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MANAGEMENT AND OUTCOMES OF PATIENTS WITH APPENDICITIS AND CROHN'S DISEASE: A CASE SERIES IN A HIGH-VOLUME CROHN'S DISEASE CENTER
Asya Ofshteyn*, Emma Rosenbluth, Celia M. Divino
Surgery, Mount Sinai Medical Center, New York, NY
There has been a paucity of research regarding the appropriate management of suspected appendicitis in the setting of Crohn’s disease. We reviewed the management and outcomes of suspected appendicitis in patients with concurrent diagnosis of Crohn’s disease in a high-volume inflammatory bowel disease center.
A retrospective chart review was undertaken to find Crohn’s disease patients with suspected appendicitis between 2006 and 2016. Data was captured using ICD-9 and CPT codes from an electronic medical record of a large tertiary care center. Data collected included patient demographics, comorbidities, symptoms upon presentation, laboratory and radiologic study results, interventions and subsequent complications.
Of 26 patients analyzed, 20 had a prior diagnosis of Crohn’s and 6 were subsequently diagnosed after their index admission. Presenting symptoms included right lower quadrant abdominal pain (n=26, 100%, mean days of pain=4.4, SD=4), fever (n=6, 23%) and leukocytosis (n=11, 42%). All patients had a dilated appendix on CT; notable CT findings included surrounding bowel inflammation (n=15, 58%) and presence of one or more fluid collections (n=9, 35%). Management on index admission included appendectomy (n=17, 65%), ileocolic resection (n=3, 11.5%) or conservative management with antibiotics (n=6, 23%). Length of stay ranged from 1 to 9 days (mean 3.2, SD 2.2). The overall 30-day morbidity rate was 28%. The complication rate in patients managed with appendectomy was 29% (n=5), compared to ICR 33% (n=0) and conservative management 33% (n=2). Minor complications included ileus, urinary retention, AKI and mild pancreatitis (all n=1, 4%). Major complications included readmission (overall n=4, 7.7%, appendectomy n=2, 12%; antibiotics alone n=2, 33%), surgery on readmission (n=2, 15%; antibiotics alone=2, 33%) and abscess requiring IR drainage (n=3, 11.5%; appendectomy n=3, 18%).
Management of suspected appendicitis in the setting of underlying Crohn’s disease can result in a high complication and readmission rate given uncertainty about the underlying etiology of right lower quadrant pain. Laparoscopic appendectomy is a safe option when clinical suspicion for acute appendicitis is high. Conservative management with antibiotics is possible in the setting of complicated appendicitis or Crohn’s flare. An ileocolic resection should be done in the setting of severe Crohn’s flare.
Table 1: Demographics, comorbidities and presenting symptoms of patients with Crohn's disease and suspected appendicitis.
| | Total (n=26) | Prior diagnosis of Crohn | Diagnosed with Crohn | | Demographics | | | | | Mean age, y (range) | 30.8 (15-73) | 33.6 (19-73) | 21.6 (15-29) | | Gender, n (%) | | | | | Male | 15 (58) | 10 (50) | 5 (83) | | Female | 11 (42) | 10 (50) | 1 (73) | | Race, n (%) | | | | | Caucasian | 18 (69) | 15 (75) | 3 (50) | | African-American | 2 (8) | 2 (10) | 0 | | Other/Unknown | 6 (23) | 3 (15) | 3 (50) | | Active or former smoker, n (%) | 6 (23) | 6 (30) | 0 | | Insurance status, n (%) | | | | | Insured | 13 (50) | 10 (50) | 3 (50) | | Uninsured | 13 (50) | 10 (50) | 3 (50) | | BMI, mean ± SD | 25.0 ± 5.42 | 26.0 ± 5.45 | 21.5 ± 3.93 | Comorbidities (total #),
mean ± SD | 0.8 ± 1.52 | 0.9 ± 1.68 | 0.5 ± 0.84 | | Medications, n (%) | | | | | Steroids | 3 (12) | 3 (15) | 0 | | 6MP | 6 (23) | 6 (30) | 0 | | Biologic | 5 (19) | 5 (25) | 0 | | Presenting symptoms | | | | | Abdominal pain, mean # of days ± SD | 4.42 ± 4.03 | 4.40 ± 4.44 | 4.50 ± 2.51 | | Fever, n (%) | 6 (23) | 5 (25) | 1 (17) | | Leukocytosis, n (%) | 11 (42) | 9 (45) | 2 (33) | | Presence of collection on CT, n (%) | 9 (35) | 6 (30) | 3 (50) | | Bowel inflammation on CT, n (%) | 15 (58) | 10 (50) | 5 (83) |
Table 2: Outcomes of patients with Crohn's disease and suspected appendicitis. | | Total (n=26) | Appendectomy (n=17) | Ileocolic Resection (n=3) | Conservative management with antibiotics (n=6) | | Procedure type, n (%) | | | | | | Laparoscopic | 19 (95) | 16 (94.2) | 3 (100) | - | | Open | 1 (5) | 1 (3.8) | 0 | - | | EBL (mL), mean ± SD | 33.7 ± 55.3 | 11.9 ± 10.9 | 150 ± 50 | - | | GI consult, n (%) | 13 (50) | 8 (47) | 0 | 5 (83) | | Length of stay (days), mean ± SD | 3.19 ± 2.17 | 3.06 ± 2.49 | 4.67 ± 1.15 | 2.83 ± 1.33 | | Time to diet (days), mean ± SD | 1.39 ± 1.14 | 1.17 ± 0.94 | 3.00 ± 1.00 | 0.67 ± 0.58 | | Number of patients with complications*, n (%) | 7 (28) | 5 (29) | 0 | 2 (33) | | Readmission | 4 (15) | 2 (12) | 0 | 2 (33) | | Surgery upon readmission | 2 (7.7) | 0 | 0 | 2 (33) | | Abscess requiring IR drainage | 3 (11.5) | 3 (18) | 0 | 0 |
*Complications within first 30 days after index admission.
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