The significance of punctiform erosion around the peri-appendiceal orifice with left-sided colitis in the diagnosis of ulcerative colitis

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The significance of punctiform erosion around the peri-appendiceal orifice with left-sided colitis in the diagnosis of ulcerative colitis


Highlights:

  • Inflammation of appendiceal orifice (IAO) may have relationship with UC.
  • Of the 52 patients in our study, 49 (94.2%) were eventually diagnosed with UC.
  • IAO with left-sided colitis might aid in the diagnosis of UC.

Running title: Association between IAO and UC

Abstract

Objectives: The aim of this study was to analyze the association between punctiform erosion around the appendiceal orifice with left-sided colitis and ulcerative colitis (UC), and to investigate the significance of this relationship in the diagnosis of UC.

Methods: This was a retrospective study approved by the West China Hospital (Chengdu, China). A total of 52 patients admitted to the department of gastroenterology were enrolled in our study during January 2007 and November 2012. Endoscopic changes (punctiform erosion around the appendiceal orifice with diffuse inflammatory changes in the left-sided colon) of the 52 patients were analyzed. The changes observed on endoscopy were compared with the final diagnosis research using biopsy results.

Results: All of the 52 patients including 24 men and 28 women exhibited punctiform erosion around the appendiceal orifice and inflammation in the left colon on endoscopy. The average age at diagnosis was 43.3±13.3 years (range, 19-68 years). Of the 52 patients with changes observed during endoscopy, 49 (94.2%) were eventually diagnosed with UC, one (1.8%) was diagnosed with schistosome enteropathy and the remaining 2 could not be diagnosed with what kind of diseases they belonged to.

Conclusion: Punctiform erosion around the appendiceal orifice with left-sided colitis may have relationship with UC and this relationship might aid in the diagnosis of UC.

Key Words: Appendiceal orifice; Skip lesion; Ulcerative colitis

INTRODUCTION

Ulcerative colitis (UC) is an inflammatory bowel disease (IBD) that affects 8–246 per 100,000 individuals (1, 2). UC is characterized by continuous and diffuse inflammation extending proximally from the rectum (3). Although the exact cause of UC is not fully understood, the predominant explanation is that there is an abnormal response of the bowel mucosa to stimuli caused by pathogens of the normal intestinal flora (4). The number of patients with UC increased year by year in our country, and UC is a risk factor for the development of cancers such as colorectal cancer (1).

UC have posed threat to public health, however, specificity standard in the diagnosis of UC is lacking (5-8). Therefore, it is essential to develop more effective methods for the diagnosis of UC. Diagnosis of UC is complicated and is based on a combination of patient history and physical examination in association with laboratory, endoscopic, and radiographic investigations (9). The correct diagnosis is important for its implications in selecting treatment and in the timing and type of surgery that may be required. Some studies found that measurement of biomarkers can also help to diagnose UC. The epithelial barrier gene extracellular matrix protein 1 (ECM1) was demonstrated to have an association with UC and may be helpful in the diagnosis of UC (10). Although tremendous efforts have been made to the diagnosis of UC, the present knowledge seems to be insufficient. Recently, the appearance of inflammation near the appendix in patients with UC has been highlighted (11). Some studies have confirmed the link between inflammation in the appendix and UC, which drew attention to this skip-lesion change in UC (12, 13). However, the clinical significance of appendiceal orifice inflammation in UC has not been well elucidated.

In this study, we collecteda total of 52 patients with punctiform erosion around the peri-appendiceal orifice and left-sided colitis. Then we analyzed the characteristic changes (continuous shallow ulcers with swelling, erosion and hyperaemia, and bowel loops) observed during endoscopy, which is the key procedure in the diagnosis of UC. Furthermore, we evaluated the relationship between punctiform erosion in the peri-appendiceal orifice with left-sided colitis and UC. The aim of this study was to investigate the significance of this relationship in the diagnosis of UC.

METHODS

Patients

This was a retrospective study approved by the West China Hospital (Chengdu, China). A total of 52 patients admitted to the department of gastroenterology were enrolled in our study during January 2007 and November 2012. In combination with histopathology and endoscopy, patients included in the present study were diagnosed with UC according to Guidelines for the management of inflammatory bowel disease in adults (14). To be included in the study, the extent of UC could not exceed the splenic flexure at disease diagnosis. Patients with edema, ulcers or polyps in the peri-appendiceal orifice, or inflammation in the ascending or transverse colon were excluded.

Methods

All patients had at least one complete colonoscopy (evaluation to cecum). Medical records of all cases were accurately reviewed for epidemiological variables (gender, age, family history of inflammatory bowel disease), inflammatory changes (goblet cell decrease, crypt abscess and lymphoid tissue hyperplasia), UC-related clinical variables at disease diagnosis (continuous edema, hyperemia, undefined blood vessel lamina and scattered punctiform erosion in the rectum and sigmoid colon), as well as the total number of colonoscopies during this period.

RESULTS

A total of 52 patients exhibited punctiform erosion in the peri-appendiceal orifice and inflammation in the left colon on endoscopy. Of them, 24 (46%) were men and 28 (54%) were women, and there were 36 patients (69%) with rectum type, 9 patients (17%) with rectosigmoid type, 4 patients (8%) with sigmoid type and 3 patients (6%) with left hemicolon type. The majority (78%) of UC patients was diagnosed with proctitis. The mean age at diagnosis was 43.3±13.3 years (range, 19-68 years). None of them had a family history of inflammatory bowel disease.

