Appendicular abscess: Difference between revisions
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==Diagnosis== | ==Diagnosis== | ||
Revision as of 17:24, 2 March 2017
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Appendicular abscess Microchapters |
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Appendicular abscess On the Web |
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American Roentgen Ray Society Images of Appendicular abscess |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]
Overview
Appendicular abscess is defined as a collection of pus resulting from necrosis of the tissue superimposed with infection in an inflamed appendix. It is unusual and rare entity and a life threatening complication of 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. [1]
Classification
- No known classification of appendicular abscess exists.
Causes
Natural gut flora which includes gram negative and anaerobic bacteria play a major role in the development of appendicular abscess.[2]
| Aerobic bacteria | Anaerobes bacteria |
|---|---|
Diagnosis
History
The key to an efficient and accurate diagnosis is a detailed and thorough history. The following information should be obtained:[3]
- Onset, location, radiation, and duration of pain
- Aggravating or relieving factors
- Severity of pain (constant or intermittent)
- Characteristics of the pain
- History of the pain
- Association with nausea, vomiting, anorexia, or diarrhea
- Time of last bowel movement and
- Recent use of analgesics, narcotics, or antibiotics.
Symptoms
Symptoms of an appendicular abscess include that of appendicitis with late presentation and can overlap. Typical symptoms of appendicitis may or may not be present but patient presents with
- Fever >38.5 C
- Generalized abdominal pain [4]
- Vomiting
- Prolonged diarrhea
- Increased micturition due to irritation of the bladder wall by the inflamed appendix.
- Tenesmus can be also be noticed.
Physical Examination
Physical examinations mostly focus on abdominal findings. The patient may appear in pain with a fever and mild tachycardia. Even minimal pressure on the abdomen can elicit a marked response from the patient due to pain.
Vitals
- Fever
- Tachycardia
- Hypotension if the abscess is ruptured and associated with hemorrhage.
- Tachypnea.[5]
Skin
Abdomen
- The abdominal wall is very sensitive to mild palpation.
- Rebound tenderness (it cannot be elicited in most of the patients due to abscess formation)
- Abdominal guarding
- Rovsing's sign Deep palpation of the left iliac fossa may cause pain in the right iliac fossa.
- Psoas sign Occasionally, an inflamed appendix lies on the psoas muscle and the patient will lie with the right hip flexed for pain relief.
- Obturator sign[6] If an inflamed appendix is in contact with the obturator internus, spasm of the muscle can be demonstrated by flexing and internally rotating the hip.This maneuver will cause pain in the hypogastrium.
- A digital rectal examination elicits tenderness in the rectovesical pouch in special cases of appendicitis.[4]
- In case of a retrocaecal appendix even deep pressure in the right lower quadrant may fail to elicit tenderness.
Laboratory findings
Lab findings that are not specific but include leukocytosis with a shift to the left along with elevation of ESR and CRP
Electrocardiogram
There are no clear indications to obtain an ECG in patients with appendicular abscess.
X-Ray
- Plain abdominal radiography is not the most useful tool in making a diagnosis of appendicular abscess.
Ultrasound
- Ultrasound is the first choice of investigation to evaluate a suspected appendicular pathology.
- Findings of an appendicular abscess include: Fluid collection (hypoechoic) in the appendicular region which may be well circumscribed and rounded or ill-defined and irregular in appearance appendix may be visualized within the mass.
US showing an area of high echogenicity measuring 5.2 X 6.7 cm in relation to the right hepatic lobe with echogenic rim.
{{#ev:youtube|4qOYL0y3hPY}}
CT
- CT is significantly more sensitive than US for the diagnosis of appendicitis, but that US should be considered in children
- Fluid collection is seen in the appendicular region with air fluid levels.
CT of abdomen showing an abscess in the retrocaecal location with an adjacent appendicolith with ascending colon being displaced anteriorly.
