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| {{Appendicular abscess}} | | {{Appendicular abscess}} |
| {{CMG}}; {{AE}}{{ADG}} | | {{CMG}}; {{AE}}{{ADG}} |
| | ==[[Appendicular abscess overview|Overview]]== |
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| ==Overview== | | ==[[Appendicular abscess historical perspective|Historical Perspective]]== |
| Appendicular abscess is defined as a collection of [[pus]] resulting from [[necrosis]] of the tissue superimposed with infection in an [[Appendicitis|inflamed appendix]]. It is unusual and rare entity and a life threatening complication of [[Appendicitis|acute appendicitis]]. It is seen in 2-7% of population presenting with appendicitis. When the appendix become inflamed ([[appendicitis]]), complications arise if it is not treated promptly. When the abscess develops it remains limited by the walls of cavity formed by the inflamed coils of intestine and usually forms in the right lower abdomen. The abscess can spread to [[pelvis]] leading [[peritonitis]] if the wall is ruptured. In most of the patients the intestinal coils and [[omentum]] in the abdominal cavity tend to cover the inflamed appendix forming an appendicular mass. <ref>{{cite book | last = Williams | first = Norman | title = Bailey & Love's short practice of surgery | publisher = CRC Press | location = Boca Raton, FLa | year = 2013 | isbn = 978-1444121285 }}</ref> | |
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| ==Classification== | | ==[[Appendicular abscess classification|Classification]]== |
| *No known classification of appendicular abscess exists.
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| ==Causes== | | ==[[Appendicular abscess pathophysiology|Pathophysiology]]== |
| Natural gut flora which includes [[Gram-negative bacteria|gram negative]] and [[anaerobic bacteria]] play a major role in the development of appendicular abscess.<ref name="pmid20034345">{{cite journal| author=Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ et al.| title=Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2010 | volume= 50 | issue= 2 | pages= 133-64 | pmid=20034345 | doi=10.1086/649554 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20034345 }} </ref>
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| {| border="1"
| | ==[[Appendicular abscess causes|Causes]]== |
| !colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Aerobic bacteria}}
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| !colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Anaerobes bacteria}}
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| |-
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| |valign=top|
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| * [[Enterococcus]]
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| * [[Escherichia coli]]
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| * [[Klebsiella pneumoniae]]
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| * [[Pseudomonas aeruginosa]]
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| * [[Staphylococcus aureus]]
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| * [[Proteus]]
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| |valign=top|
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| * [[Bacteroides fragilis]]
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| * [[Clostridium perfringens]]
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| |}
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| ==Diagnosis== | | ==[[Appendicular abscess differential diagnosis|Differentiating Appendicular abscess from other Diseases]]== |
| ==Electrocardiogram== | | |
| There are no clear indications to obtain an ECG in patients with appendicular abscess.
| | ==[[Appendicular abscess epidemiology and demographics|Epidemiology and Demographics]]== |
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| | ==[[Appendicular abscess risk factors|Risk Factors]]== |
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| ==X-Ray== | | ==[[Appendicular abscess screening|Screening]]== |
| *[[Abdominal X-ray|Plain abdominal radiography]] is not the most useful tool in making a diagnosis of appendicular abscess.
