Appendiceal Orifice Inflammation Research Articles

Clinical significance and long-term prognosis of ulcerative colitis patients with appendiceal orifice inflammation

BackgroundAppendiceal orifice inflammation (AOI) or peri-appendiceal red patch is a skip lesion with segments of continuous colitis from the rectum. Frequently observed in ulcerative colitis (UC) patients, this lesion might be associated with proximal extension in some studies. However, the clinical significance of this lesion and long-term outcomes including therapy remain unclear. Thus, the aim of this study was to evaluate the clinical implication of AOI during long-term periods in patients with UC.MethodsWe retrospectively reviewed 376 patients with UC who performed complete colonoscopic examinations between April 2000 and December 2020. We compared clinical characteristics and outcomes of patients manifesting AOI with those who did not show AOI during a mean follow-up period of 66.1 months. Long-term outcomes included maximal extent of colitis, proximal extension, therapeutic medical histories, UC-related hospitalization, and relapse.ResultsNinety-eight (26.1%) patients showed AOI without evidence of inflammation in the right colon. Mild disease activity at the diagnosis of UC was more included in patients with AOI than in those without AOI. Other baseline characteristics including disease extent, smoking history, external intestinal manifestation, and terminal ileal ulceration were not significantly different between the two groups. During follow-up periods, patients with and without AOI showed no significant difference in proximal extension, Mayo endoscopic score at the last endoscopic examination, UC-related hospitalization, or relapse. Of medication history, patients with AOI were less included in the group treated with high-dose aminosalicylates than those without AOI. However, therapeutic histories of steroids, immunosuppressive agents, and biologics were not significantly different. Of 62 patients with AOI who underwent follow-up colonoscopy, 36 (58.1%) showed resolution of AOI. Clinical outcomes of the resolution group were not different than those of the non-resolution group. Biopsy results of 77 patients with AOI showed chronic active or erosive colitis.ConclusionsLong-term outcomes of UC patients with AOI were not different from those without AOI. Outcomes of resolution and non-resolution groups of AOI patients were not different either. Thus, AOI might have no prognostic implication in distal UC patients.

Significance of diagnosis and prognosis for appendiceal orifice inflammation in ulcerative colitis: a real-world study.

ObjectiveUlcerative colitis (UC) is a chronic inflammatory disease of the large intestine. At present, the significance of appendiceal orifice inflammation (AOI) in UC prognosis is still controversial. This prospective observational study investigated the importance of AOI in UC diagnosis and prognosis. Additionally, it compared the therapeutic efficacy of treatments in UC patients with or without AOI.DesignThis study was a prospective, observational, single-centre, real-world study. Patients with AOI were included in the observation group, and patients without AOI were assigned to the control group. All patients were followed up for 1 year; the disease remission and treatment efficacy were re-examined by colonoscopy. In addition, the clinical, endoscopic and pathological features were collected before and after the treatment.ResultsPatients with endoscopic diffuse inflammatory changes in the distal colorectum accompanied by AOI had a higher positive UC diagnosis rate than those without (96.5% vs 78.0%). Also, AOI had a specificity of 95.2% and a sensitivity of 28.3% for UC diagnosis. However, no difference in the modified Mayo score (p=0.881) or Baron grading was observed between the control and observation groups, indicating that AOI does not affect the treatment outcome of UC patients.ConclusionIn this study, the observation of AOI improved the UC diagnostic accuracy in patients with diffuse lesions in the distal colorectum. Furthermore, the presence of AOI does not affect the treatment efficacies of UC.Trial registration numberChiCTR1800017753.

Appendiceal Orifice Inflammation Is Associated with Lower Rate of Complete Endoscopic Remission in Patients with Ulcerative Colitis.

