicitis does make an appearance, with Galen in the second
Speaker 3: century describing lower right quadrant pain that at the time
Speaker 3: was treated with either draining the abscess that formed or
Speaker 3: letting the patient die quote unquote a peaceful death, oh dear,
Speaker 3: from the sepsis that ultimately developed. Okay, peaceful as I
Speaker 3: think in the eye of the beholder, probably in that instance, yep.
Speaker 3: Over the next thousand years, or so, no doubt, people
Speaker 3: continued to get ill and die from appendicitis, but the
Speaker 3: labeling of human dissection as sacrilegious kept people from identifying
Speaker 3: where exactly the trouble was coming from. Like, you have
Speaker 3: this pain, but what's causing it? We don't know because
Speaker 3: we can't cut into your body. Yeah, And if people
Speaker 3: did perform dissections, it was on animal and most animals
Speaker 3: outside of primates and the wombat, don't have the same
Speaker 3: looking appendix in humans, they don't have the vermiform appendix.
Speaker 4: This is the second time we've talked about wombats in
Speaker 4: like two weeks.
Speaker 3: Wombats are all the rage. Their poop is cube cubular.
Speaker 3: Maybe that helps contribute to theilar air the fecalith I
Speaker 3: don't know. In any case, it wasn't until the fifteenth
Speaker 3: and sixteenth centuries, when dissection was back on the menu,
Speaker 3: that Anatomus identified and described the appendix, somewhat sloppily and
Speaker 3: with no clear idea of what its purpose was. Da
Speaker 3: Vinci illustrated the appendix in fourteen ninety two, but it
Speaker 3: didn't get published until a couple hundred years later. Andreas
Speaker 3: Vesalius also drew the appendix, but called it the secum,
Speaker 3: which led to decades of confusion over terminology and the
Speaker 3: link between the organ and the condition, like is this
Speaker 3: actually what is this condition caused? By?
Speaker 1: Right?
Speaker 4: Got it?
Speaker 3: Passion was one term used to describe what was probably appendicitis.
Speaker 3: I love using passion today by iliac is feeling very
Speaker 3: and advice for patients experiencing this type of passion was
Speaker 3: to manage it with big bouts of blood letting enemas
Speaker 3: that cooled or gave you diarrhea. You know, a cooling
Speaker 3: enema or a diarrhea enema, opiates, and something called warm
Speaker 3: animal compresses. I don't.
Speaker 4: I don't know know what that is. Maybe it's just
Speaker 4: putting a warm animal on you.
Speaker 3: Oh my god, just snuggle with your pup. Okay, I
Speaker 3: do that every day.
Speaker 4: It feels like it's something different, I don't.
Speaker 3: I think it's maybe a little more gruesome than just
Speaker 3: a cuddle sash.
Speaker 4: Yeah.
Speaker 3: Perforated appendixes leading to absesses also made appearances in medical texts,
Speaker 3: and the first appendectomy followed one such perforation. By the way,
Speaker 3: appendixes is the plural for appendix, like the human organ,
Speaker 3: but appendices is the plural for like an appendix, like
Speaker 3: a book appendix. Oh isn't that fascinating?
Speaker 4: That is fascinating. Yeah.
Speaker 3: I learned that in a great YouTube video by Patrick Kelly,
Speaker 3: who has an incredible channel of YouTube videos on like
Speaker 3: the history of medicine. Definitely check it out. I watched
Speaker 3: this video on appendicitis, loved it. Great, great stuff. And
Speaker 3: that's where I learned about appendixes because I heard it
Speaker 3: and I was like, I'm pretty sure it's appendices, and
Speaker 3: he's like, no, it's not. So it's great. Anyway. In
Speaker 3: seventeen thirty five, Claudius Amiand treated an eleven year old
Speaker 3: boy for his hernia, and in the process he found
Speaker 3: a fecal fistula to the scrotum, caused by a pin
Speaker 3: that the boy had ingested that had perforated his appendix.
Speaker 4: Oh my gosh, I really know, awful, awful.
