Received: 26 May 2022 | First decision: 5 July 2022 | Accepted: 11 October 2022

DOI: 10.1111/apt.17267

Intestinal ultrasound detects an increased diameter and

submucosal layer thickness in the appendix of patients with
ulcerative colitis compared to healthy controls –­a prospective
cohort study

Maud A. Reijntjes1,2 | Floris A. E. de Voogd2,3 | Willem A. Bemelman1,4 |

Roel Hompes1 | Geert d'Haens3 | Christianne J. Buskens1 | Krisztina B. Gecse3

1
Department of Surgery, Amsterdam UMC,
Amsterdam, the Netherlands
2
Amsterdam Gastroenterology
Endocrinology Metabolism Research
Institute, Amsterdam, the Netherlands
3
Department of Gastroenterology and
Hepatology, Amsterdam UMC, Amsterdam,
the Netherlands
4
IBD Unit, Gastroenterology and Endoscopy,
IRCCS Ospedale san Raffaele and University
Vita-­Salute San Raffaele Milano, Milano,
Italy
Correspondence
Krisztina B. Gecse, Departement of
Gastroenterology and Hepatology,
Amsterdam UMC, Meibergdreef 9, 1105 AZ
Amsterdam, the Netherlands.
Email: k.b.gecse@amsterdamumc.nl
Summary
Background: Increasing evidence suggests that appendicectomy as alternative treat-
ment for ulcerative colitis (UC), especially in patients with histopathological appendi-
ceal inflammation. Intestinal ultrasound (IUS) is a non-­invasive diagnostic modality to
characterise appendiceal inflammation.
Aims: To assess appendiceal IUS characteristics in UC patients and compare findings
to healthy controls (HC).
Methods: In this prospective study, appendiceal IUS was performed in consecutive
UC patients with active (A; n = 35) or quiescent (Q; n = 30) disease and in HC (n = 30).
Transverse appendiceal diameter (TAD) and additional IUS parameters (bowel wall
thickness, submucosal layer thickness and colour Doppler signal) were assessed.
Results: The appendix was visualised in 41/65 UC patients (63.1%; A vs. Q: 23/35 vs.
18/30, p = 0.67) and 18/30 (60%) HC. UC patients had a higher TAD (A: 5.5 mm, Q:
5.0 mm, HC: 4.3 mm; A-­HC p < 0.01; Q-­HC p = 0.01, A-­Q p = ns) and submucosal layer
thickness (A: 1.0 mm, Q: 1.0 mm, HC: 0.7 mm; A-­HC p < 0.01, Q-­HC: p = 0.01, A-­Q:
p = ns) when compared to HC. A TAD ≥6 mm corresponding to an ultrasonographic
suspicion of acute appendicitis was mainly reported in A-­UC patients (A: 43%; Q: 6%;
HC: 0%, p = 0.01) and occurred irrespective of disease extent. However, none of the
patients had a clinical suspicion of acute appendicitis.
Conclusion: A TAD ≥6 mm was predominantly seen in A-­UC. TAD was higher in UC
patients compared to HC irrespective of disease activity and was characterised by an
increased submucosal layer thickness. IUS therefore has the potential to identify UC
patients with appendiceal inflammation.

The Handling Editor for this article was Professor Richard Gearry, and it was accepted for publication after full peer-review.

Maud A. Reijntjes and Floris A.E. de Voogd have contributed equally.

This is an open access article under the terms of the Creative Commons Attribution-­NonCommercial-­NoDerivs License, which permits use and distribution in
any medium, provided the original work is properly cited, the use is non-­commercial and no modifications or adaptations are made.
© 2022 The Authors. Alimentary Pharmacology & Therapeutics published by John Wiley & Sons Ltd.

Aliment Pharmacol Ther. 2023;57:127–135.  wileyonlinelibrary.com/journal/apt | 127