Appendiceal orifice inflammation (AOI) is commonly considered a skip lesion in ulcerative colitis (UC). However, the clinical significance of AOI in UC patients remains controversial. This study aimed to evaluate the clinical feature and long-term outcomes of AOI by comparing UC patients with and without AOI. This study was conducted as a retrospective design of patients who were newly diagnosed or referred within 3 months after diagnosis at Seoul St. Mary’s Hospital from 1 January 2001 to 31 December 2020. All patients underwent index and follow-up colonoscopies. The long-term outcomes involved achieving complete endoscopic remission (ER), use of biologics, hospitalization, and proximal disease extension. Complete ER was defined as Mayo endoscopic subscore 0. In total, 318 UC patients were included, of which 140 had AOI. The baseline characteristics were not significantly different between AOI and non-AOI groups. The cumulative risk of complete ER was a significant difference between AOI and non-AOI groups (p = 0.041). The other cumulative risks of disease outcomes were not significantly different between AOI and non-AOI groups (use of biologics, p = 0.542; hospitalization, p = 0.795; proximal disease extension, p = 0.403). The multivariate Cox regression analysis also revealed that AOI was the significant factor of complete ER (hazard ratio, 0.656; 95% confidence interval, 0.462–0.932; p = 0.019) in UC patients. AOI shows a significant association with lower rate of complete ER in UC patients. Therefore, a meticulous treatment strategy may be recommended to achieve complete ER in UC patients with AOI.

P180 The prevalence and clinical course of atypical distribution of inflammation in newly diagnosed ulcerative colitis

Abstract Background Ulcerative colitis (UC) is characterized by continuous mucosal inflammation extending from rectum to the proximal lesion. However, there are cases of atypical distribution of inflammation, such as appendiceal orifice inflammation (AOI), skipped lesion, and rectal sparing. This study aimed to evaluate the prevalence and clinical course of atypical distribution of inflammation in newly diagnosed UC. Methods Between 2013 and 2021, 374 patients who underwent a colonoscopy at the time of diagnosis of UC were retrospectively reviewed. Clinical courses including relapse rate within 1-year, 2-year of diagnosis and exposure to immunomodulator or biologics during follow-up were retracted from the prospective IBD registry (ClinicalTrial.gov, NCT02193464). Atypical UC was defined as patients with AOI, skipped lesion or rectal sparing at initial colonoscopy. The clinical courses and changes of endoscopic findings were compared between typical UC group and atypical UC group. Results Of 374 patients, 116 (31.0%) categorized as atypical UC; specifically, 90 (24.1%) showed AOI, 17 (4.5%) showed rectal sparing and 49 (13.1%) showed skipped lesion. When 90 patients with AOI were reclassified according to the extent of inflammation, 62(16.6%) had a localized inflammation at peri-appendiceal area, 13(3.5%) had an inflammation of the entire cecum, 15(4.0%) had an inflammation extends to the proximal A-colon. The clinical courses of atypical UC were not different from typical UC group, however, patients with skipped lesion showed a lower 1-year relapse rate compared to those without skipped lesion (P=0.042). Of 96 patients with atypical UC who underwent follow-up endoscopy, 73 (75.8%) demonstrated a typical distribution of UC at their follow-up colonoscopy. Conclusion Atypical distribution of UC including AOI, skipped lesion, and rectal sparing are not uncommon in patient with newly diagnosed UC. However, most of these features do not appear to correlate significantly with prognosis in the clinical course of UC. In majority of patients with atypical UC, the lesion turned into typical UC on follow-up colonoscopy.

P228 Appendiceal Orifice Inflammation Is Associated with Lower Rate of Complete Endoscopic Remission in Patients with Ulcerative Colitis

