Appendicular abscess

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]

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.

Aerobic bacteria	Anaerobes bacteria
Enterococcus Escherichia coli Klebsiella pneumoniae Pseudomonas aeruginosa Staphylococcus aureus Proteus	Bacteroides fragilis Clostridium perfringens

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.

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.

Percutaneous drainage

• Percutaneous drainage can be performed under USG or CT guidance, using either the Seldinger or trocar technique.
• 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.
• 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.
• If the fluid collection is sterile, a transgluteal approach is preferred because it allows for sterile technique.
• 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.

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.

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.
• Exclude neoplasms as a cause (such as carcinoid, adenocarcinoma, mucinous cystadenoma, and cystadenocarcinomas)

Complications of interval appendectomy

• Wound Infection (sepsis)
• Pelvic abscess
• Aspiration pneumonia

Late complication

• Abdominal adhesions
• Fecal fistula

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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.

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.