128 | REIJNTJES et al.
1 | I NTRO D U C TI O N
An inverse relation between appendectomy during childhood and
ulcerative colitis (UC) incidence has previously been described.1,2
It is hypothesised that the appendix plays a role in the recolo-
nisation of colonic microbiome and influences local immuno-
logical pathways, serving as a potential disease trigger in UC. 3,4
Consequently, the role of appendectomy is increasingly being in-
vestigated as a potential alternative treatment for UC. Clinical re-
sponse after appendectomy was reported in 46%–­9 0% of patients
with UC 5,6 and a quarter of these therapy-­refractory patients
demonstrated endoscopic remission 3.5 years after appendec-
tomy. 5 It would be clinically relevant to identify patients who are
most likely to respond to appendectomy. Previous studies sug-
gest favourable outcomes for appendectomy in UC patients with
a histopathologically inflamed appendix.7,8 Ulcerative appendi-
citis, a chronic active inflammation in the resection specimen is
9–­11
frequently seen (50–­8 0%) in UC. The presence of microscopic
appendiceal inflammation is not significantly different in patients
in remission or with active disease and is also comparable in lim-
ited and extensive disease. 8
In order to identify patients who will benefit most from a ther-
apeutic appendectomy and a pre-­operative diagnosis of appendi-
ceal inflammation is warranted. Identification of a peri-­appendiceal
red patch (PARP) is predictive of histopathological inflammation of
8,12–­15
the appendix but is only present in 10%–­20% of UC patients.
However, 50%–­8 0% of UC patients exhibit microscopic appendiceal
inflammation and therefore better predictive, and preferably less in-
vasive, diagnostic modalities are being searched for.9–­11
Intestinal ultrasound (IUS) is a non-­invasive and easily accessible
cross-­sectional imaging modality with an appendiceal detection rate
that ranges between 49 and 82%.16–­19 IUS is widely established in
diagnosing acute appendicitis with a 75%–­85% accuracy. One of the
leading IUS parameters supporting the diagnosis of acute appendi-
citis in presence of a clinical suspicion is a transverse appendiceal
diameter (TAD) exceeding 6 millimetres (mm).17,20–­22 IUS is emerging
as imaging modality in UC as it is accurate in determining disease
23–­25
activity and monitoring treatment response. Appendiceal in-
flammation on IUS in UC patients has not been described previously.
Therefore, the aim of this study was to evaluate appendiceal
IUS characteristics of UC patients with active (A) and quiescent (Q)
disease and to compare findings to those of healthy controls (HC).
Additionally, appendiceal characteristics on IUS were correlated
to both disease activity in the remaining colon and the presence of
peri-­appendiceal inflammation on endoscopy.
2 | M ATE R I A L S A N D M E TH O DS
2.1 | Study design
This was a mono-­centre prospective observational cohort study con-
ducted in the Amsterdam UMC, Location AMC. IUS investigations
were performed between July 2020 and September 2021 in consec-
utive patients with UC visiting the outpatient clinic. This study was
waived from review by the medical ethics boards of the Amsterdam
UMC. Informed consent was obtained from all patients and healthy
controls.
2.2 | Inclusion criteria
All included patients had an established diagnosis of UC. Patients
included in the A-­UC cohort had a simple clinical colitis activity
index (SCCAI) > 5 and faecal calprotectin level (FCP) ≥ 250 μg/g
within 4 weeks from IUS. For the Q-­UC cohort, SCCAI had to be
≤5 and FCP ≤ 150 μg/g within 4 weeks from IUS. 26 Patients with
FCP between 150 and 250 μg/g were excluded from this study.
IUS was performed as part of standard care and (medical) treat-
ment was not modified between SCCAI/FCP measurements and
IUS examination.
A cohort of HC subjects (n = 30) with comparable age-­ and
gender was also included. Patients and healthy controls with BMI
≥30 kg/m2 or appendectomy in their medical history were excluded
from the study.
2.3 | Study procedures
2.3.1 | Recruitment
Consecutive UC patients meeting inclusion criteria and undergo-
ing routine IUS as part of disease monitoring were recruited during
outpatient visits. Appendiceal imaging was performed with a negli-
gible additional investigation duration of 5–­10 min. The HC cohort
consisted of hospital employees and patient relatives without any
conflicts of interest for this study.
2.3.2 | Intestinal ultrasound
Still images and cine-­loops of the appendix, rectum, sigmoid, de-
scending, transverse and ascending colon were collected in UC
patients both in a longitudinal and cross-­sectional plane. IUS was
performed using a convex 5-­1 and linear 12-­5 probe with an EPIQ
5G ultrasound machine (Philips, The Netherlands). IUS images were
optimised for gain, frequency and focus. The colour Doppler velocity
scale was set at 5 cm/s.
During the IUS examination, one ultrasonographer (FV, 4 years of
experience) scored visibility of the appendix (Table 1). Subsequently,
MR selected all appendices scored visible, excluded all cine-­loops
and images for the colonic segments, blinded the images and cine-­
loops of the appendix for disease activity/healthy control group and
assigned random numbers to all cases. FV scored the blinded images
and cineloops ≥1 month after the last inclusion for all appendiceal
IUS parameters (Table 1). Transverse appendiceal diameter (TAD),
REIJNTJES et al. | 129

TA B L E 1 IUS characteristics of the appendix vermiformis

Intestinal ultrasound
parameter Technique Measurement/categories

Visibility of the Identification of a blind-­ending bowel segment originating from 0: not visible
appendix the caecum in the right lower abdomen 1: uncertain
2: visible
Diameter transverse Measured from muscularis propria-­serosa interface to (1x longitudinal plane +1x cross-­sectional plane)/2
appendix in mma muscularis propria-­serosa during compression
Bowel wall thickness Measured from lumen-­mucosa interface to muscularis propria-­ (1x longitudinal plane +1x cross-­sectional plane)/2
anterior wall layer serosa interface
Colour Doppler Signal Velocity scale was set to 5 cm/s 0: absent;
1: small spots (single vessels) within the wall;
2: long stretches within the wall;
3: long stretches extending into the mesentery
Incompressibility of the Graded compression of the appendix as previously described40 0: no;
appendix 1: yes
Hyperechoic Presence of a white and in ratio to the muscularis propria 0: not present;
submucosa thickened submucosa 1: present
Peri-­appendicular fat Presence of grey/white hypertrophic mesenteric fit 0: absent;
surrounding the appendix 1: present
Peri-­appendicular fluid Presence of hypoechoic fluid surrounding the appendix 0: absent;
1: present
Lymph nodes Presence of lymph nodes in the right lower abdomen with a 0: absent;
diameter in the shortest axis ≥5.0 mm 1: present
a 20–­22
A cut-­off for transverse appendiceal diameter of 6 mm was applied to determine appendicitis.

bowel wall thickness (BWT), colour Doppler signal (CDS), incom- on IUS and study cohorts based on clinical and biochemical param-
pressibility, hyperechoic submucosa, peri-­appendicular fat, peri-­ eters was calculated.
appendicular fluid and lymph nodes were then scored for all cohorts.

