Management of Terminal Ileitis with Normal Appendix During Open Appendectomy
Close the abdomen without performing appendectomy and proceed with medical workup including colonoscopy and antibiotics. 1
Primary Recommendation
The ECCO-ESCP consensus explicitly states that appendectomy of a macroscopically normal appendix in the presence of terminal ileitis has an elevated risk of intra-abdominal septic complications and fistulas. 1 This is the most critical guideline addressing your exact clinical scenario.
Rationale for Avoiding Appendectomy
Terminal ileitis at emergency exploration is non-specific and cannot reliably differentiate between Crohn's disease and infectious etiologies intraoperatively 1
The ileitis can typically be treated medically in the absence of stricturing or penetrating disease, which are not described in this case 1
Removing a normal appendix in the setting of terminal ileitis significantly increases the risk of intra-abdominal abscess formation and fistula development 1
Definitive diagnosis requires full assessment and multidisciplinary consultation after the acute setting, not intraoperative decision-making 1
Why Not Ileocecal Resection?
Immediate resection is not indicated because the patient does not have stricturing or penetrating disease that would require urgent surgical intervention 1
While one older study suggested early ileocolic resection for acute Crohn's ileitis found at laparotomy 2, this contradicts current high-quality consensus guidelines from ECCO-ESCP (2018) which prioritize medical management and proper diagnostic workup first 1
The decision to perform resection should occur after complete evaluation, not during emergency surgery for presumed appendicitis 1
Postoperative Management Algorithm
Immediate Steps:
Administer broad-spectrum antibiotics covering gram-negative and anaerobic organisms for the acute inflammatory process 3
Clinical monitoring for signs of complications (abscess, perforation, sepsis) 1
Outpatient Workup (within 2-4 weeks):
Colonoscopy with ileoscopy and biopsies to establish definitive diagnosis of Crohn's disease versus infectious/other etiologies 1
Stool studies to exclude infectious causes (bacterial pathogens, parasites) 1
Laboratory evaluation including CBC (looking for anemia, thrombocytosis), inflammatory markers (CRP, ESR), and nutritional parameters 4
Consider MR enterography if Crohn's disease is confirmed to assess extent of small bowel involvement 1
Differential Diagnosis Considerations
The terminal ileitis in this 17-year-old male could represent:
Crohn's disease (most common in this age group with terminal ileum involvement) 1, 4
Infectious ileitis (Yersinia, Campylobacter, tuberculosis) 1
Lymphoid hyperplasia 4
Early presentation of other inflammatory conditions 4
Predictive Features for Crohn's Disease
If this patient has the following characteristics, Crohn's disease becomes more likely 4:
Male gender (83.8% of CD patients in acute TI presentation) 4
Younger age (median 27 years for CD vs 39 for other causes) 4
History of chronic abdominal pain, diarrhea, weight loss, or anemia prior to this acute presentation 4
Lower mean corpuscular volume (MCV) and elevated platelet count on labs 4
Radiologic signs of complicated disease (though not present in this case description) 4
Critical Pitfalls to Avoid
Do NOT perform appendectomy just because you're already in the abdomen—this significantly increases morbidity 1
Do NOT assume this is definitely Crohn's disease without proper postoperative workup, as infectious causes are common and treatable 1
Do NOT perform ileocecal resection in the emergency setting without definitive diagnosis and assessment for medical management options 1
Do NOT delay antibiotic therapy while awaiting cultures, as empiric coverage is essential 3
Answer: A - Close then colonoscopy (with antibiotics initiated immediately postoperatively)