Abstract Background Appendiceal orifice inflammation (AOI) is commonly considered a skip lesion in ulcerative colitis (UC). However, the clinical significance of AOI in UC patients remains controversial. This study aimed to evaluate the clinical feature and long-term outcomes of AOI by comparing UC patients with and without AOI. Methods This study was conducted as a retrospective design of patients who were newly diagnosed or referred within 3 months after diagnosis at Seoul St. Mary’s Hospital from January 1, 2001 to December 31, 2020. All patients underwent index and follow-up colonoscopies. The long-term outcomes involved achieving complete endoscopic remission (ER), use of biologics, hospitalization, and proximal disease extension. Complete ER was defined as Mayo endoscopic subscore 0. Results In total, 318 UC patients were included, of which 140 had AOI. The baseline characteristics were not significantly different between AOI and non-AOI groups. The cumulative risk of complete ER was a significant difference between AOI and non-AOI groups (p=0.041). The other cumulative risks of disease outcomes were not significantly different between AOI and non-AOI groups (use of biologics, p=0.542; hospitalization, p=0.795; proximal disease extension, p=0.403). The multivariate Cox regression analysis also revealed that AOI was the only significant factor of complete ER (hazard ratio, 0.636; 95% confidence interval, 0.446–0.906; p=0.012) in UC patients. Conclusion AOI shows a significant association with lower rate of complete ER in UC patients. Therefore, a meticulous treatment strategy may be recommended to achieve complete ER in UC patients with AOI.

Prognostic Value of Terminal Ileal Inflammation in Patients with Ulcerative Colitis

Background/AimsFew studies have investigated terminal ileal lesions and their prognostic value in patients with ulcerative colitis (UC). We evaluated the clinical significance of these lesions as a prognostic factor in patients with UC who were in clinical remission.MethodsWe retrospectively selected 567 of 4,066 colonoscopy reports that included positive findings from orificial observations of the terminal ileum (TI) and appendix in patients with UC. We finally recruited patients who were in clinical remission (n=204). We compared the clinical courses, including relapse and other prognostic parameters associated with UC, between the groups.ResultsThe baseline patient characteristics were not significantly different between patients with (n=69, TI+ group) and without TI lesions (n=135, TI– group), although there were more never-smokers in the TI+ group (n=57 [82.6%] in the TI+ group; n=86 [63.7%] in the TI– group; p=0.005). Of note, appendiceal orifice inflammation (AOI) was less frequently found in the TI+ group (14.5%) than in the TI– group (71.9%, p<0.001). The cumulative relapse rate was numerically higher in the TI– group, but it was not significantly different according to the Kaplan-Meier analysis (p=0.116). Multivariate Cox regression analysis also revealed advanced age at diagnosis as the most significant factor (adjusted hazard ratio, 0.964; 95% confidence interval, 0.932 to 0.998; p=0.037), but neither TI inflammation nor AOI were significantly associated with the cumulative relapse rate in patients with UC in clinical remission.ConclusionsFor patients with UC in clinical remission, neither terminal ileal lesions nor AOI had significant clinical or predictive value for future relapse.

Appendiceal Orifice Inflammation in Severe Ulcerative Colitis and Its Resolution With Infliximab and Plant-based Diet as First-line Therapy.

Lay Summary Appendiceal orifice inflammation, which is often observed in mild or moderate distal ulcerative colitis, was observed in a case of severe UC. Appendiceal orifice inflammation resolved after new induction therapy for severe UC: infliximab and a plant-based diet as first-line therapy.

Diagnostic evaluation of appendiceal orifice inflammation in ulcerative colitis.

To evaluate the diagnostic significance of appendiceal orifice inflammation (AOI) in ulcerative colitis (UC) patients. We retrospectively examined data from patients with colitis from May 2010 to January 2014 and assigned them to two groups: UC cases and specific colitis cases. First, we clarified the difference in the AOI+ rate between the two groups. Thereafter, imaging findings of all the patients with colitis were re-examined. Features of AOI alone or in combination with proctitis (referred to as "combination features") were considered as the two separate diagnostic criteria for diagnosing UC. By comparing the current diagnoses with the previous diagnoses, evaluation indexes were obtained. A total of 3582 colitis cases (UC cases: 427; specific colitis cases: 3155) were examined. The mean AOI+ rates in UC and specific colitis cases were 26.2% and 0.7%, respectively; a Chi-squared test indicated that the difference between these rates was statistically significant (x2=6.81; p<0.001, OR=50.99). When the AOI features alone were used to diagnose UC, the sensitivity was 26.2% [95% confidence interval (CI), 22.3%-30.6%], agreement rate was 90.6%, and specificity was 99.3% (95% CI, 98.9%-99.5%). When the combination features were used to diagnose UC, the sensitivity was 26.2% (95% CI, 22.3%-30.6%), agreement rate was 91.1%, and specificity was 99.9% (95% CI, 99.7%-100%). Combining AOI features and proctitis may lead to a more effective UC diagnosis and enable physicians to identify this condition more promptly among miscellaneous diseases.