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| ==Treatment== | | ==[[Appendicular abscess natural history, complications and prognosis|Natural History, Complications, and Prognosis]]== |
| No universal standard treatment exists for appendicitis complicated by abscess. The preferred treatment includes non-operative management such as drainage and broad spectrum IV antibiotics along with IV fluids followed by surgery which includes interval laparoscopic appendectomy. It has proved to have a high success rates up to 97% and low incidences of complications.<ref name="pmid12037755">{{cite journal |vauthors=Samuel M, Hosie G, Holmes K |title=Prospective evaluation of nonsurgical versus surgical management of appendiceal mass |journal=J. Pediatr. Surg. |volume=37 |issue=6 |pages=882–6 |year=2002 |pmid=12037755 |doi= |url=}}</ref><ref name="pmid16175691">{{cite journal |vauthors=Kaminski A, Liu IL, Applebaum H, Lee SL, Haigh PI |title=Routine interval appendectomy is not justified after initial nonoperative treatment of acute appendicitis |journal=Arch Surg |volume=140 |issue=9 |pages=897–901 |year=2005 |pmid=16175691 |doi= |url=}}</ref><ref name="pmid21540609">{{cite journal |vauthors=Ansaloni L, Catena F, Coccolini F, Ercolani G, Gazzotti F, Pasqualini E, Pinna AD |title=Surgery versus conservative antibiotic treatment in acute appendicitis: a systematic review and meta-analysis of randomized controlled trials |journal=Dig Surg |volume=28 |issue=3 |pages=210–21 |year=2011 |pmid=21540609 |doi=10.1159/000324595 |url=}}</ref><ref name="pmid17999120">{{cite journal |vauthors=Meshikhes AW |title=Management of appendiceal mass: controversial issues revisited |journal=J. Gastrointest. Surg. |volume=12 |issue=4 |pages=767–75 |year=2008 |pmid=17999120 |doi=10.1007/s11605-007-0399-1 |url=}}</ref>
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| ===Percutaneous drainage===
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| *Percutaneous drainage can be performed under USG or CT guidance, using either the Seldinger or trocar technique.<ref name="pmid14767853">{{cite journal |vauthors=Hogan MJ |title=Appendiceal abscess drainage |journal=Tech Vasc Interv Radiol |volume=6 |issue=4 |pages=205–14 |year=2003 |pmid=14767853 |doi= |url=}}</ref>
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| *USG is limited if the abscess is small, obscured by other structures, or if precise placement is required because of nearby vessels or organs. In these cases, CT is the optimal imaging modality.<ref name="pmid11232683">{{cite journal |vauthors=Gress F, Schmitt C, Sherman S, Ciaccia D, Ikenberry S, Lehman G |title=Endoscopic ultrasound-guided celiac plexus block for managing abdominal pain associated with chronic pancreatitis: a prospective single center experience |journal=Am. J. Gastroenterol. |volume=96 |issue=2 |pages=409–16 |year=2001 |pmid=11232683 |doi=10.1111/j.1572-0241.2001.03551.x |url=}}</ref>
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| *When an abscess is deep in the pelvis, depending on the specific location of the fluid collection, access may be obtained via transgluteal, transvaginal, or transrectal approaches.<ref name="urlRetroperitoneal Perforation of the Appendix Presenting as a Right Thigh Abscess">{{cite web |url=http://dx.doi.org/10.1155/2015/707191 |title=Retroperitoneal Perforation of the Appendix Presenting as a Right Thigh Abscess |format= |work= |accessdate=}}</ref>
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| *If the fluid collection is sterile, a transgluteal approach is preferred because it allows for sterile technique.<ref name="pmid11232683">{{cite journal |vauthors=Gress F, Schmitt C, Sherman S, Ciaccia D, Ikenberry S, Lehman G |title=Endoscopic ultrasound-guided celiac plexus block for managing abdominal pain associated with chronic pancreatitis: a prospective single center experience |journal=Am. J. Gastroenterol. |volume=96 |issue=2 |pages=409–16 |year=2001 |pmid=11232683 |doi=10.1111/j.1572-0241.2001.03551.x |url=}}</ref>
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| *Depending on the location of abscess,patient is placed in prone or supine position on the CT table
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| *Localization scan using CT allows in selecting a safe window of access into the collection.
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| *A coaxial micropuncture introducer set is advanced into the abscess under CT guidance.
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| *An Amplatz guidewire is advanced through the sheath and coiled within the abscess.
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| *After serial dilatation of the tract with a dilator, an pigtail drain is advanced over the guidewire and deployed.
