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| __NOTOC__ | | __NOTOC__ |
| {{SI}} | | {{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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| ==Historical Perspective== | | ==[[Appendicular abscess classification|Classification]]== |
| *During the late 1600s, Lorenz Heister was the first surgeon to perform [[post-mortem]] sections of [[appendicitis]] and gave an unequivocal description of a perforated [[Vermiform appendix|appendix]] and [[abscess]].<ref name="pmid17848045">{{cite journal |author=Shklar G, Chernin DA |title=Lorenz Heister and oral disease with the original text from his papers |journal=[[Journal of the History of Dentistry]] |volume=55 |issue=2 |pages=68–74 |year=2007 |pmid=17848045 |doi= |url= |accessdate=2012-08-09}}</ref>
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| *In 1886, Fitz diagnosed and described [[appendicitis]] for the first time.<ref name="pmid3890203">{{cite journal |vauthors=Carmichael DH |title=Reginald Fitz and appendicitis |journal=South. Med. J. |volume=78 |issue=6 |pages=725–30 |year=1985 |pmid=3890203 |doi= |url=}}</ref><ref> yjbm .1937 Jul; 9(6): 509.b1–520, PMC= 2601730</ref>
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| *In 1894, McBurney performed an [[appendectomy]] for the first time.<ref name="MusanaYale2005">{{cite journal|last1=Musana|first1=K.|last2=Yale|first2=S. H.|title=John Benjamin Murphy (1857 - 1916)|journal=Clinical Medicine & Research|volume=3|issue=2|year=2005|pages=110–112|issn=1539-4182|doi=10.3121/cmr.3.2.110}}</ref>
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| ==Classification== | | ==[[Appendicular abscess pathophysiology|Pathophysiology]]== |
| *No known classification of appendicular abscess exists.
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| ==Pathophysiology== | | ==[[Appendicular abscess causes|Causes]]== |
| *Obstruction of the tubular space inside the [[Vermiform appendix|appendix]] is the main inciting event, this initial problem leads to the inflammation of the appendix, obstruction of the blood vessels supplying it, and finally infection. <ref name="pmid626573">{{cite journal |vauthors=Bradley EL, Isaacs J |title=Appendiceal abscess revisited |journal=Arch Surg |volume=113 |issue=2 |pages=130–2 |year=1978 |pmid=626573 |doi= |url=}}</ref>
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| *Once these blood vessels are obstructed, appendiceal tissue starts to die and leak out its cellular components.<ref> Wangensteen OH, Bowers WF. Significance of the obstructive factor in the genesis of acute appendicitis. Arch Surg 1937;34:496-526 </ref>
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| *This leads to an increase in endoluminal and intramural pressure, which can result in an occlusion of the venules in the appendiceal wall resulting in [[thrombosis]] and occlusion and [[stasis]] of blood and lymphatic flow.
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| *The stasis favors the bacterial growth leading to infection of the appendix .
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| *[[Inflammation|Inflammatory]] mediators along with various bacterial [[toxins]] and [[Proteolytic enzyme|proteolytic]] enzymes from the [[neutrophils]] are released, resulting in the formation of abscess in appendix.
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| ===Transmission===
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| *The abscesses usually contain a mixture of [[Aerobic bacteria|aerobic]] and [[anaerobic bacteria]] from the [[Gastrointestinal tract|gastrointestinal trac]]<nowiki/>t.
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| ===Duration===
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| *The risk of perforation or abscess formation is negligible within the first 12 h of untreated symptoms, but then increases to 8.0% within the first 24 h.<ref name="pmid626573">{{cite journal |vauthors=Bradley EL, Isaacs J |title=Appendiceal abscess revisited |journal=Arch Surg |volume=113 |issue=2 |pages=130–2 |year=1978 |pmid=626573 |doi= |url=}}</ref>
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| ===Gross Pathology===
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| *The serosal surface of the appendix looks pale with rough edges and yellowish [[exudate]] along with [[hyperemia]]
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| ===Microscopic findings===
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| *A focally necrotic appendiceal debris is seen in the [[Mucosa|mucosal]] wall.