2.5 | Sample size

2.4 | Study objectives and outcomes
The primary objective of this study was to assess the TAD among A-­
and Q-­UC patients. TAD was measured by taking the average of two
measurements (one in the cross-­sectional plane, one in the longitu-
dinal plane) at the same location in the appendix while using graded
compression. The secondary objectives were to evaluate the pres-
ence of a TAD measuring ≥6 mm on IUS. This cut-­off corresponds
to one of the main parameters for diagnosing acute appendicitis on
17
ultrasound. Remaining secondary objectives were the visibility of
the appendix and additional appendiceal IUS parameters as demon-
strated in Table 1. Additionally, the findings of the UC cohorts were
compared with HC. The presence of PARP on concurrent (within
≤3 months of IUS) colonoscopy was assessed for UC patients. The
presence of disease activity per colonic segment (rectum, sigmoid,
descending, transverse, ascending colon and caecum) and disease
extent at IUS was scored for UC patients. Disease activity on IUS was
defined as bowel wall thickness (BWT) >3.0 mm and the presence of
one of the following additional IUS parameters: colour Doppler sig-
nal ≥2; loss of haustrations; loss of wall layer stratification or pres-
ence of inflammatory fat. The agreement between disease activity
As there are no data available on appendiceal ultrasound character-
istics, power calculation was based on the capability of IUS to detect
a difference among cohorts. Based on recently published studies,
IUS is accurate to detect a difference of 1.0 mm. 27,28 To detect a po-
tential difference of 1.0 mm (1.0 mm SD), with a power of β = 90%
and a significance of α = 0.05, 20 patients per cohort were neces-
sary. Taking into consideration the possibility of not visualising the
appendix in 30% of patients due to over-­projecting gas in the bowel
lumen, 30 patients per cohort were necessary to answer the re-
search questions. 29 Inclusion for all cohorts stopped when the last
cohort completed inclusion of 30 patients.
2.6 | Statistical analyses
Categorical data were presented as frequencies and percentages.
To compare dichotomous data, the chi-­s quare test or Fisher's
exact test were used as appropriate. Continuous data were pre-
sented as mean and standard deviation (SD) or as median and in-
terquartile range (IQR), according to their distribution. To compare
130 | REIJNTJES et al.

continuous data, the Mann–­W hitney U or Kruskal–­Wallis test was
used for not normally distributed data, according to number of
tested groups. Normally distributed continuous data were ana-
lysed with Student's t-­test. All tests were two-­sided, with a level
of significance set a p < 0.05. Agreement between disease activity
on IUS and cohort was calculated by a Kappa measure of agree-
ment test; agreement was considered slight, fair, moderate, sub-
stantial or perfect for 0.0–­0 .20, 0.21–­0 .40, 0.41–­0 .60, 0.61–­0 .80
and 0.81–­1.00, respectively. 30 Statistical analyses were performed
using Statistical Package of Social Sciences (SPSS, IBM Corp.,
Armonk, NY, USA).
3 | R E S U LT S
3.1 | Visibility of the appendix
3.1.1 | Active versus quiescent UC patients
The appendix was clearly visible in 41 out of 65 (63.1%) IUS inves-
tigations in UC patients. Visibility was uncertain in six patients, and
the appendix could not be visualised in 18 patients. Visibility of the
appendix was similar between UC cohorts (A: 23/35, 66% and Q:
18/30, 60%, p = 0.67). Age (42.0 [27.0–­55.0] years vs 42.5 [31.0–­
61.75] years, p = 0.36), sex (17/41 male, 41.5% vs. 8/18 male, 44.4%,
p = 0.13) and disease duration (6.0 [2.5–­16.0] years vs 8.0 [5.0–­17.0]
years, p = 0.24) were similar between patients with visible and non-­
visible appendices.

Sixty-­five consecutive UC patients (A-­UC: n = 35and Q-­UC: n = 30) 3.1.2 | UC patients versus healthy controls
meeting the inclusion criteria underwent IUS during outpatient visits
between July 2020 and September 2021. The majority of patients were Visibility of the appendix was similar among UC patients and HC. (A:
female (40/65, 62%) and the median age at time of IUS was 42 [29–­57] 23/35, 66%, Q: 18/30, 60% and HC: 18/30, 60%, p = 0.86).
years. Baseline characteristics (Table 2) were comparable between the
two groups of UC patients except for disease duration (A-­UC: 6.0 vs.
Q-­UC: 14.0 years, p = 0.01) and disease extent (E3 disease in A-­UC: 3.2 | Appendiceal diameter
59% vs Q-­UC: 30%, p = 0.04). With the cohort of healthy individu-
als (n = 30), a total number of 95 IUS investigations were performed. 3.2.1 | Active versus quiescent UC patients
No significant differences in median age (A-­UC: 40.0, Q-­UC: 48.5, HC:
37.5, p = 0.16) and gender distribution (A-­UC: 31% male, Q-­UC: 47% The overall median TAD of 41 UC patients with a visible appendix was
and HC: 47% male, p = 0.35) were found among the three cohorts. 5.3 [4.4–­6.0] mm. The A-­UC cohort had higher median TAD when
TA B L E 2 Baseline characteristics

Total (n = 65) Active UC (n = 35) Quiescent UC (n = 30) Missing

Patient characteristics n % n % n % p-­value n %

Male 25 38.5 11 31.4% 14 46.7% 0.21 0 0.0%

Age at time of IUS, years, median [IQR] 42.0 [29.0–­57.0] 40.0 [28.0–­49.0] 48.5 [31.0–­62.3] 0.07 0 0.0%
Disease Duration, years, median [IQR] 8.0 [3.0–­16.0] 6.0 [2.0–­9.0] 14.0 [3.8–­17.8] 0.01 0 0.0%
Endoscopic disease extent (phenotype)
E1 9 13.8% 2 5.7% 7 23.3% 0.04 1 1.5%
E2 26 40.0% 13 37.1% 13 46.7%
E3 29 44.6% 20 57.1% 9 30.0%
Smoking
Currently 4 6.2% 2 5.7% 2 6.7% 0.83 3 4.6%
Previously 14 21.5% 9 25.7% 5 16.7%
No 44 67.7% 23 65.7% 21 70.0%
Medication at time of IUS
None 2 3.1% 1 2.9% 1 3.3% 1.00 0 0.0%
Aminosalycates 48 73.8% 22 62.9% 26 86.7% 0.03
Immunomodulators 23 35.4% 15 42.9% 8 26.7% 0.15
Systemic steroids 11 16.9% 10 28.6% 1 3.3% 0.01
Biologicals 18 27.7% 10 28.6% 8 26.7% 0.87
Tofacitinib 10 15.4% 8 22.9% 2 6.7% 0.09

Note: Bold values are the p values.

