What is the management of an appendicular lump?

Management of Appendicular Lump

The recommended first-line treatment for appendicular lump is non-operative management with broad-spectrum antibiotics and percutaneous drainage for abscesses ≥4cm, which is associated with fewer complications and shorter hospital stays compared to immediate surgical intervention. 1, 2

Initial Assessment and Stabilization

• Ensure hemodynamic stability with IV fluids
• Correct electrolyte abnormalities
• Start broad-spectrum antibiotics immediately to target both aerobic and anaerobic organisms (E. coli, Klebsiella, Bacteroides fragilis) 1
• Perform CT scan with contrast to assess the size and characteristics of the appendicular lump/abscess 2

Management Algorithm

For Appendicular Phlegmon or Small Abscess (<3-4cm)

1. Conservative management:
   • Broad-spectrum antibiotics for 7-10 days 1
   • Bowel rest and supportive care
   • Monitor clinical response (temperature, white blood cell count, pain)

For Appendicular Abscess (≥4cm)

1. Non-operative management:

   • Broad-spectrum antibiotics
   • Percutaneous catheter drainage (PCD) under radiological guidance 2
   • Success rates of PCD range from 70-97% 1, 2
   • Continue antibiotics for at least 7-10 days, guided by clinical response 1

2. When to consider surgery:

   • If percutaneous drainage is not available 2
   • Failure of conservative management (persistent fever, increasing pain, worsening clinical status) 2
   • Peritoneal signs or hemodynamic instability 2

Antibiotic Recommendations

• Recommended regimens include:
  • Meropenem
  • Imipenem/cilastatin
  • Ceftolozane/tazobactam + metronidazole 1
• Duration: At least 7-10 days, guided by clinical response

Follow-up Management

Interval Appendectomy

• Not routinely recommended after successful non-operative management 2
• Indicated only for:
  • Patients with recurrent symptoms (recurrence rate 12-24%) 2, 1
  • Patients ≥40 years old (due to 3-17% risk of appendiceal neoplasms) 1, 2

Additional Follow-up for Patients ≥40 Years

• Colonoscopy
• Full-dose contrast-enhanced CT scan 2, 1

Potential Complications and Pitfalls

1. Failure of PCD:

   • Risk factors include patient complexity, female gender, large poorly defined periappendiceal abscess 1
   • Consider surgical intervention if no improvement within 24-48 hours

2. Recurrence:

   • 12-24% of patients may experience recurrent appendicitis after non-operative management 1, 2
   • Monitor for recurrent symptoms after discharge

3. Missed Malignancy:

   • Higher risk in patients ≥40 years old (3-17%) 1, 2
   • Ensure proper follow-up with colonoscopy and imaging in this age group

4. Septicemia:

   • Primary concern in patients with appendicular abscess
   • Can lead to septic shock and organ failure
   • Requires immediate attention to source control and appropriate antimicrobial therapy 1

The management approach to appendicular lump has evolved significantly, with evidence strongly supporting initial non-operative management in most cases. This approach results in fewer complications compared to immediate surgery while maintaining high success rates 2, 1. The key is early diagnosis, appropriate antibiotic therapy, and timely percutaneous drainage when indicated.