Clinical relevance of endoscopic peri-appendiceal red patch in ulcerative colitis patients

Background: Increasing evidence is suggesting appendectomy as an alternative treatment for ulcerative colitis (UC), especially in case of histological appendiceal inflammation. Therefore, preoperative identification of appendiceal inflammation could be beneficial. This study aimed to assess the prevalence of peri-appendiceal red patch (PARP) on colonoscopy. In addition, prognostic relevance of PARP for disease course and its predictive value for histological appendiceal inflammation in patients undergoing appendectomy was assessed. Methods: UC patients undergoing colonoscopy in 2014/2015 were included to determine PARP-prevalence in a cross-sectional study. Findings were correlated to patient and disease characteristics, upscaling of treatment and colectomy rates after cross-sectional colonoscopy. In patients undergoing appendiceal resection, histopathological inflammation was assessed using the Robarts Histopathology Index (RHI). Results: In total, 249 patients were included of which 17.7% (44/249) had a PARP. Patients with PARP were significantly younger with a shorter disease course. The majority of patients with PARP (61.4%) was in endoscopic remission. Patients with PARP required more upscaling of medical therapy (81.8% vs. 58.0%, p < 0.01), and more PARP patients underwent colectomy (13.6% vs. 4.9%, p = 0.04). Patients with PARP had a higher median RHI in resection specimens (14 vs. 7, p < 0.01). Conclusion: PARP was present during colonoscopy regardless disease activity and was predominantly found in UC patients with younger age and shorter disease duration. PARP patients had a more severe course of UC, and in case of appendectomy, more severe histopathological appendiceal inflammation. Appendectomy as an experimental therapy for UC has been suggested to be predominantly effective in UC patients with appendiceal inflammation. This study demonstrates that presence of a PARP on colonoscopy predicts appendiceal inflammation. After consensus has been reached on the therapeutic effect of appendectomy, assessing PARP presence during colonoscopy could therefore contribute to identifying patients most likely to respond.

[1]  C. Buskens,et al.  High prevalence of ulcerative appendicitis in patients with ulcerative colitis , 2021, United European gastroenterology journal.

[2]  G. Pond,et al.  Extent of Surgical Resection in Inflammatory Bowel Disease Associated Colorectal Cancer: a Population-Based Study , 2021, Journal of Gastrointestinal Surgery.

[3]  L. Beyer-Berjot,et al.  Segmental colectomy for ulcerative colitis: is there a place in selected patients without active colitis ? An international multicentric retrospective study in 72 patients. , 2020, Journal of Crohn's & colitis.

[4]  C. Buskens,et al.  Prospective cohort study of appendicectomy for treatment of therapy‐refractory ulcerative colitis , 2019, The British journal of surgery.

[5]  C. Buskens,et al.  Appendectomy for Therapy-Refractory Ulcerative Colitis Results in Pathological Improvement of Colonic Inflammation: Short-Term Results of the PASSION Study , 2018, Journal of Crohn's & colitis.

[6]  C. Buskens,et al.  Lymphocytes populations in appendiceal lavage fluid predictive of IBD-related inflammation , 2018 .

[7]  S. Ishihara,et al.  Appendiceal orifice inflammation is associated with proximal extension of disease in patients with ulcerative colitis , 2016, Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland.

[8]  C. Buskens,et al.  The Link between the Appendix and Ulcerative Colitis: Clinical Relevance and Potential Immunological Mechanisms , 2016, The American Journal of Gastroenterology.

[9]  S. Travis,et al.  Endoscopic Disease Activity in Inflammatory Bowel Disease , 2015, Current Gastroenterology Reports.

[10]  L. Stitt,et al.  Development and validation of a histological index for UC , 2015, Gut.

[11]  C. Buskens,et al.  The ACCURE-trial: the effect of appendectomy on the clinical course of ulcerative colitis, a randomised international multicenter trial (NTR2883) and the ACCURE-UK trial: a randomised external pilot trial (ISRCTN56523019) , 2015, BMC Surgery.

[12]  Douglas G Altman,et al.  The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies. , 2014, International journal of surgery.

[13]  E. Loftus,et al.  Appendiceal Skip Inflammation and Ulcerative Colitis , 2014, Digestive Diseases and Sciences.

[14]  T. Joh,et al.  Inflammatory bowel disease of primary sclerosing cholangitis: a distinct entity? , 2014, World journal of gastroenterology.

[15]  E. Cabré,et al.  Long-term outcome of patients with distal ulcerative colitis and inflammation of the appendiceal orifice. , 2011, Journal of gastrointestinal and liver diseases : JGLD.

[16]  D. Rubin,et al.  The Peri-appendiceal Red Patch in Ulcerative Colitis: Review of the University of Chicago Experience , 2010, Digestive Diseases and Sciences.

[17]  S. Riordan,et al.  Appendicectomy as a Therapy for Ulcerative Proctitis , 2009, The American Journal of Gastroenterology.

[18]  J. Katz,et al.  Clinical Significance of Isolated Peri-Appendiceal Lesions in Patients With Left Sided Ulcerative Colitis , 2008, Gastroenterology research.

[19]  S. Pocock,et al.  The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. , 2007, Preventive medicine.

[20]  Gheorghe Doros,et al.  The Boston bowel preparation scale: a valid and reliable instrument for colonoscopy-oriented research. , 2007, Gastrointestinal endoscopy.

[21]  G. Lee,et al.  Clinical Course of Distal Ulcerative Colitis in Relation to Appendiceal Orifice Inflammation Status , 2005, Inflammatory bowel diseases.

[22]  K. Ladefoged,et al.  Skip inflammation of the appendiceal orifice: A prospective endoscopic study , 2005, Scandinavian journal of gastroenterology.

[23]  M. Shimizu,et al.  Significance of appendiceal involvement in patients with ulcerative colitis. , 2002, Gastrointestinal endoscopy.

[24]  B. Iizuka,et al.  Clinical and Colonoscopic Investigation of Skipped Periappendiceal Lesions in Ulcerative Colitis , 2002, Scandinavian journal of gastroenterology.

[25]  T. Hibi,et al.  Appendectomy protects against the development of ulcerative colitis and reduces its recurrence: results of a multicenter case-controlled study in Japan , 2001, American Journal of Gastroenterology.

[26]  W. Hong,et al.  Appendiceal orifice inflammation as a skip lesion in ulcerative colitis: an analysis in relation to medical therapy and disease extent. , 1999, Gastrointestinal endoscopy.

[27]  K. Togashi,et al.  Significance of Periappendiceal Inflammation in the Patients with Distal Ulcerative Colitis , 1999 .

[28]  D. Rampton,et al.  Appendiceal inflammation in ulcerative colitis , 1998, Histopathology.

[29]  P. Rutgeerts,et al.  Patchy cecal inflammation associated with distal ulcerative colitis: a prospective endoscopic study. , 1997, The American journal of gastroenterology.

[30]  H. Asakura,et al.  Appendiceal Involvement in Patients with Ulcerative Colitis , 1997 .

[31]  P. Rutgeerts,et al.  Appendectomy protects against ulcerative colitis. , 1994, Gastroenterology.

[32]  T. Molnár,et al.  Third European Evidence-based Consensus on Diagnosis and Management of Ulcerative Colitis. Part 2: Current Management. , 2017, Journal of Crohn's & colitis.

[33]  M. Iida,et al.  Histological and Immunological Features of Appendix in Patients with Ulcerative Colitis , 2004, Digestive Diseases and Sciences.

[34]  R. Biggar,et al.  Appendectomy and protection against ulcerative colitis. , 2001, The New England journal of medicine.