What is the most appropriate next step for a patient with a normal appendix and cecum, but an edematous and inflamed terminal ileum with fibrinopurulent exudate found during open appendectomy?

Perform Appendectomy and Close with Antibiotics

In a patient with a normal appendix and cecum but inflamed terminal ileum with fibrinopurulent exudate found during surgery for suspected appendicitis, the most appropriate next step is to perform appendectomy and close, followed by antibiotic therapy (Option C). This approach prevents future diagnostic confusion and provides appropriate treatment for the terminal ileitis.

Rationale for Appendectomy Despite Normal Appearance

• Performing appendectomy when the appendix appears normal is standard practice during exploration for suspected appendicitis, even when alternative pathology is identified 1
• Removing the normal appendix eliminates it as a source of future diagnostic confusion if the patient develops right lower quadrant pain again 1
• The appendix may appear grossly normal but still show microscopic inflammation on pathology 1
• Appendectomy adds minimal additional morbidity to the procedure already underway and prevents the need for future operations if appendicitis develops 1

Management of Terminal Ileitis

• Terminal ileitis with fibrinopurulent exudate in this acute presentation does NOT warrant ileocecal resection 2
• The traditional surgical dictum is to leave acutely inflamed terminal ileum in place when discovered incidentally during appendectomy, provided the cecum is normal 2
• Ileocecal resection is reserved for patients with established Crohn's disease presenting with intractability, obstruction, fistula, or perforation—not for acute inflammatory findings 2
• While one older study suggested early resection might benefit some patients, this was in the context of confirmed Crohn's disease with subsequent complications, not acute incidental findings 2

Antibiotic Therapy

• All patients with complicated intra-abdominal infection require antimicrobial therapy targeting facultative and aerobic gram-negative organisms plus anaerobes 1, 3
• The fibrinopurulent exudate indicates established peritoneal infection requiring therapeutic (not just prophylactic) antibiotics 1
• Appropriate regimens include metronidazole plus a fluoroquinolone or third-generation cephalosporin, or single-agent therapy with ampicillin-sulbactam or piperacillin-tazobactam 3, 4
• Antibiotic duration should continue until clinical signs of infection resolve, typically 3-7 days for complicated intra-abdominal infections 1, 4

Why Other Options Are Inappropriate

Option A (Close then colonoscopy):

• Colonoscopy is not indicated in the acute setting and would not change immediate management 1
• If Crohn's disease is suspected based on pathology, colonoscopy can be performed electively weeks later 2

Option B (Close + Antibiotics without appendectomy):

• Leaving the appendix in place creates future diagnostic uncertainty if the patient develops recurrent right lower quadrant pain 1
• This violates standard surgical practice for negative appendectomy 1

Option D (Ileocecal resection):

• Resection of acutely inflamed terminal ileum is NOT indicated for incidental findings during appendectomy 2
• This would constitute overtreatment with significantly increased morbidity including risk of short bowel syndrome with repeated resections if Crohn's disease is present 2
• Ileocecal resection is reserved for established complications, not acute inflammatory findings 2

Critical Pitfalls to Avoid

• Do not perform ileocecal resection for acute terminal ileitis found incidentally—this dramatically increases operative morbidity without proven benefit 2
• Do not leave the appendix in place—this creates diagnostic confusion for future episodes of abdominal pain 1
• Do not forget therapeutic antibiotics—the fibrinopurulent exudate indicates established infection requiring treatment beyond prophylaxis 1, 3
• Ensure pathology examination of both the appendix and any biopsied ileal tissue to establish diagnosis 1

Postoperative Management

• Continue antibiotics until clinical resolution of infection (typically 3-7 days) 1, 4
• Monitor for signs of persistent infection or complications 1
• If pathology confirms Crohn's disease, refer to gastroenterology for long-term management and consideration of immunomodulatory therapy 2
• Elective colonoscopy can be performed 6-8 weeks postoperatively if Crohn's disease is suspected 2