What is the management of a perihepatic abscess following an appendectomy?

Management of Perihepatic Abscess After Appendectomy

Percutaneous image-guided drainage combined with appropriate antibiotic therapy is the first-line treatment for perihepatic abscesses following appendectomy when interventional radiology is available. 1, 2

Diagnostic Approach

• CT scan is the preferred imaging modality to confirm the presence, size, and location of perihepatic abscesses 1
• Multidetector CT with sagittal and coronal reformatting helps distinguish collections from adjacent structures 1
• Clinical features suggesting abscess formation include persistent fever, tachycardia, leukocytosis, and right upper quadrant pain despite antibiotic therapy 1, 3

Treatment Algorithm

First-Line Management

• Percutaneous catheter drainage (PCD) is the treatment of choice for perihepatic abscesses >3 cm in diameter 1, 2
• PCD has a reported efficacy of 70-90% for intra-abdominal abscesses 1
• PCD is associated with significantly lower complication rates and shorter hospital stays compared to surgical intervention 1, 4
• When percutaneous drainage is not available or feasible, surgical intervention is indicated 1

Antibiotic Therapy

• Broad-spectrum antibiotics should be administered concurrently with drainage 1, 2
• Recommended regimens include:
  • Piperacillin-tazobactam (3.375g IV every 6 hours) for intra-abdominal infections including abscesses 5
  • Metronidazole in combination with other antibiotics for coverage of anaerobic bacteria commonly found in intra-abdominal abscesses 6
• Antibiotic therapy should cover facultative and aerobic gram-negative organisms and anaerobic organisms 2
• Continue antibiotics until the patient is afebrile and leukocytosis resolves 7

Surgical Options (When PCD is Not Available/Feasible)

• Laparoscopic drainage is a safe and effective alternative to open laparotomy 7
• Laparoscopic approach offers advantages of less post-operative pain and shorter hospital stay 2, 7
• Open surgical drainage may be necessary in cases with peritoneal signs, active hemorrhage, or anatomic constraints that preclude PCD 1

Special Considerations

• For perihepatic abscesses caused by retained appendicoliths, removal of the appendicolith is essential as antibiotics and drainage alone are usually insufficient 3, 8
• Transcutaneous removal of accessible retained appendicoliths may be feasible and safe 8
• Multiple catheters may be required for adequate drainage of complex or multiloculated abscesses 4
• Routine use of intraoperative irrigation during the initial appendectomy does not prevent intra-abdominal abscess formation 1

Pitfalls to Avoid

• Delaying drainage beyond 24 hours from diagnosis increases the risk of adverse outcomes 2
• Relying solely on antibiotic therapy without drainage for abscesses >3 cm is inadequate 1
• Failing to consider and search for retained appendicoliths in cases of recurrent abscesses 3, 8
• Routine abdominal drainage during appendectomy does not prevent intraperitoneal abscess formation and may increase hospital stay and mortality 9

Follow-up

• Clinical monitoring with serial imaging is recommended to ensure resolution of the abscess 1
• If symptoms recur after successful drainage, consider the possibility of a retained appendicolith or inadequate drainage 3, 8