From the Guidelines
If you find Crohn's ileitis with a normal appendix during exploratory laparoscopy, the recommended approach is to leave the appendix intact and not perform an appendectomy, as supported by the ECCO-ESCP consensus on surgery for Crohn's disease 1. This approach prioritizes minimizing surgical trauma and preserving potential future sites for stoma creation, while also reducing the risk of fistula formation at the appendiceal stump.
When encountering Crohn's ileitis, it is essential to obtain biopsies of the inflamed ileum to confirm the diagnosis histologically, and document the extent and severity of the disease with photographs and measurements. Post-operatively, the patient should be referred to gastroenterology for medical management of Crohn's disease, which may include anti-inflammatory medications like mesalamine or corticosteroids, followed by immunomodulators such as azathioprine or methotrexate for maintenance. For moderate to severe disease, biologic agents like infliximab or adalimumab may be necessary.
Key considerations in this approach include:
- Avoiding unnecessary surgical trauma in patients prone to healing complications
- Preserving the appendix as a potential future site for stoma creation
- Reducing the risk of fistula formation at the appendiceal stump
- Potential immunological benefits of the appendix in inflammatory bowel disease As stated in the ECCO-ESCP consensus, terminal ileitis resembling Crohn’s disease found at a laparotomy for suspected appendicitis should not routinely be resected 1, supporting the recommendation to prioritize a conservative approach and avoid appendectomy in the presence of a normal appendix.
From the Research
Decision Making for Crohn's Ileitis with Normal Appendix
When performing an exploratory laparoscopy and finding Crohn's ileitis but a normal appendix, several factors must be considered in deciding the best course of action. The following points summarize the key considerations:
- Surgical Intervention: A study from 1996 2 suggests that traditional therapy for patients with terminal ileitis found at laparotomy for appendicitis has been to perform appendectomy when the cecum is normal and to leave the diseased ileum in place. However, the study found that the majority of patients required early ileocolic resection, indicating that nonoperative therapy may not be in the best long-term interest of these patients.
- Medical Therapy: Research from 2010 3 compared the efficacy of infliximab and azathioprine therapy alone or in combination for Crohn's disease. The study found that patients treated with infliximab plus azathioprine or infliximab monotherapy were more likely to have a corticosteroid-free clinical remission than those receiving azathioprine monotherapy.
- Prevention of Recurrent Bowel Obstruction: A study from 2014 4 investigated the effectiveness of azathioprine in preventing recurrent bowel obstruction in patients with ileocecal Crohn's disease. The results showed that azathioprine was more effective than mesalazine in preventing recurrent bowel obstruction.
- Laparoscopic Ileocaecal Resection vs. Infliximab: A 2020 study 5 compared the long-term outcomes of laparoscopic ileocaecal resection and infliximab for terminal ileitis in Crohn's disease. The results showed that both treatments had similar quality-of-life outcomes, and the duration of treatment effect was similar in both groups.
- Imaging Findings and Disease Progression: Another 2020 study 6 found that Crohn's disease patients with imaging findings of ileal inflammation at computed tomography or magnetic resonance enterography, despite negative ileoscopy and biopsy, were likely to have active inflammatory Crohn's disease. The study suggested that disease detected by imaging may worsen over time or respond to medical therapy.
Key Considerations
When deciding on the best course of action for a patient with Crohn's ileitis and a normal appendix, the following factors should be considered:
- The severity and extent of the ileitis
- The patient's medical history and previous treatments
- The potential benefits and risks of surgical intervention versus medical therapy
- The patient's quality of life and preferences
- The potential for disease progression and the need for ongoing monitoring and treatment adjustments.