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I am listening to Rick Rubin's The Creative Act: A Way of Being on Audible, and in his chapter "look for Clues" at 2 minutes and 45 seconds, he makes a peculiar claim. He claims that his appendix burst and was never removed. He makes it seem as if he never had surgery at all. I suspect this is a case of misdiagnosis, but I wanted to know if it were even possible to survive such a calamity.

My understanding, from having my own appendectomy 20 years earlier, when an appendix bursts, it's because something blocked the exit end and fecal matter was filling the appendix, stretching it and causing pain, until it finally bursts, which can temporarily bring relief. If and when it ruptures, the fecal material enters the body cavity that can lead to abscesses, peritonitis, and sepsis, and greatly increases the risk of death. For non-perforated cases of appendicitis, the mortality rate is 1%; whereas, with a ruptured appendix, the mortality rate increases to 5%, which is why antibiotics are usually prescribed after an appendix bursts. But, that is with appendectomy patients. It does not address patients whose appendix has perforated and they refuse surgical treatment.

The question arises, "How would we know". I mean, if a patient never has surgery, how can we be sure the person's appendix ever burst? And, I came up with two possible ways. the first would be a case of where a surgeon goes to operate on another unrelated issue and finds a ruptured appendix that had occurred in the distant past. Alternatively, a med student or some other person conducting an autopsy or using the cadaver for training purposes could find a ruptured appendix that never managed to cause their death.

Some subquestions could be:

A) Is it possible for a ruptured appendix to heal by itself?

B) Would we even be able to tell, i.e. would there be obvious scarring or other easily detectable signs that the appendix ever burst in the first place if it healed?

C) Is it possible for gastrointestinal material, for lack of a better word, to enter the abdominal cavity and remain there indefinitely without causing obvious issues such as infection?

D) (D1) Could the body, beat back or prevent the infection, (D2) excrete or isolate the material from abdominal cavity, and (d3) then heal the ruptured appendix without any outside intervention?

Is any of this even possible?

To be clear, you do not need to answer A through D, though that would provide me a little more insight. Those are just sort of guiding questions to the overall question of: Is it possible to survive a ruptured appendix without surgical intervention? Is this something that is even knowable at this time? The suggestion I get from the review says this is a subjective question. If this is true, could someone explain why before closing it? Are there several competing, well-accepted schools of thought on the possibility of surviving a ruptured appendix?

My intuition tells me that the conditions mentioned towards the start — abscesses, peritonitis, and sepsis, especially the last two, would prove fatal in virtually, if not literally, all cases.

As far as my preferred answers go:

  1. A peer reviewed article mentioning the case of a confirmed burst appendix that healed without medical intervention.

  2. Medical explanations from reputable sources explaining how it would be possible to survive a burst appendix — OR — explaining why it would NOT be possible.

  3. Any medical reasoning as to how/why it would be possible/impossible to survive a burst appendix.

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  • Imaging of the abdomen in suspected cases of acute appendicitis is very common now, perhaps even the gold standard, but was unheard of when I first started practicing. The increasing accuracy/resolution of imaging (via ultrasound, CT or MRI) started its use about 25 years ago. Feb 22 at 20:07
  • Maybe this is a new type of imaging, but back around 2012 when I was involved in a car crash, then later in 2014 when I was suffering from gallstones, they did CT scans of my abdomen. In both cases, they noted my appendix was "present and unremarkable" or something to that extent. When they removed my gallbladder, the surgeon confirmed to me that I did not have an appendix. My point is that I am skeptical of the accuracy of imaging on diagnosing a non-obvious problem. Then again, maybe my experiences are rare. Feb 27 at 17:35
  • Imaging studies are themselves excellent, but the quality is dependent on the technician doing the imaging, and the radiologist reading the images. I know first hand of a case where a urologist missed a 5 cm mass compressing and displacing the left ureter, and IVP's are their bread and butter. You may be as skeptical as you like, but images don't make mistakes; radiologists and other people do. It's possible your appendix is retrocecal, which would falsely look like absence. ... Feb 27 at 17:52
  • Also, the appendix gets smaller during midlife and after. (40 and over.) If you never had your appendix removed, there's only a 1:100,000 that you never have one. I can think of a number of reasonable explanations for the discrepancy, but the value of imaging is not at all a question in my mind. It has been indispensable for the diagnosis of millions (upon millions) of diseases. I believe I answered your question, at the very least, unless you doubt all the research using imaging. Feb 27 at 17:58

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Edited to add: This is a useful paper to understand appendicitis, general and best treatment approaches, interval appendectomies, and other aspects referred to in this answer. Please note: I think that acute appendicitis should be treated surgically, but that the diagnosis of appendicitis should be confirmed (and evaluated) by imaging studies before surgery.


People have survived ruptured appendixes. The appendix is an elongated sac, a blind pouch, which can get infected.

You state,

...until it finally bursts...

That was a common belief decades ago, and is the reason for the high rate of operative treatment of appendicitis.* But progression from non-perforated to perforated appendicitis is not well understood and for many, that progression just doesn't occur.

