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Tonsillectomy and risk of acute appendicitis
2806
Letters to the Editor
Reprint requests and correspondence: Joseph C. Yarze, M.D., Gastroenterology Associates of Northern New York, PC, Five Irongate Center, Glens Falls, NY. Received July 11, 2003; accepted July 15, 2003.
Tonsillectomy and Risk of Acute Appendicitis TO THE EDITOR: The mucosas are an entrance for many pathogenic agents and are the contact area for several antigens (e.g., environmental, alimentary). They are much more fragile than the skin as a barrier but nevertheless are covered by a local protection system and they present a characteristic immune response. This immune response is developed by the mucosa-associated lymphoid tissue. Most of the lymphoid tissue in the body (more than 50%) is part of the mucosal system, mostly intestinal, and IgA is the most abundant immunoglobulin (1). Tonsillectomy and adenoidectomy are two of the most frequent surgical procedures performed in general and are very common in children and adolescents. Indications for these procedures are still considered to be controversial (2). Tonsillectomy has been implicated as a risk factor in alterations of the MALT system (3) and Hodgkin’s disease (4, 5). An association has also been found between tonsillectomy and Crohn’s disease, especially terminal ileum Crohn’s disease (6, 7). The purpose of this study was to examine the possible association between tonsillectomy or adenoidectomy and the risk of subsequent acute appendicitis. A transverse study was performed that included randomly selected patients admitted to the emergency department of the Arnau de Vilanova Hospital, Valencia, Spain. A survey was performed to investigate previous tonsillectomy, adenoidectomy, and appendectomy and at what age they had been performed. A total of 650 patients were selected. Appendectomy was considered the response variable; tonsillectomy and adenoidectomy were considered explicative variables. The sex and age of the patient were included in the statistical analysis as control variables. The mean age of patients was 45.6 yr; 50.3% were men; 25.5% of patients had undergone a tonsillectomy and 11.5% an adenoidectomy. No significant differences were found between sexes. Table 1 shows the analysis of the association between tonsillectomy or adenoidectomy and subsequent appendectomy. Our results indicate a significant positive association; patients with a previous tonsillectomy present 3.25 times more probability of being operated on subsequently for acute appendicitis: OR ⫽ 3.25 (95% CI ⫽ 2.13– 4.96). The association between adenoidectomy and appendectomy was also significant: OR ⫽ 2.35 (95% CI ⫽ 1.37– 4.03). A multivariable analysis controlled for age and sex showed similar results. The OR of the association between tonsillectomy and appendicitis was 3.23 (95% ⫽ 2.11– 4.94) and between adenoidectomy and appendicitis 2.57 (95% CI ⫽ 1.48 – 4.46). However, after controlling the variable tonsil-
AJG – Vol. 98, No. 12, 2003
Table 1. Frequency of Procedures and Association Between Tonsillectomy and Adenoidectomy and Appendectomy n (%)
Crude OR* (95% CI)
Adjusted OR† (95% CI)
Tonsillectomy 166 (25.5%) Adenoidectomy 75 (11.5%) 2.35 (1.37–4.04) 1.26 (0.67–2.38) Appendectomy 114 (17.5%) 3.25 (2.13–4.96) 2.97 (1.82–4.82) * Odds ratio of the association between tonsillectomy and adenoidectomy and between tonsillectomy and appendectomy. † Logistic regression model adjusted for age, sex, and appendectomy (for adenoidectomy); and age, sex, and adenoidectomy (for appendectomy).
