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Krieg S, Kolbe EW, Loosen SH, Roderburg C, Krieg A, Kostev K. Is there a link between appendicitis and the risk of diverticular disease?: a large German cohort study. Int J Colorectal Dis 2024; 39:50. [PMID: 38598172 PMCID: PMC11006757 DOI: 10.1007/s00384-024-04624-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 04/11/2024]
Abstract
PURPOSE Appendicitis, characterized by inflammation of the vermiform appendix, is a common abdominal emergency necessitating appendectomy. Recent evidence suggests a potential link between appendicitis and subsequent diverticular disease, yet population-based studies investigating this association are limited. METHODS Utilizing the Disease Analyzer database encompassing data from over 1000 primary care practices in Germany, we conducted a retrospective cohort study. We included 25,379 adults diagnosed with appendicitis and an equal number of matched controls without appendicitis. The incidence of diverticular disease over a 10-year follow-up period was compared between the two cohorts. Cox regression analysis was performed to assess the association between appendicitis and diverticular disease, adjusting for potential confounders. RESULTS Our findings revealed a significant association between appendicitis and subsequent diverticular disease (HR: 1.76; 95% CI: 1.57-1.97), with an increased risk observed across all age groups. Notably, this association was stronger in men (HR: 2.00; 95% CI: 1.68-2.37) than in women (HR: 1.58; 95% CI: 1.36-1.84). The cumulative 10-year incidence of diverticular disease was higher in patients with appendicitis (6.5%) compared to those without (3.6%). Additionally, we observed a clear age-dependent increase in the incidence of diverticular disease. CONCLUSION This large-scale population-based study provides valuable insights into the interaction between appendicitis and diverticular disease. The study underscores the need for further research elucidating the underlying mechanisms linking appendicitis to diverticular disease. Probiotics emerge as a potential therapeutic avenue warranting exploration in the management of both conditions. These findings have important implications for clinical practice, highlighting the importance of considering appendicitis as a potential risk factor for diverticular disease, particularly in men. Further investigation is warranted to validate these findings and explore potential therapeutic interventions targeting the shared pathophysiological pathways underlying both conditions.
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Affiliation(s)
- Sarah Krieg
- Department of Inclusive Medicine, University Hospital Ostwestfalen-Lippe, Bielefeld University, 33617, Bielefeld, Germany
| | - Ernst W Kolbe
- Department of General and Visceral Surgery, Thoracic Surgery and Proctology, Medical Campus OWL, University Hospital Herford, Ruhr University Bochum, 32049, Herford, Germany
| | - Sven H Loosen
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty, University Hospital Duesseldorf, Heinrich Heine University Duesseldorf, 40225, Duesseldorf, Germany
| | - Christoph Roderburg
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty, University Hospital Duesseldorf, Heinrich Heine University Duesseldorf, 40225, Duesseldorf, Germany
| | - Andreas Krieg
- Department of General and Visceral Surgery, Thoracic Surgery and Proctology, Medical Campus OWL, University Hospital Herford, Ruhr University Bochum, 32049, Herford, Germany.
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Collard MK, Bardin J, Marquet B, Laurin M, Ogier-Denis É. Correlation between the presence of a cecal appendix and reduced diarrhea severity in primates: new insights into the presumed function of the appendix. Sci Rep 2023; 13:15897. [PMID: 37741857 PMCID: PMC10517977 DOI: 10.1038/s41598-023-43070-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 09/19/2023] [Indexed: 09/25/2023] Open
Abstract
Increased severity or recurrence risk of some specific infectious diarrhea, such a salmonellosis or Clostridium difficile colitis, have been reported after an appendectomy in human patients. While several other mammals also possess an appendix, the suspected protective function against diarrhea conferred by this structure is known only in humans. From a retrospective collection of veterinary records of 1251 primates attributed to 45 species, including 13 species with an appendix and 32 without, we identified 2855 episodes of diarrhea, 13% of which were classified as severe diarrhea requiring a therapeutic medication or associated with a fatal issue. We identified a lower risk of severe diarrhea among primate species with an appendix, especially in the early part of life when the risk of diarrhea is maximal. Moreover, we observed a delayed onset of diarrhea and of severe diarrhea in species possessing an appendix. Interestingly, none of the primates with an appendix were diagnosed, treated or died of an acute appendicitis during the 20 years of veterinarian follow-up. These results clarify the function of the appendix among primates, as protection against diarrhea. This supports its presumed function in humans and is congruent with the existence of a selective advantage conferred by this structure.
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Affiliation(s)
- Maxime K Collard
- Centre de Recherche sur l'Inflammation, INSERM, U1149, CNRS, ERL8252, Team Gut Inflammation, Université de Paris, BP 416, 75018, Paris, France.
- Department of Colorectal Surgery, Saint-Antoine Hospital, 184 Rue du Faubourg Saint-Antoine, 75012, Paris, France.
| | - Jérémie Bardin
- CR2P (Centre de Recherche en Paléontologie - Paris; UMR 7207), CNRS/MNHN/Sorbonne Université, Muséum National d'Histoire Naturelle, Paris, France
| | | | - Michel Laurin
- CR2P (Centre de Recherche en Paléontologie - Paris; UMR 7207), CNRS/MNHN/Sorbonne Université, Muséum National d'Histoire Naturelle, Paris, France
| | - Éric Ogier-Denis
- Centre de Recherche sur l'Inflammation, INSERM, U1149, CNRS, ERL8252, Team Gut Inflammation, Université de Paris, BP 416, 75018, Paris, France
- INSERM U1242, Centre Eugène Marquis, Université de Rennes 1, Rennes, France
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3
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Franko J. Removing the Appendix: Prologue to Severe Clostridioides difficile Infection and Recurrence? Dig Dis Sci 2023; 68:3488-3489. [PMID: 37402982 DOI: 10.1007/s10620-023-07978-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 05/15/2023] [Indexed: 07/06/2023]
Affiliation(s)
- Jan Franko
- MercyOne Medical Center, 411 Laurel Street, Suite 2100, Des Moines, IA, 50314, USA.
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4
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Naga YSE, Dhindsa BS, Bapaye J, Tun KM, Dhaliwal A, Ramai D, Saghir SM, Chandan S, Adler DG. A Systematic Review and Meta-Analysis: A Prior Appendectomy Does Not Increase the Risk of Severe Clostridioides difficile Infection or Recurrence. Dig Dis Sci 2023; 68:3714-3720. [PMID: 37402978 DOI: 10.1007/s10620-023-07998-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 06/06/2023] [Indexed: 07/06/2023]
Abstract
BACKGROUND AND OBJECTIVES There is conflicting evidence regarding the association between a prior appendectomy and severity of Clostridioides difficile infection. The aim of this study was to perform a systematic review and meta-analysis to evaluate this association. PATIENTS AND METHODS Comprehensive review of multiple databases was performed up to May 2022. The primary outcome assessed was the rate of severe Clostridioides difficile infection in patients with a prior appendectomy compared to patients with an appendix. The secondary outcomes assessed were recurrence, mortality, and colectomy rates associated with Clostridioides difficile infection in patients with a prior appendectomy compared to patients with an appendix. RESULTS Eight studies with 666 patients with a prior appendectomy and 3580 patients without an appendectomy were included. The odds ratio of severe Clostridioides difficile infection in patients who underwent prior appendectomy was 1.03 (95% CI 0.6-1.78, p = 0.92). The odds ratio of recurrence in patients who underwent prior appendectomy was 1.29 (95% CI 0.82-2.02, p = 0.28). The odds ratio of colectomy due to Clostridioides difficile infection in patients who underwent prior appendectomy was 2.16 (95% CI 1.27-3.67, p = 0.004). The odds ratio of mortality due to Clostridioides difficile infection in patients with a prior appendectomy was 0.92 (95% CI 0.62-1.37, p = 0.68). CONCLUSION Patients with appendectomy are not at increased risk for developing severe Clostridioides difficile infection or recurrence. Further prospective studies are needed to establish these associations.
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Affiliation(s)
- Yassin Shams Eldien Naga
- Department of Internal Medicine, University of South Florida Morsani College of Medicine, 12901 Bruce B Downs Blvd, Tampa, FL, 33612, USA
| | - Banreet Singh Dhindsa
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, 982000 Nebraska Medical Center, Omaha, NE, 68198-2000, USA
| | - Jay Bapaye
- Department of Internal Medicine, Rochester Regional Health, 1425 Portland Avenue, Rochester, NY, 14621, USA
| | - Kyaw Min Tun
- Department of Internal Medicine, University of Nevada Las Vegas School of Medicine, 1701 W Charleston Blvd., Las Vegas, NV, 89102, USA
| | - Amaninder Dhaliwal
- Division of Gastroenterology and Hepatology, McLeod Regional Medical Center, Florence, SC, 29506, USA
| | - Daryl Ramai
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, 30 N 1900 E, Room 4R118, Salt Lake City, UT, 84132, USA
| | - Syed Mohsin Saghir
- Division of Gastroenterology and Hepatology, Creighton University School of Medicine, Omaha, NE, 68124, USA
| | - Saurabh Chandan
- Division of Gastroenterology and Hepatology, Creighton University School of Medicine, Omaha, NE, 68124, USA
| | - Douglas G Adler
- Center for Advanced Therapeutic Endoscopy, Centura Health, Denver, CO, USA.
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Chen YW, Hsu PK, Lin SP, Chen HH. Appendicitis is associated with an increased risk of systemic lupus erythematosus: a nationwide, population-based, case-control study. Clin Rheumatol 2023:10.1007/s10067-023-06585-w. [PMID: 37040052 DOI: 10.1007/s10067-023-06585-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/20/2023] [Accepted: 03/22/2023] [Indexed: 04/12/2023]
Abstract
OBJECTIVE To examine the association between appendicitis and the risk of systemic lupus erythematosus (SLE). METHODS Using claims data from the 2003-2013 Taiwanese National Health Insurance Research Database, we selected 6054 patients with newly diagnosed SLE from 2007 to 2012 and 36,324 age-, sex- and year of SLE diagnosis date-matched (1:6) non-SLE controls. After controlling for potential confounders, a multivariable conditional logistic regression model was used to calculate the adjusted odds ratio (aOR) with 95% confidence interval (CI) for the association of appendicitis history with SLE. Sensitivity analyses were conducted using various definitions of appendicitis. Subgroup analyses were conducted to examine possible modification effects by age, gender, level of urbanization, income and Charlson Comorbidity Index (CCI). RESULTS The average age of patients was 38 years old in both groups. The proportion of females was 86.5%. 75 (1.2%) of SLE cases and 205 (0.6%) of non-SLE controls had appendicitis history before the index date. After adjusting for potential confounding factors, appendicitis was associated with a higher risk of SLE (aOR, 1.84; 95% CI, 1.34-2.52), and such association remained robust after variation of appendicitis definition. No significant modification effects were found for the association between appendicitis and SLE by age, gender, urbanization level, income and CCI. CONCLUSION This nationwide, population-based case-control study demonstrates an association between appendicitis and incident SLE. Lack of individual smoking status is a major limitation. Key Points • Appendicitis was significantly associated with an increased risk of SLE. • Such association remained robust using various definitions of appendicitis.
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Affiliation(s)
- Yun-Wen Chen
- Division of General Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, Taiwan, 40705, ROC
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, Taiwan, 40705, ROC
- Department of Post-Baccalaureate Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Po-Ke Hsu
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Gastroenterology, Changhua Christian Hospital, Changhua, Taiwan
| | - Shih-Ping Lin
- Division of General Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, Taiwan, 40705, ROC
- Department of Post-Baccalaureate Medicine, National Chung Hsing University, Taichung, Taiwan
- Division of Infection, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hsin-Hua Chen
- Division of General Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, Taiwan, 40705, ROC.
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, Taiwan, 40705, ROC.
- Department of Post-Baccalaureate Medicine, National Chung Hsing University, Taichung, Taiwan.
- School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan.
- Department of Industrial Engineering and Enterprise Information, Tunghai University, 1650 Taiwan Boulevard Sect. 4, Taichung, Taiwan, 40705, ROC.
