Appendicular Abscess New

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Appendicular abscess is the localized collection of pus in the peri-appendicular area (right iliac fossa) following appendicitis and its perforation. An inflammatory mass occurs either as phlegmon or abscess in 2% to 6% patients with appendicitis. CLINICAL FEATURES History of pain in right iliac fossa and mass formation over few days is always present. Rarely it may present without prolonged history which may happen in deep and retrocaecal appendicitis. The common presenting features are : PAIN Pain is usually present in the right iliac fossa. It is not very severe to start with. It is continuous and gets worse gradually. The pain becomes throbbing and unbearable TENDERNESS as the abscess formation occurs. The mass in the right iliac fossa becomes tender not only to touch but to respiratory movements as well. On MASS RIGHT ILIAC FOSSA examination even gentle palpation is very painful. There is mass formation in the right iliac fossa which is tender to touch. Over lying skin is usually normal. The PARALYTIC ILEUS local temperature may or may not be raised. The mass Mostly these patients are already diagnosed cases of may increase in size and become more painful than appendicular mass and are on conservative treatment before. when they develop paralytic ileus. FEVER Patients may present with paralytic ileus which may be Fever is present in association with other symptoms. It is due to appendicular abscess. continuous and is not responsive to antibiotics. It has a typical pattern showing progressive rise in the peak of 1,2,3 ASSOCIATED SYMPTOMS temperature. (Swinging temperature) Patient may present with difficulty in micturition, frequency of micturition, acute retention of urine and In fact the appendicular abscess is diagnosed with haematuria. The symptoms are due to presence of reasonable certainty when the patient with appendicular abscess and inflammatory mass near right lower ureter mass starts running high grade temperature regularly. and bladder. 01 APPENDICULAR ABSCESS GIT - 30 Shuja Tahir, FRCS (Edin), FCPS Pak (Hon) Awais Shuja, MRCS SURGERY - GASTRO-INTESTINAL PROBLEMS 247 105 103 101 99 97 APPENDICULAR MASS / ABSCESS

Transcript of Appendicular Abscess New

Page 1: Appendicular Abscess New

Appendicular abscess is the localized collection of pus in the peri-appendicular area (right iliac fossa) following appendicitis and its perforation. An inflammatory mass occurs either as phlegmon or abscess in 2% to 6% patients with appendicitis.

CLINICAL FEATURESHistory of pain in right iliac fossa and mass formation over few days is always present. Rarely it may present without prolonged history which may happen in deep and retrocaecal appendicitis. The common presenting features are :

PAINPain is usually present in the right iliac fossa. It is not very severe to start with. It is continuous and gets worse gradually. The pain becomes throbbing and unbearable

TENDERNESSas the abscess formation occurs.The mass in the right iliac fossa becomes tender not only to touch but to respiratory movements as well. On MASS RIGHT ILIAC FOSSAexamination even gentle palpation is very painful.There is mass formation in the right iliac fossa which is

tender to touch. Over lying skin is usually normal. The PARALYTIC ILEUSlocal temperature may or may not be raised. The mass Mostly these patients are already diagnosed cases of may increase in size and become more painful than appendicular mass and are on conservative treatment before.when they develop paralytic ileus.

FEVERPatients may present with paralytic ileus which may be Fever is present in association with other symptoms. It is due to appendicular abscess.continuous and is not responsive to antibiotics. It has a

typical pattern showing progressive rise in the peak of 1,2,3 ASSOCIATED SYMPTOMStemperature. (Swinging temperature)

Patient may present with difficulty in micturition, frequency of micturition, acute retention of urine and In fact the appendicular abscess is diagnosed with haematuria. The symptoms are due to presence of reasonable certainty when the patient with appendicular abscess and inflammatory mass near right lower ureter mass starts running high grade temperature regularly.and bladder.

01APPENDICULAR ABSCESS

GIT - 30

Shuja Tahir, FRCS (Edin), FCPS Pak (Hon) Awais Shuja, MRCS

SURGERY - GASTRO-INTESTINAL PROBLEMS 247

105

103

101

99

97

APPENDICULAR MASS / ABSCESS

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ULTRASOUND GUIDED PERCUTANEOUS INVESTIGATIONSDRAINAGEURINE EXAMINATIONWhen the appendicular abscess is diagnosed by It is a simple investigation which helps to exclude the sonography. It can be aspirated with the help of a wide renal causes of urological symptoms in patients with bore needle under ultrasound control. It is simple, safe appendicular abscess.and effective. It may be repeated if the abscess collects.