Abbreviations: IQR, inter-­quartile range; IUS, intestinal ultrasonography; UC, Ulcerative colitis.
REIJNTJES et al. | 131

p < 0.01 Mucosa (mm)

p = 0.20 Submucosa (mm)
p = 0.01 Muscularis propria (mm)
8,00 2,5
Average appendiceal diameter (mm)

2,0
6,00
1,5

4,00 1,0

0,5
2,00
0,0
Active Quiescent Healthy
Cohort
,00
Active Quiescent Healthy
F I G U R E 2 Box plots representing thickness of appendix
F I G U R E 1 Dot and box plots representing the average mucosa, submucosa and muscularis propria among cohorts.
transverse appendiceal diameter among cohorts.

compared to Q-­UC patients, although this difference was not signifi-
cant (A: 5.5 mm vs Q: 5.0 mm, p = 0.20, Figure 1).
Eleven out of 41 (27%) UC patients with a visible appendix on
IUS had a TAD measuring ≥6 mm. A significantly larger proportion of
A-­UC patients had a TAD ≥6 mm when compared to Q-­UC patients
(A: 43%, Q: 6%, p = 0.01, Appendix S1).
Thickness of the mucosa, submucosa and muscularis propria were
measured separately on IUS, with overall medians of 0.7 [0.5–­0.8], 1.0
[0.8–­1.4] and 0.5 [0.4–­0.6] mm, respectively. No significant differences
between A-­and Q-­UC patients were observed for median thickness of
the mucosa (A: 0.7 vs. Q: 0.7 mm, p = 0.33), submucosa (A: 1.0 mm vs.
Q: 1.0 mm, p = 0.82) or muscularis propria (0.5 vs. 0.5 mm, p = 0.78).
3.2.2 | UC patients versus healthy controls
A TAD measuring ≥6 mm was found in both A-­ and Q-­UC patients
when compared to HC (A: 5.5 mm, Q: 5.0 mm, HC: 4.3 mm, A-­HC:
p < 0.01, Q-­HC: p = 0.01, Figure 1). No healthy controls had a TAD
measuring ≥6 mm on IUS (Appendix S1).
The submucosal wall thickness was significantly higher for UC
patients (A: 1.0 mm, Q: 1.0 mm, HC: 0.7 mm; A-­ HC: p < 0.01, Q-­ HC:
p < 0.01, Figure 2). There were no significant differences among co-
horts regarding thickness of the mucosa or the muscularis propria
(p = 0.61 and 0.84, respectively).
patients due to over-­projecting gas or deep position of the appendix.
Overall, six (50%) A-­UC patients showed signs of hypervascularity on
CDS, of which two had hypervascular spots and four had hypervascu-
lar stretches limited to the appendiceal wall. Comparable proportions
of incompressible appendices (A: n = 7, 30%, Q: n = 5, 28%, p = 0.85)
and hyperechoic submucosa (A: n = 10, 43%, Q: n = 7, 39%, p = 0.77)
were found among A-­and Q-­UC cohorts (Table 3, Appendix S2).
3.3.2 | UC patients versus healthy controls
Sixteen HC underwent CDS during IUS, of which two (13%) demon-
strated hypervascular spots and none demonstrated stretches limited
to or extending beyond the appendiceal wall. None of the HC demon-
strated an incompressible appendix (A: n = 7, 30%, Q: n = 5, 28%, HC:
0%, p = 0.02), or demonstrated a hyperechoic submucosa (A: n = 10,
44%, Q: n = 7, 29%, HC: 0%, p = 0.01, Table 3, Appendix S2).
3.4 | Peri-­appendiceal inflammation on endoscopy
A total of 17/65 (26%) UC patients underwent (ileo)colonoscopy
≤3 months of IUS. PARP was present in seven (41%) patients. A nu-
merically higher median TAD was observed in patients with a vis-
ible appendix and PARP when compared to patients without PARP
(6.1 mm vs. 5.3 mm, p = 0.22).

3.3 | Appendiceal characteristics on IUS

3.5 | Disease activity by IUS
3.3.1 | Active versus quiescent UC patients
At IUS, 10 out of 35 (29%) patients had left-­sided and 15 (43%) pa-
Colour Doppler sonography (CDS) was applied on 22 (A-­UC n = 12, tients had extensive UC. An additional 10 patients had no disease
Q-­UC n = 10) out of 41 UC patients with a visible appendix to as- activity at IUS of whom eight (23%) had a suspicion of active dis-
31
sess hypervascularity. CDS was not assessable in the remaining 19 ease limited to the rectum. In two (6%) A-­UC patients, there was an
132 | REIJNTJES et al.

TA B L E 3 Appendiceal characteristics on IUS

Total visible Active visible Remission visible Healthy visible

Appendiceal characteristics (n = 59) (n = 23) (n = 18) (n = 18) p-­value

Avg maximum diameter (Median, IQR) 4.8 (4.2–­5.6) 5.5 (4.4–­6.3) 5.0 (4.3–­5.5) 4.3 (3.7–­4.7) <0.01
Max. diameter longitudinal (Median, IQR) 4.8 (4.1–­5.9) 5.9 (4.6–­6.6) 5.1 (4.4–­5.6) 4.3 (3.8–­4.7) <0.01
Max. diameter cross-­sect. (Median, IQR) 4.9 (4.2–­5.5) 5.3 (4.6–­6.1) 5.0 (4.4–­5.5) 4.1 (3.7–­4.7) <0.01
Wall thickness mucosa (Median, IQR) 0.7 (0.5–­0.8) 0.7 (0.5–­0.9) 0.7 (0.4–­0.8) 0.7 (0.5–­0.8) 0.61
Wall thickness submucosa (Median, IQR) 0.9 (0.7–­1.3) 1.0 (0.8–­1.5) 1.0 (1.0–­1.4) 0.7 (0.5–­0.8) <0.01
Wall thickness musc. Propr. (Median, IQR) 0.5 (0.4–­0.6) 0.5 (0.4–­0.6) 0.5 (0.4–­0.6) 0.5 (0.4–­0.5) 0.84
Avg. appendiceal diameter ≥6 mm (n %) 11 19% 10 43% 1 6% 0 0.0% <0.01
Incompressibility (n %) 12 20% 7 30% 5 28% 0 0.0% 0.02
Hyperechoic submucosa (n %) 17 29% 10 43% 7 39% 0 0.0% 0.01
Hyperechoic peri-­appendiceal fat (n %) 7 12% 5 22% 2 11% 0 0.0% 0.10
Lymph nodes Right lower abdomen (n %) 2 3% 2 9% 0 0.0% 0 0.0% 0.33
Peri-­appendiceal fluid (n %) 1 2% 1 4% 0 0.0% 0 0.0% 1.00
Hypervascularity via Doppler (n = 33) (n %) 8 24% 6 50% 0 0.0% 2 15% 0.03
Spots 2 6% 2 17% 0 0.0% 0 0.0%
Stretches limited to wall 4 12% 4 33% 0 0.0% 0 0.0%