- Institute of Biomedical Science and Rong Hsing Research Center for Translational Medicine & Big Data Center, National Chung Hsin University, Taichung, Taiwan.
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Sterling KG, Dodd GK, Alhamdi S, Asimenios PG, Dagda RK, De Meirleir KL, Hudig D, Lombardi VC. Mucosal Immunity and the Gut-Microbiota-Brain-Axis in Neuroimmune Disease. Int J Mol Sci 2022; 23:13328. [PMID: 36362150 PMCID: PMC9655506 DOI: 10.3390/ijms232113328] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 10/27/2022] [Accepted: 10/28/2022] [Indexed: 07/30/2023] Open
Abstract
Recent advances in next-generation sequencing (NGS) technologies have opened the door to a wellspring of information regarding the composition of the gut microbiota. Leveraging NGS technology, early metagenomic studies revealed that several diseases, such as Alzheimer's disease, Parkinson's disease, autism, and myalgic encephalomyelitis, are characterized by alterations in the diversity of gut-associated microbes. More recently, interest has shifted toward understanding how these microbes impact their host, with a special emphasis on their interactions with the brain. Such interactions typically occur either systemically, through the production of small molecules in the gut that are released into circulation, or through signaling via the vagus nerves which directly connect the enteric nervous system to the central nervous system. Collectively, this system of communication is now commonly referred to as the gut-microbiota-brain axis. While equally important, little attention has focused on the causes of the alterations in the composition of gut microbiota. Although several factors can contribute, mucosal immunity plays a significant role in shaping the microbiota in both healthy individuals and in association with several diseases. The purpose of this review is to provide a brief overview of the components of mucosal immunity that impact the gut microbiota and then discuss how altered immunological conditions may shape the gut microbiota and consequently affect neuroimmune diseases, using a select group of common neuroimmune diseases as examples.
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Affiliation(s)
| | - Griffin Kutler Dodd
- Department of Microbiology and Immunology, University of Nevada, Reno School of Medicine, Reno, NV 89557, USA
| | - Shatha Alhamdi
- Clinical Immunology and Allergy Division, Department of Pediatrics, King Abdullah Specialist Children’s Hospital, King Saud bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Riyadh 11426, Saudi Arabia
| | | | - Ruben K. Dagda
- Department of Pharmacology, School of Medicine, University of Nevada, Reno, NV 89557, USA
| | | | - Dorothy Hudig
- Department of Microbiology and Immunology, University of Nevada, Reno School of Medicine, Reno, NV 89557, USA
| | - Vincent C. Lombardi
- Department of Microbiology and Immunology, University of Nevada, Reno School of Medicine, Reno, NV 89557, USA
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Arjomand Fard N, Armstrong H, Perry T, Wine E. Appendix and Ulcerative Colitis: a Key to Explaining the Pathogenesis and Directing Novel Therapies? Inflamm Bowel Dis 2022; 29:151-160. [PMID: 35749298 PMCID: PMC9825289 DOI: 10.1093/ibd/izac106] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Indexed: 02/05/2023]
Abstract
The vermiform appendix is generally considered a redundant organ, but recent evidence suggests that the appendix could contribute to the pathogenesis of inflammatory bowel diseases, in particular ulcerative colitis (UC), and may even have a therapeutic role; however, mechanisms of the appendix involvement remain unclear. Here, we highlight current evidence on the link between the appendix and UC and consider plausible therapeutic implications. A literature search was conducted using PubMed and PubMed Central from inception to Nov 2021 using the terms "Appendix", "UC", "Appendix & UC," "Appendectomy", and "Peri-appendicular patch," including only articles published in English. Reference lists from the selected studies were manually searched and reviewed to gather additional related reports. Inflammation around the appendix ("peri-appendicular patch") has been frequently observed in UC patients without other cecal involvement, and this inflammation can even precede the onset of UC. Epidemiologic studies propose that appendectomy reduces the risk of developing UC or even the risk of flare after UC is diagnosed, although this remains controversial. We reviewed studies showing altered host-microbe interactions in the appendix in UC, which suggest that the appendix could act as a priming site for disease via alterations in the immune response and changes in microbiota carried distally to the colon. In summary, recent literature suggests a possible role for microbes and immune cells within the appendix; however, the role of the appendix in the pathogenesis of UC remains unclear. Further research could clarify the therapeutic potential related to this organ.
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Affiliation(s)
- Nazanin Arjomand Fard
- Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, AB, T6G 2X8, Canada,Department of Physiology, University of Alberta, Edmonton, AB T6G 1C9, Canada
| | - Heather Armstrong
- Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, AB, T6G 2X8, Canada,Department of Pediatrics, University of Alberta, Edmonton Clinic Health Academy, Room 4-577, 11405 87th Ave, Edmonton, AB T6G 1C9, Canada,Department of Internal Medicine, University of Manitoba, Winnipeg, MB R3E 3P4, Canada
| | - Troy Perry
- Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, AB, T6G 2X8, Canada,Department of Surgery, University of Alberta, Edmonton, AB T6G 1C9, Canada
| | - Eytan Wine
- Address correspondence to: Dr. Eytan Wine, Department of Pediatrics, University of Alberta, Edmonton Clinic Health Academy, Room 4-577, 11405 87th Ave, Edmonton, AB T6G 1C9, Canada ()
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8
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Kumar M, Peters M, Karabon P, Brahmamdam P. Clostridioides difficile infection after appendectomy: An analysis of short-term outcomes from the NSQIP database. Surgery 2022; 172:791-797. [PMID: 35705427 DOI: 10.1016/j.surg.2022.03.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 02/28/2022] [Accepted: 03/28/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Clostridioides difficile infection can be a significant complication in surgical patients. The purpose of this study was to describe the incidence and impact on outcomes of Clostridioides difficile infection in adult patients after appendectomy. METHODS The American College of Surgeons National Surgical Quality Improvement Program data set was used to identify all patients with the primary procedure code of appendectomy between 2016 and 2018. Patient demographics and clinical characteristics were extracted from the database, and descriptive statistics were performed. A multivariate logistic regression was created to identify predictors of Clostridioides difficile infection following appendectomy. RESULTS A total of 135,272 patients who underwent appendectomy were identified, and of those, 469(0.35%) developed Clostridioides difficile infection. Patients with Clostridioides difficile infection were more likely to be older (51.23 vs 40.47 years; P < .0001), female (P = .004), American Society of Anesthesiology score >2 (P < .0001), present with septic shock (P < .0001), or lack functional independence (P < .0001). Patients with Clostridioides difficile infection were more likely to have increased operative time (62.9 vs 50.4 minutes; P < .0001), have perforated appendicitis (48.9% vs 23.5%; P < .0001), and underwent open surgery (7.0% vs 4.0%; P = .0006). Postoperatively, patients with Clostridioides difficile infection required a longer length of stay (4.8 vs 1.8 days; P < .0001), had increased mortality (2.1% vs 0.1%; P < .0001), higher incidences of postoperative abscess (14.9% vs 2.9%; P < .0001), postoperative sepsis (15.1% vs 4.0%; P < .0001), and readmission (30.7% vs 3.4%; all P < .0001). On multivariate analysis, older age (P < .0001), female sex (P = .0043), septic shock (P = .0002), open surgery (P = .037), and dirty wound class (P = .0147) were all independently predictive factors of Clostridioides difficile infection after appendectomy. CONCLUSION Clostridioides difficile infection is an uncommon postoperative complication of appendectomy and is associated with worse outcomes and higher mortality. Older patients, female sex, those with sepsis, and those undergoing open surgery are at higher risk for developing Clostridioides difficile infection.
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Affiliation(s)
- Mohineesh Kumar
- Department of Surgery, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - Mallory Peters
- Department of Surgery, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - Patrick Karabon
- Office of Research, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - Pavan Brahmamdam
- Department of Surgery, Oakland University William Beaumont School of Medicine, Royal Oak, MI.
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9
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Patel BK, Singh AR, Umamahesweran S, Ashok Badhe B. Vermiform Appendix and the Potential for Missed Pathologies. Cureus 2022; 14:e25055. [PMID: 35719826 PMCID: PMC9199560 DOI: 10.7759/cureus.25055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction The appendix is considered an appendage of little value and is often treated disdainfully, be it as part of evolutionary process, on a grossing table, under a microscope or while archiving specimens and slides. It is only recently, with data indicating its importance in gut immunity and as the origin of pseudomyxoma, that its space in a human body appears vindicated. Aim Our aim was to screen the histopathologic spectrum of appendix lesions observed in our hospital for rare, incidental or clinico-radiologically uncertain lesions that would help emphasize a necessary seriousness in its sampling. Method All appendectomy specimens over ten years were screened for diagnosis other than acute/chronic/resolving appendicitis and pseudomyxoma peritonei. Among the recorded rare diagnoses, one representative case each, based on interesting history or pathology, was selected for discussion. Observation Forty-three lesions were found to meet inclusion criteria comprising 12 varied etiologies. Among these, 25 had a normal-appearing appendix and 27 were not suspected on radiology or on clinical/surgical assessment. Histopathology comprised, among others, neoplastic entities such as (Diffuse large B-cell) lymphoma, metastasis, carcinoid as well as interesting non-neoplastic diagnoses such as pinworm infestation (in the elderly) and (post-menopausal) endometriosis. Conclusion Sampling and histopathologic assessment of the appendix should be compulsory, careful and representative. Each specimen must be treated as harboring a potential pathology, until microscopically proven otherwise because missed “rare” diagnoses could delay therapy or alter key management decisions as cancer staging.
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10
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Smith HF. A review of the function and evolution of the cecal appendix. Anat Rec (Hoboken) 2022; 306:972-982. [PMID: 35363436 DOI: 10.1002/ar.24917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/10/2022] [Accepted: 03/10/2022] [Indexed: 11/06/2022]
Abstract
Since its initial discovery in the 1500s, the cecal appendix has been an anatomical structure of great intrigue, notorious for its inconvenient tendency to become inflamed and often require surgical intervention. Appendicitis is one of the most common indications for emergency abdominal surgery, costing healthcare systems billions of dollars globally and causing tens of thousands of deaths annually. Yet, recent studies have indicated that the appendix may serve important protective functions in fortifying the body's immune response against invading pathogens and re-inoculating the gut with commensal bacteria after periods of gastrointestinal illness. While the cecal appendix was once believed to be a synapomorphy of hominoids (humans and other great apes), recent studies suggested that it is a recurrent trait found in several other species of primates, rodents, lagomorphs, marsupials, and monotremes. Mapping appendiceal and other gastrointestinal traits across a mammalian consensus phylogeny revealed that the cecal appendix has evolved independently numerous times throughout mammalian evolution, significantly more than would be expected due to chance alone, suggesting that the appendix is adaptively advantageous. However, attempts to identify an overarching ecological, behavioral, dietary, or environmental factor driving some species to evolve an appendix have been largely unsuccessful, indicating that the cecal appendix has a complex and diverse evolutionary history. This review discusses the current understanding of the pathophysiology, evolution, and possible functions of the appendix, both within humans and broadly across the class Mammalia.
