IBD and Appendectomy - A Comprehensive Review and Analysis

Introduction:

The human appendix is similar to a cecum diverticulum, a vestigial organ. Because the biological function of the appendix was previously unknown and surgically removed in cases of inflammation, clinicians believe that appendectomy is a safe and effective method of treating appendicitis. The appendix submucosa contains multiple lymphoid follicular centers. Furthermore, complex immune system cells can be found in the appendix's mucosa for example- Treg cells, M cells, and T and B cells) and submucosa ( B lymphocytes, T lymphocytes, macrophages, centrocytes, and CD4+/CD8+ cells). According to research, the appendix interacts with intestinal flora and helps to balance the intestinal immune system. The bacteria in the appendix may function as a biofilm inoculum of the intestinal commensal microbiome, making reinoculation of the proximal large bowel and terminal ileum easier. The appendix's complex immune system and microbiome shelter can balance proinflammation and antiinflammation of the bowel and maintain homeostasis.

What Is Inflammatory Bowel Diseases?

1. Crohn's disease (CD) and ulcerative colitis (UC) are the most common inflammatory bowel diseases (IBDs), which cause chronic inflammation of the gastrointestinal tract, typically starting in adolescence or early adulthood.

2. Ulcerative Colitis: UC is characterized by chronic extensive intestine inflammation and abnormal immune system activation. It affects the colon's and rectum's innermost layer.

3. Crohn’s Disease: CD can affect the intestinal tract at any level, from the mouth to the anus and across all bowel wall layers. However, the lower small intestine (ileum) and colon are the most commonly affected.

4. IBDs are complex chronic inflammatory disorders characterized by several factors, including psychological distress, autonomic dysfunction, dysbiosis of the gut microbiome, and immune modulations associated with disease activity. In the past few decades, the prevalence of IBDs has increased.

5. The etiology of the disease has yet to be understood entirely. However, genetic and environmental factors play a role in the etiology of IBD, influencing the interaction between the intestinal mucosa and luminal bacteria, resulting in a malfunction in the regulatory constraints of mucosal immune responses to enteric bacteria. In addition, UC and CD are remitting and relapsing chronic disorders similar to IBD.

What Are the Symptoms and Complications of IBD?

• IBD Symptoms Include - diarrhea, rectal bleeding, nausea and vomiting on and off, and abdominal pain or tenderness. The symptoms are caused by damage to the intestinal mucosa caused by an exaggerated inflammatory response.

• Extra-intestinal Symptoms - can include joint disorders like - arthralgia (pain in the joints), arthritis, ankylosing spondylitis), rashes, and skin conditions like - erythema nodosum (inflammation of the fat cells under the skin, psoriasis, chronic liver disease (primary sclerosing cholangitis) and eye conditions like uveitis.

What Are the Complications of IBD?

The complications of IBD are listed below:

• Anemia.

• Malnourishment.

• Bowel obstruction.

• Fistula.

• Infection.

• Elevated risk of colon cancer is a complication of immune-mediated diseases.

What Are the Contributing Factors in IBD?

• IBDs are extremely complicated diseases with various factors that may contribute to their etiology and pathogenesis. Therefore, a growing body of research is being conducted to investigate potential factors contributing to the etiology of IBDs.

• Over the last two decades, various advances have emphasized the mechanisms and possible interactions of the factors involved in IBD disease activities and progression.

• Among these are adequate molecular and cell biology knowledge, a greater understanding of the immune response and possible immune cascades in chronic inflammatory disorders, and breakthrough technologies in genetic disease analysis.

• A combined approach to studying IBDs is required to understand better the entire orchestra of extremely complicated contributors to the disease, including genetics, microbiome-related, dietary-related, autonomic function, environmental, and psychosocial factors, and their longitudinal interplay.

What Is the Pathophysiology of IBD?

• The intestinal immune system plays a significant role in the pathogenesis of inflammatory bowel disease (IBD). By forming sealed intercellular junctions, the intestinal epithelium restricts bacteria and antigens from entering the circulation.

• These junctions are defective in IBD due to failure of primary barrier function or severe inflammation. Mucus production by goblet cells and Paneth cells secretion of a-defensins with intrinsic antimicrobial activity are two additional protective mechanisms.

• Excessive inflammatory reactions cause prolonged worsening of the epithelium and increased exposure to intestinal microbes, exacerbating the inflammation.

Ulcerative Colitis: Mucosal inflammation is always present, resulting in edema, ulcers, bleeding, and loss of electrolytes. In ulcerative colitis, inflammation typically begins in the rectum and proceeds linearly to the proximal colon. In nearly twenty percent of patients with ulcerative colitis, the disease is confined to the rectum. Pancolitis affects about fifteen percent of patients. As the disorder progresses, the colon becomes more rigid and short, with haustral markings loss, resulting in a 'lead-pipe' appearance on a barium enema.