Speaker 3: And so this guy, Claudius Amyon, took the appendix out,
Speaker 3: and from what I can tell, I actually found it
Speaker 3: hard to kind of piece together what happened afterwards. The
Speaker 3: child survived the surgery, like I went back to find
Speaker 3: the paper. But other cases of opportunistic apendectomies, like the
Speaker 3: surgeon took out the appendix during another procedure, but the
Speaker 3: appendix was not the initial target. These continued throughout the
Speaker 3: seventeen hundreds and into the eighteen hundreds, but people still
Speaker 3: weren't really making the connection between this organ which was
Speaker 3: occasionally described as black or swollen or gangrenous, and the
Speaker 3: abdominal pain associated interesting.
Speaker 4: Yeah, you would think, I mean, especially in the age
Speaker 4: of humors, something I know, black and gangrenous. That seems
Speaker 4: like bad humor.
Speaker 3: I don't know whether it was just like the frequency.
Speaker 3: It's not like people were performing surgeries left and right
Speaker 3: in the seventeen hundreds.
Speaker 4: That makes sense, Yeah, yeah, how interesting, and.
Speaker 3: Two major developments in the eighteen hundreds eventually paved the
Speaker 3: way for physicians to point the finger of blame towards
Speaker 3: the appendix and his role in right lower quadrant pain
Speaker 3: sometimes leading to death, athesia and antiseptics. Anesthesia and antiseptics
Speaker 3: meant people were more willing to undergo surgery, and surgeons
Speaker 3: more willing to perform them, since surgery was no longer
Speaker 3: as much of a death sentence as it had been
Speaker 3: in previous centuries. And glossing over a lot of old
Speaker 3: white dude names and most of the nineteenth century. More
Speaker 3: surgeries meant more opportunities to observe the appendix in its
Speaker 3: natural habitat inflamed, uninflamed, ruptured, gangrenous, perforated, just all the
Speaker 3: different flavors, like the spectrum of what the appendix can
Speaker 3: look like, right, and so getting more of that information
Speaker 3: would allow them to kind of make more classifications on
Speaker 3: when is it what is a healthy looking appendix versus
Speaker 3: what is not a healthy looking appendix, And eventually physicians
Speaker 3: and surgeons began to see the appendix as a surgical
Speaker 3: target in itself, not taken out just because you happened
Speaker 3: to be elbow deep in someone's intestines and you think,
Speaker 3: may as well kill two birds with one stone. Kind
Speaker 3: of a thing, but a reason to cut to begin with.
Speaker 3: In eighteen eighty six, Reginald Herbert Fitz, a pathologist, first
Speaker 3: introduced the term appendicitis and proposed that at any sign
Speaker 3: of lower right quadrant pain, that appendix has got to go.
Speaker 3: Just a year later, Thomas Morton performed the first appendectomy
Speaker 3: solely for appendectomy's sake, and the patient recovered. Another of
Speaker 3: his patients, however, did not dying from stepsis soon after surgery,
Speaker 3: which made Morton go is this really the right call? Like,
Speaker 3: do we really need to be doing this? In response
Speaker 3: to Morton's hesitancy, one doctor Chapman replied, quote, A true
Speaker 3: vermiform appendix is found only in six animals man, gorilla, chimpanzee,
Speaker 3: orange gibbon, and wombat. There can be no doubt therefore,
Speaker 3: that the sekl appendix is one of those parts of
Speaker 3: the human body having no particular function of significance, being
Speaker 3: of use only in animals. In the human being, it
Speaker 3: ought to be removed with no bad effect whatsoever. So
Speaker 3: that I thoroughly agree with doctor Morton and what he
Speaker 3: has to say regarding the opening of the abdomen and
Speaker 3: taking out the appendix. It seems to me that the
Speaker 3: human being is better off without the appendix than with it,
Speaker 3: for it is nothing but a trap to catch cherry
Speaker 3: stones and other foreign bodies.
Speaker 4: End quote. Okay, I have so many thoughts. First of all,
Speaker 4: everyone's always picking on things like cherry pits. First of all,
Speaker 4: who's eating cherry pits? But also why the fact that
Speaker 4: it's only in existence in some animals does that make
Speaker 4: it not functional in humans? Like most animals don't have
Speaker 4: opposable thumbs, and I think we can all respect that
Speaker 4: they're really important.
Speaker 3: I think it is like human superiority. So it's like,
Speaker 3: we don't need this, animals have this, Why the heck
Speaker 3: would we need it? Aaron, I'm not saying it's logical.
Speaker 4: It's so illogical because it's also like, well, only a
Speaker 4: few have it, So why did it evolve? In the
Speaker 4: they didn't evolution?