Appendiceal orifice inflammation is associated with proximal extension of disease in patients with ulcerative colitis.

Ulcerative colitis (UC) is considered to be a disease of continuous mucosal inflammation extending proximally from the rectum. However, appendiceal orifice inflammation (AOI) is a skip lesion with segments of continuous involvement from the rectum. The aim of this study was to examine the clinical characteristics and clinical course, particularly focused on proximal extension, of UC in patients with AOI. A retrospective evaluation of patients with UC who underwent total colonoscopy at the Department of Surgical Oncology, The University of Tokyo, from 2004 to 2014. The degree of AOI was graded endoscopically as follows: 0 (no inflammation); 1 (slight oedema); 2 (moderate inflammation); and 3 (marked inflammation). A total of 189 patient records were reviewed retrospectively. The presence of AOI was analysed with regard to the clinical information of each patient, and its association with proximal extension of proctitis or left-sided colitis was evaluated. Of 189 patients with UC who underwent total colonoscopy at our institution, 92 were diagnosed with pancolitis, 50 with left-sided colitis and 47 with proctitis. Endoscopic findings of AOI were observed in 26 patients, including 11 (12.0%) with pancolitis, six (12.0%) with left-sided colitis and nine (19.1%) with proctitis. During follow up, proximal extension of the disease occurred in all nine patients with proctitis AOI. AOI is more frequently observed in patients with proctitis. Our results showed correlations between AOI and subsequent proximal extension of mucosal inflammation in patients with proctitis.

The correlation of inflammatory severity between appendiceal orifice inflammation and ulcerative colitis

Objective To evaluate the correlation of inflammatory severity between appendiceal orifice inflammation(AOI) and ulcerative colitis(UC). Methods A retrospective analysis of the patients who were diagnosed as UC was conducted to investigate the correlation of the severity of inflammation between AOI and UC by linear trend test. Results The detective rate of UC during the above period was 2.3%(991/42 928), with the patient number of 991.Appendiceal orifice observation did not perform in 45 cases due to patients reasons. In 946 patients, 260 cases were diagnosed as having AOI, which accounted for 27.5% of the total cases examined.AOI positive rates were significantly different between groups based on endoscopic severity standard(χ2=27.39, P 0.0125], both significantly higher than that in mild group[4.3%(4/92), P<0.0125]. In linear regression analysis, regression coefficient was 0.32, χ2return=29.48(P<0.05)and χ2partial=31.66(P<0.05), which proved a positive correlation between the two drawn existed but not a simple linear relationship. Conclusion AOI is a sign in some active UC patients. Its severity of inflammation can reflect the degree of inflammation in UC, which may offer a terminal point when treating a slice of UC individuals and giving a signal of its relapse. Key words: Ulcerative colitis; Appendiceal orifice inflammation; Skip lesion; Retrospective study

Meta-analysis of the association between appendiceal orifice inflammation and appendectomy and ulcerative colitis.