From the BJM:

The contrast with the widely varying incidence of non-perforating appendicitis supports Luckman's proposition that perforating and non-perforating appendicitis are separate entities, as do earlier observations of higher rate of obstruction and faecaliths in gangrenous and perforating appendices than in phlegmonous appendixes. [emphasis mine]

Is it possible for a ruptured appendix to heal by itself?

Yes. The way the body does this is by isolating/"walling off" the infected area during the immune response to the inflammation the rupture causes; it is only successful some of the time. (This is true of many infections, maybe most observable of wounds containing foreign bodies where a tough capsule of connective tissue surrounds.)

Many with appendicitis are unable to obtain surgical treatment, e.g. sailors, submariners, those without access to prompt medical care, etc. Whenever possible, these are treated with antibiotics. Some will progress to perforation. Others will simply have the appendicitis subside, and a subgroup will develop recurring appendicitis.

In some countries, appendicitis is not always treated surgically, because the progression to perforation has never been established.

Would we even be able to tell [if someone survived a perforated appendix]?

In the past (more than today), one way to know would be to find a walled off, encapsulated area in the vicinity of the appendix when someone is having abdominal surgery for an unrelated reason or on autopsy (again, remote to the event.) This has happened many times.

Since high-resolution imaging became a common tool in the evaluation of suspected appendicitis, one can see perforated appendixes in those who have not accessed medical care in the early stages. This paper is one of many that discusses such cases, so clearly, people have survived perforated appendixes.

Appendixes which have perforated form a mass of some kind (see above paper.) Interval appendicectomy refers to an appendectomy performed after an interval of conservative management, i.e. non-operative.

From the Lancet, in the CHINA study (CHildren's INterval Appendicectomy (2017):

Despite a scarcity of supporting evidence, most surgeons recommend routine interval appendicectomy after successful non-operative treatment of an appendix mass in children. We aimed to compare routine interval appendicectomy with active observation. Between Aug 8, 2011, and Dec 31, 2014, we randomly assigned 106 patients, 52 patients to interval appendicectomy and 54 to active observation....

Since not all appendicitis progresses to rupture, and rupture (perforation) can be managed non-operatively, it can be concluded that some cases of perforated appendicitis survive without operative (or medical) care, but how many is impossible to discern, as many do not present for medical care.

*When I was a med student, then resident (many decades ago), general surgeons had a motto: "If you're not removing healthy appendixes 20% of the time, you're missing a lot of appendicitis." This belief is supported by the fact that a normal appendix is found in 15-40% of patients who have an emergency appendectomy. The most common mistake is misdiagnosing mesenteric adenitis as acute appendicitis.

Active observation versus interval appendicectomy after successful non-operative treatment of an appendix mass in children (CHINA study): an open-label, randomised controlled trial

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I had a dig through the literature, specifically looking for papers prior to the main advent of antibiotic therapy, which, as I am sure you know, significantly reduces mortality from bacterial infection.

The best paper I found dates from 1949 by Griswold and Goodspeed1 (read for free on Pubmed Central - see PMCID in ref below). This paper indicates that another publication (which I can't find, but Griswold is one of the authors, see ref 2 below) of a 5 year survey of 1412 cases found:

In a report compiled for the years 1931-1937 inclusive and representing a study of 1412 consecutive cases of all types of appendicitis it was found that those cases complicated by perforation had a mortality of 15.3 per cent.

The paper is worth a read as they also cite other similar (often lower) statistics from around the same time and other papers in the 1940's after the introduction of sulfonamide drugs, which started to reduce the mortality.

I would take this as meaning that in ruptured appendix cases where there was no surgical intervention, and no antibiotic therapy, the survival rate is about 85% or higher, that's about 3 out of every 20 cases dying.. That's still a significant risk of death, but not impossible.

Refs:

  1. Griswold ML, Goodspeed WK. Factors in the Mortality of the Ruptured Appendix. Ann Surg. 1949 Feb;129(2):260-6. doi: 10.1097/00000658-194902000-00010. PMID: 17859305; PMCID: PMC1513951.

  2. Munger, R. T., and M. L. Griswold, Jr.: A Five Year Survey of 1412 Cases of Appendicitis in a Suburban Hospital. J. Med. Soc., New Jersey, 35: 355, 1938. I can't find this one, feel free to track it down.

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    My search found a higher mortality, but it's important to keep in mind that many cases of appendicitis (with perforation and infection which may well remain localized) occur where no medical care is available, so we can't even count those, as they never interface with people who study and report such cases. Feb 22 at 8:17
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    @anongoodnurse Yes, good point. Unfortunately, I suspect impossible to find stats on for pretty obvious reasons.
    – bob1
    Feb 22 at 19:03
  • Were antibiotics not in use during that time for patients with appendicitis? Or were you just saying that was the closest you could get pre-antibiotic times? Feb 27 at 17:55
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    @CuriousLayman There were sulfonamides at that time, these were the first antibiotics and I suspect not widely used. They first appeared around the late 1930's. I don't know how effective they would be for appendicitis, for which surgery was the treatment was at the time, as it was until quite recently. It was the earliest that I could find as sort of "pre-antibiotic".
    – bob1
    Feb 27 at 19:54

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