LOWER ODDS OF APPENDECTOMY IN PATIENTS WITH IBD AND ACUTE APPENDICITIS
Alex M. Kesler, Paul T. Kroner*, Peter Abader, Mohammad Afsh, Victor Ciofoaia, Frank Lukens
Mayo Clinic Florida, Jacksonville, FL
Introduction
Appendicitis and appendectomy in inflammatory bowel disease (IBD) is an increasingly studied topic. Appendectomy prior to diagnosis of ulcerative colitis (UC) may be associated with less odds of undergoing colectomy, while the odds of developing Crohn's disease (CD) may be increased after an episode of appendicitis. However, data is lacking on in hospital outcomes in acute appendicitis in IBD, although these patients are known to have worse surgical outcomes. The aim of this study is to assess inpatient prevalence, and outcomes of acute appendicitis in patients with UC or CD.
Methods
Case-control study using the NIS 2016, the largest public inpatient database in the US. All patients with ICD10CM codes for IBD were included. Patients with acute appendicitis undergoing appendectomy were identified using respective ICD codes. The primary outcome was determining the odds of appendectomy in patients with IBD and acute appendicitis, stratified by UC and CD. Secondary outcomes included determining inpatient morbidity, post-operative complications, resource utilization, hospital length of stay (LOS), and inflation-adjusted total hospital costs and charges. Multivariate regression analyses were used to adjust for age, gender, Charlson Comorbidity Index, race, income in patient zip code, hospital region, location, size and teaching status.
Results
Out of 331,950 patients with IBD that were identified, 1,480 had appendicitis, 875 of which underwent appendectomy. The mean patient age was 44 years, and 45% were female. For the primary outcome, the odds of appendectomy in patients with appendicitis and IBD was 0.24 (p<0.01) when compared to the general population. When stratified by patients with CD and UC the odds are 0.18 (p<0.01), and 0.44 (p<0.01), respectively. For secondary outcomes, there was increased odds of TPN, and increased adjusted mean costs, charges, and length of stay in patients with either CD or UC. Patients with CD had higher odds of shock. There was no significant difference in mortality, AKI, multi-organ failure or ICU admission. Adjusted odds and means are shown in Table 1.
Conclusions
Patients with CD and UC had decreased odds of undergoing appendectomy, but there was no difference in mortality, AKI, ICU stay, or multi-organ failure. There was increased odds of requiring TPN, and patients with CD specifically had higher rates of shock. The lower odds of appendectomy most likely reflects the fact that data has shown that patients with IBD develop more surgical complications and have slower recovery, thus surgeons most likely will pursue medical management first and reserve surgical management in only the best surgical candidates with IBD.
Adjusted odds ratios and additional adjusted means for evaluated factors in patients with IBD and appendicitis that underwent appendectomy compared to patients without IBD that underwent appendectomy.
| Variable | Adjusted Odds Ratio | 95% Confidence Interval | p-value |
| Appendectomy IBD | 0.24 | 0.19 - 0.31 | <0.01 |
| Appendectomy CD | 0.18 | 0.13 - 0.24 | <0.01 |
| Appendectomy UC | 0.44 | 0.27 - 0.72 | <0.01 |
| Mortality IBD | 0.97 | 0.32 - 4.07 | 0.97 |
| Mortality CD | 0.82 | 0.12 - 5.72 | 0.84 |
| Mortality UC | 1.11 | 0.13 - 9.10 | 0.92 |
| AKI CD | 1.27 | 0.74 - 2.18 | 0.39 |
| AKI UC | 1.26 | 0.68 - 2.34 | 0.46 |
| Shock CD | 2.43 | 1.21 - 4.86 | 0.01 |
| Shock UC | 1.21 | 0.35 - 4.12 | 0.76 |
| ICU CD | 1.48 | 0.79 - 2.76 | 0.22 |
| ICU UC | 0.93 | 0.34 - 2.51 | 0.89 |
| TPN CD | 4.39 | 2.86 - 6.74 | <0.01 |
| TPN UC | 2.92 | 1.40 - 6.10 | <0.01 |
| CT Abdomen CD | 1.14 | 0.45 - 2.86 | 0.79 |
| CT Abdomen UC | 3.03 | 1.20 - 7.61 | 0.02 |
| US Abdomen CD | 2.02 | 0.21 - 19.68 | 0.54 |
| Multi-organ failure CD | 1.29 | 0.78 - 2.12 | 0.32 |
| Multi-organ failure UC | 1.04 | 0.56 - 1.92 | 0.91 |
| Post shock CD | 6.63 | 1.56 - 28.18 | 0.01 |
| Bleed CD | 2.17 | 0.29 - 16.21 | 0.45 |
| GN Sepsis CD | 3.13 | 1.26 - 7.78 | 0.01 |
| Variable | Adjusted Mean | 95% Confidence Interval | p-value |
| Additional Costs CD | $8,212 | 4479 - 11944 | <0.01 |
| Additional Costs UC | $4,530 | 396 - 8663 | 0.03 |
| Additional Charges CD | $29,196 | 14437 - 43956 | <0.01 |
| Additional Charges UC | $18,542 | 158 - 36926 | 0.05 |
| Additional Length of Stay (days) CD | 3.4 | 2.32 - 4.53 | <0.01 |
| Additional Length of Stay (days) UC | 1.6 | 0.25 - 2.86 | 0.02 |
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