All pathology reports were reviewed and all patients exhibited inflammatory changes (goblet cell decrease, crypt abscess and lymphoid tissue hyperplasia). Of the 52 patients, 49 (94.2%) were eventually diagnosed with UC; one (1.9%) was diagnosed with schistosome enteropathy based on biopsy results and showed widespread deposition of nonviable schistosome ova and schistosome granulomas in the peri-appendiceal orifice and left colon. The remaining 2 (3.8%) patients could not be diagnosed with what kind of diseases they belonged to.

All 49 UC patients exhibited continuous edema, hyperemia, undefined blood vessel lamina and scattered punctiform erosion in the rectum and sigmoid colon, as shown by endoscopy (Fig. 1); the changes were more extensive in the rectum than in the sigmoid colon. The patient with schistosome enteropathy was found to have punctiform erosions in the peri-appendiceal orifice with segmental inflammation of the left colon. All patients in the study had undergone colonoscopic biopsy of both the appendiceal orifice and the left colon. Of the 49 UC patients, 40 had a similar histopathology report in the two ends of the colon. Of the 40 UC patients, 36 were in the active stage of the disease (inflammatory infiltrate, goblet cell decrease, mucosal erosion, ulcer, lymphoid tissue hyperplasia, crypt abscess, etc.) and 4 patients were in the quiescent stage.

DISCUSSION

As a type of IBD, UC affects the quality of people's lives (15). Moreover, UC is associated with an increased risk of developing colorectal cancer, however, it has no specificity standard in the diagnosis of UC until now (5-8). In our study, we analyzed the association between punctiform erosion around the appendiceal orifice with left-sided colitis and UC, then we investigated the significance of this relationship in the diagnosis of UC. Endoscopic changes of 52 patients were analyzed and the results showed that they exhibited punctiform erosion around the appendiceal orifice and inflammation in the left colon on endoscopy. We found that 94.2% patients were eventually diagnosed with UC, which indicated that punctiform erosion around the appendiceal orifice with left-sided colitis may aid in the diagnosis of UC.

Cecal appendix has been repeatedly involved in the pathogenesis and the clinical course of UC (16). Appendectomy is strongly correlated with a decreased incidence of UC (17-20). Moreover, some authors suggested that UC patients undergoing appendectomy experience an improvement in their clinical course (21). All of the studies above indicated that inflammation near the appendix might have relationship with UC and the appearance of inflammation near the appendix in patients with UC had been highlighted (11). Skip inflammation of the peri-appendiceal region in UC was first described in 1958 (12). Cohen et al. described a case of appendiceal involvement of UC as a skip lesion in 1974 (13). Jahadi et al. found that 47 % UC patients had appendiceal involvement, and all of these cases had chronic UC involving the right colon or the cecum (22). Furthermore, other studies showed that 71- 88 % of children with extensive UC had active inflammation in the appendix (23, 24). All these studies drew attention to this skip-lesion change in UC. However, the clinical significance of appendiceal orifice inflammation in UC has not been well elucidated. It is not well known if appendiceal orifice inflammation could aid in the diagnosis of UC.

In our study, 94.2% patients which exhibited punctiform erosion around the appendiceal orifice and inflammation in the left colon on endoscopy were eventually diagnosed with UC. The results indicated that when punctiform erosion in the peri-appendiceal orifice with diffuse inflammation in the left colon was observed during colonoscopy, UC should be considered. Some reports found the reason why appendectomy could delay the progression of UC was that suppressor T cells could inhibit UC and the appendix was one of the organs responsible for T cell growth (25-27). Studies involving rodent models have suggested that the appendix is responsible for the onset of UC and appendix serves as an immunological factor involving in the UC (27, 28). The studies above indicated that the appendix may play a role in UC due to its immune functions. Furthermore, studies showed that Infectious colitis is not rare in China, and is difficult to distinguish from UC because they have very similar clinical symptoms and the endoscopic changes (29, 30). In our investigation, the characteristic features observed on endoscopy may help to distinguish UC from infectious colitis, and it also may be helpful to the diagnosis of UC. In a word, our studies provided a new method for the diagnosis of UC.

Conclusion

In our studies, we showed that punctiform erosion around the appendiceal orifice with left-sided colon diffuse inflammation may have relationship with UC. When punctiform erosion in the peri-appendiceal orifice with left-sided colitis was observed during colonoscopy, UC should be considered. Furthermore, our results also indicated that this relationship might aid in the diagnosis of UC.

Acknowledgments: The authors thank West China Hospital for excellent technical support.

Figure1. Endoscopic image of patients with punctiform erosion around the peri-appendiceal orifice and left-sided colitis who were diagnosed with ulcerative colitis

A refers to the characteristics of the appendiceal orifice; B refers to the characteristics of the ileocecus; C refers to the characteristics of the rectum; D refers to the characteristics of the rectum in another angle. As shown by endoscopy, patients exhibited continuous edema, hyperemia, undefined blood vessel lamina, and scattered punctiform erosion in the rectum.

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