Management of the

Appendix Mass

Index case:
History
52 year old female
No chronic illnesses
2 week history of RLQ pain
Intermittent vomiting
Fever

Index case (Contd)

O/E
Afebrile
Normal vitals
Mass palpable in RIF
Localized peritonism at McBurneys
NOS PV and PR examinations

Results:

Hb 13.2, WBC 19.5

Normal U+Es

Sonography
4.9 x 2.7 x 3.6 cm mixed echogenic mass lesion
in RIF. Minimal free fluid in RIF
Left ovary: Normal, Right ovary: Not visualized

Diagnosis
INFLAMMATORY APPENDIX MASS

Initial Management

IVF
Liquid diet
IV Cipro / Flagyl
IV Analgesics
Vitals q4h
Daily assessment of RIF mass

Day 4 Post Admission

Tolerating Normal diet

Normal vitals
Afebrile
Abdomen non Tender
Vague impression of RIF mass
WBC 6.9

DISCHARGED DAY 5

F/U Plan

Advised to return if febrile, abdo pain,

vomiting
To complete 10 days of A/B
SOPD in 2/52 with repeat US
Arrange Colonoscopy
? Interval Appendicectomy

Definition

The appendiceal mass is the end result of a

walled-off appendiceal perforation.
Pathologically it may represent a spectrum
ranging from phlegmon to abscess

Magnitude of the Problem

Acute appendicitis is the most common

cause of acute abdomen requiring surgery
Peri-appendicular mass occurs in 2-6 per
cent of cases of acute appendicitis

Typical Findings

History of RIF Pain

Nausea or Vomiting
Tender ill-defined RIF mass
Longer duration of symptoms, late
presentation (after 5-7 days)
Higher fever and WBC than uncomplicated
appendicitis

Beware !!!!!

Clinical distinction between a periappendicular phlegmon and a liquefied

appendicular abscess is notoriously difficult

Imaging: Sonography

Problem: The sonographic appearance may

be variable with echogenic abscess and
sonolucent phlegmon
CT found to be more reliable

Imaging: CT Scan
On contrast-enhanced CT
Peri-appendiceal phlegmons appear as soft
tissue high-density masses
abscesses are significantly lower in density

CT contd
N.B :
Contrast enhancement is essential to
discriminate between areas of solid
inflammatory tissue and liquid pus

Abscesses

NOT ALL ABSCESSES NEED TO BE

DRAINED
Jeffrey et al in 1989 oulined 3 groups
phlegmon and abcesses < 3cm dia. (Grp 1)
larger localized abcesses (Grp 2)
Extensive Abcesses, multi compartments (Grp 3)

Grp 1: 88% complete resolution with A/B

alone

Grp 2: 92% success with CT guide

drainage

Grp 3: Open Drainage

Yamini et al 1998: 87% success rate with

percutaneous drainage. Some needed 2nd
drainage procedure.
Iatrogenic fistula a possibility

Phlegmon
Basically 3 approaches
Emergent appendectomy (EA)
Conservative Mx and interval
appendectomy (CIA)
Conservative Mx only (CMx)

No consensus exists. Only 1 small PRC study

(Kumar et al 2004)
EA: Early definitive Mx.
Complication rate 36%
LHOS EA > CIA > CMx
Unnecessary surgery

CIA
Currently standard approach
Is IA necessary?
Large Retrospective cohort: 32943 ptns
5% recurrence in CMx grp
Recurrance had milder disease
LOHS in CIA > EA > Recurrence
Concluded that routine CIA not necessary

CMx

Shortest LHOS (Kumar et al 2004, Kaminiski et al 2005)

Recurrence rate between 0-20%
Lowest overall complication rate
If recurrence occurs likely to be within 1 yr
Limited evidence to support as routine Mx

Follow Up Strategy

Incorrect diagnosis 0-12%

Main fear is Caecal tumour
Over 40 yrs old need F/U colonoscopy or
Ba Enema
Persisting symptoms CT Scan or surgery

Proposed criteria for CMx

No immuno-compromising states
Stable
Localized Peritonitis
Clear RIF mass
Phlegmon or Localized collection on U/S
Low tolerance for conversion
Facilities for perc. drainage must exist
F/U modalities must be available