Speaker 3: But still, well, I think this was this was evolution.
Speaker 3: This is post Darwin. But Darwin himself was like in
Speaker 3: eighteen seventy one wrote quote, with respect to the alimentary canal,
Speaker 3: I have met with an account of only a single rudiment,
Speaker 3: namely the vermiform appendage of the sekum. Not only is
Speaker 3: it useless, but it is sometimes the cause of death.
Speaker 3: End quote. And so okay, I can see in some
Speaker 3: regard if you are when people get appendicitis and it's
Speaker 3: not treated or it's not removed, which would have been
Speaker 3: the case in much of the eighteen hundreds, you think,
Speaker 3: what is this thing that exists that kills us? If
Speaker 3: it gets bad? And if we take it out and
Speaker 3: someone survives the surgery, they survive it's not like your heart.
Speaker 3: It's not like your liver, right, like you can recover
Speaker 3: with no Effecteah.
Speaker 4: So it's also probably because it's so small and little,
Speaker 4: like how could it be important? Right? You think there's
Speaker 4: some sizism going on.
Speaker 3: No doubt, no doubt. But yeah, I think it was
Speaker 3: also like, you know, a handful of animals have it.
Speaker 3: We have it, but we can remove it easily with
Speaker 3: no problem, and we're better than animals. Maybe it's like
Speaker 3: all of these different things together, my guess is weird. Yeah,
Speaker 3: and so Darwin's hypothesis was that it once served a
Speaker 3: function in early humans, but as diet shifted from leaves
Speaker 3: to fruits, it was no longer necessary. This was again
Speaker 3: furthered by or like underlined by the fact that people
Speaker 3: who had their APPENICX taken out seemed to recover fine,
Speaker 3: and then that pattern encouraged further appendectomy because it was
Speaker 3: like might as well, no big deal.
Speaker 4: Yeah. Well, also like appendectomy versus death, it's an easy choice.
Speaker 3: It's an easy choice. Yeah. A few famous appendectomy cases
Speaker 3: further popularized the procedure. The most headlined worthy one was
Speaker 3: that of King Edward the seventh, the firstborn son of
Speaker 3: Queen Victoria. After the Queen's death in nineteen oh one,
Speaker 3: Edward was set to the throne on June twenty sixth
Speaker 3: and like coronation, but on the fourteenth of June, twelve
Speaker 3: days before, he began to develop severe abdominal pains, was
Speaker 3: diagnosed with likely appendicitis. He tried to delay the surgery
Speaker 3: and be like, we gotta do the coronation first, but
Speaker 3: then ended up having to delay the coronation to have
Speaker 3: the surgery. For the first few decades of the twentieth century,
Speaker 3: appendectomies were like ton selectomies, right, like we said, just
Speaker 3: get them out, it's fine, no need, no need. But
Speaker 3: unlike ton selectomies, people started to ring the alarm bell
Speaker 3: or like pump the brakes a bit earlier for the appendix,
Speaker 3: like let's just take a pause. Maybe we could use
Speaker 3: the appendix From a nineteen thirty one paper quote the
Speaker 3: diagnosis of chronic appendicitis must be made only after the
Speaker 3: history has been very carefully taken and thorough exclusion has
Speaker 3: been made of the numerous conditions simulating appendicitis. The day
Speaker 3: of indiscriminate appendectomy has passed and quote, but has it
Speaker 3: Some researchers think perhaps not. The introduction of antibiotics in
Speaker 3: the nineteen forties and the use of laparoscopic surgery in
Speaker 3: the nineteen eighties further lowered the threshold for appendectomy. But
Speaker 3: in the last few decades some people have questioned whether
Speaker 3: some cases of appendicitis could be instead treated with antibiotics
Speaker 3: rather than with the knife, like we talked about, And
Speaker 3: part of that questioning springs from the mystery of the
Speaker 3: appendix itself. What causes appendicitis? Does the appendix serve a purpose?
Speaker 3: If so, what is that purpose? And is it important
Speaker 3: enough to try to preserve the appendix when we can.
Speaker 3: Darwin's dismissal of the appendix in the eighteen seventies stuck
Speaker 3: around like a bad habit for about one hundred years
Speaker 3: or so, although a few people had their doubts for
Speaker 3: much longer, like a researcher named Barry, who reported in
Speaker 3: nineteen hundred that the human appendix contains lots of lymphoid
Speaker 3: tissue Gault Gault.