Crohn’s Disease: Crohn's disease can affect any part of the gastrointestinal tract, causing strictures, inflammation, and the formation of fistulas. Crohn's disease is distinguished because it affects all layers of the bowel (transmural). The mucosa will have a cobblestone appearance in the later stages of the disease because of the linear ulcers between the normal mucosa. Crohn's disease primarily affects the colon and ileum, with only 5 percent of cases affecting the gastroduodenal. The rectum is typically spared in Crohn's disease, but anorectal problems such as fistulas and abscesses are common.

How Is IBD Evaluated?

• IBD is diagnosed using an amalgamation of clinical findings, laboratory inflammatory markers, imaging findings, and endoscopic biopsies. Microcytic anemia, leukocytosis, and thrombocytosis are common hematologic findings, and inflammatory markers like the erythrocyte sedimentation rate (ESR) and high-sensitivity C-reactive protein are frequently elevated.

• In some patients, ruling out parasitic diseases such as giardia, amebiasis, Strongyloides, and tuberculosis may be necessary. In addition, a complete blood count can detect anemia, leukocytosis, and albumin levels.

• Calprotectin levels in feces can be used to diagnose intestinal inflammation. In addition, Crohn's disease may cause an increase in perinuclear antineutrophilic cytoplasmic and anti-Saccharomyces cerevisiae antibodies. Finally, stool analysis is required to diagnose ova and parasitic organisms.

• The abdominal X-ray can detect free air, bowel obstruction, and toxic megacolon.

• To characterize bowel disease, barium studies are performed; a lead pipe presence suggests ulcerative colitis, sparing of the rectum indicates Crohn’s disease and thumb printing indicates mucosal inflammation. Furthermore, barium studies may expose skip lesions and ileum stricture formation, which are signs of Crohn's disease (a type of inflammatory bowel disease).

What Is the Treatment of IBD?

A step-by-step approach to IBD management is described below:

• Aminosalicylates represent the initial step in pharmacologic treatment for IBD. If the patient doesn't somehow respond to a correct dosage of aminosalicylates, the next step is to give corticosteroids, which have been shown to reduce inflammation significantly. Once the response has been observed, the dose can be gradually reduced.

• Immune-modifying agents (anti-TNF agents) are used when a patient doesn't respond to corticosteroids, when steroids are needed for an extended period, or when the steroids cannot be tapered down without causing a recurrence of symptoms.

• For individuals with elevated risk or severe disease, a step-down approach is increasingly preferred. This includes the early administration of higher-level drugs, such as anti-TNF agents, followed by a rapid de-escalation when a response is observed. In patients with high-risk or severe diseases, the step-down approach enhances the patient's outcomes and prevents complications.

• Step four involves disease-specific clinical trial agents; some only work for ulcerative colitis, and others only for Crohn's disease. Thalidomide and interleukin (IL)-11 for Crohn's disease, butyrate enema, nicotine patch, and heparin for ulcerative colitis are examples of these experimental agents.

What Is the Prognosis of IBD?

• The prognosis of UC and CD is determined by the disease's severity and the treatment response. Lactoferrin and calprotectin levels in the stool can be used to predict postoperative CD recurrence. Patients with IBD, on the other hand, have a much higher mortality rate than the general population. Primary disease, infections, and respiratory illness are among the causes of death. In IBD, heart disease is not a leading cause of death. Finally, IBD patients have a high level of psychological morbidity and a low quality of life.

What Are the Complications of IBD?

Inflammatory bowel disease (IBD) complications are classified as intestinal or extraintestinal.

1. Intestinal:

• Hemorrhage (loss of blood).

• Perforation of the colon.

• Fistula of the anus.

• Abscesses in the pelvis or perirectal.

• Toxic megacolon.

• Colon cancer, cholangiocarcinoma.

2. Extraintestinal:

• Osteoporosis (low bone mass).

• Deep vein thrombosis (clotting in the vein of leg).

• Anemia (low hemoglobin level).

• Gallstones.

• Primary sclerosing cholangitis.

• Aphthous ulcerations.

• Arthritis (Inflammation of the joints).

• Iritis (Inflammation of the iris).

• Pyoderma gangrenosum (painful sores in skin and lungs).

Conclusion:

Inflammatory bowel disease (IBD) patients are typically young, and the disease is chronic and lifelong, so an increase in patient understanding improves compliance and aids in management. IBD patients must be monitored for the rest of their lives. No specific diet or supplement has been demonstrated to delay or prevent disease symptoms. Should closely monitor antibiotic treatment strategy for appendicitis for any potential impact on IBD occurrence.