What is the management approach when an exploratory laparoscopy (surgical procedure using a laparoscope) reveals inflammatory bowel disease (IBD) with a normal appendix?

From the Guidelines

If during an exploratory laparoscopy you find inflammatory bowel disease (IBD) with a normal appendix, the recommended approach is to leave the appendix intact and proceed with appropriate management of the IBD. This approach is supported by the WSES-AAST guidelines for the management of inflammatory bowel disease in the emergency setting 1. The guidelines recommend performing a laparoscopic approach in hemodynamically stable patients presenting with complications related to IBD, when skills are available, in order to decrease morbidity and length of hospital stay.

Key Considerations

• Take biopsies of the inflamed bowel segments to confirm the diagnosis histologically, as recommended by the guidelines for managing IBD complications 1.
• Document all findings thoroughly with photographs if possible.
• The surgery should then focus on addressing any complications of IBD such as strictures, fistulas, or abscesses if present and amenable to surgical intervention.
• Postoperatively, consult with gastroenterology for appropriate medical management, which typically includes anti-inflammatory medications like mesalamine, corticosteroids (prednisone), immunomodulators (azathioprine, 6-mercaptopurine), or biologics (infliximab, adalimumab) depending on disease severity.

Rationale

• Removing a normal appendix in this scenario provides no benefit to the patient and may eliminate a potential future site for stoma creation if needed for IBD management.
• The appendix has immunological functions that may be beneficial in IBD patients.
• The patient should be informed of the findings and the rationale for the surgical decisions made during the procedure, ensuring transparency and patient-centered care.

From the Research

Decision Making for Inflammatory Bowel Disease

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

• The type of inflammatory bowel disease (IBD) present, such as Crohn's disease or ulcerative colitis, as management strategies can differ significantly between the two 2, 3.
• The extent and severity of the disease, as this can influence the choice of surgical procedure or the decision to manage the condition conservatively with pharmaceuticals 4, 5.
• The presence of complications such as strictures, fistulas, or abscesses, which may require immediate surgical intervention 2, 3.

Surgical Considerations

Surgical options for IBD include:

• Laparoscopic procedures, which offer the benefits of reduced recovery time, less pain, and better cosmesis compared to open surgery 4, 3.
• Total proctocolectomy with ileoanal pouch anastomosis (IPAA) for ulcerative colitis, which can provide a cure and good quality of life 3.
• Ileocecal resection for Crohn's disease affecting the terminal ileum, which is considered a standard approach for complicated cases 3.

Pharmaceutical Management

For patients with IBD, pharmaceutical management is aimed at:

• Controlling symptoms and inducing remission 5.
• Maintaining remission to prevent disease flare-ups and complications 5.
• Biologic therapy has improved treatment outcomes for many patients with IBD, though there is still a need for new therapeutic targets 5.

Diagnostic Challenges

Diagnosing IBD can be challenging due to:

• Overlapping symptoms with other conditions, requiring a comprehensive diagnostic work-up 6.
• The possibility of indeterminate colitis, where the disease cannot be definitively classified as Crohn's disease or ulcerative colitis 2, 6.
• The importance of distinguishing IBD from infectious or parasitic diseases, especially in developing countries 5.