Speaker 4: Got associated lymphoid tissue.
Speaker 3: Uh huh, and so Barry suggested that the appendix might
Speaker 3: play some sort of immune role, or like Sir William McEwen,
Speaker 3: who wrote in nineteen oh four, quote, is this body
Speaker 3: of ours so very imperfect that we require to submit
Speaker 3: it to the numerous rectifications which are sometimes recommended to
Speaker 3: be carried out after it comes into the world. When
Speaker 3: a child is born into this country, some consider it
Speaker 3: necessary that he be circumcised. A few years later, the
Speaker 3: tonsils are removed. This is followed by the removal of
Speaker 3: the pharyngial tonsil a few years later. The appendix becomes
Speaker 3: an ever increasing terror, which is only a laid when
Speaker 3: that organ has been placed in a glass jar. The
Speaker 3: majority of mankind seems to do very well with the appendix.
Speaker 3: It gives rise to no annoyance in them, for it is,
Speaker 3: after all a small percentage of the community that becomes
Speaker 3: the victims of appendicitis? Is the appendix really a useless organ?
Speaker 1: End?
Speaker 4: Quote? I really love that quote? Aeric.
Speaker 3: Isn't that funny?
Speaker 4: It's really good?
Speaker 3: Why are we.
Speaker 4: Doing so much cutting?
Speaker 3: Yeah? And that question, which was posed in nineteen oh four,
Speaker 3: would only get a solid answer one hundred years later.
Speaker 3: In the early two thousands, researchers at Duke University discovered
Speaker 3: that hiding within the appendix was a little concentrated cluster
Speaker 3: of beneficial bacteria mediated by the host's own immune system.
Speaker 3: Biofilms like this exist throughout many mammals and testines, and
Speaker 3: they play a role in keeping the bad bacteria from
Speaker 3: taking over and helping with digestion of nutrients. But what
Speaker 3: happens when you get food poisoning or something just kind
Speaker 3: of like cleans out your entire gut, taking all the
Speaker 3: good bacteria in these biofilms along with it. That's where
Speaker 3: the appendix comes into play.
Speaker 2: Huh.
Speaker 3: Researchers think that the appendix acts as a quote unquote
Speaker 3: safe house for good gut bacteria, so that when about
Speaker 3: of diarrheal illness wipes out the good microbes living in
Speaker 3: your intestines, they can be recolonized buy the bacteria from
Speaker 3: your appendix.
Speaker 4: I love that idea, Aaron.
Speaker 3: Isn't that really cool?
Speaker 4: Have they? Can? I ask questions?
Speaker 3: Sure? Yeah?
Speaker 4: Have they? Because I know I was looking at some
Speaker 4: papers that looked at like whether there's a shift in
Speaker 4: your microbiome after an appendectomy and things like that, and
Speaker 4: it seemed like it was minor. Yeah, So then have
Speaker 4: they looked at like following an appendectomy, following a diarrheal illness.
Speaker 4: Is there a shift that is for the worst if
Speaker 4: you've had an appendectmy versus not or things like that.
Speaker 3: I wish I knew the answer to that. The only
Speaker 3: so there is some evidence of this in terms of
Speaker 3: like post appendectomy and seedediff infection. As we know from
Speaker 3: our seadiff episode from a million years ago. People who
Speaker 3: have like a seadiff infection, the bacteria just like colonize
Speaker 3: the entire intestinal tract and make it really difficult for
Speaker 3: any other commensal or like your your good bacteria to
Speaker 3: recolonize in your gut, and it's just like it's bad news, right,
Speaker 3: And so there have been studies that show that people
Speaker 3: who have had their appendix taken out have higher rates
Speaker 3: of sea diff infection, Okay, And so it's thought that
Speaker 3: the appendix helps to initiate an immune response after exposure
Speaker 3: to seed diff as like one of these things, Yeah,
Speaker 3: got bacteria that we'll just take all over.
Speaker 4: I will also say that in the studies that have
Speaker 4: looked at antibio, because antibiotic use is one of the
Speaker 4: major risk factors for sea diff infection, there does not
Speaker 4: seem to be an increase in sea diff infection after
Speaker 4: antibiotics for appendicitis. So if you're using antibiotics insteadive surgery,
Speaker 4: there's not an increased risk in seed iff.