This study aimed to investigate the relationship between appendiceal orifice inflammation (AOI) and appendectomy and ulcerative colitis (UC) by a meta-analysis. Databases were thoroughly searched for studies on AOI and UC up to January 2016. Three comparisons were performed: a) whether the previous appendectomy was a risk factor of UC; b) influence of appendectomy on UC courses; c) influence of AOI on UC severity. Odds ratios (ORs) and 95% confidence intervals (CIs) were the effects sizes. The merging of results and publication bias assessment were performed by using RevMan 5.3. Sensitivity analysis was conducted using Stata 12.0. Nineteen studies were selected in the present study. Results of comparison I showed that appendectomy was a protective factor of UC (OR = 0.44; 95% CI [0.30, 0.64]). Comparison II indicated appendectomy had no significant influence in the courses of UC (proctitis: OR = 1.03, 95% CI [0.74, 1.42]; left-sided colitis: OR = 1.01, 95% CI [0.73, 1.39]; pancolitis: OR = 0.92, 95% CI [0.59, 1.43]; colectomy: OR = 1.38, 95% CI [0.62, 3.04]). Comparison III indicated UC combined with AOI did not affect the courses of UC (proctitis: OR = 1.15, 95% CI [0.67, 1.98]; left-sided colitis: OR = 1.14, 95% CI [0.24, 5.42]; colectomy: OR = 0.36, 95% CI [0.10, 1.23]). Sensitivity analysis confirmed the robust of the results in the present study. In conclusion, this meta-analysis indicated appendectomy can reduce the risk of UC. But appendectomy or AOI had no influence on the severity of the disease and the effect of surgical treatment.

Appendicular Histology and Its Clinical Significance in Patients with Ulcerative Colitis: A Prospective Study from North India

ABSTRACT Background and aims The appendix may be involved in ulcerative colitis (UC) to variable extent. Clinical significance of appendicular involvement is not clear and it has long been considered an innocent bystander. This study prospectively investigated appendiceal histology and its clinical significance in patients with UC. Materials and methods Colonoscopy was performed in 60 patients and biopsies were taken from appendiceal orifice, cecum, and colon. Appendiceal histology was classified as active if there was presence of neutrophils with crypt distortion. Inactive inflammation was defined as positive for crypt distortion and negative for neutrophils. Otherwise the histology was reported as normal or nonspecific changes. The patients were followed for a minimum period of 6 months. Results In patients evaluated endoscopically, 63% patients had histological involvement of the appendiceal orifice. Pancolitis was seen more commonly in patients with appendicular orifice inflammation than in patients with normal appendicular histology (44.7 vs 9%, p = 0.001). Most patients with appendiceal orifice inflammation had involvement of the cecum. Skip lesion of the appendix without cecum involvement was seen in 37% of the patients. The patients with appendiceal orifice inflammation had a significantly higher grade of endoscopic colitis compared to patients with normal histology (p = 0.006). Relapse rate was higher in patients with appendiceal orifice inflammation than in patients with normal appendiceal histology (18.4 vs 9%), although the difference was insignificant (p = 0.329). Conclusion Appendicular involvement in ulcerative colitis is not uncommon. Its involvement may predict the course, extent, and severity of colitis. How to cite this article Parvez N, Rana SS, Nada R, Sharma V, Sharma R, Chhabra P, Gunjan D, Dhalaria L, Gupta R, Bhasin DK. Appendicular Histology and Its Clinical Significance in Patients with Ulcerative Colitis: A Prospective Study from North India. J Postgrad Med Edu Res 2016;50(3):141-147.

Appendiceal Skip Inflammation and Ulcerative Colitis

In recent decades, the appearance of inflammation near the appendix in patients with distal ulcerative colitis (UC) has been highlighted. Many epidemiological studies have confirmed the link between appendectomy and decreased incidence of UC. However, the clinical significance of appendiceal orifice inflammation (AOI) or peri-appendiceal red patch (PARP) as a "skip lesion" in UC has not been well elucidated. In this review, we summarized the literature regarding AOI/PARP and the role of this lesion in relation to UC. Since the appendiceal "skip area" in UC was first described in 1958, several reports using histologic examination of colectomy specimens and colonoscopy have been published. AOI/PARP has been more frequently associated with distal, mild UC than extensive, severe disease. Although it is still controversial, AOI/PARP seems to have little prognostic implication in the disease course of UC, including remission, relapse and proximal disease extension. However, some case reports have raised the possibility of a relationship between AOI/PARP and appendiceal neoplasms such as appendiceal cystadenoma and appendiceal adenocarcinoma. In addition, some investigators have treated UC patients who were resistant to conventional medical therapy with appendectomy and have reported inconsistent therapeutic effect. Further research may lead to the discovery of etiologic and pathogenic roles of appendiceal inflammation in UC.

