What is the best course of action for a patient with a normal appendix, but inflamed cecum and terminal ileum, during a laparoscopic appendectomy for suspected acute appendicitis?

Recommended Action: Appendectomy with Biopsy and Gastroenterology Referral

When encountering a normal-appearing appendix with inflamed cecum and terminal ileum during laparoscopic appendectomy for suspected acute appendicitis, you should perform appendectomy, obtain biopsies of the inflamed cecum and terminal ileum, and refer the patient to gastroenterology for evaluation of inflammatory bowel disease (specifically Crohn's disease).

Rationale for Appendectomy Despite Normal Appearance

• The European Association of Endoscopic Surgery recommends performing appendectomy when the appendix appears normal during surgery for suspected acute appendicitis 1
• Intra-operative macroscopic assessment is unreliable: 19-40% of visually normal appendices are pathologically abnormal on histopathology 1, 2
• Studies demonstrate that 90% of normal-looking appendices removed during laparoscopy harbor inflammatory changes on pathological examination 1
• The World Society of Emergency Surgery provides a weak recommendation (2C) supporting appendix removal when it appears normal during surgery in symptomatic patients 1

Critical Importance of Biopsy

The finding of a normal appendix with inflamed cecum and terminal ileum is highly suggestive of Crohn's disease, making tissue diagnosis essential for appropriate long-term management.

• Biopsies of the inflamed cecum and terminal ileum are necessary to establish the diagnosis of inflammatory bowel disease 3
• Routine histopathology after appendectomy is strongly recommended (1B) to identify unexpected findings 4, 1
• The pathological diagnosis will guide subsequent medical therapy and determine the need for future surgical intervention 3

Why NOT Right Hemicolectomy

• Immediate resection (right hemicolectomy or ileocolic resection) at the time of initial diagnostic laparoscopy for suspected appendicitis is not indicated when Crohn's disease is unexpectedly discovered 3
• While historical data shows that 92% of patients with Crohn's disease found at appendectomy eventually required ileocolic resection (65% within 3 years), this decision should be made electively after proper diagnosis, medical optimization, and gastroenterology consultation 3
• Emergency resection should be reserved for complications such as perforation, obstruction, or non-viable bowel—not for uncomplicated inflammatory changes 3, 5

Why NOT Close Without Intervention

• Simply closing without appendectomy risks leaving a potentially abnormal appendix that may cause persistent symptoms 1
• Failing to obtain tissue diagnosis leaves the patient without a definitive diagnosis, delaying appropriate medical therapy for likely Crohn's disease 3
• While one study showed only 1% of patients developed appendicitis after leaving a normal-appearing appendix in place, that study did not address the specific scenario of inflamed terminal ileum and cecum 6

Surgical Technique Considerations

• Perform standard appendectomy using endoloops/suture ligation or polymeric clips for stump closure 4
• Obtain multiple biopsies from the inflamed cecum and terminal ileum for histopathological examination 3
• Avoid peritoneal irrigation; suction alone is recommended 4
• Do not place drains, as they are associated with longer hospitalization and potentially increased morbidity 4

Postoperative Management

• Send all specimens (appendix and biopsies) for histopathological examination 4, 1
• Arrange prompt gastroenterology referral for evaluation of inflammatory bowel disease 3
• The gastroenterologist will determine the need for additional diagnostic studies (colonoscopy, imaging) and initiate appropriate medical therapy if Crohn's disease is confirmed 3

Common Pitfall to Avoid

The major pitfall is performing an extensive bowel resection (right hemicolectomy) at the initial operation without tissue diagnosis or medical optimization. While older data suggested early resection might benefit some patients 3, current practice favors establishing a definitive diagnosis first, attempting medical management, and reserving resection for medically refractory disease or complications 3.