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| ===Medical Therapy===
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| Antibiotics should be started immediately once the diagnosis of abscess is made. Preoperative antibiotics have been associated with lower rates of wound and intra-abdominal infections.<ref name="pmid20034345">{{cite journal| author=Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ et al.| title=Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2010 | volume= 50 | issue= 2 | pages= 133-64 | pmid=20034345 | doi=10.1086/649554 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20034345 }} </ref> <ref name="SartelliViale2013">{{cite journal|last1=Sartelli|first1=Massimo|last2=Viale|first2=Pierluigi|last3=Catena|first3=Fausto|last4=Ansaloni|first4=Luca|last5=Moore|first5=Ernest|last6=Malangoni|first6=Mark|last7=Moore|first7=Frederick A|last8=Velmahos|first8=George|last9=Coimbra|first9=Raul|last10=Ivatury|first10=Rao|last11=Peitzman|first11=Andrew|last12=Koike|first12=Kaoru|last13=Leppaniemi|first13=Ari|last14=Biffl|first14=Walter|last15=Burlew|first15=Clay Cothren|last16=Balogh|first16=Zsolt J|last17=Boffard|first17=Ken|last18=Bendinelli|first18=Cino|last19=Gupta|first19=Sanjay|last20=Kluger|first20=Yoram|last21=Agresta|first21=Ferdinando|last22=Di Saverio|first22=Salomone|last23=Wani|first23=Imtiaz|last24=Escalona|first24=Alex|last25=Ordonez|first25=Carlos|last26=Fraga|first26=Gustavo P|last27=Junior|first27=Gerson Alves Pereira|last28=Bala|first28=Miklosh|last29=Cui|first29=Yunfeng|last30=Marwah|first30=Sanjay|last31=Sakakushev|first31=Boris|last32=Kong|first32=Victor|last33=Naidoo|first33=Noel|last34=Ahmed|first34=Adamu|last35=Abbas|first35=Ashraf|last36=Guercioni|first36=Gianluca|last37=Vettoretto|first37=Nereo|last38=Díaz-Nieto|first38=Rafael|last39=Gerych|first39=Ihor|last40=Tranà|first40=Cristian|last41=Faro|first41=Mario Paulo|last42=Yuan|first42=Kuo-Ching|last43=Kok|first43=Kenneth Yuh Yen|last44=Mefire|first44=Alain Chichom|last45=Lee|first45=Jae Gil|last46=Hong|first46=Suk-Kyung|last47=Ghnnam|first47=Wagih|last48=Siribumrungwong|first48=Boonying|last49=Sato|first49=Norio|last50=Murata|first50=Kiyoshi|last51=Irahara|first51=Takayuki|last52=Coccolini|first52=Federico|last53=Lohse|first53=Helmut A Segovia|last54=Verni|first54=Alfredo|last55=Shoko|first55=Tomohisa|title=2013 WSES guidelines for management of intra-abdominal infections|journal=World Journal of Emergency Surgery|volume=8|issue=1|year=2013|pages=3|issn=1749-7922|doi=10.1186/1749-7922-8-3}}</ref>
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| ====Empiric therapy====
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| Monotherapy with a beta-lactam/beta-lactamase inhibitor:
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| *Preferred regimen (1):[[Ampicillin-Sulbactam|Ampicillin-sulbactam]] 3 g IV q6h
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| *Preferred regimen (2):[[Ticarcillin-Clavulanate|Ticarcillin-clavulanate]] 3 g IV q4h
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| *Preferred regimen (3):[[Piperacillin-tazobactam]] 3 g or 4.5 g IV q6h
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| Combination third generation cephalosporins PLUS metronidazole
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| *Preferred regimen (1): [[Ceftriaxone]] 1 g IV q24h {{and}} [[Metronidazole]] 500 mg IV q8h {{or}} 1500 mg q24h.