Note: Bold values are the p values.

Abbreviations: Avg, Average; IQR, Inter-­quartile range; Max, Maximum; Mm: Millimetres; Musc. propria, Muscularis Propria.

F I G U R E 3 Flowchart representing
Appendiceal diameter IUS disease extent of appendices with a
≥ 6 mm on IUS diameter ≥6 mm.
(n=11)

No IUS disease E1 disease E2 disease E3 disease

n=1 (10%) n=2 (18%) n=1 (10%) n=7 (64%)

No IUS disease Rectum Descending colon Transverse colon Ascending colon Cecum
n=1 (10%) n=2 (18%) n=1 (10%) n=1 (10%) n=1 (10%) n=5 (45%)

absence of disease on IUS investigation. One out of 30 (3%) patients
in the Q-­UC cohort showed extended (right-­sided) disease. The agree-
ment between clinically and biochemically established A-­ and Q-­UC
cohorts and the presence of disease activity on IUS was almost per-
fect (κ = 0.91, 0.82–­1.00, Appendix S3). Five out of 11 (45%) patients
with a TAD measuring ≥6 mm had disease extent including the caecum
on IUS. The remaining six patients with a TAD measuring ≥6 mm had
IUS disease limited to the colon (ascending n = 1, transverse n = 1,
descending n = 1) or rectum (n = 2). One Q-­UC patient with a TAD
measuring ≥6 mm showed an absence of disease on IUS (Figure 3).
4 | D I S CU S S I O N
Appendiceal IUS in UC patients was feasible and the appendix was
visible in 63% of UC patients. UC patients had a significantly higher
median TAD and submucosal wall thickness when compared to healthy
controls. Interestingly, there were no significant differences regarding
median TAD and submucosal wall thickness among patients with ac-
tive or quiescent disease. This finding corresponds with literature that
confirmed similar histopathological appendiceal inflammation rates
among A-­ and Q-­UC patients.8,15 A TAD ≥6 mm, which corresponds
to a diagnosis of acute appendicitis on ultrasound, was predominantly
found in patients with active disease and was not related to disease
extent. These findings support that the appendix is either involved
in the pathophysiology or is a separate site of inflammation in UC.
Interestingly, we found a substantial number of patients with a TAD
measuring ≥6 mm with active disease limited to the distal colon, sug-
gesting a synchronous inflammation rather than a continuous spread.
Alternatively, previous studies hypothesised that the appendix may
play a role in immunological activation and microbiotic recolonisa-
tion in UC.3,4 After appendectomy in UC, nearly half of the patients
REIJNTJES et al.
demonstrated clinical response, and a quarter of the patients demon-
6,7
strated endoscopic remission after a median follow-­up of 3.5 years.
Importantly, patients with a histopathologically inflamed appendix had
more favourable outcomes after appendectomy, when evaluated by
endoscopy or histology.7,8 If currently ongoing studies assessing the
therapeutic efficacy of appendectomy in both active and quiescent pa-
tients (Trial Registry Number 2883 and NCT03912714) confirm these
previous findings, IUS has the potential to identify appendiceal inflam-
mation and could lead to a patient-­tailored treatment approach.32
Interestingly, in our study, the submucosa was observed to be
the most thickened wall layer in UC patients, regardless of disease
activity. There is emerging evidence that the submucosa is indeed
the most prominent wall layer in UC.33,34 Most intestinal vasculature
is present in the submucosa resulting in oedema in this wall layer in
presence of inflammation. Furthermore, recent studies found most
chronic and fibrotic damage in the muscularis mucosae and submu-
cosa in the colectomy resection specimens.35,36 It was therefore of
interest to investigate submucosal thickness of the appendix as an
ultrasonographic parameter specific for appendiceal inflammation in
ulcerative colitis.
In the current study, the diagnostic cut-­off for acute appendi-
citis on IUS was applied. Overall, 27% of UC patients met that spe-
cific ultrasonographic criterion for the diagnosis of appendicitis
(TAD >6 mm) in the absence of clinical symptoms of acute appen-
dicitis. 20 The highest proportion of patients who met this criterion
(43%) was in the A-­UC cohort. This inflammation rate corresponds
well with previous literature reporting on histopathological inflamed
appendices in resection specimens of A-­UC patients specifically
(46%–­85%).7,8,10 However, as acute appendicitis involves transmural
inflammation, a lower UC -­specific cut-­off for ulcerative appendicitis
might reach higher accuracy. Ulcerative appendicitis has a different
etiopathogenesis than acute appendicitis, reflecting more chronic
versus acute inflammation. Ulcerative appendicitis is presumed to
involve oedema and thickening in particular wall layers and the ab-
sence of transmural inflammation in both active and quiescent UC
patients.8
These factors may result in a lower deviation from the healthy
standard for ulcerative appendicitis when compared to acute ap-
pendicitis. Furthermore, other IUS parameters such as CDS and the
presence of inflammatory fat might further increase accuracy to de-