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| *[[Intravascular|Intravascular fibrin]] is seen in medium-sized blood vessels.
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| *Clusters of [[neutrophils]] are seen on the [[Serosa|serosal]] aspect.
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| ==Causes== | | ==[[Appendicular abscess differential diagnosis|Differentiating Appendicular abscess from other Diseases]]== |
| 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 epidemiology and demographics|Epidemiology and Demographics]]== |
| !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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| ==Differential diagnosis== | | ==[[Appendicular abscess risk factors|Risk Factors]]== |
| Appendicular abscess should be diagnosed early and treat promptly not only to reduce [[morbidity]] and [[mortality]], but it is also important to differentiate from other abdominal diseases presenting with [[Right lower quadrant abdominal pain resident survival guide|RLQ pain]] , fever, nausea and vomiting such as [[psoas abscess]], [[cellulitis]], torsion of [[Testicular torsion|testis]] and [[Ovarian torsion|ovaries]], [[ectopic pregnancy]] etc as the un-drained abscess carries high risk of mortality
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| {| class="wikitable"
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| ! rowspan="3" align="center" style="background:#4479BA; color: #FFFFFF;"|Diseases
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| ! colspan="5" align="center" style="background:#4479BA; color: #FFFFFF;"|Clinical features
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| ! colspan="2" align="center" style="background:#4479BA; color: #FFFFFF;"|Diagnosis
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| ! rowspan="3" align="center" style="background:#4479BA; color: #FFFFFF;"|Associated findings
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| |-
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| ! colspan="4" align="center" style="background:#4479BA; color: #FFFFFF;"|Symptoms
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| ! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;"|Signs
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| ! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;"|Laboratory fingdings
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| ! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;"|Radiological findings
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| |-
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| |style="background:#4479BA; color: #FFFFFF|'''Fever'''
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| |style="background:#4479BA; color: #FFFFFF|'''Abdominal pain'''
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| |style="background:#4479BA; color: #FFFFFF|'''Nausea'''
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| '''vomiting'''
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| |style="background:#4479BA; color: #FFFFFF|'''Diarrhea'''
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| |-
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| |style="background:#4479BA; color: #FFFFFF|'''Psoas abscess'''
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| |✔
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| Dull RLQ pain radiating to hip and thigh
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| |✔
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| |✘
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| Positive Psoas sign
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| *↑ WBC
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| *↑ ESR
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| *↑ BUN
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| CT demostrates enhancing collection in the psoas muscle.
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| *Associated with IV drug abuse and HIV
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| *Staphylococcus Aureus is the most common pathogen involved
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| |-
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| |style="background:#4479BA; color: #FFFFFF|'''Cellulitis of right thigh'''<ref name="pmid27658552">{{cite journal |vauthors=van Hulsteijn LT, Mieog JS, Zwartbol MH, Merkus JW, van Nieuwkoop C |title=Appendicitis Presenting As Cellulitis of the Right Leg |journal=J Emerg Med |volume=52 |issue=1 |pages=e1–e3 |year=2017 |pmid=27658552 |doi=10.1016/j.jemermed.2016.07.008 |url=}}</ref>
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| |✔
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| |✘
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| |✘
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| |✘
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| Involved site is red, hot, swollen, and tender<ref name="pmid27658552">{{cite journal |vauthors=van Hulsteijn LT, Mieog JS, Zwartbol MH, Merkus JW, van Nieuwkoop C |title=Appendicitis Presenting As Cellulitis of the Right Leg |journal=J Emerg Med |volume=52 |issue=1 |pages=e1–e3 |year=2017 |pmid=27658552 |doi=10.1016/j.jemermed.2016.07.008 |url=}}</ref>
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| *↑ WBC
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| *↑ ESR
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| *↑ BUN
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| * Ultrasonographic-guided aspiration of pus is both gold standard for diagnostic and therapeutic<ref name="pmid27658552">{{cite journal |vauthors=van Hulsteijn LT, Mieog JS, Zwartbol MH, Merkus JW, van Nieuwkoop C |title=Appendicitis Presenting As Cellulitis of the Right Leg |journal=J Emerg Med |volume=52 |issue=1 |pages=e1–e3 |year=2017 |pmid=27658552 |doi=10.1016/j.jemermed.2016.07.008 |url=}}</ref>
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| * In early cellulitis: Diffuse increase in the thickening and echogenicity of the subcutaneous tissue
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| * Late cellulitis: Accumulation of fluid in the subcutaneous tissue
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| Severe infection is indicated by
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| *Lymphangitic spread
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| *Circumferential cellulitis
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| *Pain out of proportionon
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| |-
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| |style="background:#4479BA; color: #FFFFFF|'''Crohn's disease'''
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| |✔
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| RLQ continuous localized pain
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| |✔
