What is the best course of action when a patient with suspected acute appendicitis (inflammation of the appendix) has a normal appendix but an inflamed cecum (first part of the large intestine) and terminal ileum (last part of the small intestine) during a laparoscopic appendectomy (surgical removal of the appendix)?

Management of Normal Appendix with Inflamed Cecum and Terminal Ileum

The best action is C: Perform appendectomy and refer the patient to gastroenterology. This approach balances the need for tissue diagnosis, prevents future diagnostic confusion, and ensures appropriate follow-up for likely inflammatory bowel disease without the significant morbidity risks of immediate resection.

Rationale for Appendectomy

Perform the appendectomy despite the normal appearance because macroscopic assessment is unreliable, with 19-40% of visually normal appendices showing pathological abnormalities on histopathology 1. Studies demonstrate that 90% of normal-looking appendices removed during laparoscopy harbor inflammatory changes on pathological examination 1. The World Society of Emergency Surgery recommends appendix removal in symptomatic patients when no other disease is found (weak recommendation, 2C) 1.

Key Benefits of Appendectomy in This Scenario:

• Prevents future diagnostic confusion: Leaving the appendix in place when the patient has ongoing right lower quadrant symptoms from inflammatory bowel disease creates diagnostic uncertainty in future presentations 1
• Enables tissue diagnosis: Routine histopathology after appendectomy is strongly recommended (1B) to identify unexpected findings 1
• Avoids reoperation: Cases requiring reoperation for appendectomy have been described when normal appendices were left in place 1

Critical: Obtain Biopsies from Cecum and Terminal Ileum

Take multiple biopsies from the inflamed cecum and terminal ileum for histopathological examination 2. The combination of a normal appendix with inflamed cecum and terminal ileum strongly suggests Crohn's disease, making tissue diagnosis essential for appropriate long-term management 2.

Surgical Technique:

• Perform standard appendectomy using endoloops/suture ligation or polymeric clips for stump closure 2
• Obtain multiple biopsies from inflamed areas of cecum and terminal ileum 2
• Avoid peritoneal irrigation and drain placement, which are associated with longer hospitalization and potentially increased morbidity 2

Why NOT Right Hemicolectomy (Option A)

Do not perform ileocecal resection in the emergency setting. The ECCO-ESCP consensus explicitly states that terminal ileitis resembling Crohn's disease found at laparotomy for suspected appendicitis should not routinely be resected (EL5) 1.

Critical Pitfalls:

• Appendectomy in the setting of terminal ileitis has elevated risk of intra-abdominal septic complications and fistulas 3
• Terminal ileitis at emergency exploration is non-specific and cannot reliably differentiate between Crohn's disease and infectious etiologies intraoperatively 3
• The ileitis can typically be treated medically in the absence of stricturing or penetrating disease 3
• Definitive diagnosis requires full assessment and multidisciplinary consultation after the acute setting, not intraoperative decision-making 3

Why NOT Close Without Intervention (Option B)

Closing without appendectomy creates several problems: 20.7% of patients are readmitted with right iliac fossa pain when the appendix is left in place 1, and you miss the opportunity for tissue diagnosis that could expedite appropriate treatment for inflammatory bowel disease 2.

Postoperative Management Algorithm

Arrange prompt gastroenterology referral for evaluation of inflammatory bowel disease 2:

1. Colonoscopy with ileoscopy and biopsies to establish definitive diagnosis of Crohn's disease versus infectious/other etiologies 3
2. Stool studies to exclude infectious causes (bacterial pathogens, parasites) 3
3. MR enterography if Crohn's disease is confirmed to assess extent of small bowel involvement 3
4. Clinical monitoring for signs of complications (abscess, perforation, sepsis) 3

The gastroenterologist will determine the need for additional diagnostic studies and initiate appropriate medical therapy if Crohn's disease is confirmed 2.

Common Pitfalls to Avoid

• Do NOT assume this is definitely Crohn's disease without proper postoperative workup, as infectious causes are common and treatable 3
• Do NOT perform resection just because you're already in the abdomen—this significantly increases morbidity 3
• Do NOT skip the biopsies—tissue diagnosis is essential for guiding long-term management 2