Brief Article
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World J Gastrointest Surg. Aug 27, 2013; 5(8): 233-238
Published online Aug 27, 2013. doi: 10.4240/wjgs.v5.i8.233
Fulminant Clostridium difficile infection: An association with prior appendectomy?
Jesse Clanton, Michael Subichin, Katherine Drolshagen, Timothy Daley, Michael S Firstenberg
Jesse Clanton, Michael Subichin, Michael S Firstenberg, Department of Surgery, Northeast Ohio Medical University, Summa Akron City Hospital, Akron, OH 44304, United States
Katherine Drolshagen, Department of Pathology, Northeast Ohio Medical University, Summa Akron City Hospital, Akron, OH 44304, United States
Timothy Daley, Department of Mathematics, University of Southern California, Los Angeles, CA 90089, United States
Author contributions: Clanton J, Daley T and Subichin M were responsible for the original concept and design of the study; Clanton J and Drolshagen K were responsible for data collection; Daley T and Subichin M performed the statistical analysis, with interpretation of the data performed by Clanton J, Subichin M, Drolshagen K and Firstenberg MS; Clanton J did the primary writing of the manuscript with substantial contributions and revisions from Subichin M, Daley T, Drolshagen K and Firstenberg MS; all authors approved the final version.
Correspondence to: Michael S Firstenberg, MD, Assistant Professor of Surgery, Department of Surgery, Northeast Ohio Medical University, Summa Akron City Hospital, 75 Arch Street, Suite 407, Akron, OH 44304, United States. firstenbergm@summahealth.org
Telephone: +1-330-3849001 Fax: +1-330-3849002
Received: May 15, 2013
Revised: June 20, 2013
Accepted: July 17, 2013
Published online: August 27, 2013
Processing time: 105 Days and 8.9 Hours
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.

Keywords: Appendectomy; Fulminant colitis; Clostridium difficile

Core tip: We demonstrated a significant relationship between fulminant Clostridium difficile infections and previous appendectomy. Early surgical management of at risk patients might improve outcomes and further studies can hopefully explore the role of appendectomy on chronic colonic colonization and future infection risks.