Atypical Distribution of Inflammation in Newly Diagnosed Ulcerative Colitis is not Rare

Appendiceal orifice inflammation (AOI) is a common 'skip lesion' in patients with ulcerative colitis (UC). However, other skip lesions are less well known. To evaluate the atypical distribution of UC lesions, other than AOI, in terms of their frequency, pattern, risk factors and prognostic implications. A retrospective analysis of colonoscopic findings and clinical course of 240 adult UC patients who were initially diagnosed at Asan Medical Center (Seoul, South Korea) was performed. # Of 240 patients, 46 (19.2%) showed an atypical distribution of lesions at initial colonoscopy: eight (3.3%) had rectal sparing (segmental-type UC); and 38 (15.8%) had patchy⁄segmental skip lesions other than AOI. Skip lesions were detected more frequently in proximal segments of the colon than in distal segments (P=0.001). An atypical distribution was more common in patients with AOI (31.3%) than in those without AOI (10.6%; P<0.001). The clinical course of patients with an atypical distribution was not different from that of patients with a typical distribution in terms of remission, relapse, disease extension, colectomy and mortality. In addition, of the 36 patients with an atypical distribution of lesions at diagnosis who underwent follow-up colonoscopy, 24 (66.7%) demonstrated a typical distribution of lesions. Patchy⁄segmental skip lesions and rectal sparing occur not infrequently in adult patients with newly diagnosed, untreated UC. As such, these features alone should not be considered to be definitive evidence against a diagnosis of UC. There does not appear to be a prognostic implication of an atypical distribution of lesions.

Ulcerative Colitis – What Can We Learn from the Asia-Pacific Region?