lectomy, the association between appendicitis and adenoidectomy disappears (OR ⫽ 1.26; 95% CI ⫽ 0.67–2.38). The study of the possible interactions between the variables showed a significant modification of effect (p ⫽ 0.013) between tonsillectomy and sex. A stratified analysis controlled for age showed a result similar to the simple analysis: OR ⫽ 1.74 (95% CI ⫽ 0.90 –3.39) for men and of 5.20 (95% CI ⫽ 2.91–9.28) for women. In conclusion, a clear association was found between tonsillectomy and acute appendicitis. This association is not as evident (by multivariable analysis) between adenoidectomy and appendicitis. There is also an important difference in the association between tonsillectomy and appendicitis in men and women. An explanation for these differences is not clear, although some studies indicate differences in the development of the immune system related to the X chromosome (8) or estrogens (9). Further studies on this possible risk factor for acute appendicitis are needed. J. C. Andreu-Ballester, M.D. Rubio E. Colomer, M.D. Emergency Service Hospital Arnau de Vilanova de Valencia M. Milla´n Scheiding, M.D. Service of Surgery del Hospital Arnau de Vilanova de Valencia F. Ballester, M.D. Unit of Epidemiology and Statistics Valencian School of Studies for Health Valencia, Spain
REFERENCES 1. Roitt I, Brostoff J, Male D. Immunologia. 5th ed. Madrid: Harcourt Editions, 2001. 2. Llorente JL, Suarez C. Indicaciones de la amigdalectomia. Bol Pediatr 1999;39:72–5. 3. Ogra PL. Effect of tonsillectomy and adenoidectomy on nasopharyngeal antibody resonse to poliovirus. N Engl J Med 1971; 284:59 –64. 4. Liaw KL, Adami J, Gridley G, et al. Risk of Hodgkin’s disease subsequent to tonsillectomy: A population-based cohort study in Sweden. Int J Cancer 1997;72:711–3. 5. Abramson JH, Pridan H, Sacks MI, et al. A case controlled study of Hodgkin’s disease in Israel. J Natl Cancer Inst 1978; 61:307–14.
AJG – December, 2003
Letters to the Editor
2807
6. Koutroubakis IE, Vlachonikolis IG, Kapsoritakis A, et al. Appendectomy, tonsillectomy, and risk of inflammatory bowel disease. case-controlled study in Crete. Dis Colon Rectum 1999;42:225–30. 7. Mate-Jimenez J, Correa-Estan JA, Perez-Miranda M, et al. Tonsillectomy and inflammatory bowel disease location. Eur J Gastroenterol Hepatol 1996;8:1185–8. 8. Eskola J, Nurmi T, Ruuskanen O. Defective B cell function associated with inherited interstitial deletion of the short arm of the X chromosome. J Immunol 1983;131:1218 –21. 9. Medina KL, Strasser A, Kincade PW. Estrogen influences the differentiation, proliferation, and survival of early B-lineage precursors. Blood 2000;95:2059 –67. Reprint requests and correspondence: Juan Carlos Andreu, M.D., C/Juan Ramon Jime´ nez, 29-14, 46006 Valencia, Spain. Received July 14, 2003; accepted July 25, 2003.
Patent Accessory Pancreatic Duct Prevents Acute Pancreatitis TO THE EDITOR: Pancreatitis is the most important complication of ERCP. Moreover, efforts to understand its pathogenesis and to identify ways to reduce the frequency and severity of this complication have shown no convincing benefit to date. Although very complex factors are involved in the development of post-ERCP pancreatitis, two types of injury, mechanical injury to the papilla causing papillary edema and restriction of pancreatic juice flow, and hydrostatic injury from over-injection, are the most common causes (1, 2). The accessory pancreatic duct (APD) is the smaller and less constant pancreatic duct in comparison with the main pancreatic duct (MPD), and its patency has been difficult to evaluate endoscopically. We have prospectively examined patency of the APD in 443 subjects by dyeinjection ERP, as follows: during ERP, 2 or 3 ml of contrast medium containing indigo carmine was injected through a catheter in the MPD with the usual pressure. Dye excretion from the minor papilla was then observed endoscopically (3, 4). Of 312 controls, patency of the APD was observed in 43%, whereas in 51 patients with acute pancreatitis, eight (16%) had a patent APD. The difference in patency in these groups was significant (p ⬍ 0.01). In particular, patency of the APD was seen in only one of 17 patients with acute biliary pancreatitis. Patency of the APD showed a close relationship to the course and terminal shape of the APD. The longtype APD, which joined the MPD at its neck portion and ran straight from the upper dorsal pancreatic duct, was more frequently patent than was the short-type APD, which joined the MPD near its first inferior branch and followed a descending course (75.5% patency vs 36.0%). Regarding terminal shape of the APD, patency of the cudgel type (89.2%) and spindle type (92.0%) was more
Figure 1. ERP images of the APD. (A) Patent, long-type APD with spindle terminal shape. (B) Nonpatent, short-type APD with branch terminal shape.
frequent than in the branch type (5.9%) or saccular type (16.7%). To expand on the above findings, we retrospectively examined patency of the APD in 25 patients with acute pancreatitis after diagnostic ERP (from a total of 6500 procedures). Patency of the APD was estimated at only 8% (2/25). Furthermore, three patients showing acute pancreatitis after stone extraction with endoscopic balloon dilation exhibited nonpatent APD. A patent APD might prevent acute pancreatitis by lowering the pressure in the MPD. During diagnostic or
Letters to the Editor
Reprint requests and correspondence: Joseph C. Yarze, M.D., Gastroenterology Associates of Northern New York, PC, Five Irongate Center, Glens Falls, NY. Received July 11, 2003; accepted July 15, 2003.