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| *Preferred regimen (2): [[Cefazolin]] 1–2 g IV q8h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
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| *Preferred regimen (3): [[Cefuroxime]] 1.5 g IV q8h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
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| *Preferred regimen (4): [[Cefotaxime]] 1–2 g IV q6–8 h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
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| ====Alternative empiric regimens====
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| Combination fluoroquinolone PLUS metronidazole:
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| *Preferred regimen (1): [[Ciprofloxacin]] 400 mg IV q12h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
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| *Preferred regimen (2): [[Levofloxacin]] 750 mg IV q24h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
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| Monotherapy with a carbapenem
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| *Preferred regimen (1): [[Imipenem-Cilastatin|Imipenem-cilastatin]] 500 mg IV q6h {{or}} 1 g q8h
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| *Preferred regimen (2): [[Meropenem]] 1 g IV q8h
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| *Preferred regimen (3): [[Doripenem]] 500 mg IV q8h
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| *Preferred regimen (4): [[Ertapenem]] 1 g IV q24h
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| ====Duration====
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| The duration of treatment with intravenous antibiotics ranges from 5 to 10 days, until fever resolves, white blood cell count normalizes, and bowel function returns.<ref name="SartelliViale2013">{{cite journal|last1=Sartelli|first1=Massimo|last2=Viale|first2=Pierluigi|last3=Catena|first3=Fausto|last4=Ansaloni|first4=Luca|last5=Moore|first5=Ernest|last6=Malangoni|first6=Mark|last7=Moore|first7=Frederick A|last8=Velmahos|first8=George|last9=Coimbra|first9=Raul|last10=Ivatury|first10=Rao|last11=Peitzman|first11=Andrew|last12=Koike|first12=Kaoru|last13=Leppaniemi|first13=Ari|last14=Biffl|first14=Walter|last15=Burlew|first15=Clay Cothren|last16=Balogh|first16=Zsolt J|last17=Boffard|first17=Ken|last18=Bendinelli|first18=Cino|last19=Gupta|first19=Sanjay|last20=Kluger|first20=Yoram|last21=Agresta|first21=Ferdinando|last22=Di Saverio|first22=Salomone|last23=Wani|first23=Imtiaz|last24=Escalona|first24=Alex|last25=Ordonez|first25=Carlos|last26=Fraga|first26=Gustavo P|last27=Junior|first27=Gerson Alves Pereira|last28=Bala|first28=Miklosh|last29=Cui|first29=Yunfeng|last30=Marwah|first30=Sanjay|last31=Sakakushev|first31=Boris|last32=Kong|first32=Victor|last33=Naidoo|first33=Noel|last34=Ahmed|first34=Adamu|last35=Abbas|first35=Ashraf|last36=Guercioni|first36=Gianluca|last37=Vettoretto|first37=Nereo|last38=Díaz-Nieto|first38=Rafael|last39=Gerych|first39=Ihor|last40=Tranà|first40=Cristian|last41=Faro|first41=Mario Paulo|last42=Yuan|first42=Kuo-Ching|last43=Kok|first43=Kenneth Yuh Yen|last44=Mefire|first44=Alain Chichom|last45=Lee|first45=Jae Gil|last46=Hong|first46=Suk-Kyung|last47=Ghnnam|first47=Wagih|last48=Siribumrungwong|first48=Boonying|last49=Sato|first49=Norio|last50=Murata|first50=Kiyoshi|last51=Irahara|first51=Takayuki|last52=Coccolini|first52=Federico|last53=Lohse|first53=Helmut A Segovia|last54=Verni|first54=Alfredo|last55=Shoko|first55=Tomohisa|title=2013 WSES guidelines for management of intra-abdominal infections|journal=World Journal of Emergency Surgery|volume=8|issue=1|year=2013|pages=3|issn=1749-7922|doi=10.1186/1749-7922-8-3}}</ref>
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| ===Surgery===
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| ====Emergency appendectomy====
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| Indications:
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| *When patients present with life-threatening signs of [[peritonitis]]
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| *large appendiceal abscess,
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| *In patients with an extraluminal [[appendicolith]].