A recent epidemiological study clearly demonstrated that inflammatory bowel disease (IBD), especially ulcerative colitis, is a rapidly emerging disease in the Asia Pacific region (1). A systematic review of the global incidence and prevalence of IBD before publication of the Asia Pacific data (2) confirmed the worldwide nature of IBD. In time-trend analyses, it showed that 75% of Crohn disease studies and 60% of ulcerative colitis studies reported statistically significant increases in incidence (2). The emergence of IBD in the Asia Pacific region suggests strong environmental influence on the pathogenesis of IBD including socioeconomic, lifestyle and dietary changes. The age-standardized incidence of ulcerative colitis in the Asia Pacific region ranged from 0.24 to 7.47 per 100,000 population, with the lowest incidence in Bangkok and the highest in Australia. Even highly westernized Asian countries, such as Hong Kong, have an ulcerative colitis incidence of 1.30 per 100,000 population (1). The incidence of Crohn disease in Australia was nearly double that of ulcerative colitis; however, in the Asian countries, ulcerative colitis was generally more prevalent than Crohn disease. In a recent Asia Pacific epidemiology study of IBD incidence (1), the distribution of ulcerative colitis location in Australia and in Asia were similar, with approximately one-third each being proctitis, left-sided colitis, and extensive or total colitis (1). The Asia Pacific epidemiology study did not include South Korea, Japan or India, which tend to have a higher incidence of IBD than other Asian countries. However, in the current issue of the Journal, Park et al (3) (pages 125 to 130) reported a retrospective analysis of disease location at diagnosis in 240 ulcerative colitis patients diagnosed at Asan Medical Centre, Seoul, South Korea. Approximately 19% of patients had an atypical distribution of disease, including patchy or skip lesions or, less commonly, rectal sparing. Such atypical distribution was more common in patients reported to demonstrate appendiceal orifice inflammation. Skip lesions were more common in the proximal colon. While such atypical distribution inevitably raises the question of Crohn’s colitis, 67% of ulcerative colitis patients showing atypical distribution at diagnosis had reverted to the typical distribution of lesions at follow-up colonoscopy. The ulcerative colitis disease course and outcome of individuals with atypical disease location was similar to those with more classical disease location. While such atypical distribution of ulcerative colitis has been sporadically reported in the West (4,5), including 27% of ulcerative colitis patients showing discontinuous inflammation of the appendiceal orifice in a prospective study, rectal sparing is considered to be unusual in the West after meticulous pathological examination of colectomy specimens (6). This is not surprising given that in the study by Park et al (3), follow-up colonoscopy showed that the distribution of ulcerative colitis had reverted to the classical in the majority of patients. However, several reports from Asia, especially Japan, Korea and India, with higher incidence of ulcerative colitis in Asia, have reported atypical distribution of ulcerative colitis (7–9) despite the contrary data in the recent Asia Pacific epidemiology study. Although single-centre and retrospective, the study by Park et al (3) substantiates these previous findings. It is important to recognize that the Asia Pacific region is a vast, inhomogeneous area with multiple cultures, lifestyles, environment, diet and genetics. For example, three regions of mainland China had ulcerative colitis incidences of 2.05, 0.42 and 0.41 per 100,000 population (1), suggesting unique environmental influences in specific regions. The study by Park et al (3) and previous studies encourage us to obtain additional epidemiological and environmental data collected prospectively from geographical regions with emerging IBD. It will be important to understand whether disease presentation varies in different geographical areas based on colonic microbiome, dietary habits and genetics. This may shed light on its pathogenesis and provide more evidence to answer the question whether ulcerative colitis is ‘one disease or many’. This discussion may be even more relevant in the case of Crohn disease. It especially points to the challenges of epidemiological studies that attempt to distinguish between ulcerative colitis and Crohn’s colitis.

Appendiceal Orifice Inflammation Mimicking Submucosal Tumor on Roentgenogram in Ulcerative Colitis

Appendiceal orifice inflammation (AOI) is observed as skip lesion in distal ulcerative colitis (UC). The endoscopic frequency of AOI is reported to be 7.9% to 76% of distal colitis. UC is a relapsing and remitting disease and a morphological change of the large bowel occurs over time. Patient and physician can easily understand the shape of the whole large bowel not through endoscopic photograph but by roentgenogram of the bowel. Therefore, the authors undertake barium enema study when a diagnosis of UC is made. We have experienced a patient with proctitis in which an appendiceal submucosal tumor (SMT) was suspected on the roentgenogram but it was turned out to be a protruding lesion of AOI. A 16-year-old boy visited us with complaining of blood in his stool for the past 10 days. Sigmoidoscopy revealed mild diffuse inflammation. Crypt abscess was found in biopsy specimen. A diagnosis of UC, proctitis type, was made. A double contrast barium enema study revealed a defect shadow with a smooth surface, length 37 mm, height 12 mm, over the appendix. An appendiceal SMT was suspected. Abdominal ultrasonography and computed tomography were non-contributory. Colonoscopy revealed a spiral inflamed mucosa at the site of an appendiceal orifice. There was an inflammation in the cecum surrounding the orifice. Biopsy specimen of the appendiceal orifice showed inflammatory cells infiltration, goblet cell depletion, and cryptitis. The suspected SMT lesion was concluded to be AOI.