tect appendiceal inflammation in UC patients. In that perspective,
future studies should correlate appendiceal IUS findings with histo-
pathological inflammation.
Furthermore, the appendix was not always visible which ham-
pers conclusions in those patients. Although similar visibility rates
are reported for acute appendicitis patients, the lower deviation in
diameter in ulcerative appendicitis may challenge the feasibility of
visualising the appendix.37 Still, identifying potential characteristics
that predict treatment response would enable a patient-­t ailored
treatment approach for UC patients in the ever-­increasing treatment
armamentarium.
In addition to UC patients, we also included healthy controls in
the present study. A higher TAD for healthy controls was reported
| 133
in the sparse available literature, when compared to the HC cohort
in the current study.38,39 However, ultrasound imaging techniques
have improved over the past decades with possible higher sensitivity
to depict subtle pathology.
The strengths of this study were the prospective design and in-
clusion of a healthy control group with similar demographic charac-
teristics. The study sample was powered and the IUS images were
read blinded for the cohort.
Our study also had some limitations. Firstly, an inter-­observer
agreement was not investigated. In an attempt to mitigate this bias,
assessment of IUS parameters was performed blindly. Secondly, IUS
findings could not be correlated with macroscopic or histopatho-
logical findings after appendectomy. Thirdly, IUS parameters other
than TAD may contribute to further identification of appendiceal
inflammation. However, the numbers in the current study were too
low to draw conclusions. Likewise, a small number of patients un-
derwent concurrent colonoscopy, which precluded the correlation
of IUS findings to the presence of endoscopic disease activity and
periappendicular inflammation. Lastly, as this is the first study in-
vestigating appendiceal ultrasonographic parameters in UC patients,
comparison of our findings and techniques to current literature was
challenging.
In conclusion, UC patients, irrespective of disease activity, had a
more prominent TAD and submucosal wall layer thickness compared
to healthy controls. Future studies should correlate appendiceal IUS
findings to the histopathology of appendix resection specimens.
Currently, ongoing studies incorporated IUS to investigate whether
appendiceal inflammation as detected by IUS is able to identify pa-
tients who are most likely to benefit from an appendectomy. If so,
IUS could provide a non-­invasive patient-­t ailored approach in the
treatment of UC patients.
AU T H O R C O N T R I B U T I O N S
Floris de Voogd: Conceptualization (lead); data curation (lead); for-
mal analysis (lead); investigation (lead); methodology (lead); project
administration (lead); resources (equal); validation (lead); visualiza-
tion (lead); writing –­ original draft (lead); writing –­ review and ed-
iting (lead). Willem Bemelman: Conceptualization (supporting);
methodology (supporting); resources (supporting); writing –­ review
and editing (supporting). Roel Hompes: Conceptualization (equal);
project administration (equal); resources (equal); writing –­ original
draft (equal); writing –­ review and editing (equal). Geert D'Haens:
Conceptualization (equal); project administration (equal); resources
(equal); writing –­ review and editing (equal). Christianne J Buskens:
Conceptualization (equal); data curation (equal); formal analysis
(equal); investigation (equal); methodology (equal); project admin-
istration (equal); resources (equal); supervision (equal); validation
(equal); writing –­ original draft (equal); writing –­ review and editing
(equal).
C O N FL I C T O F I N T E R E S T
MR had none to declare. FV received honoraria or speakers' fees
from AbbVie and Janssen. WB Speaker fees: Takeda, Johnson &
134 | REIJNTJES et al.
Johnson, Medtronic, Braun Grant: VIFOR, Braun. GD has served
as advisor for Abbvie, Ablynx, Amakem, AM Pharma, Avaxia,
Biogen, Bristol Meiers Squibb, Boehringer Ingelheim, Celgene,
Celltrion, Cosmo, Covidien, Ferring, DrFALK Pharma, enGene,
Galapagos, Gilead, Glaxo Smith Kline, Hospira, Immunic, Johnson
and Johnson, Lycera, Medimetrics, Millenium/Takeda, Mitsubishi
Pharma, Merck Sharp Dome, Mundipharma, Novo Nordisk, Pfizer,
Prometheus laboratories/Nestle, Protagonist, Receptos, Robarts
Clinical Trials, Salix, Sandoz, Setpoint, Shire, Teva, Tigenix,
Tillotts, Topivert, Versant and Vifor and received speaker fees
from Abbvie, Ferring, Johnson and Johnson, Merck Sharp Dome,
Mundipharma, Norgine, Pfizer, Shire, Millenium/Takeda, Tillotts
and Vifor. CB received an unrestricted grant from Boehringer
Ingelheim and Roche, and honoraria or speaker fees from Abbvie,
Tillotts, Takeda and Janssen. KG has received grants from Pfizer
Inc, Celltrion and Galapagos; consultancy fees from AbbVie,
Arena Pharmaceuticals, Galapagos, Gilead, Immunic Therapeutics,
Janssen Pharmaceuticals, Novartis, Pfizer Inc., Samsung Bioepis
and Takeda and speaker's honoraria from Celltrion, Ferring,