Speaker 3: So that's very interesting. Yeah, there you go. And so
Speaker 3: Darwin I think got this one wrong, right. The appendix
Speaker 3: certainly does serve a purpose. Is that purpose essential to
Speaker 3: life or health? No, but it does play a role,
Speaker 3: which begs the question, well, why don't all animals have them?
Speaker 3: So early I mentioned that alongside humans, we have just
Speaker 3: a few other species that have these worm like vermiform appendixes,
Speaker 3: But as it turns out, many other animal species have
Speaker 3: what is functionally classified as an appendix, even if it
Speaker 3: doesn't have the same worm look to it. Marsupials, primates,
Speaker 3: and gliers, which is a new word for me. It
Speaker 3: means rodents and lagomorphs like rabbits, compires all have species
Speaker 3: within those groups that have an appendix, and researchers estimate
Speaker 3: that the appendix has evolved independently at least twenty nine
Speaker 3: times in mammals.
Speaker 4: Nine Okay, that alone, I feel like tells you that
Speaker 4: there's some functionality going on.
Speaker 3: Uh huh, and it's been lost twelve times, right, So
Speaker 3: like the balance is definitely in the favor of this
Speaker 3: being having evolved multiple times, suggesting this strongly suggests that
Speaker 3: this organ this appendix has been pretty important in evolutionary history.
Speaker 3: But does its serve the same purpose in these different species?
Speaker 3: Not necessarily, And there doesn't seem to be a strong pattern.
Speaker 3: And who has an appendix and who doesn't? Like is
Speaker 3: it influenced by diet, by environmental factors, by habitat, by
Speaker 3: other aspects of ecology, by life history characteristics. We don't
Speaker 3: yet know. There's even variation within a species. So in
Speaker 3: certain primate species, some individuals have an appendix and others don't.
Speaker 4: Stop it?
Speaker 3: What right? Yeah, I don't know. In general, people think
Speaker 3: that in humans and other primates and maybe some rodents,
Speaker 3: the appendix serves this immunological function, like helping to protect
Speaker 3: us from invading pathogenic gut bacteria and sort of recolonizing
Speaker 3: when we do get a GI infection. In marsupials, it
Speaker 3: might just be that the appendix acts as kind of
Speaker 3: like the more developed sekum found in other animals, and
Speaker 3: in lagomorphs like rabbits, it might trap sand like.
Speaker 4: Oh, my dolar needs.
Speaker 3: Maybe that's why I'm involved in humans, maybe just for
Speaker 3: toddlers for toddlers, but yeah, I mean, it seems like
Speaker 3: we don't fully know why the appendix, like, what purpose
Speaker 3: the appendix serves in these different animal species or groups,
Speaker 3: and is it the same, is it different? Why do
Speaker 3: some organisms have it and others don't? And there might not
Speaker 3: be one thing driving the evolution of the appendix across
Speaker 3: all these animal species. But that being said, until recently,
Speaker 3: most research has focused on human appendixes, and other animals
Speaker 3: have largely been ignored. And so it might be that
Speaker 3: we get more clarity on that in the years to come,
Speaker 3: as we hopefully will for the causes of appendicitis and
Speaker 3: being able to better manage like treatment and weighing the
Speaker 3: scales in the favor of antibiotics or surgery. But speaking
Speaker 3: of the years to come, what else this might be
Speaker 3: on the horizon for appendix research? Can you hit me
Speaker 3: with some global appendicitis numbers?
Speaker 2: Oh?
Speaker 4: I would love to try right after this break. Some
Speaker 4: of the papers that I read, a lot of the
Speaker 4: papers actually cite that acute appendicitis is the most common
Speaker 4: abdominal surgical emergency in the world with an incident. This
Speaker 4: is an incidence that I think is based on US numbers,
Speaker 4: but I don't actually know. But the incidence is estimated
Speaker 4: at ninety six to one hundred cases per one hundred
Speaker 4: thousand adult Okay, which is pretty high. So this is
Speaker 4: like thousands, hundreds of thousands of people in the US,
Speaker 4: millions of people across the globe that get appendicitis every year.
