Negative Appendectomy: Now What?

abdominal pain

Acute abdominal pain is the number one presenting complaint in the emergency department, and often requires surgical intervention. However, there are a number of nonsurgical disorders that often masquerade as more serious conditions, leading to unnecessary surgery. In particular, functional disorders involving the digestive system, such as irritable bowel syndrome (IBS), functional abdominal pain syndrome (FAPS), and chronic abdominal wall pain (CAWP), are associated with an increased rate of negative appendectomy in hospitals.

A negative appendectomy occurs when a normal appendix is removed following a medical workup for acute abdominal pain that indicates surgical intervention, and is more common in people diagnosed with IBS. Long thought to be a vestigial, or unnecessary organ, it is now considered possible that the appendix is a repository for symbiotic gut bacteria which help to recolonize the microbiome following a disturbance to the intestinal ecosystem. Therefore, a negative appendectomy may have long-term consequences beyond those simply due to the surgical procedure. For example, negative appendectomy is higher in pregnant women, and increases the chances of losing the baby.

Anxiety and depression can also contribute to abdominal pain. Other functional disorders, such as adverse reactions to food (ARFs) and mast cell activation syndrome (MCAS) can also contribute to abdominal pain warranting a trip to the emergency room. While often a prudent choice, once the ER team has determined that a surgical intervention is not indicated, they have little else to offer besides for some pain relievers and referral to a specialist.

Approximately 30% of patients admitted to the hospital for acute abdominal pain are discharged without fully determining the cause of the pain, as lab tests are often of limited value. Advanced imaging studies like multidetector-row computed tomography (MDCT) are very helpful in diagnosis of abdominal pain, however as cost as well as a patient's cumulative dose of ionizing radiation need to be taken into account, it doesn't always make sense to order these studies.

When the source of an episode of acute abdominal pain remains unidentified, or when chronic pain persists for more than three months, patients are often diagnosed with functional gastrointenstinal disorders (FGID). These disorders sometimes respond to drug therapy with antispasmodics or antidepressants. However, in those for whom standard treatment is inadequate, or who wish to avoid pharmaceuticals due to side-effects, or other reasons, there are many non-pharmacological options offered by Complementary and Alternative Medicine (CAM). Abdominal pain remains one of the top reasons people seek CAM, particularly in those diagnosed with IBS, or a history of abdominal surgery like appendectomy.

Despite the prevalence of integrative gastroenterology, physician knowledge about the use and regulation of dietary supplements remains generally poor. Many clinicians are in need of additional training regarding the use of herbs and dietary supplements, which may result in a higher rate of self-prescription by patients who do not trust their doctor's advice regarding CAM therapies. In addition, biased or anecdotal information on the Internet encourages people to make decisions regarding the use of dietary supplements without consulting an adequately trained health professional.

There are a number of natural solutions for abdominal pain due to functional digestive health complaints, each with varying levels of risk and evidence for efficacy. While a negative appendectomy often leads to a search for remedies outside of conventional medicine, positive outcomes are more likely when complementary and alternative methods are coordinated between one's primary physician, and a natural health professional, such as a naturopathic physician.

Journal References

Ashar BH, Rice TN, Sisson SD. Physicians' understanding of the regulation of dietary supplements. Arch Intern Med. 2007 May 14;167(9):966-9. [PMID: 17502539]

Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among adults and children: United States, 2007. Natl Health Stat Report. 2008 Dec 10;(12):1-23. [PMID: 19361005]

Carmona-Sanchez R, Tostado-Fernandez FA. Prevalence of use of alternative and complementary medicine in patients with irritable bowel syndrome, functional dyspepsia and gastroesophageal reflux disease. Rev Gastroenterol Mex. 2005 Oct-Dec;70(4):393-8. [PMID: 17058977]

Cartwright SL, Knudson MP. Evaluation of acute abdominal pain in adults. Am Fam Physician. 2008 Apr 1;77(7):971-8. [PMID: 18441863] Free Full Text Online