Tonsillectomy and Risk of Acute Appendicitis TO THE EDITOR: The mucosas are an entrance for many pathogenic agents and are the contact area for several antigens (e.g., environmental, alimentary). They are much more fragile than the skin as a barrier but nevertheless are covered by a local protection system and they present a characteristic immune response. This immune response is developed by the mucosa-associated lymphoid tissue. Most of the lymphoid tissue in the body (more than 50%) is part of the mucosal system, mostly intestinal, and IgA is the most abundant immunoglobulin (1). Tonsillectomy and adenoidectomy are two of the most frequent surgical procedures performed in general and are very common in children and adolescents. Indications for these procedures are still considered to be controversial (2). Tonsillectomy has been implicated as a risk factor in alterations of the MALT system (3) and Hodgkin’s disease (4, 5). An association has also been found between tonsillectomy and Crohn’s disease, especially terminal ileum Crohn’s disease (6, 7). The purpose of this study was to examine the possible association between tonsillectomy or adenoidectomy and the risk of subsequent acute appendicitis. A transverse study was performed that included randomly selected patients admitted to the emergency department of the Arnau de Vilanova Hospital, Valencia, Spain. A survey was performed to investigate previous tonsillectomy, adenoidectomy, and appendectomy and at what age they had been performed. A total of 650 patients were selected. Appendectomy was considered the response variable; tonsillectomy and adenoidectomy were considered explicative variables. The sex and age of the patient were included in the statistical analysis as control variables. The mean age of patients was 45.6 yr; 50.3% were men; 25.5% of patients had undergone a tonsillectomy and 11.5% an adenoidectomy. No significant differences were found between sexes. Table 1 shows the analysis of the association between tonsillectomy or adenoidectomy and subsequent appendectomy. Our results indicate a significant positive association; patients with a previous tonsillectomy present 3.25 times more probability of being operated on subsequently for acute appendicitis: OR ⫽ 3.25 (95% CI ⫽ 2.13– 4.96). The association between adenoidectomy and appendectomy was also significant: OR ⫽ 2.35 (95% CI ⫽ 1.37– 4.03). A multivariable analysis controlled for age and sex showed similar results. The OR of the association between tonsillectomy and appendicitis was 3.23 (95% ⫽ 2.11– 4.94) and between adenoidectomy and appendicitis 2.57 (95% CI ⫽ 1.48 – 4.46). However, after controlling the variable tonsil-
AJG – Vol. 98, No. 12, 2003
Table 1. Frequency of Procedures and Association Between Tonsillectomy and Adenoidectomy and Appendectomy n (%)
Crude OR* (95% CI)
Adjusted OR† (95% CI)
Tonsillectomy 166 (25.5%) Adenoidectomy 75 (11.5%) 2.35 (1.37–4.04) 1.26 (0.67–2.38) Appendectomy 114 (17.5%) 3.25 (2.13–4.96) 2.97 (1.82–4.82) * Odds ratio of the association between tonsillectomy and adenoidectomy and between tonsillectomy and appendectomy. † Logistic regression model adjusted for age, sex, and appendectomy (for adenoidectomy); and age, sex, and adenoidectomy (for appendectomy).