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Affiliation(s)
- Heather F Smith
- Department of Anatomy, Midwestern University, Glendale, Arizona, USA
- School of Human Evolution and Social Change, Arizona State University, Tempe, Arizona, USA
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11
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Padhi P, Worth C, Zenitsky G, Jin H, Sambamurti K, Anantharam V, Kanthasamy A, Kanthasamy AG. Mechanistic Insights Into Gut Microbiome Dysbiosis-Mediated Neuroimmune Dysregulation and Protein Misfolding and Clearance in the Pathogenesis of Chronic Neurodegenerative Disorders. Front Neurosci 2022; 16:836605. [PMID: 35281490 PMCID: PMC8914070 DOI: 10.3389/fnins.2022.836605] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 02/04/2022] [Indexed: 12/14/2022] Open
Abstract
The human gut microbiota is a complex, dynamic, and highly diverse community of microorganisms. Beginning as early as in utero fetal development and continuing through birth to late-stage adulthood, the crosstalk between the gut microbiome and brain is essential for modulating various metabolic, neurodevelopmental, and immune-related pathways. Conversely, microbial dysbiosis – defined as alterations in richness and relative abundances – of the gut is implicated in the pathogenesis of several chronic neurological and neurodegenerative disorders. Evidence from large-population cohort studies suggests that individuals with neurodegenerative conditions have an altered gut microbial composition as well as microbial and serum metabolomic profiles distinct from those in the healthy population. Dysbiosis is also linked to psychiatric and gastrointestinal complications – comorbidities often associated with the prodromal phase of Parkinson’s disease (PD) and Alzheimer’s disease (AD). Studies have identified potential mediators that link gut dysbiosis and neurological disorders. Recent findings have also elucidated the potential mechanisms of disease pathology in the enteric nervous system prior to the onset of neurodegeneration. This review highlights the functional pathways and mechanisms, particularly gut microbe-induced chronic inflammation, protein misfolding, propagation of disease-specific pathology, defective protein clearance, and autoimmune dysregulation, linking gut microbial dysbiosis and neurodegeneration. In addition, we also discuss how pathogenic transformation of microbial composition leads to increased endotoxin production and fewer beneficial metabolites, both of which could trigger immune cell activation and enteric neuronal dysfunction. These can further disrupt intestinal barrier permeability, aggravate the systemic pro-inflammatory state, impair blood–brain barrier permeability and recruit immune mediators leading to neuroinflammation and neurodegeneration. Continued biomedical advances in understanding the microbiota-gut-brain axis will extend the frontier of neurodegenerative disorders and enable the utilization of novel diagnostic and therapeutic strategies to mitigate the pathological burden of these diseases.
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Affiliation(s)
- Piyush Padhi
- Parkinson’s Disorder Research Laboratory, Department of Biomedical Sciences, Iowa State University, Ames, IA, United States
- Department of Physiology and Pharmacology, Center for Brain Sciences and Neurodegenerative Diseases, University of Georgia, Athens, GA, United States
| | - Carter Worth
- Parkinson’s Disorder Research Laboratory, Department of Biomedical Sciences, Iowa State University, Ames, IA, United States
| | - Gary Zenitsky
- Department of Physiology and Pharmacology, Center for Brain Sciences and Neurodegenerative Diseases, University of Georgia, Athens, GA, United States
| | - Huajun Jin
- Department of Physiology and Pharmacology, Center for Brain Sciences and Neurodegenerative Diseases, University of Georgia, Athens, GA, United States
| | - Kumar Sambamurti
- Department of Neuroscience, Medical University of South Carolina, Charleston, SC, United States
| | - Vellareddy Anantharam
- Department of Physiology and Pharmacology, Center for Brain Sciences and Neurodegenerative Diseases, University of Georgia, Athens, GA, United States
| | - Arthi Kanthasamy
- Department of Physiology and Pharmacology, Center for Brain Sciences and Neurodegenerative Diseases, University of Georgia, Athens, GA, United States
| | - Anumantha G. Kanthasamy
- Parkinson’s Disorder Research Laboratory, Department of Biomedical Sciences, Iowa State University, Ames, IA, United States
- Department of Physiology and Pharmacology, Center for Brain Sciences and Neurodegenerative Diseases, University of Georgia, Athens, GA, United States
- *Correspondence: Anumantha G. Kanthasamy,
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van Prehn J, Reigadas E, Vogelzang EH, Bouza E, Hristea A, Guery B, Krutova M, Norén T, Allerberger F, Coia JE, Goorhuis A, van Rossen TM, Ooijevaar RE, Burns K, Scharvik Olesen BR, Tschudin-Sutter S, Wilcox MH, Vehreschild MJGT, Fitzpatrick F, Kuijper EJ. European Society of Clinical Microbiology and Infectious Diseases: 2021 update on the treatment guidance document for Clostridioides difficile infection in adults. Clin Microbiol Infect 2021; 27 Suppl 2:S1-S21. [PMID: 34678515 DOI: 10.1016/j.cmi.2021.09.038] [Citation(s) in RCA: 220] [Impact Index Per Article: 73.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 09/23/2021] [Accepted: 09/30/2021] [Indexed: 12/13/2022]
Abstract
SCOPE In 2009, the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) published the first treatment guidance document for Clostridioides difficile infection (CDI). This document was updated in 2014. The growing literature on CDI antimicrobial treatment and novel treatment approaches, such as faecal microbiota transplantation (FMT) and toxin-binding monoclonal antibodies, prompted the ESCMID study group on C. difficile (ESGCD) to update the 2014 treatment guidance document for CDI in adults. METHODS AND QUESTIONS Key questions on CDI treatment were formulated by the guideline committee and included: What is the best treatment for initial, severe, severe-complicated, refractory, recurrent and multiple recurrent CDI? What is the best treatment when no oral therapy is possible? Can prognostic factors identify patients at risk for severe and recurrent CDI and is there a place for CDI prophylaxis? Outcome measures for treatment strategy were: clinical cure, recurrence and sustained cure. For studies on surgical interventions and severe-complicated CDI the outcome was mortality. Appraisal of available literature and drafting of recommendations was performed by the guideline drafting group. The total body of evidence for the recommendations on CDI treatment consists of the literature described in the previous guidelines, supplemented with a systematic literature search on randomized clinical trials and observational studies from 2012 and onwards. The Grades of Recommendation Assessment, Development and Evaluation (GRADE) system was used to grade the strength of our recommendations and the quality of the evidence. The guideline committee was invited to comment on the recommendations. The guideline draft was sent to external experts and a patients' representative for review. Full ESCMID endorsement was obtained after a public consultation procedure. RECOMMENDATIONS Important changes compared with previous guideline include but are not limited to: metronidazole is no longer recommended for treatment of CDI when fidaxomicin or vancomycin are available, fidaxomicin is the preferred agent for treatment of initial CDI and the first recurrence of CDI when available and feasible, FMT or bezlotoxumab in addition to standard of care antibiotics (SoC) are preferred for treatment of a second or further recurrence of CDI, bezlotoxumab in addition to SoC is recommended for the first recurrence of CDI when fidaxomicin was used to manage the initial CDI episode, and bezlotoxumab is considered as an ancillary treatment to vancomycin for a CDI episode with high risk of recurrence when fidaxomicin is not available. Contrary to the previous guideline, in the current guideline emphasis is placed on risk for recurrence as a factor that determines treatment strategy for the individual patient, rather than the disease severity.
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Affiliation(s)
- Joffrey van Prehn
- Department of Medical Microbiology, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Elena Reigadas
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Erik H Vogelzang
- Department of Medical Microbiology and Infection Control, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Adriana Hristea
- University of Medicine and Pharmacy Carol Davila, National Institute for Infectious Diseases Prof Dr Matei Bals, Romania
| | - Benoit Guery
- Infectious Diseases Specialist, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Marcela Krutova
- Department of Medical Microbiology, Charles University in Prague and Motol University Hospital, Czech Republic
| | - Torbjorn Norén
- Faculty of Medicine and Health, Department of Laboratory Medicine, National Reference Laboratory for Clostridioides difficile, Clinical Microbiology, Örebro University Hospital, Örebro, Sweden
| | | | - John E Coia
- Department of Clinical Microbiology, Hospital South West Jutland and Department of Regional Health Research IRS, University of Southern Denmark, Esbjerg, Denmark
| | - Abraham Goorhuis
- Department of Infectious Diseases, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, the Netherlands
| | - Tessel M van Rossen
- Department of Medical Microbiology and Infection Control, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Rogier E Ooijevaar
- Department of Gastroenterology, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Karen Burns
- Departments of Clinical Microbiology, Beaumont Hospital & Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Sarah Tschudin-Sutter
- Department of Infectious Diseases and Infection Control, University Hospital Basel, University Basel, Universitatsspital, Basel, Switzerland
| | - Mark H Wilcox
- Department of Microbiology, Old Medical, School Leeds General Infirmary, Leeds Teaching Hospitals & University of Leeds, Leeds, United Kingdom
| | - Maria J G T Vehreschild
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany; Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Fidelma Fitzpatrick
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland; Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ed J Kuijper
- Department of Medical Microbiology, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands; National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands.
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Shaikh DH, Patel H, Munshi R, Sun H, Mehershahi S, Baiomi A, Alemam A, Pirzada U, Nawaz I, Naher K, Hanumanthu S, Nayudu S. Patients with Clostridium difficile infection and prior appendectomy may be prone to worse outcomes. World J Gastrointest Surg 2021; 13:1436-1447. [PMID: 34950432 PMCID: PMC8649559 DOI: 10.4240/wjgs.v13.i11.1436] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 08/29/2021] [Accepted: 09/17/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Clostridium difficile infection (CDI) occurs due to a dysbiosis in the colon. The appendix is considered a ‘safe house’ for gut microbiota and may help repopulate gut flora of patients with CDI.
AIM To study the impact of prior appendectomy on the severity and outcomes of CDI.
METHODS We retrospectively reviewed data of 1580 patients with CDI, admitted to our hospital between 2008 to 2018. Patients were grouped based on the presence or absence of the appendix. The primary aim was to (1) assess all-cause mortality and (2) the severity of CDI. Severity was defined as per the Infectious Diseases Society of America criteria. Logistic regression, and propensity score analysis using inverse probability of treatment weights (IPTW) was performed.
RESULTS Of the 1580 patients, 12.5% had a history of appendectomy. There was no statistical difference in mortality between patients with a prior appendectomy or without (13.7% vs 14%, P = 0.877). However, a history of appendectomy affected the severity of CDI [odds ratio (OR) = 1.32, 95% confidence interval: 1.01-1.75]. On IPTW, this association remained significant (OR = 1.59, P < 0.05). On multivariable analysis of secondary outcomes, prior appendectomy was also associated with toxic megacolon (OR = 5.37, P < 0.05) and colectomy (OR = 2.77, P < 0.05).
CONCLUSION Prior appendectomy may affect the severity of CDI, development of toxic megacolon and the eventual need for colectomy. Since treatment of CDI is governed by its severity, stronger antibiotic regimens or earlier use of fecal microbiota transplant may be a viable option for patients with prior appendectomy.
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Affiliation(s)
- Danial Haris Shaikh
- Division of Gastroenterology, Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - Harish Patel
- Division of Gastroenterology, Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - Rezwan Munshi
- Department of Medicine, Nassau University Medical Center, New York, NY 11554, United States
| | - Haozhe Sun
- Division of Gastroenterology, Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - Shehriyar Mehershahi
- Division of Gastroenterology, Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - Ahmed Baiomi
- Division of Gastroenterology, Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - Ahmed Alemam
- Division of Gastroenterology, Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - Usman Pirzada
- Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - Iqra Nawaz
- Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - Kamrun Naher
- Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - Siddarth Hanumanthu
- Division of Gastroenterology, Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - Suresh Nayudu
- Division of Gastroenterology, Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
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Collard MK, Bardin J, Laurin M, Ogier‐Denis E. The cecal appendix is correlated with greater maximal longevity in mammals. J Anat 2021; 239:1157-1169. [PMID: 34235746 PMCID: PMC8546507 DOI: 10.1111/joa.13501] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 04/28/2021] [Accepted: 06/14/2021] [Indexed: 01/26/2023] Open
Abstract
The cecal appendix had been considered as a useless vestige since Darwin's work, but recent research questioned this idea demonstrating that the cecal appendix appeared among the mammals at least 80 million years ago and has made multiple and independent appearances without any obvious correlation with diet, social life, ecology, or size of the cecum. However, functions and probable selective advantage conferred by this anatomical structure still remain enigmatic. We found, through analyses of data on 258 mammalian species, that cecal appendix presence is correlated with increased maximal observed longevity. This is the first demonstration of a correlation between cecal appendix presence and life history. Interestingly, the classical evolutionary theory of aging that predicts an increased longevity when the extrinsic mortality is reduced has been questioned several times, but recent comparative studies asserted its validity in the taxa, which experience age-dependent and density-dependent mortality, as in mammals. Thus, the cecal appendix may contribute to the increase in longevity through a reduction of extrinsic mortality. A lower risk of fatal infectious diarrhea is one of the most plausible hypotheses that could explain it. However, several hypotheses coexist about the possible functions of the cecal appendix, and our results provide new insights about this much-disputed question. In addition, we show that the cecal appendix arose at least 16 times and was lost only once during the evolutionary history of the considered mammals, an asymmetry that supports the existence of a positive selective of this structure.
