Appendicular abscess differential diagnosis

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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]

Overview

Appendicular abscess must be differentiated from other causes of abdominal pain such as acute gastroenteritis and luminal obstruction. Age group and gender of the patient must be considered in differentiating an appendicular abscess from other intra-abdominal abscesses with similar complaints.

Differential diagnosis

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 RLQ pain, fever, nausea, and vomiting such as psoas abscess, cellulitis, torsion of testis and ovaries, and ectopic pregnancy as the undrained abscess carries high risk of mortality.[1][2][3][4][5][6][7]

Diseases Clinical features Diagnosis Associated findings
Symptoms Signs Laboratory fingdings Radiological findings
Fever Abdominal pain Nausea

vomiting

Diarrhea
Psoas abscess +

Dull RLQ pain radiating to hip and thigh

+ -

Positive Psoas sign

CT demostrates enhancing collection in the psoas muscle.

Cellulitis of right thigh + - - -

Involved site is red, hot, swollen, and tender[3]

  • Ultrasonographic-guided aspiration of pus is both gold standard for diagnostic and therapeutic[3]
  • In early cellulitis: Diffuse increase in the thickening and echogenicity of the subcutaneous tissue
  • Late cellulitis: Accumulation of fluid in the subcutaneous tissue

Severe infection is indicated by

Crohn's disease +

RLQ continuous localized pain

+

Bloody

Fullness or a discrete mass in the RLQ of the abdomen

[ASCA]) are found in Crohn disease

Transmural ulcerations are seen on colonoscopy

Gastroenteritis

(Bacterial and viral)

+

Diffuse crampy intermittent abdominal pain

+

Bloody or watery

Rebound tenderness, rash

No specific findings
Primary peritonitis +

Abrupt diffuse abdominal pain

+

Bloody/watery

Abdominal distension, rebound tenderness

Peritoneal fluid shows >500/microliter count and >25% polymorphonuclear leukocytosis.

  • History of advanced cirrhosis or nephrosis
  • Peritoneal fluid analysis confirms the diagnosis
Pyelonephritis +

Flank pain radiating to inguinal region

+ -

Costovertebral angle (CVA) tenderness

Urine microscopy and culture confirm presence of bacteria.

  • CT demonstrates round swollen kidneys with hypo-dense appearance
  • H/o reccurent UTI
Ovarian torsion -

Sudden sharp pain

+ -

Unilateral, tender adnexal mass

Ultrasonography shows ovarian cyst and decreased blood flow

  • Affects females of reproductive age group
  • Ultrasound is gold standard in diagnosing
  • Can be right or left sided
Testicular torsion -

Sudden sharp pain

+ -
  • Swollen, tender, high-riding testis with abnormal transverse lie
  • Loss of the cremasteric reflex
  • Absent or decreased blood flow in the affected testicle
  • Hypervascularity with a low resistance flow pattern (after partial torsion-detorsion)
  • Testicular Workup for Ischemia and Suspected Torsion (TWIST) is employed for determination of risk for torsion
Pelvic inflammatory disease +

Bilateral lower quadrant pain

+ -
  • Purulent discharge from cervical os.
  • Cervical motion tenderness

Transvaginal ultrasonographic scanning or magnetic resonance imaging (MRI) shows thickened, fluid-filled tubes with or without free pelvic fluid or tubo-ovarian abscess (TOA).

Laparoscopy helps in confirmation of the diagnosis

Ruptured ectopic pregnancy +

Diffuse abdominal pain

+ -
  • Unilateral or bilateral abdominal tenderness
  • Abdominal rigidity, guarding
  • On pelvic examination, the uterus may be slightly enlarged and soft, and cervicall motion tenderness

BHCG hormone level is high in serum and in urine

Ultrasound reveals presence of mass in fallopian tubes.

References

  1. Otowa Y, Sumi Y, Kanaji S, Kanemitsu K, Yamashita K, Imanishi T, Nakamura T, Suzuki S, Tanaka K, Kakeji Y (2014). "Appendicitis with psoas abscess successfully treated by laparoscopic surgery". World J. Gastroenterol. 20 (25): 8317–9. doi:10.3748/wjg.v20.i25.8317. PMC 4081711. PMID 25009411.
  2. Kim DH, Cheon JH (2017). "Pathogenesis of Inflammatory Bowel Disease and Recent Advances in Biologic Therapies". Immune Netw. 17 (1): 25–40. doi:10.4110/in.2017.17.1.25. PMC 5334120. PMID 28261018.
  3. 3.0 3.1 3.2 van Hulsteijn LT, Mieog JS, Zwartbol MH, Merkus JW, van Nieuwkoop C (2017). "Appendicitis Presenting As Cellulitis of the Right Leg". J Emerg Med. 52 (1): e1–e3. doi:10.1016/j.jemermed.2016.07.008. PMID 27658552.
  4. Cirocchi R, Afshar S, Di Saverio S, Popivanov G, De Sol A, Gubbiotti F, Tugnoli G, Sartelli M, Catena F, Cavaliere D, Taboła R, Fingerhut A, Binda GA (2017). "A historical review of surgery for peritonitis secondary to acute colonic diverticulitis: from Lockhart-Mummery to evidence-based medicine". World J Emerg Surg. 12: 14. doi:10.1186/s13017-017-0120-y. PMC 5345194. PMID 28293278.
  5. Ramakrishnan K, Scheid DC (2005). "Diagnosis and management of acute pyelonephritis in adults". Am Fam Physician. 71 (5): 933–42. PMID 15768623.
  6. Smorgick N, Maymon R (2014). "Assessment of adnexal masses using ultrasound: a practical review". Int J Womens Health. 6: 857–63. doi:10.2147/IJWH.S47075. PMC 4181738. PMID 25285023.
  7. Taran FA, Kagan KO, Hübner M, Hoopmann M, Wallwiener D, Brucker S (2015). "The Diagnosis and Treatment of Ectopic Pregnancy". Dtsch Arztebl Int. 112 (41): 693–703, quiz 704–5. doi:10.3238/arztebl.2015.0693. PMC 4643163. PMID 26554319.