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surgery.2015.pptxAppendicle abscess
Siedah Telesford MD
Dr. Griffith Team
History
CC: H.M. age 42 M p/w vomiting and diarrhea for 3 days.
HPI: Pt p/w vomiting and diarrhea for 3 days.
Pt was diagnosed with gastroenteritis at Arima General after 1 day of vomiting and diarrhea.
Pt admitted to diffuse abdominal pain x 2 weeks. Initially 5/10, took antiemetics and panadol had some relief for 1 day.
1 day later, abdominal pain got progressively worse, 8/10, diffuse, took panadol but no relief
42 yo M came to the ED with vomiting and diarrhea x3days. 2 week h/o diffuse abd pain. Diagnosed as gastro 2 days before admission. Pt had pain relief with antiemetics and panadol initially. Physical
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History
Exacerbated by movement and cough
Vomiting (3/7) 2 episodes/day of food bilious, nonbloody
Anorexia
Diarrhea
Subjective Fever
Tenesmus – he described wanting to pass stool but unable to
Denies urinary symptoms
No trauma
PMHx: Denies
Medications: Denies
PSx: Denies
Allergies: NKDA
ROS- Noncontributory
Tenesmus
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Physical Exam
General appearance: Young male in mild painful distress
V/s: P- 96 O2- 98 T- 36.4 RR- 24 BP- 131/67
Abdomen: +BS, Nondistended, firm
Tenderness in lower abd; ++RLQ , +rebound, +guarding
+Rovsing sign, -Obturator sign,+iliopsoas sign, -DRE
Respiratory: CTAB
CVS: RRR, S1/S2 heard.
Labs and ED course
WBC- 16.9 Hb- 12 Plt- 290
RFT, LFT, amylase, lipase, UA- WNL
CXR and AXR-WNL
ED course: Pt received
4mg Buscopan
50mg Gravol
50mg zantac
1L IVF NS
Imaging
Appendix measuring 1.6cm
4.5mm appendicolith within its tip
Small amount of free fluid in RIF
Fat stranding around appendix
5.1cm x 4.2cm collection with enhancing walls at tip of appendix
Fat stranding around the sigmoid colon
Working diagnosis: Appendicitis with appendicular abscess
Procedure
General anesthesia. Open lap and appendectomy. 24 French was left.
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Post op
POD # 1
V/S: WNL
Intake: 2L RL/24 hrs
Urine output: 600 ml/24 hrs
J-vac: 100 ml
WBC 14.82
- Abd: +BS, distended, tenderness at incision site.
Post op
WBC: 14.8—>13.7—>12.6
Remained NPO, IVF, pain meds
Antibiotic tx with Flagyl and Zinacef for 8 days and removal of the drain on POD #7
Management of appendicitis with abscess or mass
Management of appendicitis presenting with abscess
In acute appendicitis patients, the proportion of cases associated with an abscess or a tumor in the periappendix has been reported to be approximately 2% to 7%.
3 approaches:
Emergency surgery
Early conservative treatments followed by elective surgery
Conservative treatments and follow-up observation only
If surgery is performed under the condition that inflammation due to appendicitis has spread to adjacent areas, the inflammation may have spread over a wide area. In addition, because of edema and the vulnerability of the adjacent small intestine and large intestine, secondary fistulas, etc., may have developed. In our case, there was inflammation of the sigmoid and rectum. For such cases, instead of completing surgery after a simple appendectomy, cases requiring a simultaneous iliocecectomy in areas with inflammation and adhesion or a right colectomy are not rare [6, 8-12].
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Management of appendicitis presenting with abscess
Approach A: Emergency surgery
The incidence of complications in emergency surgery is reported to be up to 26%
If surgery is performed under the condition that inflammation due to appendicitis has spread to adjacent areas, the inflammation may have spread over a wide area
Cases requiring a simultaneous iliocecectomy in areas with inflammation and adhesion or a right colectomy are not rare
Advantages:
Less frequent follow-ups and tests
Readmission for elective surgery
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Management of appendicitis presenting with abscess
Approach B: Early conservative treatments followed by elective surgery
high success rates of 76% to 97%
incidence of complications in patients who underwent conservative managements was 15%,
With 58% in the group that underwent surgical treatments,
Similarly, between the group that underwent interval surgery after conservative managements and the group that underwent emergency surgery. The incidence of postsurgical complications between the two groups was not different.
The purpose of delay in the interval appendectomy is to avoid the morbidity of immediate appendectomy in these patients while definitively treating the underlying appendicitis.
Why interval appendectomy?
Prevent recurrence of acute appendicitis
Avoid misdiagnosing alternative pathology eg malignancy
Advantages:
Safe
Eliminates risk of recurrent appendicitis and need for readmission for interval appendectomy
Reduces total hospital stay
Disadvantages:
Complication rate of 36%
Immediate surgery leads to dissemination of infection and intestinal fistula formation
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Management of appendicitis presenting with abscess
Approach C: Observation
The recurrence rate of appendicitis in the group that underwent only observation without surgery after conservative management was 10%
Incidence of complications in patients who underwent conservative managements was 15%,
thus, intensive follow-up observation without interval surgery might be useful
- 12% were diagnosed as having different diseases, such as Crohn's disease, tumors etc
- Nonoperative treatment delayed the diagnosis of Crohn's disease and cancer in approximately 2 % of patients