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Affiliation(s)
- Maxime K. Collard
- Centre de Recherche sur l’InflammationINSERMU1149CNRSERL8252Team Gut InflammationUniversité de ParisParisFrance
| | - Jérémie Bardin
- CR2P ("Centre de Recherches sur la Paléobiodiversité et les Paléoenvironnements"UMR 7207CNRS/MNHNMuséum National d'Histoire NaturelleSorbonne UniversitéParisFrance
| | - Michel Laurin
- CR2P ("Centre de Recherches sur la Paléobiodiversité et les Paléoenvironnements"UMR 7207CNRS/MNHNMuséum National d'Histoire NaturelleSorbonne UniversitéParisFrance
| | - Eric Ogier‐Denis
- Centre de Recherche sur l’InflammationINSERMU1149CNRSERL8252Team Gut InflammationUniversité de ParisParisFrance
- INSERM U1242Université de Rennes 1RennesFrance
- Centre de Lutte contre le Cancer Eugène Marquis CLCCRennesFrance
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15
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van Rossen TM, Ooijevaar RE, Vandenbroucke-Grauls CMJE, Dekkers OM, Kuijper EJ, Keller JJ, van Prehn J. Prognostic factors for severe and recurrent Clostridioides difficile infection: a systematic review. Clin Microbiol Infect 2021; 28:321-331. [PMID: 34655745 DOI: 10.1016/j.cmi.2021.09.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/24/2021] [Accepted: 09/25/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Clostridioides difficile infection (CDI), its subsequent recurrences (rCDIs), and severe CDI (sCDI) provide a significant burden for both patients and the healthcare system. Identifying patients diagnosed with initial CDI who are at increased risk of developing sCDI/rCDI could lead to more cost-effective therapeutic choices. In this systematic review we aimed to identify clinical prognostic factors associated with an increased risk of developing sCDI or rCDI. METHODS PubMed, Embase, Emcare, Web of Science and COCHRANE Library databases were searched from database inception through March, 2021. The study eligibility criteria were cohort and case-control studies. Participants were patients ≥18 years old diagnosed with CDI, in which clinical or laboratory factors were analysed to predict sCDI/rCDI. Risk of bias was assessed by using the Quality in Prognostic Research (QUIPS) tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool modified for prognostic studies. Study selection was performed by two independent reviewers. Overview tables of prognostic factors were constructed to assess the number of studies and the respective effect direction and statistical significance of an association. RESULTS 136 studies were included for final analysis. Greater age and the presence of multiple comorbidities were prognostic factors for sCDI. Identified risk factors for rCDI were greater age, healthcare-associated CDI, prior hospitalization, proton pump inhibitors (PPIs) started during or after CDI diagnosis, and previous rCDI. CONCLUSIONS Prognostic factors for sCDI and rCDI could aid clinicians to make treatment decisions based on risk stratification. We suggest that future studies use standardized definitions for sCDI/rCDI and systematically collect and report the risk factors assessed in this review, to allow for meaningful meta-analysis of risk factors using data of high-quality trials.
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Affiliation(s)
- Tessel M van Rossen
- Amsterdam UMC, VU University Medical Center, Medical Microbiology & Infection Control, Amsterdam Infection & Immunity, Amsterdam, the Netherlands.
| | - Rogier E Ooijevaar
- Amsterdam UMC, VU University Medical Center, Gastroenterology & Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands.
| | - Christina M J E Vandenbroucke-Grauls
- Amsterdam UMC, VU University Medical Center, Medical Microbiology & Infection Control, Amsterdam Infection & Immunity, Amsterdam, the Netherlands; Aarhus University, Clinical Epidemiology, Aarhus, Denmark
| | - Olaf M Dekkers
- Leiden University Medical Center, Clinical Epidemiology, Leiden, the Netherlands
| | - Ed J Kuijper
- Leiden University Medical Center, Center for Infectious Diseases, Medical Microbiology, Leiden, the Netherlands
| | - Josbert J Keller
- Haaglanden Medical Center, Gastroenterology & Hepatology, The Hague, the Netherlands; Leiden University Medical Center, Gastroenterology & Hepatology, Leiden, the Netherlands
| | - Joffrey van Prehn
- Leiden University Medical Center, Center for Infectious Diseases, Medical Microbiology, Leiden, the Netherlands
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16
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Lee S, Jang EJ, Jo J, Park SJ, Ryu HG. Long-term impacts of appendectomy associated with increased incidence of inflammatory bowel disease, infection, and colorectal cancer. Int J Colorectal Dis 2021; 36:1643-1652. [PMID: 33594506 DOI: 10.1007/s00384-021-03886-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/09/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Although the appendix has been suggested to play a role in maintaining the gut microbiome and immune system, the ramifications of appendectomy on the development inflammatory bowel disease, sepsis, and colorectal cancer are yet to be determined. The purpose of this study was to evaluate the potential long-term impacts of appendectomy, with a focus on inflammatory bowel disease, infection, and colorectal cancer, using the National Healthcare Insurance Service (NHIS) database of Korea. METHODS The National Healthcare Insurance Service database in Korea was used for analysis. Adult patients who received appendectomy between 2005 and 2013 were identified. The control group consisted of patients who did not receive appendectomy were matched by baseline characteristics including comorbidities and frequency of healthcare resource utilization. The primary outcome was the incidence-rate ratio (IRR) of Crohn's disease, ulcerative colitis, Clostridium difficile infection, sepsis, and colorectal cancer after appendectomy or the index date. RESULTS We identified 914,208 patients who underwent appendectomy, and after matching with control patients, a total of 486,844 patients were included for analysis. Patients who underwent appendectomy showed a significantly higher incidence of Crohn's disease (IRR 4.40, 95% confidence interval (CI) 3.78-5.13) and ulcerative colitis (IRR 1.78, 95% CI 1.63-1.93) compared to the control group during the 5-year follow-up period. The associations between appendectomy and Clostridium difficile infection, sepsis, and colorectal cancer were all found to be significant. CONCLUSION Patients who underwent appendectomy may be at increased risk for developing Crohn's disease, ulcerative colitis, Clostridium difficile infection, sepsis, and colorectal cancer.
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Affiliation(s)
- Seohee Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, Republic of Korea, 03080
| | - Eun Jin Jang
- Department of Information Statistics, Andong National University, 1375 Gyeongdong-Ro, Andong, Gyeongsangbuk-do, 36729, South Korea
| | - Junwoo Jo
- Department of Statistics, Kyungpook National University, 80 Daehak-Ro, Daegu, 41566, South Korea
| | - So Jung Park
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, Republic of Korea, 03080
| | - Ho Geol Ryu
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, Republic of Korea, 03080.
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Chung WS, Chung S, Hsu CY, Lin CL. Risk of Inflammatory Bowel Disease Following Appendectomy in Adulthood. Front Med (Lausanne) 2021; 8:661752. [PMID: 34150801 PMCID: PMC8206496 DOI: 10.3389/fmed.2021.661752] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/10/2021] [Indexed: 12/18/2022] Open
Abstract
Background: The appendix has a complicated immune function, and appendectomy may derange the immune system. Studies on the relationship between appendectomy and subsequent inflammatory bowel disease (IBD) have been inconsistent. We conducted a nationwide cohort study consisting of individuals who underwent appendectomy to evaluate the incidence and risk of ulcerative colitis (UC) and Crohn's disease (CD). Methods: We identified patients aged >20 years who underwent appendectomy between 2000 and 2012 from inpatient claims of the National Health Insurance Research Database (NHIRD) and assigned them to the appendectomy cohort. Then, we randomly selected patients without appendectomy in the NHIRD and assigned them to the comparison cohort in a frequency-matched 1:1 ratio based on sex, age, and index year. We tracked down all participants until IBD diagnosis, death, or the end of 2013. Cox models were used to estimate the hazard ratio (HR), and 95% confidence intervals (CIs) were used to compare the IBD risk between the appendectomy and comparison cohorts. Results: The appendectomy and comparison cohorts in the study consisted of 246 562 patients each. The appendectomy cohort exhibited a 2.23- and 3.48-fold higher risk of UC (adjusted HR = 2.23, 95% CI = 1.59-3.12) and CD (adjusted HR = 3.48, 95% CI = 2.42-4.99), respectively, than did the comparison cohort. UC and CD risks significantly increased in the appendectomy cohort regardless of whether appendicitis was present. Conclusions: Our study suggests that appendectomy increases UC and CD risks irrespective of appendicitis.
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Affiliation(s)
- Wei-Sheng Chung
- Department of Internal Medicine, Taichung Hospital, Ministry of Health and Welfare, Taichung, Taiwan.,Department of Health Services Administration, China Medical University, Taichung, Taiwan.,Department of Healthcare Administration, Central Taiwan University of Science and Technology, Taichung, Taiwan
| | - Sunny Chung
- Department of Chemistry, Point Loma Nazarene University, San Diego, CA, United States
| | - Chung-Y Hsu
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan
| | - Cheng-Li Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan.,College of Medicine, China Medical University, Taichung, Taiwan
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Song MY, Ullah S, Yang HY, Ahmed MR, Saleh AA, Liu BR. Long-term effects of appendectomy in humans: is it the optimal management of appendicitis? Expert Rev Gastroenterol Hepatol 2021; 15:657-664. [PMID: 33350352 DOI: 10.1080/17474124.2021.1868298] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Appendectomy remains the gold standard for treating uncomplicated and complicated appendicitis. However, the vermiform appendix may play a significant role in the immune system (secondary immune function) and maintain a reservoir of the normal microbiome for the human body. The aim of this study was to summarize the long-term effects after appendectomy and discuss whether appendectomy is suitable for all appendicitis patients. AREAS COVERED A comprehensive and unbiased literature search was performed in PubMed. The terms 'appendix,' 'appendicitis,' 'appendectomy,' and 'endoscopic retrograde appendicitis therapy' were searched in the title and/or abstract. This review summarizes the long-term effects of appendectomy on some diseases in humans and describes three methods including appendectomy, medical treatment, and an 'organ-sparing' technique, named endoscopic retrograde appendicitis therapy (ERAT) to treat appendicitis. EXPERT OPINION Appendectomy remains the first-line therapy for appendicitis. The patient's problem is appendix, not appendicitis. If we treat appendicitis, the problem should be resolved. During COVID-19, an initial antibiotic treatment of mild appendicitis represents a promising strategy. For patients who are worried about the long-term adverse effect after appendectomy and have a strong desire to preserve the appendix and are aware of the risk of appendicitis recurrence, medical treatment, or ERAT could be proposed.
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Affiliation(s)
- Ming-Yang Song
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,The Academy of Medical Science, Zhengzhou University, Zhengzhou, China
| | - Saif Ullah
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hui-Yu Yang
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Md Robin Ahmed
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | | | - Bing-Rong Liu
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Wu DK, Yang KS, Wei JCC, Yip HT, Chang R, Hung YM, Hung CH. Appendectomy and Non-Typhoidal Salmonella Infection: A Population-Based Matched Cohort Study. J Clin Med 2021; 10:jcm10071466. [PMID: 33918175 PMCID: PMC8037619 DOI: 10.3390/jcm10071466] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/18/2021] [Accepted: 03/30/2021] [Indexed: 02/07/2023] Open
Abstract
The potential association between appendectomy and non-typhoidal Salmonella (NTS) infection has not been elucidated. We hypothesized that appendectomy may be associated with gut vulnerability to NTS. The data were retrospectively collected from the Taiwan National Health Insurance Research Database to describe the incidence rates of NTS infection requiring hospital admission among patients with and without an appendectomy. A total of 208,585 individuals aged ≥18 years with an appendectomy were enrolled from January 2000 to December 2012, and compared with a control group of 208,585 individuals who had never received an appendectomy matched by propensity score (1:1) by index year, age, sex, occupation, and comorbidities. An appendectomy was defined by the International Classification of Diseases, Ninth Revision, Clinical Modification Procedure Codes. The main outcome was patients who were hospitalized for NTS. Cox proportional hazards models were applied to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs). Two sensitivity analyses were conducted for cross-validation. Of the 417,170 participants (215,221 (51.6%) male), 208,585 individuals (50.0%) had an appendectomy, and 112 individuals developed NTS infection requiring hospitalization. In the fully adjusted multivariable Cox proportional hazards regression model, the appendectomy group had an increased risk of NTS infection (adjusted HR (aHR), 1.61; 95% CI, 1.20-2.17). Females and individuals aged 18 to 30 years with a history of appendectomy had a statistically higher risk of NTS than the control group (aHR, 1.92; 95% CI, 1.26-2.93 and aHR, 2.67; 95% CI, 1.41-5.07). In this study, appendectomy was positively associated with subsequent hospitalization for NTS. The mechanism behind this association remains uncertain and needs further studies to clarify the interactions between appendectomy and NTS.
