Cigarette smoking and appendectomy are risk factors for extraintestinal manifestations in ulcerative colitis.
OBJECTIVE
Two common factors, cigarette smoking and appendectomy, have been found to play a role in ulcerative colitis (UC). Data on their role in the development of extraintestinal manifestations (EIM) are scarce.


METHODS
The relationship between cigarette smoking, appendectomy, and EIM was examined in a prospective study involving 535 (M/F = 319/216) consecutive UC patients followed up for 18 yr. We considered the major EIM: seronegative spondyloarthropathy, pyoderma gangrenosum/erythema nodosum, acute anterior uveitis, and primary sclerosing cholangitis. We excluded patients with a history of EIM or those colectomized before study entry, ex-smokers, and those who started to smoke during the course of UC.


RESULTS
In UC patients, seronegative spondyloarthropathy and dermatologic complications were found increased in smokers (p < 0.0001; p = 0.001) or in subjects with appendectomy (p = 0.0003; p = 0.02), while acute anterior uveitis and primary sclerosing cholangitis did not differ. The Kaplan-Meier analysis showed 18-yr rates for EIM of 71% in smokers and 45% in nonsmokers (log-rank test, p = 0.0001), and of 85% in patients with appendectomy and 48% in those without (p = 0.0001). Cox proportional-hazard model showed that cigarette smoking and appendectomy are independent factors promoting EIM. In smokers with appendectomy the adjusted hazard ratio (3.197, 95% CI 1.529-6.684) was higher than in patients with appendectomy alone (2.617, 95% CI 1.542-4.442) or smoking alone (1.947, 95% CI 1.317-2.879).


CONCLUSIONS
In UC patients, appendectomy and cigarette smoking are prognostic factors for the development of EIM. The unfavorable effect of cigarette smoking on EIM is additive to that of appendectomy.
Manguso
F
F
Department of Gastroenterology, Federico II University, Naples, Italy.
Sanges
M
M
Staiano
T
T
Gargiulo
S
S
Nastro
P
P
Gargano
D
D
Somma
P
P
Mansueto
G
G
Peluso
R
R
Scarpa
R
R
D'Armiento
F P
FP
Astarita
C
C
Ayala
F
F
Renda
A
A
Mazzacca
G
G
D'Arienzo
A
A
D000293:Adolescent; D000328:Adult; D001062:Appendectomy / Q000009:adverse effects*; D002648:Child; D015209:Cholangitis, Sclerosing / Q000209:etiology; D003093:Colitis, Ulcerative / Q000150:complications*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011446:Prospective Studies; D012307:Risk Factors; D012871:Skin Diseases / Q000209:etiology; D012907:Smoking / Q000009:adverse effects*; D013128:Spinal Osteophytosis / Q000209:etiology; D014606:Uveitis, Anterior / Q000209:etiology