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| Bloody
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| * Fullness or a discrete mass in the RLQ of the abdomen
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| [ASCA]) are found in Crohn disease
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| Transmural ulcerations are seen on colonoscopy
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| * H/O weight loss,
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| * Extra intestinal manifestaions
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| * Endoscopic biopsy for diagnosis
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| |-
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| |style="background:#4479BA; color: #FFFFFF|'''Gastroenteritis'''
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| (Bacterial and viral)
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| |✔
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| Diffuse crampy intermittent abdominal pain
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| |✔
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| Bloody or watery
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| Rebound tenderness, rash
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| * Fecal leukocytes
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| * Stool culture
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| * Stool toxin assay
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| |No specific findings
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| * H/O food poisoning, travel
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| |-
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| |style="background:#4479BA; color: #FFFFFF|'''Primary peritonitis'''
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| |✔
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| Abrupt diffuse abdominal pain
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| |✔
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| Bloody/watery
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| Abdominal distension, rebound tenderness
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| Peritoneal fluid shows >500/microliter count and >25% polymorphonuclear leukocytosis.
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| * X-ray abdomen identifies free air under the diaphragm
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| * CT demonstrates abscess or fluid in abdomen,
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| * History of advanced cirrhosis or nephrosis
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| * Peritoneal fluid analysis confirms the diagnosis
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| |-
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| |style="background:#4479BA; color: #FFFFFF|'''Pyelonephritis'''
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| |✔
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| Flank pain radiating to inguinal region
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| |✔
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| |✘
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| CVA tenderness
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| Urine microscopy and culture confirm presence of bacteria.
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| * CT demonstrates round swollen kidneys with hypo-dense appearance
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| * Abscesses may or may not be seen
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| * H/o reccurent UTI
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| |-
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| |style="background:#4479BA; color: #FFFFFF|'''Ovarian torsion'''
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| |✘
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| Sudden sharp pain
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| |✔
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| |✘
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| Unilateral, tender adnexal mass
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| Ultrasonography shows ovarian cyst and decreased blood flow
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| * Affects females of reproductive age group
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| * Ultrasound is gold standard in diagnosing
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| * Can be right or left sided
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| |style="background:#4479BA; color: #FFFFFF|'''Testicular torsion'''
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| |✘
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| Sudden sharp pain
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| |✔
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| |✘
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| * Swollen, tender, high-riding testis with abnormal transverse lie
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| * Loss of the cremasteric reflex
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| * Normal Blood test
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| * Normal Urine analysis
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| * Absent or decreased blood flow in the affected testicle
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| * Hypervascularity with a low resistance flow pattern (after partial torsion-detorsion)
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| * Testicular Workup for Ischemia and Suspected Torsion (TWIST) is employed for determination of risk for torsion
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| |-
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| |style="background:#4479BA; color: #FFFFFF|'''Pelvic inflammatory disease'''
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| |✔
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| Bilateral lower quadrant pain
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| |✔
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| |✘
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| * Purulent discharge from cervical os.
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| * Cervical motion tenderness
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| *Abundant white blood cells (WBCs) on saline microscopy of vaginal secretions
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| *Laboratory evidence of cervical infection with ''N gonorrhoeae'' or ''C trachomatis''(via culture or DNA probe)
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| Transvaginal ultrasonographic scanning or magnetic resonance imaging (MRI) shows thickened, fluid-filled tubes with or without free pelvic fluid or tubo-ovarian abscess (TOA).