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Affiliation(s)
- Den-Ko Wu
- Institute of Biotechnology and Chemical Engineering, I-Shou University, Kaohsiung 840, Taiwan;
- Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung 813, Taiwan
| | - Kai-Shan Yang
- School of Post-Baccalaureate Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan;
| | - James Cheng-Chung Wei
- Graduate Institute of Integrated Medicine, China Medical University, Taichung 404, Taiwan;
- Division of Allergy, Immunology and Rheumatology, Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
| | - Hei-Tung Yip
- Management Office for Health Data, China Medical University Hospital, Taichung 404, Taiwan;
| | - Renin Chang
- Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung 813, Taiwan
- Correspondence: (R.C.); (Y.-M.H.); (C.-H.H.); Tel.: +886-73422121 (R.C.); +886-75552565 (Y.-M.H.); +886-76577711 (ext. 3414) (C.-H.H.)
| | - Yao-Min Hung
- Department of Internal Medicine, Kaohsiung Municipal United Hospital, Kaohsiung 804, Taiwan
- College of Health and Nursing, Meiho University, Pingtung 912, Taiwan
- Department of Internal Medicine, Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
- Correspondence: (R.C.); (Y.-M.H.); (C.-H.H.); Tel.: +886-73422121 (R.C.); +886-75552565 (Y.-M.H.); +886-76577711 (ext. 3414) (C.-H.H.)
| | - Chih-Hsin Hung
- Institute of Biotechnology and Chemical Engineering, I-Shou University, Kaohsiung 840, Taiwan;
- Correspondence: (R.C.); (Y.-M.H.); (C.-H.H.); Tel.: +886-73422121 (R.C.); +886-75552565 (Y.-M.H.); +886-76577711 (ext. 3414) (C.-H.H.)
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Essrani R, Saturno D, Mehershahi S, Essrani RK, Hossain MR, Ravi SJK, Berger A, Mehmood A. The Impact of Appendectomy in Clostridium difficile Infection and Length of Hospital Stay. Cureus 2020; 12:e10342. [PMID: 33062466 PMCID: PMC7549846 DOI: 10.7759/cureus.10342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Introduction We aim to investigate Clostridium difficile infection (CDI) recurrence, severity, complications, and length of hospital stay in patients with and without prior history of appendectomy who were admitted to the hospital with CDI. Method We analyzed retrospective data for 862 patients, 18 years and older, with C. difficile inpatients diagnosed between January 1, 2017 and December 31, 2018 and sorted into two groups, with or without prior appendicectomy, to look for outcomes such as recurrence, hospital stay, complications, and related death in each group and use statistical analysis for comparison. Result There were 862 patients admitted with CDI, of which 122 (14.2%) had a prior history of appendectomy and 740 (85.8%) did not. Patients with an appendectomy prior were older (median age of 75 vs. 69, p = 0.0033) and had a higher proportion of females (68.9% vs. 53.6%, p = 0.0017). C. difficile recurrence in prior appendicectomy group vs. no appendectomy group was 12.3% and 9.3%, respectively, but no statistical difference was noted (p = 0.28). Also, there was no statistical difference in complications like ileus, colectomy, and mortality related to CDI in both groups. However, patients with appendectomies had significantly shorter hospital stays during C. difficile admission compared to patients without appendectomies (median of six days vs. seven days, p = 0.0014). Conclusion Our study shows that there is no statistical difference in the recurrence, severity, and complications of CDI in the presence or absence of the appendix but remarkably noted that people with prior appendicectomy had a shorter hospital stay.
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Affiliation(s)
- Rajesh Essrani
- Internal Medicine, Geisinger Medical Center, Danville, USA.,Internal Medicine, Lehigh Valley Health Network, Allentown, USA
| | - Dany Saturno
- General Internal Medicine, BronxCare Health System, Bronx, USA
| | | | | | | | | | - Andrea Berger
- Biostatistics, Geisinger Medical Center, Danville, USA
| | - Asif Mehmood
- Internal Medicine, Geisinger Medical Center, Danville, USA.,Internal Medicine, Abington Hospital - Jefferson Health, Abington, USA
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Heindl SE, Tsouklidis N. Appendectomy as a Potential Predisposing Factor for the Development of Recurrent and Fulminant Clostridium Difficile. Cureus 2020; 12:e10091. [PMID: 32874818 PMCID: PMC7455376 DOI: 10.7759/cureus.10091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
This literature review assesses how the vermiform appendix has been considered a vestigial organ by many, but over the years, new research has allowed us to reconsider its potential purpose. Studies have indicated that the appendix plays an evident role in immune response and harbors a biofilm that may remain unaffected by gastrointestinal infections, such as infection with Clostridium difficile. Our research analyzes the prominent gut-associated lymphoid tissue (GALT) as a mechanism of defence in infection, as well as the robust biofilm that could aid in the reinoculation of beneficial bacteria within the colon. Furthermore, we wanted to determine if patients who have undergone a prior appendectomy, leading to decreased GALT and a lack of a bacterial reservoir, were predisposed to the development of Clostridium difficile, with particular emphasis in the recurrence and development of fulminant Clostridium difficile infections. Although research continues to be conflicting, there appears to be some connection between these variables, but prospective studies are needed in order to say for certain that there is a link.
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Affiliation(s)
- Stacey E Heindl
- Medicine, Avalon University School of Medicine, Willemstad, CUW.,Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Nicholas Tsouklidis
- Health Care Administration, University of Cincinnati Health, Cincinnati, USA.,Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA.,Medicine, Atlantic University School of Medicine, Gros Islet, LCA
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Franko J, Ferrel B, Pierson P, Raman S, Frankova D, Rearigh LM, Afroze A, Guevara Hernandez MA, Terrero-Salcedo D, Kermode D, Gorvet M. Influence of prior appendectomy and cholecystectomy on Clostridioides difficile infection recurrence and mortality. Am J Surg 2020; 220:203-207. [DOI: 10.1016/j.amjsurg.2019.10.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 10/13/2019] [Accepted: 10/18/2019] [Indexed: 11/15/2022]
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Wu MC, Tsou HK, Lin CL, Wei JCC. Incidence and risk of sepsis following appendectomy: a nationwide population-based cohort study. Sci Rep 2020; 10:10171. [PMID: 32576857 PMCID: PMC7311524 DOI: 10.1038/s41598-020-66943-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 05/21/2020] [Indexed: 11/09/2022] Open
Abstract
Appendectomy is a frequently performed surgical procedure; however, long-term consequences have not been fully explored. We used a nationwide population-based cohort to determine whether patients undergoing appendectomy are at an increased risk of sepsis. Overall, 252,688 patients undergoing appendectomy and 252,472 matched controls were identified from the National Health Insurance Research Database in Taiwan. A propensity score analysis was used for matching age, sex, index year and comorbidities at a ratio of 1:1. Multiple Cox regression and stratified analyses were used to estimate the adjusted hazard ratio (aHR) of developing sepsis. Patients undergoing appendectomy had a 1.29 times (aHR: 1.29; 95% confidence interval [CI], 1.26-1.33) higher risk of developing sepsis than those not undergoing. Patients aged 20-49 years had a 1.58-fold higher risk of sepsis in the appendectomy cohort (aHR; 95% CI, 1.50-1.68). Also, having undergone appendectomy, patients had a higher likelihood of sepsis, regardless of sex and with or without comorbidities. Patients with <1 year follow-up showed a 1.98-fold risk of sepsis in the appendectomy cohort. Patients with 1-4 and ≥5 years follow-up showed a 1.29 and 1.11-fold risk of sepsis, respectively. Future research is required to elucidate the possible immuno-pathological mechanisms of these associations.
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Affiliation(s)
- Meng-Che Wu
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Division of Gastroenterology, Children's Medical Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hsi-Kai Tsou
- Functional Neurosurgery Division, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Rehabilitation, Jen-Teh Junior College of Medicine, Nursing and Management, Miaoli County, Taiwan
| | - Cheng-Li Lin
- College of Medicine, China Medical University, Taichung, Taiwan.,Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - James Cheng-Chung Wei
- Department of Rheumatology, BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, China. .,Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China. .,Division of Allergy, Immunology and Rheumatology, Chung Shan Medical University Hospital; Institute of Medicine, College of Medicine, Chung Shan Medical University, Taichung, Taiwan. .,Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan.
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Yang CY, Wu MC, Lin MC, Wei JCC. Risk of irritable bowel syndrome in patients who underwent appendectomy: A nationwide population-based cohort study. EClinicalMedicine 2020; 23:100383. [PMID: 32637891 PMCID: PMC7329725 DOI: 10.1016/j.eclinm.2020.100383] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 05/01/2020] [Accepted: 05/01/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Appendectomy is one of the most common surgical procedures; however, the possible long-term consequences have not been fully explored. The appendix has been associated with microflora of the gut and immune functions. However, literature examining the relationship between prior appendectomy and the risk of irritable bowel syndrome (IBS) is lacking. The aim of this study was to evaluate the risk of irritable bowel syndrome for patients who underwent appendectomy by using a nationwide longitudinal population-based cohort. METHODS Data from this study was collected from Taiwan's National Health Insurance Research Database (NHIRD), a population-based database. We identified 12,760 patients who underwent appendectomy between January 1, 2000 and December 31, 2012. A total of 9236 patients who had appendectomy (case group) were randomly matched with 9236 patients who had not undergone appendectomy (control group) in a ratio of 1:1 by means of propensity scores. The hazard ratio (HR) of IBS was calculated by multiple Cox regression. Furthermore, sensitivity test and stratified analysis were performed. FINDINGS The incidence rate of IBS was 51.30 per 10,000 person-years in patients having appendectomy, more than the 35.28 per 10,000 person-years in patients not having appendectomy. Patients who underwent appendectomy had 1.46-fold risk of IBS compared to patients not having appendectomy (HR, 1.46; 95% CI, 1.24-1.72). Stratified analysis revealed that the higher HR of 1.55 (95% CI, 1.18-2.04) in patients <40 years old, and particularly within the first 5 years follow-up period of undergoing appendectomy. In addition, patients diagnosed with fibromyalgia had a greater risk of suffering IBS after appendectomy (HR, 1.41; 95% CI, 1.04-1.92). INTERPRETATION Patients with appendectomy have a higher incidental risk of IBS than the control population. The risk is higher for patients under 40 years old and those who received appendectomy within 5 years. Physicians could take this into consideration for treatment plans of patients who have underwent this surgery. Further research on the pathogenesis of this association is required. FUNDING This work was supported by grants from the Ministry of Health and Welfare, Taiwan (MOHW108-TDU-B-212-133004), China Medical University Hospital, Academia Sinica Stroke Biosignature Project (BM10701010021), MOST Clinical Trial Consortium for Stroke (MOST 108-2321-B-039-003-), Tseng-Lien Lin Foundation, Taichung, Taiwan, and Katsuzo and Kiyo Aoshima Memorial Funds, Japan.