Long term follow-up of appendiceal and distal right-sided colonic inflammation

The aim of this study was to investigate the possibility of appendiceal orifice inflammation (AOI) as a preceding lesion in the development of ulcerative colitis. A total of 20 patients were identified (mean age 41.2 years; 11 males) who had ulcerative colitis-like inflammatory lesions at the appendiceal orifice without concomitant typical features of ulcerative colitis, such as rectal involvement. A total of 19 patients were followed up endoscopically for a mean duration of 18.4 months (range 2 - 84 months). Typical ulcerative colitis developed in five patients (25 %; four proctitis, one pancolitis) in a mean time of 18.4 months (range 2 - 36 months). Negative conversion of all inflammatory lesions occurred in seven patients (35 %) after a mean follow-up of 20 months (range 3 - 84 months). In the remaining seven patients (35 %), initial lesions did not progress to ulcerative colitis and did not go into remission during a mean follow-up of 16.9 months (range 2 - 42 months). These results suggest that, at least in some cases, AOI precedes development of ulcerative colitis.

Appendiceal Orifice Inflammation in an 8-Year-Old Girl with Ulcerative Colitis Complicating Wilson's Disease

Appendiceal orifice inflammation (AOI) may occur as a skipped lesion in ulcerative colitis (UC). Cases of ulcerative colitis complicated by Wilson's disease have also been reported. We report herein a case of AOI that occurred as a missed lesion in an 8-year-old girl with UC complicating Wilson's disease, which is rare in children.

Characteristics and Trends in the Incidence of Inflammatory Bowel Disease in Korean Children: A Single-Center Experience

Inflammatory bowel disease (IBD) is rare in Asian children and few reports on pediatric IBD have appeared. We, therefore, investigated the incidence trends and clinical characteristics of pediatric IBD in Korea. We enrolled 48 children with Crohn's disease (CD) and 14 children with ulcerative colitis (UC) from 1996 to 2007. Trends in annual enrollment and clinical characteristics were retrospectively evaluated by medical record review. During the 12 years of observation, the number of new enrollments gradually increased. CD showed male predominance (33 boys, 15 girls), but more females presented with UC (4 boys, 10 girls). A relevant family history was observed in 3 (4.9%) of the 61 unrelated families. The most common presenting symptom was abdominal pain (67%) in CD and hematochezia (93%) in UC. Growth delay was observed in 10% of CD patients, but not in any of the UC patients. In CD, colonic involvement occurred in 87% of patients, ileal involvement in 87%, and both the small bowel and colon were affected in 75%. With UC, pancolitis occurred in 43% of patients, left-sided colitis in 36%, and proctitis in 21%, including all three patients with appendiceal orifice inflammation. The most frequent disease behavior was inflammatory in 85% of patients, but perianal fistula was noted in 50% of CD patients. This study showed that the incidence of pediatric IBD has been rapidly increasing in Korea in recent years. Relevant family history is less prevalent and phenotypic expression differs from what is seen in Western countries.

Appendiceal Orifice Inflammation in Ulcerative Colitis

A 44-year-old man was diagnosed with distal ulcerative colitis (UC) when he had hematochezia at the age of 34. He had had a few relapses on maintenance oral mesalazine. He desired a total colonoscopy in the clinical remission. Physical examination showed no abnormalities and routine laboratory tests were normal. Colonoscopy disclosed the appendiceal orifice inflammation (AOI) with reddish and friable mucosa and mucopus (Fig. 1). The remaining colorectum showed no inflammation. He remains well during the follow-up. Since Cohen et al. first coined ‘‘ulcerative appendicitis’’ [1], AOI is uncommon but has increasingly been recognized in patients of distal UC. UC classically extends proximally from the rectum without skip lesions. Isolated AOI has been more frequently observed in patients with less extensive UC and is unlikely the result of patchy improvement due to treatments. The human appendix has long been recognized as a vestigial remnant. Although the pathogenesis of UC has not been fully clarified, clinical evidence has revealed the protective role of appendicectomy on onset and severity of UC [2, 3], indicating the appendix as a priming site for UC [4]. Experimental studies of murine models have also shown that the appendix may serve a central role in antigen sampling and immunological signaling [5]. Therefore, further studies of AOI may unveil not only its clinical implication but also the immunopathogenesis of UC. References