Noa Kirel and Daniel Peretz's honeymoon in Japan was supposed to be a chance to relax after months of busy schedules, but it was cut short by a medical emergency that led to Kirel's hospitalization at Tel Aviv Sourasky Medical Center. She later told her followers that she had appendicitis and reassured them that she was doing well.
Assuming her diagnosis was indeed appendicitis, the case serves as a reminder that what initially appears to be a harmless stomachache can sometimes turn out to be a condition requiring prompt diagnosis and, in some cases, surgery.
So what exactly is the appendix, how can people tell when abdominal pain warrants a trip to the emergency room, and when can the condition be treated with antibiotics rather than surgery?
What is the appendix?
"The appendix is a small organ, several centimeters long, attached to the right side of the large intestine and located in the lower right abdomen," said Dr. Asher Fine, a specialist in general surgery, trauma and emergency surgery at Assuta Ashdod Hospital. "That's why it's called the appendix — essentially a small extension of the intestine."
According to Fine, although the appendix is best known because of the inflammation that can develop in it, its role in the body remains unclear.
"One theory is that in the past, when human diets were different and included more grasses and plants, it played some role in digestion, perhaps helping break down food," he said. "With evolution and changes in diet, that role diminished, and today it has no clear or defined function. In addition, recent studies suggest it may play some role in the immune and lymphatic systems."
The classic sign of appendicitis is pain that often begins in the center of the abdomen and later migrates to the lower right side. "That's a very classic story for appendicitis," Fine said.
Dr. Asher FinePhoto: Assuta Ashdod HospitalOther symptoms can include loss of appetite, nausea and sometimes changes in bowel habits. The more severe the inflammation, the more pronounced the symptoms may become.
"There may also be fever, and blood tests can show elevated inflammatory markers," he said.
Still, not every stomachache is appendicitis. According to Fine, one factor that distinguishes appendicitis from temporary abdominal pain is the pattern and progression of the pain.
"If someone describes abdominal pain that started as diffuse pain and then moved to the lower right abdomen, that's very consistent with appendicitis," he said. "During a physical examination, we look for localized tenderness in that area."
Not every stomachache requires a visit to the emergency room, but there are situations in which waiting is not recommended.
"When sudden abdominal pain appears, pain that doesn't improve with painkillers, or pain that feels unlike anything the person has experienced before, that's a red flag," Fine said. "Sometimes the pain worsens with walking or movement, for example when using the thigh muscles. If there is also a fever, that further strengthens the need for evaluation."
In women, he added, diagnosis can be more complicated. "The differential diagnosis in women is broader than in men because conditions involving the reproductive system can mimic appendicitis," he said. "Examples include ovarian torsion, ectopic pregnancy and other gynecological conditions."
How is it diagnosed?
Diagnosis in the hospital is based on a combination of the clinical history, physical examination, blood tests and imaging.
"First we look at the clinical picture — where the pain is, how it started, whether it migrated to the right side and whether there is localized tenderness on examination," Fine said. "Then we order blood tests, which sometimes show elevated inflammatory markers."
The next step is determining which imaging study is appropriate. "The preferred test for diagnosing appendicitis is a CT scan," Fine said. "Ultrasound can also be used, but we usually reserve it for very young patients, children or pregnant women, in whom we prefer to avoid CT scans whenever possible. Ultimately, the diagnosis is both clinical and imaging-based."
When appendicitis is not diagnosed or treated in time, complications can develop. "At a certain point, the appendix can perforate," said Dr. Elchanan Quint, a surgeon with Maccabi Healthcare Services' Southern District.
"That can cause an intra-abdominal infection or an abscess, leading to abdominal pain, fever and additional symptoms. The most serious complication is when the infection is no longer confined to the appendix and spreads throughout the abdominal cavity, a condition known as peritonitis," he said. "That's the worst-case scenario, in which the appendix ruptures and contaminated intestinal contents spill into the abdomen."
How is it treated?
In most cases, appendicitis is treated surgically, but not always. "There are cases that can be managed with medication alone, meaning antibiotics and painkillers," Quint said. "That's true for uncomplicated appendicitis. The treatment has good success rates, but there is also a risk of recurrence — up to 40% within five years. In cases involving more complicated inflammation, surgery is clearly recommended."
Dr. Elchanan QuintPhoto: Eliav MasonAccording to Quint, the procedure is now performed almost exclusively using minimally invasive laparoscopic techniques. "In the past, open surgery was common, but today it is rarely performed," he said. "Three small incisions are made in the abdominal wall, through which a camera and two instruments are inserted to remove the appendix."
The operation usually lasts about 30 minutes, although it can take longer depending on the circumstances. "Sometimes, if there is more extensive infection, the abdominal cavity must be irrigated and a drain left in place, but that is relatively uncommon," Quint said. "In most cases, only the appendix is removed. Although this is a very common procedure, possible risks include injury to nearby organs, bleeding and intra-abdominal infection."
Recovery is generally relatively quick. "If the appendicitis is uncomplicated and the surgery goes smoothly, patients are usually discharged the next day and recover over several days," he said. "If there is a significant abdominal infection, several additional days of antibiotics and hospitalization may be required."
Returning to eating and normal activities is usually gradual but relatively rapid. "Patients can generally start drinking shortly after surgery, and normal eating usually resumes the following day, depending on recovery," Quint said. "Returning to work is very individual, but generally requires one to two weeks of recovery. The same applies to physical activity, where we usually recommend one to two weeks of rest."
Kirel's case raised questions, chief among them why she chose to return to Israel instead of receiving treatment in Japan.
For many Israelis who experience a medical emergency while traveling abroad, the dilemma is familiar: whether to receive treatment locally or return to a familiar health care system, in a familiar language and closer to family. In cases of appendicitis, especially when complications are suspected, the decision depends on the patient's condition, the availability of treatment and doctors' assessment of whether flying is safe.
"Japan has excellent medical centers," Quint said. "I believe she preferred to deal with the situation in a place that was more familiar and comfortable for her. I'm sure she could have received excellent treatment in Japan as well, assuming it was indeed appendicitis."