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Affiliation(s)
- Chi-Ya Yang
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Meng-Che Wu
- Division of Gastroenterology, Children's Medical Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Mei-Chen Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
| | - James Cheng-Chung Wei
- Department of Rheumatology, BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, China
- Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
- Department of Allergy, Immunology & Rheumatology, Chung Shan Medical University Hospital; Institute of Medicine, College of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan
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Abstract
For decades, the mandatory treatment for acute uncomplicated appendicitis was urgent appendicectomy. This dogma has now been questioned by several randomized controlled trials, which demonstrated the safety of antibiotic treatment of uncomplicated appendicitis without increased morbidity and mortality. The efficacy of this conservative treatment, however, is inferior to surgery: Within the first year after antibiotic treatment of acute appendicitis, approximately 30% of patients require appendicectomy. Within 5 years the rate of appendicectomy increases to 40% and the life-long risk of appendicectomy after conservative treatment can be expected to be even higher. The advantages of conservative treatment of appendicitis are faster recovery and the lack of postoperative wound pain; however, all currently available trials compared conservative treatment almost exclusively with conventional appendicectomy, trials comparing laparoscopic appendicectomy to antibiotics are currently not available. As laparoscopic appendicectomy is a well-established and safe treatment ubiquitously available in Germany, conservative treatment in patients with uncomplicated appendicitis cannot generally be recommended. As antibiotic treatment is a less effective but equally safe procedure, it can be offered to selected patients only.
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Killinger B, Labrie V. The Appendix in Parkinson's Disease: From Vestigial Remnant to Vital Organ? JOURNAL OF PARKINSON'S DISEASE 2019; 9:S345-S358. [PMID: 31609697 PMCID: PMC6839473 DOI: 10.3233/jpd-191703] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 09/13/2019] [Indexed: 02/07/2023]
Abstract
Parkinson's disease (PD) has long been considered a brain disease, but studies now point to the gastrointestinal (GI) tract as a potential starting point for PD. In particular, the human vermiform appendix has been implicated in PD. The appendix is a tissue rich in immune cells, serving as part of the gut-associated lymphoid tissue and as a storehouse for the gut microbiome. The functions of the appendix converge with recent evidence demonstrating that gut inflammation and shifts in the microbiome are linked to PD. Some epidemiological studies have linked removal of the appendix to lowered PD risk, though there is controversy among these associations. What is apparent is that there is an abundance of aggregated forms of α-synuclein in the appendix relevant to PD pathology. α-Synuclein pathology is thought to propagate from gut to brain via the vagus nerve, which innervates GI tract locations, including the appendix. Remarkably, α-synuclein aggregates in the appendix occur not only in PD patients, but are also present in healthy individuals. This has led to the proposal that in the appendix α-synuclein aggregates are not unique to PD. Moreover, the molecular events leading to PD and the mechanisms by which α-synuclein aggregates transfers from gut to brain may be identifiable in the human appendix. The influence of the appendix on GI inflammation, autoimmunity, microbiome storage, and the lymphatic system may be yet unexplored mechanisms by which the appendix contributes to PD. Overall, the appendix represents a promising tissue site to advance our understanding of PD pathobiology.
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Affiliation(s)
- Bryan Killinger
- Department of Neurological Sciences, Rush Medical College, Chicago, IL, USA
| | - Viviane Labrie
- Center for Neurodegenerative Science, Van Andel Research Institute, Grand Rapids, MI, USA
- Division of Psychiatry and Behavioral Medicine, College of Human Medicine, Michigan State University, Grand Rapids, MI, USA
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Effects of Appendectomy on the Onset and Course of Ulcerative Colitis in Chinese Patients. Gastroenterol Res Pract 2018; 2018:2927891. [PMID: 30524476 PMCID: PMC6247428 DOI: 10.1155/2018/2927891] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 10/09/2018] [Accepted: 10/15/2018] [Indexed: 12/15/2022] Open
Abstract
Background Previous epidemiological studies have suggested that appendectomy may be a protective factor against the development of ulcerative colitis (UC). However, the results of these studies were inconsistent, with rare studies in Chinese populations. Aim This study examined the associations between appendectomy performed before UC diagnosis and the occurrence and clinical course of UC in Chinese patients. Methods A case control study was conducted to compare the rate of appendectomy between UC patients and controls matched for age and sex at two Chinese hospitals. Clinical course of UC was compared between UC patients who underwent appendectomies before UC diagnosis and who did not. Results 402 UC patients and 402 controls were included. The percentage of appendectomy performed before UC diagnosis in UC patients did not differ significantly from controls (2.74% vs 3.98%, P = 0.442). Subgroup analysis on the basis of localization of UC patients did not find significant difference from controls. The extent of disease involvement in UC patients who underwent appendectomy was smaller than patients who did not (P = 0.009). Appendectomy was found to be significantly related to the location of the disease independent of smoking status in multivariate analysis (P < 0.001). Appendectomy did not influence severity of disease and need for immunosuppressive treatment or colectomy. Conclusion We did not find a significant negative association between appendectomy and the UC occurrence in Chinese patients. Appendectomy performed before UC diagnosis may reduce the extent of UC involvement.
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Chung WS, Lin CL, Hsu CY. Women who had appendectomy have increased risk of systemic lupus erythematosus: a nationwide cohort study. Clin Rheumatol 2018; 37:3009-3016. [PMID: 29971583 DOI: 10.1007/s10067-018-4192-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 06/12/2018] [Accepted: 06/25/2018] [Indexed: 12/18/2022]
Abstract
The appendix is involved in immune function, and an appendectomy may alter the immune system. Studies evaluating the relationship between previous appendectomy and the risk of systemic lupus erythematosus (SLE) are lacking. This nationwide cohort study investigated the incidence and risk of SLE in patients who underwent appendectomy. Patients aged > 20 years who received appendectomy from 2000 to 2011 were identified from the National Health Insurance Research Database and assigned to the appendectomy cohort. Patients without appendectomy were randomly selected from the NHIRD and assigned to the control cohort; they were frequency matched to each study patient at a 4:1 ratio by sex, age, and index year. All patients were followed until SLE diagnosis, withdrawal from the National Health Insurance program, or the end of 2011. We used Cox models to estimate the hazard ratio (HR) and 95% confidence interval (CI) to compare the risk of SLE between the appendectomy and control cohorts. From 23.74 million people in the cohort, 80,582 patients undergoing appendectomy and 323,850 patients without appendectomy were followed for 723,438 and 2,931,737 person-years, respectively. The appendectomy cohort had a 2.04-fold higher risk of SLE than the control cohort (adjusted HR = 2.04, 95% CI = 1.52-2.76). Women aged ≤ 49 years who underwent appendectomy had a 2.27-fold higher risk of SLE than the corresponding controls (adjusted HR = 2.27, 95% CI = 1.62-3.19). Women aged ≤ 49 years who underwent appendectomy have a significantly higher risk of SLE.
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Affiliation(s)
- Wei-Sheng Chung
- Department of Internal Medicine, Taichung Hospital, Ministry of Health and Welfare, No. 199, Section 1, San-Min Road, Taichung, 40343, Taiwan. .,Department of Health Services Administration, China Medical University, Taichung, Taiwan. .,Department of Healthcare Administration, Central Taiwan University of Science and Technology, Taichung, Taiwan.
| | - Cheng-Li Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan.,College of Medicine, China Medical University, Taichung, Taiwan
| | - Chung-Y Hsu
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan
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Appendectomy and Risk of Subsequent Diverticular Disease Requiring Hospitalization: A Population-Based Case-Control Study. Dis Colon Rectum 2018; 61:830-839. [PMID: 29878951 DOI: 10.1097/dcr.0000000000001086] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Appendicitis and acute diverticulitis share clinical features and are both influenced by genetic and environmental factors. Appendectomy has been positively associated with diverticular disease in hospital-based case-control studies. OBJECTIVE The aim of the present study was to investigate, in a population-based setting, whether appendectomy, with or without appendicitis, is associated with an altered risk of hospitalization with diverticular disease. DESIGN This was a population-based case-control study. SETTINGS The study was based on national healthcare and population registers. PATIENTS We studied 41,988 individuals hospitalized between 2000 and 2010 with a first-time diagnosis of colonic diverticular disease and 413,115 matched control subjects. MAIN OUTCOME MEASURES The association between appendectomy with or without appendicitis and diverticular disease was investigated by conditional logistic regression, including a model adjusting for hospital use. RESULTS A total of 2813 cases (6.7%) and 19,037 controls (4.6%) had a previous record of appendectomy (appendectomy with acute appendicitis: adjusted OR = 1.31 (95% CI, 1.24-1.39); without appendicitis: adjusted OR = 1.30 (95% CI, 1.23-1.38)). Appendectomy was most strongly associated with an increased risk of diverticular disease within 1 year (with appendicitis: adjusted OR = 2.26 (95% CI, 1.61-3.16); without appendicitis: adjusted OR = 3.98 (95% CI, 2.71-5.83)), but the association was still present ≥20 years after appendectomy (with appendicitis: adjusted OR = 1.22 (95% CI, 1.12-1.32); without appendicitis: adjusted OR = 1.19 (95% CI, 1.10-1.28)). LIMITATIONS Detailed clinical information on the cases was not available. There were unmeasured potential confounders, such as smoking and dietary factors. CONCLUSIONS The findings are consistent with a hypothesis of appendectomy causing an increased risk of diverticular disease, for example, by affecting the mucosal immune system or the gut microbiome. However, several other mechanisms may contribute to, or account for, the positive association, including a propensity for abdominal pain increasing the risk of both the exposure and the outcome. See Video Abstract at http://links.lww.com/DCR/A604.
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Joshi T, Elderd BD, Abbott KC. No appendix necessary: Fecal transplants and antibiotics can resolve Clostridium difficile infection. J Theor Biol 2018; 442:139-148. [PMID: 29355542 DOI: 10.1016/j.jtbi.2018.01.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Revised: 12/04/2017] [Accepted: 01/15/2018] [Indexed: 12/18/2022]
Abstract
The appendix has been hypothesized to protect the colon against Clostridium difficile infection (CDI) by providing a continuous source of commensal bacteria that crowd out the potentially unhealthy bacteria and/or by contributing to defensive immune dynamics. Here, a series of deterministic systems comprised of ordinary differential equations, which treat the system as an ecological community of microorganisms, model the dynamics of colon microbiome. The first model includes migration of commensal bacteria from the appendix to the gut, while the second model expands this to also include immune dynamics. Simulations and simple analytic techniques are used to explore dynamics under biologically relevant parameters values. Both models exhibited bistability with steady states of a healthy state and of fulminant CDI. However, we find that the appendix size was much too small for migration to affect the stability of the system. Both models affirm the use of fecal transplants in conjunction with antibiotic use for CDI treatment, while the second model also suggests that anti-inflammatory drugs may protect against CDI. Ultimately, in general neither the appendiceal migration rate of commensal microbiota nor the boost to antibody production could exert an appreciable impact on the stability of the system, thus failing to support the proposed protective role of the appendix against CDI.
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Affiliation(s)
- Tejas Joshi
- Feinberg School of Medicine, Northwestern University, 303. East Chicago Ave., Chicago, IL 60611, USA.
| | - Bret D Elderd
- Department of Biological Sciences, Louisiana State University, Baton Rouge, LA, USA.
| | - Karen C Abbott
- Department of Biology, Case Western Reserve University, Cleveland, OH, USA.
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Girard-Madoux MJ, Gomez de Agüero M, Ganal-Vonarburg SC, Mooser C, Belz GT, Macpherson AJ, Vivier E. The immunological functions of the Appendix: An example of redundancy? Semin Immunol 2018; 36:31-44. [DOI: 10.1016/j.smim.2018.02.005] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 02/16/2018] [Indexed: 12/12/2022]
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The Brain-Intestinal Mucosa-Appendix- Microbiome-Brain Loop. Diseases 2018; 6:diseases6020023. [PMID: 29614774 PMCID: PMC6023457 DOI: 10.3390/diseases6020023] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 02/28/2018] [Accepted: 03/29/2018] [Indexed: 12/20/2022] Open
Abstract
The brain and the gut are connected from early fetal life. The mother's exposure to microbial molecules is thought to exert in utero developmental effects on the fetus. These effects could importantly underpin the groundwork for subsequent pathophysiological mechanisms for achieving immunological tolerance and metabolic equilibrium post birth, events that continue through to 3-4 years of age. Furthermore, it is understood that the microbiome promotes cues that instruct the neonate's mucosal tissues and skin in the language of molecular and cellular biology. Post birth mucosal lymphoid tissue formation and maturation (most probably including the vermiform appendix) is microbiota-encouraged co-establishing the intestinal microbiome with a developing immune system. Intestinal mucosal tissue maturation loops the brain-gut-brain and is postulated to influence mood dispositions via shifts in the intestinal microbiome phyla. A plausible appreciation is that dysregulated pro-inflammatory signals from intestinal resident macrophages could breach the loop by providing adverse mood signals via vagus nerve afferents to the brain. In this commentary, we further suggest that the intestinal resident macrophages act as an upstream traffic controller of translocated microbes and metabolites in order to maintain local neuro-endocrine-immunological equilibrium. When macrophages are overwhelmed through intestinal microbiome and intestinal epithelial cell dysbiosis, pro-inflammatory signals are sustained, which may then lead to mood disorders. The administration of probiotics as an adjunctive medicine co-administered with antidepressant medications in improving depressed mood may have biological and clinical standing.
