Irritable bowel syndrome and negative appendectomy: a prospective multivariable investigation

Abstract

Objective: To examine prospectively whether irritable bowel syndrome (IBS) or other variables-that is, psychiatric profiles, health-related quality of life (HRQoL) and clinical features-are associated with negative appendectomy (NA). Design: Longitudinal study. Setting: Inpatient and emergency service in a university-affiliated teaching hospital. Patients: 430 consecutive patients underwent emergent surgery for suspected appendicitis. Main outcome measures: Rome-II IBS questionnaire; the Hospital Anxiety and Depression Scale; the ShortForm 36 survey; the clinical, pathological and CT findings. Results: The NA group (n = 68, 15.8%) was younger, with female predominance, higher prevalence of Rome-II IBS, higher anxiety/depression scores and lower levels of HRQoL than the positive appendectomy group. The patients with NA tended to have atypical presentations (absence of migration pain/fever/muscle guarding), lower white cell count and percentage of polymorphonuclear cells (PMNC) and lower rate of CT scan usage than the positive group. After multiple logistic regression, IBS (OR 2.17; 95% CI 1.14 to 4.24), degree of anxiety (OR 1.12; 95% CI 1.02 to 1.49), absence of migrating pain (OR 3.43; 95% CI 1.90 to 5.95)/muscle guarding (OR 3.72; 95% CI 2.07 to 6.70), a lower PMNC percentage (,75%; OR 3.05; 95% CI 1.69 to 5.51) and no CT scan usage (OR 2.32; 95% CI 1.27 to 4.26) were found to be the independent factors in predicting NA. Conclusion: Both patient (IBS, anxiety, atypical presentation) and physician (low CT scan usage) factors are the independent determinants predicting NA. Physicians should be cautious before operating on or referring patients with IBS for appendectomy. CT scan should be considered in patients with suspected appendicitis, particularly in those with IBS and atypical clinical presentations.A cute appendicitis is the most common cause of an acute abdomen with at least 250 000 cases per year in the US. 1The life-time risk of appendectomy is 12.0% for men and 23.1% for women.2 Although clinical symptoms are often characteristic, a high rate of misdiagnosis, often referred to as negative appendectomy (NA), suggests otherwise. Several studies have shown that over 15% of appendectomies performed revealed no pathological evidence of appendicitis. [3][4][5][6]

Avoiding unnecessary surgery in irritable bowel syndrome

“…5 Much of this increased surgery must be unnecessary, and high surgical rates have been reported from the UK, Western Europe, Scandinavia, North America, Latin America and South Africa. The association of IBS with normal appendiceal pathology after urgent appendectomy, as reported by investigators from Taiwan in this issue, 9 (see page 655) further emphasises the worldwide importance of avoiding unnecessary surgery in IBS.…”

“…More research on the effectiveness of specific measures would be valuable, but the study by Lu et al, 9 previous research observations, and basic clinical principles support both general and operationspecific approaches.…”

Irritable Bowel Syndrome and Migraine: Bystanders or Partners?

“…Furthermore, IBS subjects usually receive additional abdominal surgeries. It is likely due to their coexisting multiple somatic and psychiatric comorbidities leading to the unexpected surgeries 31,32. Very similarly, migraineurs also manifest these overlapped comorbidities including IBS 8,9,10,33,34…”

The continuing dilemma of chronic appendicitis

“…However, the therapeutic dilemma centres on the patient with persistent symptoms in whom all investigations are completely normal, where the most likely diagnosis is a functional gastrointestinal disorder, particularly irritable bowel syndrome (IBS). Many patients with the more severe forms of IBS give a history of multiple surgical interventions, including appendicectomy, and seem to be particularly susceptible to postoperative pain syndromes [Longstreth and Yao, 2004;Cole et al 2005;Lu et al 2007]. Consequently, it currently seems reasonable to conclude that in patients with investigation-negative right lower quadrant abdominal pain, with additional symptoms suggestive of a functional gastrointestinal disorder, surgical intervention is best avoided.…”