Treatment
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.[7][8][9][10]
Percutaneous drainage
- Percutaneous drainage can be performed under USG or CT guidance, using either the Seldinger or trocar technique.[11]
- 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.[12]
- 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.[13]
- If the fluid collection is sterile, a transgluteal approach is preferred because it allows for sterile technique.[12]
- Depending on the location of abscess,patient is placed in prone or supine position on the CT table
- Localization scan using CT allows in selecting a safe window of access into the collection.
- A coaxial micropuncture introducer set is advanced into the abscess under CT guidance.
- An Amplatz guidewire is advanced through the sheath and coiled within the abscess.
- After serial dilatation of the tract with a dilator, an pigtail drain is advanced over the guidewire and deployed.
Medical Therapy
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.[2] [14]
Empiric therapy
Monotherapy with a beta-lactam/beta-lactamase inhibitor:
- Preferred regimen (1):Ampicillin-sulbactam 3 g IV q6h
- Preferred regimen (2):Ticarcillin-clavulanate 3 g IV q4h
- Preferred regimen (3):Piperacillin-tazobactam 3 g or 4.5 g IV q6h
Combination third generation cephalosporins PLUS metronidazole
- Preferred regimen (1): Ceftriaxone 1 g IV q24h AND Metronidazole 500 mg IV q8h OR 1500 mg q24h.
- Preferred regimen (2): Cefazolin 1–2 g IV q8h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
- Preferred regimen (3): Cefuroxime 1.5 g IV q8h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
- Preferred regimen (4): Cefotaxime 1–2 g IV q6–8 h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
Alternative empiric regimens
Combination fluoroquinolone PLUS metronidazole:
- Preferred regimen (1): Ciprofloxacin 400 mg IV q12h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
- Preferred regimen (2): Levofloxacin 750 mg IV q24h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
Monotherapy with a carbapenem
- Preferred regimen (1): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h
- Preferred regimen (2): Meropenem 1 g IV q8h
- Preferred regimen (3): Doripenem 500 mg IV q8h
- Preferred regimen (4): Ertapenem 1 g IV q24h
Duration
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.[14]
Surgery
Emergency appendectomy
Indications:
- When patients present with life-threatening signs of peritonitis
- large appendiceal abscess,
- In patients with an extraluminal appendicolith.
Interval Appendectomy
Following drain and antibiotics an interval appendectomy is recommended for patients after six to eight weeks, it is done to :
- Prevent recurrence of appendicitis.[9]
- Exclude neoplasms as a cause (such as carcinoid, adenocarcinoma, mucinous cystadenoma, and cystadenocarcinomas)
Complications of interval appendectomy
Late complication
- Abdominal adhesions
- Fecal fistula[15]
{{#ev:youtube|SRMOktFZim0}}
Prevention
Primary Prevention
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.[16]
Secondary prevention
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.
References
- ↑ Williams, Norman (2013). Bailey & Love's short practice of surgery. Boca Raton, FLa: CRC Press. ISBN 978-1444121285.
- ↑ 2.0 2.1 Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ; et al. (2010). "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". Clin Infect Dis. 50 (2): 133–64. doi:10.1086/649554. PMID 20034345.
- ↑ Jordan JS, Kovalcik PJ, Schwab CW (1981). "Appendicitis with a palpable mass". Ann. Surg. 193 (2): 227–9. PMC 1345047. PMID 7469557.
- ↑ 4.0 4.1 Appendicitis. Wikipedia (2016). http://schools-wikipedia.org/wp/a/Appendicitis.htm Accessed on February 4, 2016
- ↑ Hardin, M. Acute Appendicitis: Review and Update. Am Fam Physician".1999, Nov 1;60(7):2027-2034
- ↑ Stockman III, James A. (2012), Year Book of Pediatrics 2012 (2012 ed.), Maryland Heights, MO: Mosby
- ↑ Samuel M, Hosie G, Holmes K (2002). "Prospective evaluation of nonsurgical versus surgical management of appendiceal mass". J. Pediatr. Surg. 37 (6): 882–6. PMID 12037755.