BLOOD EXAMINATION In fact, the drainage is a better option than the aspiration. Haemoglobin percentage is decreased.Leukocyte count is raised. EMERGENCY (IMMEDIATE) SURGERYPolymorphonucleo-leukocytosis is present. It is required when abscess fails to resolve or recurs. It is Sedimentation rate is raised. also required when the general condition of patient

deteriorates inspite of conservative management. RADIOLOGICAL EXAMINATION Incision and drainage of the abscess is performed. The PLAIN X-RAY OF THE ABDOMEN appendix, its debris or inflammatory mass is also It may show loops of distended small gut around the removed if safely possible at the same operation, abscess area (sentinel loops). otherwise, it is left for later stage to be removed as

elective operation.ULTRASOUND SCANThe differentiation between appendicular mass and LAPAROSCOPIC DRAINAGEabscess is easily done with the ultrasound scan. The abdominal ultrasound scan shows a solid mass in the right iliac fossa as hypo epoic area (fluid collection). The amount of fluid collection varies with the amount of pus present. The shadow of adherent and distended loops of bowel is also seen. Percutaneous drainage under ultrasound guidance is minimally invasive.

CT SCANIt can reliably distinguish phlegmonous inflammation from a liquified abscess. It can delineate the full extent of such inflammatory mass. Percutaneous drainage under

4CT control is safe, effective and carries low morbidity .

It is less traumatic and less invasive procedure but it TREATMENTshould better be avoided as the risk of spread of infection The treatment of appendicular abscess has following into the peritoneal cavity is too high. components;

EXPECTANT TREATMENT • Ultrasound guided drainage of abscessIf the patient is haemodynamically stable, the patient is • Emergency surgery observed and treated symptomatically and conserva-• Laparoscopic drainage tively. It is safe and effective alternative to immediate

• Expectant treatment 5surgery. It is monitored with ultrasound and CT scan . • Delayed surgeryInitial expectant treatment has following components.

Appendicular abscess (laprascopic view)

30.01

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Parenteral antibioticsFluid replacement

Nill Orally

Serial Ultrasounds

PersistentRecurrent abcess

Open drainage Surgery

Delayed surgery (Appendicectomy)Age >40 yearsBarium enema Colonoscopy

APPENDICULAR MASS LEADING TO ABSCESS FORMATION

No abcess

MassResolves

Percutaneous drainage

Abscess formation

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FLUID AND ELECTROLYTES REFERENCESThe patients are given fluids intravenously. These are 1. Okoji GD. Caveron BH. Appendicitis presenting with given according to the daily requirements of the patient. dysuria in a 2 years old: Ultrasound aided diagnosis. Serum electrolytes are estimated and any deficit should Annals of tropical paediatrics. [JC:6ab]1991.: 389-be corrected. 90.

NIL ORALLY 2. Parrish GA. Wright GD. Falk JL. Acute urinary The patients with appendicular abscess are not given any retention an unusual presentation of appendiceal thing orally. Nasogastric aspiration is required in some abscess. Annals of emergency medicine. [JC:4z7] cases to help in relieving the paralytic ileus, vomiting and 1993 May. 22(5); 851-60. abdominal discomfort.

3. Monu JU. Akumabor PN. Appendiceal abscess unusual cause of acute urinary retention. PARENTERAL ANTIBIOTICSInternational journal of urology and nephrology. Appropriate antibiotics are started as soon as the

condition is diagnosed. Triple regimen of antibiotics is [JC:gug] 1990. 22(5) : 429-32. usually used. It is a combination of drugs against gram

4. Shapiro MP. Gale ME. Gerzof SG. CT of appendicitis negative, gram positive and anaerobic organisms. diagnosis and treatment. Radiologic clinics of North Commonly used drugs are amino glycosides, ampicillin America. [JC: qq1]1989, Jul. 27(4): 753-62. and metronidazole.

5. Haffmann J. Rolff M. Lomborg V. Franzmam M. There are two forms of surgery for treatment of Ultraconservative management of appen-diceal appendicular abscess as following;abscess. Journal of the Royal College of Surgeons of Edinburgh. [JC:jvc]1991 Feb. 36(1): 18-20. DELAYED SURGERY

Interval appendicectomy is performed about six to eight 6. A Tekin, tic kurtoglu. Routine interval appendectomy

weeks afterwards. This is performed to prevent recurrent is unnecessary after conservative treatment of attacks and will provide definitive diagnosis. Recently appendicle mass colorectal disease, April 2007. there is growing evidence against routinely performing 10,465-468. interval appendicectomy as the risk of recurrent attack is

only 14% and most of it occurs in first three months.

COMPLICATIONSFollowing complications may be seen in patients with appendicular abscess ;! Peritonitis.! Pelvic abscess.! Subphrenic abscess.! Paralytic ileus.! Adhesion formation.! Intestinal obstruction.! Septicaemia.

SUMMARY

Appendicular abscessClinical featuresInvestigationsTreatment

POSSIBLE QUESTIONS

1. What is an appendicular abscess?

2. How it is diagnosed?

3. Discuss treatment options? ?