lectomy, the association between appendicitis and adenoidectomy disappears (OR ⫽ 1.26; 95% CI ⫽ 0.67–2.38). The study of the possible interactions between the variables showed a significant modification of effect (p ⫽ 0.013) between tonsillectomy and sex. A stratified analysis controlled for age showed a result similar to the simple analysis: OR ⫽ 1.74 (95% CI ⫽ 0.90 –3.39) for men and of 5.20 (95% CI ⫽ 2.91–9.28) for women. In conclusion, a clear association was found between tonsillectomy and acute appendicitis. This association is not as evident (by multivariable analysis) between adenoidectomy and appendicitis. There is also an important difference in the association between tonsillectomy and appendicitis in men and women. An explanation for these differences is not clear, although some studies indicate differences in the development of the immune system related to the X chromosome (8) or estrogens (9). Further studies on this possible risk factor for acute appendicitis are needed. J. C. Andreu-Ballester, M.D. Rubio E. Colomer, M.D. Emergency Service Hospital Arnau de Vilanova de Valencia M. Milla´n Scheiding, M.D. Service of Surgery del Hospital Arnau de Vilanova de Valencia F. Ballester, M.D. Unit of Epidemiology and Statistics Valencian School of Studies for Health Valencia, Spain
REFERENCES 1. Roitt I, Brostoff J, Male D. Immunologia. 5th ed. Madrid: Harcourt Editions, 2001. 2. Llorente JL, Suarez C. Indicaciones de la amigdalectomia. Bol Pediatr 1999;39:72–5. 3. Ogra PL. Effect of tonsillectomy and adenoidectomy on nasopharyngeal antibody resonse to poliovirus. N Engl J Med 1971; 284:59 –64. 4. Liaw KL, Adami J, Gridley G, et al. Risk of Hodgkin’s disease subsequent to tonsillectomy: A population-based cohort study in Sweden. Int J Cancer 1997;72:711–3. 5. Abramson JH, Pridan H, Sacks MI, et al. A case controlled study of Hodgkin’s disease in Israel. J Natl Cancer Inst 1978; 61:307–14.
AJG – December, 2003
Letters to the Editor
2807
6. Koutroubakis IE, Vlachonikolis IG, Kapsoritakis A, et al. Appendectomy, tonsillectomy, and risk of inflammatory bowel disease. case-controlled study in Crete. Dis Colon Rectum 1999;42:225–30. 7. Mate-Jimenez J, Correa-Estan JA, Perez-Miranda M, et al. Tonsillectomy and inflammatory bowel disease location. Eur J Gastroenterol Hepatol 1996;8:1185–8. 8. Eskola J, Nurmi T, Ruuskanen O. Defective B cell function associated with inherited interstitial deletion of the short arm of the X chromosome. J Immunol 1983;131:1218 –21. 9. Medina KL, Strasser A, Kincade PW. Estrogen influences the differentiation, proliferation, and survival of early B-lineage precursors. Blood 2000;95:2059 –67. Reprint requests and correspondence: Juan Carlos Andreu, M.D., C/Juan Ramon Jime´ nez, 29-14, 46006 Valencia, Spain. Received July 14, 2003; accepted July 25, 2003.
Patent Accessory Pancreatic Duct Prevents Acute Pancreatitis TO THE EDITOR: Pancreatitis is the most important complication of ERCP. Moreover, efforts to understand its pathogenesis and to identify ways to reduce the frequency and severity of this complication have shown no convincing benefit to date. Although very complex factors are involved in the development of post-ERCP pancreatitis, two types of injury, mechanical injury to the papilla causing papillary edema and restriction of pancreatic juice flow, and hydrostatic injury from over-injection, are the most common causes (1, 2). The accessory pancreatic duct (APD) is the smaller and less constant pancreatic duct in comparison with the main pancreatic duct (MPD), and its patency has been difficult to evaluate endoscopically. We have prospectively examined patency of the APD in 443 subjects by dyeinjection ERP, as follows: during ERP, 2 or 3 ml of contrast medium containing indigo carmine was injected through a catheter in the MPD with the usual pressure. Dye excretion from the minor papilla was then observed endoscopically (3, 4). Of 312 controls, patency of the APD was observed in 43%, whereas in 51 patients with acute pancreatitis, eight (16%) had a patent APD. The difference in patency in these groups was significant (p ⬍ 0.01). In particular, patency of the APD was seen in only one of 17 patients with acute biliary pancreatitis. Patency of the APD showed a close relationship to the course and terminal shape of the APD. The longtype APD, which joined the MPD at its neck portion and ran straight from the upper dorsal pancreatic duct, was more frequently patent than was the short-type APD, which joined the MPD near its first inferior branch and followed a descending course (75.5% patency vs 36.0%). Regarding terminal shape of the APD, patency of the cudgel type (89.2%) and spindle type (92.0%) was more
Figure 1. ERP images of the APD. (A) Patent, long-type APD with spindle terminal shape. (B) Nonpatent, short-type APD with branch terminal shape.
frequent than in the branch type (5.9%) or saccular type (16.7%). To expand on the above findings, we retrospectively examined patency of the APD in 25 patients with acute pancreatitis after diagnostic ERP (from a total of 6500 procedures). Patency of the APD was estimated at only 8% (2/25). Furthermore, three patients showing acute pancreatitis after stone extraction with endoscopic balloon dilation exhibited nonpatent APD. A patent APD might prevent acute pancreatitis by lowering the pressure in the MPD. During diagnostic or