Q. Hello, Dr C. My name is Buddy and I live in Savannah. A close friend of mine had his appendix removed because he developed acute appendicitis. He said that it had to be removed when he developed worsening pain in the right lower abdominal area over a period of two days. A CT scan of the abdomen showed an inflamed appendix and he had band aid (laparoscopic) surgery the same day. He was discharged the following morning, returned to work the next day and continues to do well. It all took place without a hitch. I am happy for him. However, he did have an organ removed, albeit small. Has he lost anything of importance?

A. Buddy, you pose a very interesting question and the answer will likely surprise most of the general public as well as many members of the medical community. For more than a century little has been known about the appendix other than its location, size, and propensity to become acutely inflamed as in your friend. The appendix is a tubular structure located near the junction of the large bowel (colon) and the small intestine in the right lower portion of the abdominal cavity. It is about the size of your pinky finger. Acute inflammation of the appendix or appendicitis may occur at any age but it usually occurs between the ages of ten and twenty years. When symptoms begin it is important to have it evaluated quickly as it is a medical emergency. When surgical removal is done quickly, patients usually do well as your friend did. If the appendix ruptures, intestinal contents leak into the abdominal cavity and severe infection (peritonitis) may develop. This complication is the most feared because it can lead to prolonged hospitalization or even be fatal. Acute appendicitis always requires expeditious surgical intervention. Antibiotics are given in addition but are not the mainstay of treatment for an inflamed appendix. Having had his appendix removed appropriately, did he in the course of necessary surgery lose anything of value for his overall health? We have a century of experience to say that his health is not going to be harmed in any measureable way. For this reason, the appendix has long been considered an anatomical evolutionary curiosity that only has significance in the requirement that it be removed when it becomes inflamed. Hardly a laudable function! In the past several years and even in the past month, the functions of the appendix and indeed its presence as superb example of a biological, bacteriologic and immune defense system for the digestive tract has been convincingly theorized on the basis of scientific data that has astounding implications. Science is interested in the contents and the walls of the appendix. The appendix contains bacteria that are healthy and supportive for the entire gut. These good bacteria are enclosed in a biofilm, which is biological barrier that functions as a sort of protective condominium. When a major insult strikes the gut, such as acute gastroenteritis or infectious diarrhea, the normal bacterial flora are wiped out throughout the gut except those protected in the biofilm within the appendix. During recovery, the bacteria are released from the biofilm to assist in healing of the digestive tract. The appendix is a re-boot system for intestinal bacteria. Given that in many third world countries diarrhea is a leading cause of death, the appendix is indeed an organ to be respected as a protector of the gut. The concept of biofilms is also a major research interest because of the role they play in common, serious infections in the body that are now believed to be due to bad bacteria that hide in biofims and are therefore many times more resistant to antibiotics than expected. Biofilms likely play a role in our difficult to- treat infections such as ear infections in children, cystic fibrosis pneumonia, heart valve infections, chronic skin infections, infected surgical wounds and infected artificial hip joints. We are discovering how to treat biofilm-related disease; this treatment will revolutionize our treatments of nearly all bacterial infections. In this respect, the appendix lumen bacteria are part of one of the exploding arenas of health science. The wall of the appendix is another exciting frontier of medicine. This wall is a rich immune cell stockpile that may play a role in the development appendicitis and other digestive inflammatory illnesses. While appendicitis is rare in under-developed countries, it is very common in countries that have hot water, sewers, and sanitation programs. It may be that the appendix is seldom called upon in our hygienic society. When any intestinal invader appears, the appendix immune lining cells may over-react leading to the sudden onset of the local edema, pain, and inflammation of appendicitis. In this manner, appendicitis is a form of an allergic, immunologic disorder due to the activation of the immune cells of the appendix. The intestinal immune system is now being defined as a key element of other intestinal disorders such as colitis and Crohns Disease. In summary, the appendix became inflamed, likely due to an immune or allergic reaction of the cells lining the appendix. Surgery was required to remove the inflamed appendix and prevent serious complications. Because your friend lives in a relatively sanitary environment, he is not likely to miss his appendix. On the other hand, the world is becoming a smaller place and travel to remote areas is more common. It would probably be a good idea to rethink the common medical practice of removing a normal appendix at the time of other operations such as hysterectomy, etc. The appendix is not an evolutionary curiosity but rather an organ containing a protective biofilm and is part of the extensive immune system of the digestive tract. Lets show a little respect. I hope this answers your question.

Dr. Nicholas Costrini writes regularly for the Savannah Morning News. His articles occur every other week in the close-up section. He may be contacted at ncostrini@georgiagi.com.

The Savannah Morning News Good for What Ails You and Dr. Nicholas V. Costrini would appreciate hearing favorable comments. Please call: 912.652.0370 Vox Populi