appendix mass

8/18/2019 Appendix Mass

1/25

Management of the

Appendix Mass


2/25

Index case:

History

52 year old female

No chronic illnesses 2 week history of RLQ pain

Intermittent vomiting

Fever


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Index case (Cont’d)

O!

"fe#rile

Normal vitals $ass palpa#le in RIF

Locali%ed peritonism at $c&'rney(s

NO) *+ and *R e,aminations


4/25

Results:

H# -./20 1& -3/5

Normal 4!(s

)onography

6/3 , 2/7 , ./8 cm mi,ed echogenic mass lesion

in RIF/ $inimal free fl'id in RIF

Left ovary9 Normal0 Right ovary9 Not vis'ali%ed


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Diagnosis

INFL"$$":OR; "**!N


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Initial Management

I+F

Li>'id diet

I+ ipro Flagyl I+ "nalgesics

+itals >6h


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Day 4 Post Admission

:olerating Normal diet

Normal vitals

"fe#rile "#domen non :ender

+ag'e impression of RIF mass

1& 8/3


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!" Plan

"dvised to ret'rn if fe#rile0 a#do pain0

vomiting

:o complete -@ days of "& )O*< in 252 with repeat 4)

"rrange olonoscopy

A Interval "ppendicectomy


10/25

Definition

:he appendiceal mass is the end res'lt of a

walledBoff appendiceal perforation/

*athologically it may represent a spectr'mranging from phlegmon to a#scess


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Magnitude of the P#o$lem

"c'te appendicitis is the most common

ca'se of ac'te a#domen re>'iring s'rgery

*eriBappendic'lar mass occ'rs in 2B8 percent of cases of ac'te appendicitis


12/25

%ypical indings

History of RIF *ain Na'sea or +omiting

:ender illBdefined RIF mass Longer d'ration of symptoms0 late

presentation Cafter 5-7 daysD

Higher fever and 1& than 'ncomplicatedappendicitis


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&e'a#e

linical distinction #etween a periB

appendic'lar phlegmon and a li>'efied

appendic'lar a#scess is notorio'sly diffic'lt


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Imaging: onog#aphy

*ro#lem9 :he sonographic appearance may

#e varia#le with echogenic a#scess and

sonol'cent phlegmon : fo'nd to #e more relia#le


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Imaging: C% can

On contrastBenhanced :

*eriBappendiceal phlegmons appear as soft

tiss'e highBdensity masses a#scesses are significantly lower in density


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C% cont’d

N/& 9ontrast enhancement is essential to

discriminate #etween areas of solidinflammatory tiss'e and li>'id pus


17/25

A$scesses

NO: "LL "&)!))!) N!!< :O &!


18/25

?rp -9 complete resol'tion with "&

alone

?rp 29 32 s'ccess with : g'ide

drainage

?rp .9 Open


19/25

;amini et al -339 7 s'ccess rate with

perc'taneo's drainage/ )ome needed 2nd

drainage proced're/ Iatrogenic fist'la a possi#ility


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Phlegmon

&asically . approaches

!mergent appendectomy C!"D

onservative $, and intervalappendectomy CI"D

onservative $, only C$,D


21/25

No consens's e,ists/ Only - small *R st'dy

C'mar et al 2@@6D

!"9 !arly definitive $,/ omplication rate .8

LHO) !" J I" J $,

4nnecessary s'rgery


22/25

CIA

'rrently standard approach

Is I" necessaryA Large Retrospective cohort9 .236. ptns

5 rec'rrence in $, grp

Rec'rrance had milder disease

LOH) in I" J !" J Rec'rrence

oncl'ded that ro'tine I" not necessary


23/25

CMx

)hortest LHO) C'mar et al 2@@60 aminiski et al 2@@5D

Rec'rrence rate #etween @B2@

Lowest overall complication rate If rec'rrence occ'rs likely to #e within - yr

Limited evidence to s'pport as ro'tine $,


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ollo' "p t#ategy

Incorrect diagnosis @B-2

$ain fear is aecal t'mo'r

Over 6@ yrs old need F4 colonoscopy or&a !nema

*ersisting symptoms : )can or s'rgery


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P#oposed c#ite#ia fo# CMx

No imm'noBcompromising states )ta#le Locali%ed *eritonitis lear RIF mass *hlegmon or Locali%ed collection on 4) Low tolerance for conversion

Facilities for perc/ drainage m'st e,ist F4 modalities m'st #e availa#le

appendix mass

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