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| Laparoscopy helps in confirmation of the diagnosis
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| |-
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| |style="background:#4479BA; color: #FFFFFF|'''Ruptured ectopic pregnancy'''
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| |✔
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| Diffuse abdominal pain
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| |✔
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| |✘
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| * Unilateral or bilateral abdominal tenderness
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| * Abdominal rigidity, guarding
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| * On pelvic examination, the uterus may be slightly enlarged and soft, and cervical motion tenderness
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| HCG hormone level is high in serum and in urine
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| Ultrasound reveals presence of mass in fallopian tubes.
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| * Triad of amenorrhea, abdominal pain and vaginal bleeding
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| * SIgns of hypotension
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| * Transvaginal ultrasound with BHCG levels are the gold standard for diagnosis
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| |}
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| ==Epidemiology and Demographics== | | ==[[Appendicular abscess screening|Screening]]== |
| ===Prevalance===
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| The lifetime risk of appendicitis is 8.6 % for males and 6.7 % for female of which only 2-7% develops abscess.<ref name="pmid2239906">{{cite journal |vauthors=Addiss DG, Shaffer N, Fowler BS, Tauxe RV |title=The epidemiology of appendicitis and appendectomy in the United States |journal=Am. J. Epidemiol. |volume=132 |issue=5 |pages=910–25 |year=1990 |pmid=2239906 |doi= |url=}}</ref>
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| ===Incidence===
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| Annual incidence of appendicitis in united states is 9.38 per 100,000 persons.<ref name="pmid26926413">{{cite journal |vauthors=D'Souza N, Nugent K |title=Appendicitis |journal=Am Fam Physician |volume=93 |issue=2 |pages=142–3 |year=2016 |pmid=26926413 |doi= |url=}}</ref>
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| ===Age=== | | ==[[Appendicular abscess natural history, complications and prognosis|Natural History, Complications, and Prognosis]]== |
| It occurs most often between the ages of 10 and 30.<ref name="pmid2239906">{{cite journal |vauthors=Addiss DG, Shaffer N, Fowler BS, Tauxe RV |title=The epidemiology of appendicitis and appendectomy in the United States |journal=Am. J. Epidemiol. |volume=132 |issue=5 |pages=910–25 |year=1990 |pmid=2239906 |doi= |url=}}</ref>
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| ===Gender===
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| Males are more commonly affected with appendicular abscess than females. The male to female ratio is approximately 1.4 to 1.<ref name="pmid2239906">{{cite journal |vauthors=Addiss DG, Shaffer N, Fowler BS, Tauxe RV |title=The epidemiology of appendicitis and appendectomy in the United States |journal=Am. J. Epidemiol. |volume=132 |issue=5 |pages=910–25 |year=1990 |pmid=2239906 |doi= |url=}}</ref>
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| ===Race===
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| *Appendicitis usually affects individuals of the white race.Non white individuals are less likely to develop Appendicitis.<ref name="pmid2239906">{{cite journal |vauthors=Addiss DG, Shaffer N, Fowler BS, Tauxe RV |title=The epidemiology of appendicitis and appendectomy in the United States |journal=Am. J. Epidemiol. |volume=132 |issue=5 |pages=910–25 |year=1990 |pmid=2239906 |doi= |url=}}</ref>
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| *Appendicitis rates were 1.5 times higher for whites than for nonwhites, highest (15.4 per 10,000 population per year) in the west north central region, and 11.3% higher in the summer than in the winter months.
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| ==Screening==
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| According to the Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America, there is insufficient evidence to recommend routine screening for appendicular abscess.
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| ==Natural History, Complications, and Prognosis==
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| ===Natural history===
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| *The symptoms of appendicular abscess typically develop when the inflamed appendix gets complicated due to decreased blood flow.
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| *Without treatment, the patient will likely develop symptoms of diffuse abdominal [[pain]], which is different from typical appendicitis [[pain]], starting centrally (in the periumbilical region) before localizing to the [[right iliac fossa]] in the right lower quadrant of the [[abdomen]].