Speaker 4: The incidence, at least in the US tends to be
Speaker 4: the highest in teens, so like age ten to nineteen
Speaker 4: is tends to be the highest incidents, but plenty of
Speaker 4: young adults and older adults also get appendicitis. You can
Speaker 4: get it at any age. It is pretty rare to
Speaker 4: get it under age ten, and I don't have a
Speaker 4: good answer as to why that is. My best guess
Speaker 4: is like less lymphoid tissue in there. Maybe it hasn't
Speaker 4: grown enough. I have no idea.
Speaker 3: Yeah, filled with sand still from.
Speaker 4: Yeah, you can still get that mesentery loom. You're actually
Speaker 4: really funny. You can still get mesentary lymphatinitis, which is
Speaker 4: a separate entity but is like when just like lymph
Speaker 4: tissue causes inflammation and pain in that area without actually
Speaker 4: causing dwelling and infection in the appendix, So maybe it's
Speaker 4: something to do with like, I don't know, I don't
Speaker 4: have an answer, but and I said, it's also slightly
Speaker 4: more common in those assigned male at birth compared to
Speaker 4: those assigned female at birth. But it's also the case.
Speaker 4: And what I want to focus on a little bit
Speaker 4: in terms of our statistics is that accurate diagnosis is
Speaker 4: really important, right because this is something that can very
Speaker 4: easily go from treatable to emergency, to sepsis to life threatening.
Speaker 4: Accurate diagnosis is very tightly linked to outcomes. So having
Speaker 4: a delay in your diagnosis or the incorrect diagnosis the
Speaker 4: first time that you present to care results in worse
Speaker 4: outcomes perforation, more severe infection, potentially death, and unfortunately and unsurprisingly,
Speaker 4: it is very predictable what the risk factors are that
Speaker 4: contribute to delayed diagnosis. Things like race and ethnicity are
Speaker 4: significant contributors to delays in diagnosis. So studies have found
Speaker 4: that especially in kids, Black children are less likely to
Speaker 4: get opioid pain medication compared to white children who present
Speaker 4: with appendicitis. Black children and Asian children in some studies
Speaker 4: are more likely to have appendicial rupture compared to white children,
Speaker 4: which could be a contribution of difficulties and access to
Speaker 4: care as well as delays in diagnosis. Uh huh, And
Speaker 4: there wasn't a lot of data that I found. At
Speaker 4: least it might be out there on populations like the
Speaker 4: Hispanic or Latino populations, but I would guess that, especially
Speaker 4: in this country, there are huge racial and ethnic discrepancies
Speaker 4: there as well in terms of access to care. In
Speaker 4: terms of delayed diagnosis, sex also plays a role people
Speaker 4: as on female at birth both adults and children are
Speaker 4: more likely to have a delayed or misdiagnosis of appendicitis
Speaker 4: and socioeconomic status itself, at least as measured by insurance type.
Speaker 4: So in the US, people with private insurance tend to
Speaker 4: be of higher income to those on public insurance, and
Speaker 4: people on public insurance are more likely to have a
Speaker 4: pendicial rupture than people on private insurance. So this is
Speaker 4: a huge issue of equity and discrepancies in access to care.
Speaker 4: In social determines of health, it's multifactorial. It's not just
Speaker 4: not being believed and not being diagnosed correctly or taken
Speaker 4: seriously in the emergency room, but that is part of it.
Speaker 4: It's also not having access to an emergency room close
Speaker 4: to where you live or whatever. Like, there's a lot
Speaker 4: of different things that play into it layers. Yeah, I
Speaker 4: think that in terms of one of the like where
Speaker 4: does the research go? There's like there's so much erin
Speaker 4: But I think one of the things that is going
Speaker 4: to be really interesting to watch in real time, like
Speaker 4: we are living this right now, is like, are these
Speaker 4: tides really shifting fully towards a non operative approach? And
Speaker 4: if so, how do we accomplish that? What more data
Speaker 4: do we need to know? Who is going to do
Speaker 4: really well with antibiotics alone? What are the criteria that
Speaker 4: we're using to come up with the best antibiotic regimen,
Speaker 4: because right now, there's not like a standard like, well,
Speaker 4: if you're going to do only antibiotics, here's your standard
Speaker 4: of care, right, And where do we go from here?
Speaker 4: Because the incidence of reoccurrence of appendicitis is not trivial, right,
Speaker 4: It's like fifteen to forty percent depending on the study.