Janssen Pharmaceuticals, Novartis, Pfizer Inc, Samsung Bioepis,
Takeda and Tillotts. RH none.
DATA AVA I L A B I L I T Y S TAT E M E N T
Bonafide, qualified, scientific and medical researchers may re-
quest access to deidentified study data. Upon approval, and gov-
erned by a Data Sharing Agreement, data are shared in a secured
data access.
ORCID
Maud A. Reijntjes https://orcid.org/0000-0002-1047-8847
Floris A. E. de Voogd https://orcid.org/0000-0003-4058-252X
REFERENCES
1. Andersson RE, Olaison G, Tysk C, Ekbom A. Appendectomy and pro-
tection against ulcerative colitis. N Engl J Med. 2001;344(11):808–­
14. https://doi.org/10.1056/NEJM2​0 0103​15344​1104
2. Rutgeerts P, D'Haens G, Hiele M, Geboes K, Vantrappen G.
Appendectomy protects against ulcerative colitis. Gastroenterology.
1994;106(5):1251–­3. https://doi.org/10.1016/0016-­5085(94)​90016​-­7
3. Mizoguchi A, Mizoguchi E, Chiba C, Bhan AK. Role of appendix in
the development of inflammatory bowel disease in TCR-­alpha mu-
tant mice. J Exp Med. 1996;184(2):707–­15.
4. Rachmilewitz D, Karmeli F, Takabayashi K, Hayashi T, Leider-­
Trejo L, Lee J, et al. Immunostimulatory DNA ameliorates ex-
perimental and spontaneous murine colitis. Gastroenterology.
2002;122(5):1428–­41.
5. Stellingwerf ME, Sahami S, Winter DC, Martin ST, D'Haens GR,
Cullen G, et al. Prospective cohort study of appendicectomy
for treatment of therapy-­refractory ulcerative colitis. Br J Surg.
2019;106(12):1697–­704. https://doi.org/10.1002/bjs.11259
6. Bolin TD, Wong S, Crouch R, Engelman JL, Riordan SM.
Appendicectomy as a therapy for ulcerative proctitis. Am J
Gastroenterol. 2009;104(10):2476–­82. https://doi.org/10.1038/
ajg.2009.388
7. Sahami S, Wildenberg ME, Koens L, et al. Appendectomy for
therapy-­refractory ulcerative colitis results in pathological im-
provement of colonic inflammation: short-­term results of the
PASSION study. J Crohns Colitis. 2019;13(2):165–­71. https://doi.
org/10.1093/ecco-­jcc/jjy127
8. Heuthorst L, Mookhoek A, Wildenberg ME, D'Haens GR,
Bemelman WA, Buskens CJ. High prevalence of ulcerative ap-
pendicitis in patients with ulcerative colitis. United European
Gastroenterol J. 2021;9(10):1148–­56. https://doi.org/10.1002/
ueg2.12171
9. Jo Y, Matsumoto T, Yada S, Nakamura S, Yao T, Hotokezaka M, et al.
Histological and immunological features of appendix in patients
with ulcerative colitis. Dig Dis Sci. 2003;48(1):99–­108. https://doi.
org/10.1023/a:10217​42616794
10. Scott IS, Sheaff M, Coumbe A, Feakins RM, Rampton DS. Appendiceal
inflammation in ulcerative colitis. Histopathology. 1998;33(2):168–­
73. https://doi.org/10.1046/j.1365-­2559.1998.00477.x
11. Sahami S, Gardenbroek TJ, Van Straalen PJ, et al. Lymphocytes
populations in appendiceal lavage fluid predictive of IBD-­related
inflammation. Gastroenterol Hepatol. 2018;9(2):65–­72. https://doi.
org/10.15406/​ghoa.2018.09.00296
12. Yamagishi N, Iizuka B, Nakamura T, Suzuki S, Hayashi N. Clinical and
colonoscopic investigation of skipped periappendiceal lesions in ul-
cerative colitis. Scand J Gastroenterol. 2002;37(2):177–­82. https://
doi.org/10.1080/00365​52027​53416849
13. Rubin DT, Rothe JA. The peri-­appendiceal red patch in ulcer-
ative colitis: review of the University of Chicago experience. Dig
Dis Sci. 2010;55(12):3495–­501. https://doi.org/10.1007/s1062​
0-­010-­1424-­x
14. Mutinga ML, Odze RD, Wang HH, Hornick JL, Farraye FA. The
clinical significance of right-­sided colonic inflammation in pa-
tients with left-­sided chronic ulcerative colitis. Inflamm Bowel
Dis. 2004;10(3):215–­9. https://doi.org/10.1097/00054​725-­20040​
5000-­0 0006
15. Reijntjes MA, Heuthorst L, Gecse K, Mookhoek A, Bemelman WA,
Buskens CJ. Clinical relevance of endoscopic peri-­appendiceal
red patch in ulcerative colitis patients. Therap Adv Gastroenterol.
2022;15:17562848221098849. https://doi.org/10.1177/17562​
84822​1098849
16. Lehmann B, Koeferli U, Sauter TC, Exadaktylos A, Hautz WE.
Diagnostic accuracy of a pragmatic, ultrasound-­based approach to
adult patients with suspected acute appendicitis in the ED. Emerg
Med J. 2022. Online ahead of print. https://doi.org/10.1136/
emerm​ed-­2019-­208643
17. Kadasne R, Sabih DE, Puri G, Sabih Q. Sonographic diagnosis of
appendicitis: a pictorial essay and a new diagnostic maneuver. J
Clin Ultrasound. 2021;49(8):847–­59. https://doi.org/10.1002/
jcu.23033
18. Yabunaka K, Katsuda T, Sanada S, Fukutomi T. Sonographic
appearance of the normal appendix in adults. J Ultrasound
Med. 2007;26(1):37–­43; quiz 45-­6. https://doi.org/10.7863/
jum.2007.26.1.37
19. Rioux M. Sonographic detection of the normal and abnormal ap-
pendix. AJR Am J Roentgenol. 1992;158(4):773–­8. https://doi.
org/10.2214/ajr.158.4.1546592
20. Unlu C, de Castro SM, Tuynman JB, Wust AF, Steller EP, van
Wagensveld BA. Evaluating routine diagnostic imaging in acute ap-
pendicitis. Int J Surg. 2009;7(5):451–­5. https://doi.org/10.1016/j.
ijsu.2009.06.007
21. Puylaert JB, Rutgers PH, Lalisang RI, et al. A prospective study of
ultrasonography in the diagnosis of appendicitis. N Engl J Med.