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| *They will also experience [[loss of appetite]], [[diarrhea]], High grade[[fever]], [[nauseua]], and [[vomiting]].
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| *During the final stage of the untreated disease process, the appendix will rupture, and this may eventually lead to death if [[peritonitis]] develops.<ref> Appendicitis. Wikipedia (2016). http://schools-wikipedia.org/wp/a/Appendicitis.htm Accessed on February 4, 2016</ref>
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| ===Complications===
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| Complications that can develop as a result of the untreated appendicular abscess include:
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| *[[Septicemia]]
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| *[[Rupture]]
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| *[[Peritonitis]]
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| *[[Hemorrhage]]
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| *Death
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| ===Prognosis=== | |
| *Most patients with appendicular abscess recover quickly with drain and IV [[antibiotics]], but complications can occur if treatment is delayed or if [[peritonitis]] occurs.<ref name="PhamSullins2016">{{cite journal|last1=Pham|first1=Xuan-Binh D.|last2=Sullins|first2=Veronica F.|last3=Kim|first3=Dennis Y.|last4=Range|first4=Blake|last5=Kaji|first5=Amy H.|last6=de Virgilio|first6=Christian M.|last7=Lee|first7=Steven L.|title=Factors predictive of complicated appendicitis in children|journal=Journal of Surgical Research|volume=206|issue=1|year=2016|pages=62–66|issn=00224804|doi=10.1016/j.jss.2016.07.023}}</ref><ref name="pmid17856727">{{cite journal |vauthors=Pattison AC |title=FACTORS IN THE MORTALITY OF ACUTE APPENDICITIS |journal=Ann. Surg. |volume=103 |issue=3 |pages=362–74 |year=1936 |pmid=17856727 |pmc=1391035 |doi= |url=}}</ref>
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| *It usually takes between 10 and 28 days to recover completely.
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| *Typical Abscess responds quickly to [[antibiotics]] and [[percutaneous]] drain and resolves spontaneously.
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| *If abscess resolves, [[Appendectomy|interval appendectomy]] should be performed 8-12 weeks after to prevent recurrent episodes.
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| *Atypical presentation(when the patient presents with [[fever]], [[abdominal pain]] not typical to appendicitis, [[diarrhea]]) is more difficult to diagnose and is more apt to be complicated.
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| *In such condition prompt diagnosis, and treatment with [[Appendectomy|emergent appendectomy]] yield the best results with full recovery usually occurring in two to four weeks.
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| *[[Mortality]] and severe complications are unusual but do occur in some cases, especially if [[peritonitis]] develops and is left untreated.<ref name="wiki1"> Appendicitis. Wikipedia (2016). https://en.wikipedia.org/wiki/Appendicitis#Clinical Accessed on February 4, 2016</ref>
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| ==Diagnosis== | | ==Diagnosis== |
| ===History===
| | [[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]] |
| The key to an efficient and accurate diagnosis is a detailed and thorough history. The following information should be obtained:<ref name="pmid7469557">{{cite journal |vauthors=Jordan JS, Kovalcik PJ, Schwab CW |title=Appendicitis with a palpable mass |journal=Ann. Surg. |volume=193 |issue=2 |pages=227–9 |year=1981 |pmid=7469557 |pmc=1345047 |doi= |url=}}</ref>
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| *Onset, location, radiation, and duration of [[pain]]
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| *Aggravating or relieving factors
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| *Severity of pain (constant or intermittent)
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| *Characteristics of the pain
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| *History of the pain
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| *Association with [[Nausea and vomiting|nausea, vomiting]], [[anorexia]], or [[diarrhea]]
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| *Time of last [[Defecation|bowel movement]] and
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| *Recent use of [[analgesics]], [[narcotics]], or [[antibiotics]].
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| ===Symptoms===
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| 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
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| *[[Fever]] >38.5 C
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| *[[Abdominal pain|Generalized abdominal pain]] <ref name="wiki1"> Appendicitis. Wikipedia (2016). http://schools-wikipedia.org/wp/a/Appendicitis.htm Accessed on February 4, 2016</ref>
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| *[[Nausea and vomiting|Vomiting]]
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| *Prolonged [[diarrhea]]
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| *Increased [[micturition]] due to irritation of the bladder wall by the inflamed appendix.