Speaker 4: So then my question is does the appendix go the
Speaker 4: way of the gallbladder where ideally, if you have cholisistitis,
Speaker 4: which is infection because your gallboughder gets clogged, the same
Speaker 4: way that your appendic gets clogged. Ideally you treat it
Speaker 4: with antibiotics first and then do surgery later when there's
Speaker 4: not an active, really bad infection. Because the thing that's
Speaker 4: not kind of mentioned in a lot of this is
Speaker 4: doing surgery on an abdomen that's actively infected is a
Speaker 4: lot harder than doing surgery on an abdomen that's not infected,
Speaker 4: because infection comes with a lot of other stuff. It
Speaker 4: comes with a lot of inflammation, which means that you
Speaker 4: have a more likely risk of things like adhesions and
Speaker 4: complications later on. So if you can do a surgery
Speaker 4: when things are not angry and infected, that's better. But
Speaker 4: is it necessary in the case of appendicitis or is
Speaker 4: it not? I don't know, Aaron.
Speaker 3: It's interesting, And then like, what are there instances where
Speaker 3: people who are treated with antibiotics. It's like, for sure,
Speaker 3: a case of appendicitis are treated with antibiotics and then
Speaker 3: the appendix proceeds to rupture. Does that happen?
Speaker 1: Oh?
Speaker 4: Yeah, like the like the antibotics just don't work, right, Yeah, absolutely,
Speaker 4: that happens to twelve percent of the time.
Speaker 3: Yeah, okay, So like it's yeah, I do think that
Speaker 3: that is really interesting where it's like, ideally, let's schedule
Speaker 3: this surgery, let's pencil it in, but what are the
Speaker 3: risks associated with that? And those risks can be severe, right,
Speaker 3: not just high risk, but like high risk outcomes, like
Speaker 3: the risk the outcomes are really bad.
Speaker 4: I guyes, yeah, exactly, yeah. And then there's also the
Speaker 4: risks of surgery which are not trivial and especially depending
Speaker 4: on the person, what their other risk factors are, et cetera,
Speaker 4: et cetera. Like it's it is not a straightforward thing,
Speaker 4: and that is why I think there is still such
Speaker 4: a I won't say debate, but just like what is
Speaker 4: the right answer right now? There isn't one right And
Speaker 4: so we've talked a lot on this podcast about how
Speaker 4: medicine moves slowly, and I think that this is something
Speaker 4: like the treatment of appendicitis with antibiotics is something that
Speaker 4: has been picking up more and more steam, but there's
Speaker 4: still a lot of open questions as to what the
Speaker 4: safest and best way is to do that. And so
Speaker 4: it's going to vary a lot where you are, which
Speaker 4: er you show up to, who's working, what your particular
Speaker 4: case looks like. To know, like what is the best
Speaker 4: possible outcome, and sometimes we can't possibly know that. But
Speaker 4: the more data that we have, the better of a
Speaker 4: prediction that we can have on what the quote unquote
Speaker 4: best option is, which is it's really interesting. I think
Speaker 4: that part of that will also have to go along
Speaker 4: with more information on what the heck does this appendix
Speaker 4: do right? And how bad is it to take it out?
Speaker 4: I mean, we take out gallblotters all the time. We
Speaker 4: take out appendixes all the time. We take out You
Speaker 4: can take out a spleen. You can take out so
Speaker 4: many your whole colon. You can do it all and
Speaker 4: live without these organs. But should we?
Speaker 3: It depends right? Yeah? Number one, I have two thoughts.
Speaker 3: One is the thought. One is a question, let's do
Speaker 3: an episode on gallbladders, because yes, I want to know
Speaker 3: a lot more I know, yep about call blotters for
Speaker 3: personal reasons, but also purely curious academic reasons.
Speaker 4: Personal and professional reasons exactly.
Speaker 3: And number two, why does a pendicitis make you vomit?
Speaker 3: Is it the pain?
Speaker 4: That's a good question. I have no idea. Is it
Speaker 4: the pain? Is it also just that like you have
Speaker 4: inflammation in your guts? Overall? And so your response to
Speaker 4: that is.
Speaker 3: Like, well, but why do you vomit rather than have
Speaker 3: diarrhea or something you can't havesly can have diarrhea. You
Speaker 3: could just be both. Okay, Yeah, I feel like I
Speaker 3: don't as commonly read about the diarrhea part of appendicitis,
Speaker 3: and mostly hear about the vomiting.
