What is the management approach for a patient undergoing an exploratory laparotomy (surgical procedure) who is found to have inflammatory bowel disease (IBD) with a normal appendix?

From the Guidelines

If during an exploratory laparotomy the surgeon finds inflammatory bowel disease (IBD) with a normal appendix, the appendix should generally be left intact. This approach is supported by the most recent and highest quality study, which emphasizes the importance of peri-operative care in IBD patients undergoing surgery 1. The decision to leave the appendix intact should be communicated to the patient postoperatively, explaining that the appendix was normal and that IBD was identified as the cause of symptoms.

Key Considerations

• The surgical approach should then shift to addressing the IBD findings, which may include taking biopsies to confirm the diagnosis and determine whether it's Crohn's disease or ulcerative colitis.
• Postoperatively, the patient should be referred to a gastroenterologist for comprehensive IBD management, which typically includes medications such as aminosalicylates (mesalamine), corticosteroids (prednisone), immunomodulators (azathioprine, 6-mercaptopurine), or biologics (infliximab, adalimumab) depending on disease severity and type.
• Preserving the normal appendix is important because unnecessary appendectomy can complicate future intestinal surgeries if needed for IBD, and recent evidence suggests the appendix may have immunological functions.
• Additionally, in Crohn's disease, the appendix might be needed for future bypass procedures if complications develop.

Surgical Approach

• The choice of surgical approach, whether laparotomy or laparoscopic, should be based on the patient's hemodynamic stability and the surgeon's skill, as recommended by recent guidelines 1.
• In hemodynamically unstable patients, a laparotomy may be necessary, while in stable patients, a laparoscopic approach may be preferred to decrease morbidity and length of hospital stay.

Management of IBD

• The management of IBD should be individualized based on the severity and type of disease, as well as the patient's response to treatment.
• A multidisciplinary approach, including gastroenterologists, surgeons, and other healthcare professionals, is essential for optimal management of IBD patients undergoing surgery 1.

From the Research

Decision Making for Inflammatory Bowel Disease

When performing an exploratory laparotomy and finding inflammatory bowel disease but a normal appendix, several factors must be considered in decision making:

• The presence of inflammatory bowel disease (IBD) indicates a need for treatment to manage symptoms and prevent complications 2, 3, 4, 5, 6.
• The normal appendix suggests that appendicitis is not the cause of symptoms, and treatment should focus on managing IBD 4, 5.
• Treatment options for IBD include pharmaceutical management, such as 5-aminosalicylates, corticosteroids, immunomodulators, and anti-TNF-α agents, as well as surgical intervention in some cases 2, 3, 4, 5, 6.

Treatment Considerations

Some key considerations in treating IBD include:

• The use of corticosteroids, which can be effective in inducing remission but may have significant side effects, such as opportunistic infections, diabetes mellitus, and osteoporosis 2, 3.
• The role of 5-aminosalicylates, which are generally well-tolerated but may have rare side effects, such as nephrotoxicity 2, 6.
• The importance of maintaining remission and preventing complications, such as colitis-associated colorectal cancer 4, 5.

Surgical Intervention

Surgical intervention may be necessary in some cases, such as:

• Refractory disease that does not respond to pharmaceutical management 4, 5.
• Complications, such as obstructive gastrointestinal luminal stenosis, abscesses, peritonitis, or complicated fistula formation 4.
• Colitis-associated colorectal cancer or dysplasia 4, 5.