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| *[[Tenesmus]] can be also be noticed.
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| ==Physical Examination==
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| 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.
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| ===Vitals===
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| *[[Fever]]
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| *[[Tachycardia]]
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| *[[Hypotension]] if the abscess is ruptured and associated with hemorrhage.
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| *[[Tachypnea]].<ref>Hardin, M. Acute Appendicitis: Review and Update. ''Am Fam Physician".1999, Nov 1;60(7):2027-2034</ref>
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| ===Skin===
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| *[[Diaphoresis]]
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| *[[Pallor]]
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| *[[Cool extremities|Cold extremities.]]
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| ===Abdomen===
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| * The abdominal wall is very sensitive to mild palpation.
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| * [[Rebound tenderness]] (it cannot be elicited in most of the patients due to abscess formation)
| |
| * [[Abdominal guarding]]
| |
| * [[Rovsing's sign]] Deep palpation of the [[Iliac fossa|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]]<ref>{{Citation
| |
| | last1 = Stockman III | |
| | first1 = James A.
| |
| | lastauthoramp = yes
| |
| | title = Year Book of Pediatrics 2012
| |
| | publisher = Mosby
| |
| | place = Maryland Heights, MO
| |
| | edition = 2012
| |
| | year = 2012
| |
| }}</ref> 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.<ref name="wiki1"> Appendicitis. Wikipedia (2016). https://en.wikipedia.org/wiki/Appendicitis Accessed on March 14th, 2016</ref>
| |
| *In case of a [[Appendix|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==
| |
| *[[Abdominal 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.
| |
| [[File:Appendicular_abscess_USG.gif.gif|frameless|594x594px]]<br> | |
| | |
| US showing an area of high echogenicity measuring 5.2 X 6.7 cm in relation to the right hepatic lobe with echogenic rim.<br>
| |
| {{#ev:youtube|4qOYL0y3hPY}}
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| | |
| ==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.
| |
| [[File:Appendicular_abscess_CT_gif.gif|frameless|500x500px]]<br> | |
| CT of abdomen showing an abscess in the retrocaecal location with an adjacent appendicolith with ascending colon being displaced anteriorly.
| |
|
| |
|
| ==Treatment== | | ==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.<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>
| | [[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]] |
| ===Percutaneous drainage===
| |
| *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>
| |
| *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>
| |
| *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>
| |
| *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>
| |
| *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.<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>
| |
| ====Empiric therapy====
| |
| Monotherapy with a beta-lactam/beta-lactamase inhibitor:
| |
| *Preferred regimen (1):[[Ampicillin-Sulbactam|Ampicillin-sulbactam]] 3 g IV q6h
| |
| *Preferred regimen (2):[[Ticarcillin-Clavulanate|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|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.<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>
| |
| ===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 [[Appendectomy|interval appendectomy]] is recommended for patients after six to eight weeks, it is done to :
| |
| *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>
| |
| *Exclude [[neoplasms]] as a cause (such as [[Carcinoid|carcinoid,]] [[adenocarcinoma]], [[mucinous cystadenoma]], and [[Cystadenocarcinoma|cystadenocarcinomas]])
| |
| Complications of interval appendectomy
| |
| *[[Infection|Wound Infection]] ([[sepsis]])
| |
| *[[Pelvic abscess]]
| |
| *[[Aspiration pneumonia]]
| |
| Late complication
| |
| *[[Adhesions|Abdominal adhesions]]
| |
| *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>
| |
| {{#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.<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>
| |
| | |
| ===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.
| |
|
| |
|
| | ==Case Studies== |
| | [[Appendicular abscess case study one|Case #1]] |
|
| |
|
| ==References==
| | [[Category:Disease]] |
| {{reflist|2}}
| | [[Category:Up-To-Date]] |
| | [[Category:Gastroenterology]] |
| | [[Category:Surgery]] |
| | [[Category:Emergency medicine]] |
| | [[Category:Infectious disease]] |