APPENDICULAR ABSCESS

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APPENDICULAR MASS / ABSCESS

Shuja Tahir, FRCS (Edin), FCPS Pak (Hon) Awais Shuja, MRCS Appendicular abscess is the localized collection of pus in the peri-appendicular area (right iliac fossa) following appendicitis and its perforation. An inflammatory mass occurs either as phlegmon or abscess in 2% to 6% patients with appendicitis.

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CLINICAL FEATURES
History of pain in right iliac fossa and mass formation over few days is always present. Rarely it may present without prolonged history which may happen in deep and retrocaecal appendicitis. The common presenting features are : PAIN Pain is usually present in the right iliac fossa. It is not very severe to start with. It is continuous and gets worse gradually. The pain becomes throbbing and unbearable as the abscess formation occurs. MASS RIGHT ILIAC FOSSA There is mass formation in the right iliac fossa which is tender to touch. Over lying skin is usually normal. The local temperature may or may not be raised. The mass may increase in size and become more painful than before. FEVER Fever is present in association with other symptoms. It is continuous and is not responsive to antibiotics. It has a typical pattern showing progressive rise in the peak of temperature. (Swinging temperature) 1,2,3 In fact the appendicular abscess is diagnosed with reasonable certainty when the patient with appendicular mass starts running high grade temperature regularly.
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TENDERNESS The mass in the right iliac fossa becomes tender not only to touch but to respiratory movements as well. On examination even gentle palpation is very painful. PARALYTIC ILEUS Mostly these patients are already diagnosed cases of appendicular mass and are on conservative treatment when they develop paralytic ileus. Patients may present with paralytic ileus which may be due to appendicular abscess. ASSOCIATED SYMPTOMS Patient may present with difficulty in micturition, frequency of micturition, acute retention of urine and haematuria. The symptoms are due to presence of abscess and inflammatory mass near right lower ureter and bladder.

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INVESTIGATIONS
URINE EXAMINATION It is a simple investigation which helps to exclude the renal causes of urological symptoms in patients with appendicular abscess. BLOOD EXAMINATION Haemoglobin percentage is decreased. Leukocyte count is raised. Polymorphonucleo-leukocytosis is present. Sedimentation rate is raised. RADIOLOGICAL EXAMINATION PLAIN X-RAY OF THE ABDOMEN It may show loops of distended small gut around the abscess area (sentinel loops). ULTRASOUND SCAN The differentiation between appendicular mass and abscess is easily done with the ultrasound scan. The abdominal ultrasound scan shows a solid mass in the right iliac fossa as hypo epoic area (fluid collection). The amount of fluid collection varies with the amount of pus present. The shadow of adherent and distended loops of bowel is also seen. Percutaneous drainage under ultrasound guidance is minimally invasive. CT SCAN It can reliably distinguish phlegmonous inflammation from a liquified abscess. It can delineate the full extent of such inflammatory mass. Percutaneous drainage under CT control is safe, effective and carries low morbidity4.

ULTRASOUND GUIDED PERCUTANEOUS DRAINAGE When the appendicular abscess is diagnosed by sonography. It can be aspirated with the help of a wide bore needle under ultrasound control. It is simple, safe and effective. It may be repeated if the abscess collects. In fact, the drainage is a better option than the aspiration. EMERGENCY (IMMEDIATE) SURGERY It is required when abscess fails to resolve or recurs. It is also required when the general condition of patient deteriorates inspite of conservative management. Incision and drainage of the abscess is performed. The appendix, its debris or inflammatory mass is also removed if safely possible at the same operation, otherwise, it is left for later stage to be removed as elective operation. LAPAROSCOPIC DRAINAGE
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Appendicular abscess (laprascopic view) It is less traumatic and less invasive procedure but it should better be avoided as the risk of spread of infection into the peritoneal cavity is too high. EXPECTANT TREATMENT If the patient is haemodynamically stable, the patient is observed and treated symptomatically and conservatively. It is safe and effective alternative to immediate surgery. It is monitored with ultrasound and CT scan5. Initial expectant treatment has following components.

TREATMENT
The treatment of appendicular abscess has following components; Ultrasound guided drainage of abscess Emergency surgery Laparoscopic drainage Expectant treatment Delayed surgery

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APPENDICULAR MASS LEADING TO ABSCESS FORMATION

Parenteral antibiotics Fluid replacement Nill Orally

Serial Ultrasounds

Abscess formation No abcess Percutaneous drainage

Mass Resolves

Persistent Recurrent abcess

Delayed surgery (Appendicectomy) Age >40 years Barium enema Colonoscopy

Open drainage Surgery

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FLUID AND ELECTROLYTES The patients are given fluids intravenously. These are given according to the daily requirements of the patient. Serum electrolytes are estimated and any deficit should be corrected. NIL ORALLY The patients with appendicular abscess are not given any thing orally. Nasogastric aspiration is required in some cases to help in relieving the paralytic ileus, vomiting and abdominal discomfort. PARENTERAL ANTIBIOTICS Appropriate antibiotics are started as soon as the condition is diagnosed. Triple regimen of antibiotics is usually used. It is a combination of drugs against gram negative, gram positive and anaerobic organisms. Commonly used drugs are amino glycosides, ampicillin and metronidazole. There are two forms of surgery for treatment of appendicular abscess as following; DELAYED SURGERY Interval appendicectomy is performed about six to eight weeks afterwards. This is performed to prevent recurrent attacks and will provide definitive diagnosis. Recently there is growing evidence against routinely performing interval appendicectomy as the risk of recurrent attack is only 14% and most of it occurs in first three months.

REFERENCES
1. Okoji GD. Caveron BH. Appendicitis presenting with dysuria in a 2 years old: Ultrasound aided diagnosis. Annals of tropical paediatrics. [JC:6ab]1991.: 38990.

2. Parrish GA. Wright GD. Falk JL. Acute urinary retention an unusual presentation of appendiceal abscess. Annals of emergency medicine. [JC:4z7] 1993 May. 22(5); 851-60. 3. Monu JU. Akumabor PN. Appendiceal abscess unusual cause of acute urinary retention. International journal of urology and nephrology. [JC:gug] 1990. 22(5) : 429-32. 4. Shapiro MP. Gale ME. Gerzof SG. CT of appendicitis diagnosis and treatment. Radiologic clinics of North America. [JC: qq1]1989, Jul. 27(4): 753-62. 5. Haffmann J. Rolff M. Lomborg V. Franzmam M. Ultraconservative management of appen-diceal abscess. Journal of the Royal College of Surgeons of Edinburgh. [JC:jvc]1991 Feb. 36(1): 18-20. 6. A Tekin, tic kurtoglu. Routine interval appendectomy is unnecessary after conservative treatment of appendicle mass colorectal disease, April 2007. 10,465-468.

SUMMARY
Appendicular abscess Clinical features Investigations Treatment

COMPLICATIONS
Following complications may be seen in patients with appendicular abscess ; ! Peritonitis. ! Pelvic abscess. ! Subphrenic abscess. ! Paralytic ileus. ! Adhesion formation. ! Intestinal obstruction. ! Septicaemia.

POSSIBLE QUESTIONS
1. 2. 3.

What is an appendicular abscess? How it is diagnosed? Discuss treatment options?

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SURGERY - GASTRO-INTESTINAL PROBLEMS