Speaker 4: You can have diarrhea, you can have constipation, and sometimes
Speaker 4: that can make it harder for somebody to diagnose it
Speaker 4: pinpoint as appendicitis, because you're right, the classic description doesn't
Speaker 4: include diarrhea or conversation, right.
Speaker 3: And I'm sure that like part of what's contributing to
Speaker 3: all the confusion is that people hold very strong opinions
Speaker 3: about what is the right course of action to be
Speaker 3: done well.
Speaker 4: And it's also like we're talking about surgery versus non surgery,
Speaker 4: and if you're a surgeon you're going to have a
Speaker 4: different opinion about that than if you are not a surgeon, too, write.
Speaker 3: Like or if you're the patient and you're like, I
Speaker 3: want surgery because I don't want to have to have
Speaker 3: this happen again and have to run to the er.
Speaker 4: And that's why it's such like at this point, and
Speaker 4: I think probably from this point forward it is and
Speaker 4: will be an individualized decision. It's not, it shouldn't be.
Speaker 4: That is more and more the way that me is
Speaker 4: moving right is it's like there is not a one
Speaker 4: size fits all approach because everyone is also going to
Speaker 4: have a different risk tolerance for surgery and for not surgery.
Speaker 4: Like there's so many, oh, so many. I could keep going,
Speaker 4: but if you want to just learn more instead of
Speaker 4: hearing us blatd on, We've got sources for you.
Speaker 3: We do. I have a few different sources here. So
Speaker 3: again I want to shout out that video on YouTube
Speaker 3: by Patrick Kelly titled what Happened to Appendectomies? Great channel,
Speaker 3: overall great video. Loved it. And then if you would
Speaker 3: like to learn more about the history of appendicitis and appendectomies,
Speaker 3: there is several papers. One I liked called Historic Phases
Speaker 3: of Appendicitis from like nineteen thirty one. It's a little
Speaker 3: bit old, but kind of fun. And then for the
Speaker 3: paper that discussed the function of the appendix, there's a
Speaker 3: paper from two thousand and seven titled biofilms in the
Speaker 3: large bowel suggests an apparent function of the human vermiform
Speaker 3: appendix Bolinger at all, give it, give it all to us.
Speaker 4: In the title, I had a few papers, a bunch
Speaker 4: of reviews. There was one from JAMMA twenty twenty one
Speaker 4: titled Diagnosis and Management of Acute Appendicitis in Adults a review.
Speaker 4: There was several reviews of the use of antibiotics versus
Speaker 4: surgery for appendicitis, which are really interesting, both in adults
Speaker 4: and in kids. So there's a couple different papers there.
Speaker 4: And then there's more that one where I briefly mentioned
Speaker 4: the connection between the appendix and alsative colitis. That was
Speaker 4: from a Nature Reviews in gastra Entrology paper from twenty
Speaker 4: twenty three titled the appendix and alsative colitis an Unsolved Connection.
Speaker 4: So there's a bunch there. You can find the list
Speaker 4: of sources from this episode and all of our episodes
Speaker 4: on our website This Podcast will Kill You dot Com
Speaker 4: under the episodes tab.
Speaker 3: Thank you again, Mollie so much for sharing that story
Speaker 3: with us. Just thank you.
Speaker 4: Yeah.
Speaker 3: Thank you also to Bloodmobile for providing the music for
Speaker 3: this episode and all of our episodes.
Speaker 4: Thank you to Tom Bryfogel and Leanna Scolacci for the
Speaker 4: incredible audio.
Speaker 3: Mixing thank you to everyone at exactly Right, and.
Speaker 4: Thank you to you listeners. We hope you enjoyed this episode.
Speaker 4: Do you still have your appendix? A lot of you
Speaker 4: have written in saying that you, in fact no longer
Speaker 4: have your appendix? Have your lives changed at all since
Speaker 4: having it out? I actually never asked them on that question. Curious.
Speaker 3: Yeah, and a huge thank you, as always to our
Speaker 3: fantastic patrons. We appreciate your support. It truly does mean
Speaker 3: the world to us.
Speaker 4: Thank you, thank you, thank you. Well.
Speaker 3: Until next time, wash your hands.
Speaker 4: You feel for the animals. M