1987;317(11):666–­9. https://doi.org/10.1056/NEJM1​98709​10317​
1103
22. Birnbaum BA, Wilson SR. Appendicitis at the millennium.
Radiology. 2000;215(2):337–­48. https://doi.org/10.1148/radio​lo-
gy.215.2.r00ma​24337
23. De Voogd F, Wilkens R, Gecse K, et al. A reliability study: strong
inter-­observer agreement of an expert panel for intestinal
REIJNTJES et al.
ultrasound in ulcerative colitis. J Crohns Colitis. 2021;15(8):1284–­
90. https://doi.org/10.1093/ecco-­jcc/jjaa267
24. Smith RL, Taylor KM, Friedman AB, Gibson RN, Gibson PR.
Systematic review: clinical utility of gastrointestinal ultrasound in
the diagnosis, assessment and Management of patients with ul-
cerative colitis. J Crohns Colitis. 2020;14(4):465–­79. https://doi.
org/10.1093/ecco-­jcc/jjz163
25. Maaser C, Petersen F, Helwig U, Fischer I, Roessler A, Rath S, et al.
Intestinal ultrasound for monitoring therapeutic response in patients
with ulcerative colitis: results from the TRUST&UC study. Gut.
2020;69(9):1629–­36. https://doi.org/10.1136/gutjn​l-­2019-­319451
26. Stevens TW, Gecse K, Turner JR, de Hertogh G, Rubin DT, D'Haens
GR. Diagnostic accuracy of fecal calprotectin concentration in
evaluating therapeutic outcomes of patients with ulcerative coli-
tis. Clin Gastroenterol Hepatol. 2021;19(11):2333–­42. https://doi.
org/10.1016/j.cgh.2020.08.019
27. Bots S, Nylund K, Lowenberg M, Gecse K, D'Haens G. Intestinal ul-
trasound to assess disease activity in ulcerative colitis: development
of a novel UC-­ultrasound index. J Crohns Colitis. 2021;15(8):1264–­
71. https://doi.org/10.1093/ecco-­jcc/jjab002
28. Allocca M, Fiorino G, Bonovas S, Furfaro F, Gilardi D, Argollo M,
et al. Accuracy of Humanitas ultrasound criteria in assessing dis-
ease activity and severity in ulcerative colitis: a prospective study.
J Crohns Colitis. 2018;12(12):1385–­91. https://doi.org/10.1093/
ecco-­jcc/jjy107
29. Kim DW, Suh CH, Yoon HM, Kim JR, Jung AY, Lee JS, et al. Visibility
of Normal appendix on CT, MRI, and sonography: a systematic re-
view and meta-­analysis. AJR Am J Roentgenol. 2018;211(3):W140–­
50. https://doi.org/10.2214/AJR.17.19321
30. Landis JR, Koch GG. The measurement of observer agreement for
categorical data. Biometrics. 1977;33(1):159–­74.
31. Nylund K, Maconi G, Hollerweger A, et al. EFSUMB recommen-
dations and guidelines for gastrointestinal ultrasound. Ultraschall
Med. 2017;38(3):e1–­e15. https://doi.org/10.1055/s-­0 042-­115853
32. Gardenbroek TJ, Pinkney TD, Sahami S, et al. The ACCURE-­
trial: the effect of appendectomy on the clinical course of ul-
cerative colitis, a randomised international multicenter trial
(NTR2883) and the ACCURE-­UK trial: a randomised external
pilot trial (ISRCTN56523019). BMC Surg. 2015;15:30. https://doi.
org/10.1186/s1289​3-­015-­0 017-­1
33. de Voogd F, Duijvestein M, Ponsioen C, Löwenberg M, D'Haens G,
Gecse K. P411 baseline hypertrophy of the submucosa at intestinal
ultrasound predicts failure of treatment in patients with ulcerative
colitis. J Crohns Colitis. 2021;15:S418–­9.
| 135
34. Miyoshi J, Ozaki R, Yonezawa H, et al. Ratio of submucosal thickness
to total bowel wall thickness as a new sonographic parameter to es-
timate endoscopic remission of ulcerative colitis. J Gastroenterol.
2022;57(2):82–­89. https://doi.org/10.1007/s00535-­021-­01847-­3
35. Gordon IO, Agrawal N, Goldblum JR, Fiocchi C, Rieder F. Fibrosis
in ulcerative colitis: mechanisms, features, and consequences of
a neglected problem. Inflamm Bowel Dis. 2014;20(11):2198–­206.
https://doi.org/10.1097/MIB.00000​0 0000​0 00080
36. Gordon IO, Agrawal N, Willis E, Goldblum JR, Lopez R, Allende
D, et al. Fibrosis in ulcerative colitis is directly linked to severity
and chronicity of mucosal inflammation. Aliment Pharmacol Ther.
2018;47(7):922–­39. https://doi.org/10.1111/apt.14526
37. Shrestha AKH, Poudel B, Basnet R, Basnet SB. Accuracy of ul-
trasound in the diagnosis of acute appendicitis and correlation
with histopathology. Nepal J Radiol. 2018;8(2):13–­9. https://doi.
org/10.3126/njr.v8i2.22975
38. Ferri E, Bonvicini U, Pisani M. Ultrasonography of normal vermi-
form appendix. Chir Ital. 2001;53(2):231–­8. Ecografia dell'appen-
dice vermiforme normale.
39. Rettenbacher T, Hollerweger A, Macheiner P, Gritzmann N.
Ultrasonography of the normal vermiform appendix. Ultraschall
Med. 1997;18(3):139–­42. https://doi.org/10.1055/s-­2007-­1000410
40. Puylaert JB. Mesenteric adenitis and acute terminal ileitis: US eval-
uation using graded compression. Radiology. 1986;161(3):691–­5.
https://doi.org/10.1148/radio​logy.161.3.3538138
S U P P O R T I N G I N FO R M AT I O N
Additional supporting information will be found online in the
Supporting Information section.
How to cite this article: Reijntjes MA, de Voogd FAE,
Bemelman WA, Hompes R, d’Haens G, Buskens CJ, et al.
Intestinal ultrasound detects an increased diameter and
submucosal layer thickness in the appendix of patients with
ulcerative colitis compared to healthy controls –­a
prospective cohort study. Aliment Pharmacol Ther.
2023;57:127–­135. https://doi.org/10.1111/apt.17267