Costanza CD, Longstreth GF, Liu AL. Chronic abdominal wall pain: clinical features, health care costs, and long-term outcome. Clin Gastroenterol Hepatol. 2008 Apr 1;77(7):971-8. [PMID: 15118977]

Elsenbruch S, Rosenberger C, Bingel U, Forsting M, Schedlowski M, Gizewski ER. Patients with irritable bowel syndrome have altered emotional modulation of neural responses to visceral stimuli. Gastroenterology. 2010 Oct;139(4):1310-9. doi: 10.1053/j.gastro.2010.06.054

Guthrie E, Thompson D. Abdominal pain and functional gastrointestinal disorders. BMJ. 2002 Sep 28;325(7366):701-3. [PMID: 12351366] Free Full Text Online

Hamilton MJ, Hornick JL, Akin C, Castells MC, Greenberger NJ. Mast cell activation syndrome: a newly recognized disorder with systemic clinical manifestations. J Allergy Clin Immunol. 2011 Jul;128(1):147-152.e2. doi: 10.1016/j.jaci.2011.04.037

Kaicker J, Debono VB, Dang W, Buckley N, Thabane L. Assessment of the quality and variability of health information on chronic pain websites using the DISCERN instrument. BMC Med. 2010 Oct 12;8:59. doi: 10.1186/1741-7015-8-59 Free Full Text Online

Kemper KJ, Gardiner P, Gobble J, Woods C. Expertise about herbs and dietary supplements among diverse health professionals. BMC Complement Altern Med. 2006 Apr 28;6:15. [PMID: 16646964] Free Full Text Online

Lameris W, van Randen A, van Es HW, van Heesewijk JP, van Ramshorst B, Bouma WH, ten Hove W, van Leeuwen MS, van Keulen EM, Dijkgraaf MG, Bossuyt PM, Boermeester MA, Stoker J; OPTIMA study group. Imaging strategies for detection of urgent conditions in patients with acute abdominal pain: diagnostic accuracy study. BMJ. 2009 Jun 26;338:b2431. doi: 10.1136/bmj.b2431 Free Full Text Online

Leschka S, Alkadhi H, Wildermuth S, Marincek B. Multi-detector computed tomography of acute abdomen. Eur Radiol. 2004 May;2(5):395-9. [PMID: 15118977]

Longstreth GF. Avoiding unnecessary surgery in irritable bowel syndrome. Gut. 2007 May;56(5):608-10. [PMID: 17440179] Free Full Text Online

McGory ML, Zingmond DS, Tillou A, Hiatt JR, Ko CY, Cryer HM. Negative appendectomy in pregnant women is associated with a substantial risk of fetal loss. J Am Coll Surg. 2007 Oct;205(4):534-40. [PMID: 17903726]

Ruepert L, Quartero AO, de Wit NJ, van der Heijden GJ, Rubin G, Muris JW. Bulking agents, antispasmodics and antidepressants for the treatment of irritable bowel syndrome. Cochrane Database Syst Rev. 2011 Aug 10;(8):CD003460. doi: 10.1002/14651858.CD003460.pub3

Weijenborg PT, Gardien K, Toorenvliet BR, Merkus JW, ter Kuile MM. Acute abdominal pain in women at an emergency department: predictors of chronicity. Eur J Pain. 2010 Feb;14(2):183-8. doi: 10.1016/j.ejpain.2009.04.005

Youssef NN, Atienza K, Langseder AL, Strauss RS. Chronic abdominal pain and depressive symptoms: analysis of the national longitudinal study of adolescent health. Clin Gastroenterol Hepatol. 2008 Mar;6(3):329-32. doi: 10.1016/j.cgh.2007.12.019

News References

Duke University Medical Center. "Appendix Isn't Useless At All: It's A Safe House For Good Bacteria." ScienceDaily, 8 Oct. 2007. Web. 25 Aug. 2013.

Duke University Medical Center. "Evolution Of The Human Appendix: A Biological 'Remnant' No More." ScienceDaily, 21 Aug. 2009. Web. 25 Aug. 2013.

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Last Updated: 25 Aug 13