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| ====Interval Appendectomy====
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| Following drain and antibiotics an [[Appendectomy|interval appendectomy]] is recommended for patients after six to eight weeks, it is done to :
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| *Prevent recurrence of [[Appendicitis|appendicitis.]]<ref name="pmid21540609">{{cite journal |vauthors=Ansaloni L, Catena F, Coccolini F, Ercolani G, Gazzotti F, Pasqualini E, Pinna AD |title=Surgery versus conservative antibiotic treatment in acute appendicitis: a systematic review and meta-analysis of randomized controlled trials |journal=Dig Surg |volume=28 |issue=3 |pages=210–21 |year=2011 |pmid=21540609 |doi=10.1159/000324595 |url=}}</ref>
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| *Exclude [[neoplasms]] as a cause (such as [[Carcinoid|carcinoid,]] [[adenocarcinoma]], [[mucinous cystadenoma]], and [[Cystadenocarcinoma|cystadenocarcinomas]])
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| Complications of interval appendectomy
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| *[[Infection|Wound Infection]] ([[sepsis]])
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| *[[Pelvic abscess]]
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| *[[Aspiration pneumonia]]
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| Late complication
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| *[[Adhesions|Abdominal adhesions]]
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| *Fecal fistula<ref name="pmid22451186">{{cite journal |vauthors=Singal R, Gupta S, Mittal A, Gupta S, Singh M, Dalal AK, Goyal S, Singh B |title=Appendico-cutaneous fistula presenting as a large wound: a rare phenomenon-brief review |journal=Acta Med Indones |volume=44 |issue=1 |pages=53–6 |year=2012 |pmid=22451186 |doi= |url=}}</ref>
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| {{#ev:youtube|SRMOktFZim0}}
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| ==Prevention== | | ==Diagnosis== |
| ===Primary Prevention===
| | [[Appendicular abscess history and symptoms|History and Symptoms]] | [[Appendicular abscess physical examination|Physical Examination]] | [[Appendicular abscess laboratory findings|Laboratory Findings]] | [[Appendicular abscess electrocardiogram|Electrocardiogram]] | [[Appendicular abscess chest x ray|Chest X Ray]] | [[Appendicular abscess CT|CT]] | [[Appendicular abscess MRI|MRI]] | [[Appendicular abscess echocardiography or ultrasound|Echocardiography or Ultrasound]] |
| There are no primary preventive measures available for appendicular abscess. Reducing the risk of appendicitis however, can help in the first place .Following a diet that includes fresh vegetables and fruit may lower the risk.<ref>{{cite book | last = Williams | first = Norman | title = Bailey & Love's short practice of surgery | publisher = CRC Press | location = Boca Raton, FLa | year = 2013 | isbn = 978-1444121285 }}</ref>
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| ===Secondary prevention=== | | ==Treatment== |
| [[Peritonitis]] develops from the rupturing of the [[appendix]] and can lead to death is left untreated. Acute appendicitis that is evaluated and treated early with an [[appendectomy]] generally leads to no further complications and a patient's full recovery. | | [[Appendicular abscess medical therapy|Medical Therapy]] | [[Appendicular abscess surgery|Surgery]] | [[Appendicular abscess primary prevention|Primary Prevention]] | [[Appendicular abscess secondary prevention|Secondary Prevention]] | [[Appendicular abscess cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Appendicular abscess future or investigational therapies|Future or Investigational Therapies]] |
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| | ==Case Studies== |
| | [[Appendicular abscess case study one|Case #1]] |
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| ==References==
| | [[Category:Disease]] |
| {{reflist|2}}
| | [[Category:Up-To-Date]] |
| | [[Category:Gastroenterology]] |
| | [[Category:Surgery]] |
| | [[Category:Emergency medicine]] |
| | [[Category:Infectious disease]] |