- ↑ Kaminski A, Liu IL, Applebaum H, Lee SL, Haigh PI (2005). "Routine interval appendectomy is not justified after initial nonoperative treatment of acute appendicitis". Arch Surg. 140 (9): 897–901. PMID 16175691.
- ↑ 9.0 9.1 Ansaloni L, Catena F, Coccolini F, Ercolani G, Gazzotti F, Pasqualini E, Pinna AD (2011). "Surgery versus conservative antibiotic treatment in acute appendicitis: a systematic review and meta-analysis of randomized controlled trials". Dig Surg. 28 (3): 210–21. doi:10.1159/000324595. PMID 21540609.
- ↑ Meshikhes AW (2008). "Management of appendiceal mass: controversial issues revisited". J. Gastrointest. Surg. 12 (4): 767–75. doi:10.1007/s11605-007-0399-1. PMID 17999120.
- ↑ Hogan MJ (2003). "Appendiceal abscess drainage". Tech Vasc Interv Radiol. 6 (4): 205–14. PMID 14767853.
- ↑ 12.0 12.1 Gress F, Schmitt C, Sherman S, Ciaccia D, Ikenberry S, Lehman G (2001). "Endoscopic ultrasound-guided celiac plexus block for managing abdominal pain associated with chronic pancreatitis: a prospective single center experience". Am. J. Gastroenterol. 96 (2): 409–16. doi:10.1111/j.1572-0241.2001.03551.x. PMID 11232683.
- ↑ "Retroperitoneal Perforation of the Appendix Presenting as a Right Thigh Abscess".
- ↑ 14.0 14.1 Sartelli, Massimo; Viale, Pierluigi; Catena, Fausto; Ansaloni, Luca; Moore, Ernest; Malangoni, Mark; Moore, Frederick A; Velmahos, George; Coimbra, Raul; Ivatury, Rao; Peitzman, Andrew; Koike, Kaoru; Leppaniemi, Ari; Biffl, Walter; Burlew, Clay Cothren; Balogh, Zsolt J; Boffard, Ken; Bendinelli, Cino; Gupta, Sanjay; Kluger, Yoram; Agresta, Ferdinando; Di Saverio, Salomone; Wani, Imtiaz; Escalona, Alex; Ordonez, Carlos; Fraga, Gustavo P; Junior, Gerson Alves Pereira; Bala, Miklosh; Cui, Yunfeng; Marwah, Sanjay; Sakakushev, Boris; Kong, Victor; Naidoo, Noel; Ahmed, Adamu; Abbas, Ashraf; Guercioni, Gianluca; Vettoretto, Nereo; Díaz-Nieto, Rafael; Gerych, Ihor; Tranà, Cristian; Faro, Mario Paulo; Yuan, Kuo-Ching; Kok, Kenneth Yuh Yen; Mefire, Alain Chichom; Lee, Jae Gil; Hong, Suk-Kyung; Ghnnam, Wagih; Siribumrungwong, Boonying; Sato, Norio; Murata, Kiyoshi; Irahara, Takayuki; Coccolini, Federico; Lohse, Helmut A Segovia; Verni, Alfredo; Shoko, Tomohisa (2013). "2013 WSES guidelines for management of intra-abdominal infections". World Journal of Emergency Surgery. 8 (1): 3. doi:10.1186/1749-7922-8-3. ISSN 1749-7922.
- ↑ Singal R, Gupta S, Mittal A, Gupta S, Singh M, Dalal AK, Goyal S, Singh B (2012). "Appendico-cutaneous fistula presenting as a large wound: a rare phenomenon-brief review". Acta Med Indones. 44 (1): 53–6. PMID 22451186.
- ↑ Williams, Norman (2013). Bailey & Love's short practice of surgery. Boca Raton, FLa: CRC Press. ISBN 978-1444121285.