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Saad EJ, Baenas DF, Boisseau CS, García MJ, Núñez SA, Sanchez PE, Balderramo DC, Hernández D, Caeiro JP. Streptococcus agalactiae bacteremia in non-pregnant adult patients at two teaching hospitals. Rev Argent Microbiol 2017; 50:280-284. [PMID: 29223920 DOI: 10.1016/j.ram.2017.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 07/11/2017] [Accepted: 08/09/2017] [Indexed: 11/17/2022] Open
Abstract
Streptococcus agalactiae or group B streptococcus (GBS) is a frequent pathogen in immunocompromised adults. The aim of this study was to determine the relative frequency, clinical presentation, antimicrobial susceptibility profile, and risk factors associated with GBS bacteremia in non-pregnant adult patients. We conducted a retrospective analysis of blood cultures performed in two hospitals between the years 2009-2013. From 1110 bacteremia episodes, 13 were caused by GBS, all of which were susceptible to ampicillin. GBS bacteremia was more frequent in females and in patients older than 60 years of age. The most frequent comorbidities were chronic kidney disease, cardiac failure and neoplasia. History of appendectomy was detected in 53.8% of the patients, being the most relevant comorbidity for GBS bacteremia in the multivariate analysis (OR 4.13, p=0.012). The main presentations were primary bacteremia and soft tissue infection. GBS bacteremia was infrequent in our institution, and a history of appendectomy might be related to bacteremia occurrence.
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Affiliation(s)
- Emanuel J Saad
- Internal Medicine Department, Hospital Privado Centro Médico de Córdoba, Naciones Unidas N° 346, CP:5016, Córdoba, Argentina; Instituto Universitario de Ciencias Biomédicas de Córdoba, Naciones Unidas N° 400, CP:5016, Córdoba, Argentina.
| | - Diego F Baenas
- Internal Medicine Department, Hospital Privado Centro Médico de Córdoba, Naciones Unidas N° 346, CP:5016, Córdoba, Argentina
| | - Cecilia S Boisseau
- Infectious Disease Department, Hospital Privado Centro Médico de Córdoba, Naciones Unidas N° 346, CP:5016, Córdoba, Argentina
| | - Mercedes J García
- Internal Medicine Department, Hospital Privado Centro Médico de Córdoba, Naciones Unidas N° 346, CP:5016, Córdoba, Argentina
| | - Silvana A Núñez
- Internal Medicine Department, Hospital Privado Centro Médico de Córdoba, Naciones Unidas N° 346, CP:5016, Córdoba, Argentina
| | - Pablo E Sanchez
- Infectious Disease Department, Hospital Privado Centro Médico de Córdoba, Naciones Unidas N° 346, CP:5016, Córdoba, Argentina
| | - Domingo C Balderramo
- Instituto Universitario de Ciencias Biomédicas de Córdoba, Naciones Unidas N° 400, CP:5016, Córdoba, Argentina; Gastroenterology Department, Hospital Privado Centro Médico de Córdoba, Naciones Unidas N° 346, CP:5016, Córdoba, Argentina
| | - Daniela Hernández
- Microbiology Department, Hospital Privado Centro Médico de Córdoba, Naciones Unidas N° 346, CP:5016, Córdoba, Argentina
| | - Juan P Caeiro
- Instituto Universitario de Ciencias Biomédicas de Córdoba, Naciones Unidas N° 400, CP:5016, Córdoba, Argentina; Infectious Disease Department, Hospital Privado Centro Médico de Córdoba, Naciones Unidas N° 346, CP:5016, Córdoba, Argentina
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Davidson JR, Eaton S, De Coppi P. Let sleeping dogs lie: To leave the appendix at the time of a Ladd procedure. J Pediatr Surg 2017; 53:S0022-3468(17)30570-5. [PMID: 28943135 DOI: 10.1016/j.jpedsurg.2017.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 09/02/2017] [Indexed: 11/15/2022]
Affiliation(s)
- Joseph R Davidson
- Stem Cells & Regenerative Medicine, DBC, Great Ormond Street Institute of Child Health, University College London
| | - Simon Eaton
- Stem Cells & Regenerative Medicine, DBC, Great Ormond Street Institute of Child Health, University College London
| | - Paolo De Coppi
- Stem Cells & Regenerative Medicine, DBC, Great Ormond Street Institute of Child Health, University College London.
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Appendectomy as a Risk Factor for Bacteremic Biliary Tract Infection Caused by Antibiotic-Resistant Pathogens. BIOMED RESEARCH INTERNATIONAL 2017; 2017:3276120. [PMID: 28589138 PMCID: PMC5447260 DOI: 10.1155/2017/3276120] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 04/20/2017] [Indexed: 12/13/2022]
Abstract
Background/Aims Recent evidence has suggested that appendix plays a pivotal role in the development and preservation of intestinal immune system. The aim of this study is to examine whether prior appendectomy is associated with an increased risk for the development of antibiotic-resistant bacteria in bacteremia from biliary tract infection (BTI). Methods Charts from 174 consecutive cases of bacteremia derived from BTI were retrospectively reviewed. Using multivariate analysis, independent risk factors for development of antibiotic-resistant bacteria were identified among the clinical parameters, including a history of appendectomy. Results In total, 221 bacteria strains were identified from 174 BTI events. Of those, 42 antibiotic-resistant bacteria were identified in 34 patients. Multivariate analysis revealed that prior appendectomy (Odds ratio (OR), 3.02; 95% confidence interval (CI), 1.15–7.87; p = 0.026), antibiotic use within the preceding three months (OR, 3.06; 95% CI, 1.26–7.64; p = 0.013), and bilioenteric anastomosis or sphincterotomy (OR, 3.77; 95% CI, 1.51–9.66; p = 0.0046) were independent risk factors for antibiotic-resistant bacteria. Conclusions Prior appendectomy was an independent risk factor for the development of antibiotic-resistant bacteria in bacteremia from BTI.
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Kooij IA, Sahami S, Meijer SL, Buskens CJ, Te Velde AA. The immunology of the vermiform appendix: a review of the literature. Clin Exp Immunol 2016; 186:1-9. [PMID: 27271818 DOI: 10.1111/cei.12821] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 05/30/2016] [Accepted: 05/31/2016] [Indexed: 12/19/2022] Open
Abstract
This literature review assesses the current knowledge about the immunological aspects of the vermiform appendix in health and disease. An essential part of its immunological function is the interaction with the intestinal bacteria, a trait shown to be preserved during its evolution. The existence of the appendiceal biofilm in particular has proved to have a beneficial effect for the entire gut. In assessing the influence of acute appendicitis and the importance of a normally functioning gut flora, however, multiple immunological aspects point towards the appendix as a priming site for ulcerative colitis. Describing the immunological and microbiotical changes in the appendix during acute and chronic inflammation of the appendix, this review suggests that this association becomes increasingly plausible. Sustained by the distinct composition of cells, molecules and microbiota, as well as by the ever more likely negative correlation between the appendix and ulcerative colitis, the idea of the appendix being a vestigial organ should therefore be discarded.
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Affiliation(s)
- I A Kooij
- Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, Amsterdam, the Netherlands
| | - S Sahami
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - S L Meijer
- Department of Pathology, Academic Medical Center, Amsterdam, the Netherlands
| | - C J Buskens
- Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, Amsterdam, the Netherlands
| | - A A Te Velde
- Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, Amsterdam, the Netherlands
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The Link between the Appendix and Ulcerative Colitis: Clinical Relevance and Potential Immunological Mechanisms. Am J Gastroenterol 2016; 111:163-9. [PMID: 26416189 DOI: 10.1038/ajg.2015.301] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 08/11/2015] [Indexed: 12/11/2022]
Abstract
The human appendix has long been considered as a vestigial organ, an organ that has lost its function during evolution. In recent years, however, reports have emerged that link the appendix to numerous immunological functions in humans. Evidence has been presented for an important role of the appendix in maintaining intestinal health. This theory suggests that the appendix may be a reservoir or 'safe house' from which the commensal gut flora can rapidly be reestablished if it is eradicated from the colon. However, the appendix may also have a role in the development of inflammatory bowel disease (IBD). Several large epidemiological cohort studies have demonstrated the preventive effect of appendectomy on the development of ulcerative colitis, a finding that has been confirmed in murine colitis models. In addition, current studies are examining the possible therapeutic effect of an appendectomy to modulate disease course in patients with ulcerative colitis. This literature review assesses the current knowledge about the clinical and immunological aspects of the vermiform appendix in IBD and suggests that the idea of the appendix as a vestigial remnant should be discarded.
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Almeida R, Gerbaba T, Petrof EO. Recurrent Clostridium difficile infection and the microbiome. J Gastroenterol 2016; 51:1-10. [PMID: 26153514 DOI: 10.1007/s00535-015-1099-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 06/16/2015] [Indexed: 02/04/2023]
Abstract
The diverse and densely populated gastrointestinal microbiota is essential for the regulation of host physiology and immune function. As our knowledge of the composition and function of the intestinal microbiota continues to expand, there is new interest in using these developments to tailor fecal microbiota transplantation (FMT) and microbial ecosystem therapeutics (MET) for a variety of diseases. The potential role of FMT and MET in the treatment of Clostridium difficile infection (CDI)-currently the leading nosocomial gastrointestinal infection-has proven highly effective for recurrent CDI, and has emerged as a paradigm shift in the treatment of this disease. The current review will serve as a summary of the key aspects of CDI, and will introduce the essential framework and challenges of FMT, as is currently practiced. MET represents the progression of conventional bacteriotherapy that fundamentally capitalizes on the restorative properties of intestinal bacterial communities and may be viewed as the culmination of a rationally designed therapeutic modality. As our understanding of the composition and function of the intestinal microbiota evolves, it will likely drive next-generation microbiota therapies for a range of medical conditions, such as inflammatory bowel disease, obesity, and metabolic syndrome.
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Affiliation(s)
- Rowena Almeida
- Gastrointestinal Diseases Research Unit, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Teklu Gerbaba
- Gastrointestinal Diseases Research Unit, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Elaine O Petrof
- Gastrointestinal Diseases Research Unit, Department of Medicine, Queen's University, Kingston, ON, Canada. .,Department of Medicine/ Division of Infectious Diseases, Queen's University, 76 Stuart Street, GIDRU Wing, Kingston, ON, K7L 2V7, Canada.
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Yong FA, Alvarado AM, Wang H, Tsai J, Estes NC. Appendectomy: a risk factor for colectomy in patients with Clostridium difficile. Am J Surg 2015; 209:532-5. [PMID: 25588621 DOI: 10.1016/j.amjsurg.2014.12.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 11/26/2014] [Accepted: 12/06/2014] [Indexed: 10/24/2022]
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Risk factors for recurrent Clostridium difficile infection: a systematic review and meta-analysis. Infect Control Hosp Epidemiol 2015; 36:452-60. [PMID: 25626326 DOI: 10.1017/ice.2014.88] [Citation(s) in RCA: 156] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE An estimated 20-30% of patients with primary Clostridium difficile infection (CDI) develop recurrent CDI (rCDI) within 2 weeks of completion of therapy. While the actual mechanism of recurrence remains unknown, a variety of risk factors have been suggested and studied. The aim of this systematic review and meta-analysis was to evaluate current evidence on the risk factors for rCDI. DESIGN We searched MEDLINE and 5 other databases for subject headings and text related to rCDI. All studies investigating risk factors of rCDI in a multivariate model were eligible. Information on study design, patient population, and assessed risk factors were collected. Data were combined using a random-effects model and pooled relative risk ratios (RRs) were calculated. RESULTS A total of 33 studies (n=18,530) met the inclusion criteria. The most frequent independent risk factors associated with rCDI were age≥65 years (risk ratio [RR], 1.63; 95% confidence interval [CI], 1.24-2.14; P=.0005), additional antibiotics during follow-up (RR, 1.76; 95% CI, 1.52-2.05; P<.00001), use of proton-pump inhibitors (PPIs) (RR, 1.58; 95% CI, 1.13-2.21; P=.008), and renal insufficiency (RR, 1.59; 95% CI, 1.14-2.23; P=.007). The risk was also greater in patients previously on fluoroquinolones (RR, 1.42; 95% CI, 1.28-1.57; P<.00001). CONCLUSIONS Multiple risk factors are associated with the development of rCDI. Identification of modifiable risk factors and judicious use of antibiotics and PPI can play an important role in the prevention of rCDI.
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Seretis C, Seretis F, Goonetilleke K. Appendicectomy and clostridium difficile infection: is there a link? J Clin Med Res 2014; 6:239-41. [PMID: 24883147 PMCID: PMC4039093 DOI: 10.14740/jocmr1840w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2014] [Indexed: 12/12/2022] Open
Abstract
Clostridium difficile infection (CDI) is a gradually emerging healthcare problem in the western world, occurring predominantly from the de-arrangement of the gut microbiota and the widespread use of antibiotics. Recently, it has been proposed that the presence or absence of the appendix could be a factor influencing the occurrence and/or the severity of CDI. We performed a review of the literature, aiming to identify and interpret in an accumulative way the results of the published clinical studies which addressed the issue of a possible association between prior appendicectomy and the features of CDI. A total of five suitable studies were retrieved, which were all conducted retrospectively. Although the results were conflicting regarding the impact of prior appendicectomy in the occurrence and relapse of CDI, it appears that the presence or absence of the appendix is not associated with the clinical severity of CDI. Based on the current evidence and considering the effects of the widespread use of antibiotics in the clinical practice, it appears that an in situ appendix does not have a definitive impact on the development and severity of CDI. Further observational studies are warranted to clarify any potential association.
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Affiliation(s)
- Charalampos Seretis
- Department of Colorectal Surgery, Good Hope Hospital, Heart of England NHS Foundation Trust, Birmingham, UK
| | | | - Kolitha Goonetilleke
- Department of Colorectal Surgery, Good Hope Hospital, Heart of England NHS Foundation Trust, Birmingham, UK
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Khanna S, Pardi DS. Clostridium difficile infection: management strategies for a difficult disease. Therap Adv Gastroenterol 2014; 7:72-86. [PMID: 24587820 PMCID: PMC3903088 DOI: 10.1177/1756283x13508519] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Clostridium difficile was first described as a cause of diarrhea in 1978 and in the last three decades has reached an epidemic state with increasing incidence and severity in both healthcare and community settings. There also has been a rise in severe outcomes from C. difficile infection (CDI). There have been tremendous advancements in the field of CDI with the identification of newer risk factors, recognition of CDI in populations previously thought not at risk and development of better diagnostic modalities. Several treatment options are available for CDI apart from metronidazole and vancomycin, and include new drugs such as fidaxomicin and other options such as fecal microbiota transplantation. This review discusses the epidemiology, risk factors and outcomes from CDI, and focuses primarily on existing and evolving treatment modalities.
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Affiliation(s)
- Sahil Khanna
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905, USA
| | - Darrell S. Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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Cakmak YO, Ergelen R, Ekinci G, Kaspar EC. The short appendix vermiformis as a risk factor for colorectal cancer. Clin Anat 2014; 27:498-502. [PMID: 24497155 DOI: 10.1002/ca.22375] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Accepted: 01/06/2014] [Indexed: 12/24/2022]
Abstract
The human appendix vermiformis is regarded as an evolutionarily vestigial organ, although it has presumptive immune system functions and appears to support beneficial bacterial gut flora, both of which could influence cancer progression. A review of the comparative anatomy of the mammalian appendix reveals a significantly longer appendix in herbivores than in carnivorous animals. The lengthier appendix vermiformis in herbivores has been associated with the presence of cellulose-digesting bacteria that colonize the structure. In light of recent studies that have reported the digestion of small amounts of cellulose in humans and the preventive effects of a vegetarian diet on colon cancer, we conducted a retrospective study of abdominal CT scans of 60 colon cancer patients and 60 healthy people to investigate a possible relationship between colon cancer and appendix vermiformis length. The mean length of the appendix in cancer patients [65.178 mm ± 13.46 (SD)] was shorter than that in the healthy control group [101.99 mm ± 16.58 (SD)] and the difference was statistically significant (P < 0.001). Statistical analysis demonstrated that the ages of the cancer patient group and the control group did not differ significantly (P = 0.534). The results of the present study indicate that the appendix is not merely a vestigial structure or regressed lymphoid tissue, but rather an organ that could be critical in the development of colon cancer, whether as a result of congenital or acquired appendicular factors.
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Affiliation(s)
- Yusuf Ozgur Cakmak
- Department of Anatomy, School of Medicine, Koc University, Sariyer, Istanbul, Turkey
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Tauschmann M, Prietl B, Treiber G, Gorkiewicz G, Kump P, Högenauer C, Pieber TR. Distribution of CD4(pos) -, CD8(pos) - and regulatory T cells in the upper and lower gastrointestinal tract in healthy young subjects. PLoS One 2013; 8:e80362. [PMID: 24265815 PMCID: PMC3827200 DOI: 10.1371/journal.pone.0080362] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 10/09/2013] [Indexed: 12/15/2022] Open
Abstract
The gastrointestinal immune system is involved in the development of several autoimmune-mediated diseases, including inflammatory bowel disease, multiple sclerosis, and type 1 diabetes mellitus. Alterations in T-cell populations, especially regulatory T cells (Tregs), are often evident in patients suffering from these diseases. To be able to detect changes in T-cell populations in diseased tissue, it is crucial to investigate T-cell populations in healthy individuals, and to characterize their variation among different regions of the gastrointestinal (GI) tract. While limited data exist, quantitative data on biopsies systematically drawn from various regions of the GI tract are lacking, particularly in healthy young humans. In this report, we present the first systematic assessment of how T cells--including Tregs--are distributed in the gastrointestinal mucosa throughout the GI tract of healthy young humans by means of multi-parameter FACS analysis. Gastroduodenoscopy and colonoscopy were performed on 16 healthy volunteers aged between 18 and 32. Biopsies were drawn from seven GI regions, and were used to determine the frequencies of CD8(+)-, CD4(+)- and Tregs in the gastrointestinal mucosa by means of multi-parameter FACS analysis. Our data show that there is significant variation in the baseline T-cell landscape along the healthy human gastrointestinal tract, and that mucosal T-cell analyses from a single region should not be taken as representative of the entire gastrointestinal tract. We show that certain T-cell subsets in the gastrointestinal mucosa vary significantly among regions; most notably, that Tregs are enriched in the appendiceal orifice region and the ascending colon, and that CD8(pos) T cells are enriched in the gastric mucosa.
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Affiliation(s)
- Martin Tauschmann
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Barbara Prietl
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Gerlies Treiber
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | | | - Patrizia Kump
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Christoph Högenauer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Thomas R. Pieber
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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Sanders NL, Bollinger RR, Lee R, Thomas S, Parker W. Appendectomy and Clostridium difficile colitis: Relationships revealed by clinical observations and immunology. World J Gastroenterol 2013; 19:5607-5614. [PMID: 24039352 PMCID: PMC3769896 DOI: 10.3748/wjg.v19.i34.5607] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Revised: 07/17/2013] [Accepted: 08/06/2013] [Indexed: 02/05/2023] Open
Abstract
Advances in understanding the interaction between the human immune system and the microbiome have led to an improved understanding of the function of the vermiform appendix as a safe-house for beneficial bacteria in the colon. These advances have been made despite long standing clinical observations that the appendectomy is a safe and effective procedure. However, more recent clinical data show that an appendectomy puts patients at increased risk for recurrent Clostridium difficile (C. difficile)-associated colitis, and probably other diseases associated with an altered microbiome. At the same time, appendectomy does not apparently put patients at risk for an initial onset of C. difficile-associated colitis. These clinical observations point toward the idea that the vermiform appendix might not effectively protect the microbiome in the face of broad spectrum antibiotics, the use of which precedes the initial onset of C. difficile-associated colitis. Further, these observations point to the idea that historically important threats to the microbiome such as infectious gastrointestinal pathogens have been supplanted by other threats, particularly the use of broad spectrum antibiotics.
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47
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Kirkup BC, Mahlen S, Kallstrom G. Future-Generation Sequencing and Clinical Microbiology. Clin Lab Med 2013; 33:685-704. [DOI: 10.1016/j.cll.2013.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Clanton J, Subichin M, Drolshagen K, Daley T, Firstenberg MS. Fulminant Clostridium difficile infection: An association with prior appendectomy? World J Gastrointest Surg 2013; 5:233-238. [PMID: 23983904 PMCID: PMC3753436 DOI: 10.4240/wjgs.v5.i8.233] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Revised: 06/20/2013] [Accepted: 07/19/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To examine if fulminant Clostridium difficile infections (CDI) resulting in colectomy was associated with a prior appendectomy and whether any association affected the severity of the disease.
METHODS: A retrospective chart review was performed on patients who underwent colectomy for CDI between 2001 and 2011. The appendectomy rate was calculated based on the absence of an appendix on the surgical pathology report. This was compared to an established lifetime risk of appendectomy in the general population. A chart review was performed for mortality and traditional markers of CDI disease severity. Fisher’s exact test was used to calculate the likelihood of association between prior appendectomy, mortality, and clinical markers of severity of infection.
RESULTS: Fifty-five specimens were identified with pseudomembranous colitis consistent with CDI. All patients had a clinical history consistent with CDI and 45 of 55 (81.8%) specimens also had microbiological confirmation of CDI. Appendectomy was observed in 24 of 55 specimens (0.436, 99%CI: 0.280-0.606). This was compared to the lifetime incidence of appendectomy of 17.6%. The rate of appendectomy in our sample was significantly higher than would be expected in the general population (43.6% vs 17.6%, P < 0.01). Disease severity did not differ based on presence or absence of an appendix and no association was detected between prior appendectomy and mortality (OR = 0.588, 95%CI: 0.174-1.970).
CONCLUSION: The rate of appendectomy in the patients whose CDI led to colectomy, was significantly higher than the calculated lifetime risk, suggesting an association of appendectomy and severe CDI resulting in colectomy. Larger prospective studies are needed to assess any potential causal relationships affecting fulminant CDI.
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Barlow A, Muhleman M, Gielecki J, Matusz P, Tubbs RS, Loukas M. The vermiform appendix: a review. Clin Anat 2013; 26:833-42. [PMID: 23716128 DOI: 10.1002/ca.22269] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Revised: 03/20/2013] [Accepted: 04/22/2013] [Indexed: 01/07/2023]
Abstract
New research on the vermiform appendix has shed light on its function. In further understanding the function of the appendix, this information should not negatively impact the clinical judgment in the event of appendicitis. Although the appendix and its pathology have been noted for centuries, it still presents a challenge in the operating room. The most common emergency surgical procedure performed is an appendectomy. Its highly variable position within the abdomen can cause confusion for clinicians. However, improved imaging modalities have heightened the physician's ability to diagnose disease of this organ. This article reviews germane literature regarding the human vermiform appendix.
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Affiliation(s)
- Andrew Barlow
- Department of Anatomical Sciences, School of Medicine, St. George's University, Grenada, West Indies
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Khanna S, Baddour LM, Dibaise JK, Pardi DS. Appendectomy is not associated with adverse outcomes in clostridium difficile infection: a population-based study. Am J Gastroenterol 2013; 108:626-7. [PMID: 23552320 DOI: 10.1038/ajg.2012.475] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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