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
Diagnostic Approach
- Persistent fever, tachycardia, leukocytosis, and right upper quadrant pain despite antibiotic therapy are clinical features suggesting perihepatic abscess formation after appendectomy 1
- 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
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, 3
- Multiple drainage catheters may be required for complex or multiloculated abscesses 3
Antibiotic Therapy
- Broad-spectrum antibiotics should be administered concurrently with drainage 1, 2
- Antibiotic therapy should cover facultative and aerobic gram-negative organisms and anaerobic organisms 1
- Metronidazole is indicated for treatment of liver abscesses caused by anaerobic bacteria including Bacteroides species, in conjunction with appropriate surgical procedures 4
- For critically ill patients, consider carbapenem-based regimens such as meropenem 1g every 8 hours or combination therapy with ceftolozane/tazobactam plus metronidazole 2
Surgical Options (When PCD is Not Available/Feasible)
- When percutaneous drainage is not available or feasible, surgical drainage is recommended 2
- Laparoscopic drainage is a safe and effective alternative to open laparotomy for intra-abdominal abscesses that occur after laparoscopic appendectomy when percutaneous drainage is not an option 5
- Open surgical drainage may be necessary in cases with peritoneal signs, active hemorrhage, or anatomic constraints that preclude PCD 1
Special Considerations
- Retained or dropped appendicoliths can be a cause of recurrent perihepatic abscesses and may require specific removal 6, 7, 8
- Transcutaneous removal of accessible appendicoliths using techniques such as Dormia basket recovery systems can be effective and avoid the need for surgical intervention 6, 7
- Antibiotics alone are usually insufficient for abscesses containing appendicoliths - removal of the foreign body is necessary 7
Pitfalls to Avoid
- Delaying drainage beyond 24 hours from diagnosis increases the risk of adverse outcomes 1
- Relying solely on antibiotic therapy without drainage for abscesses >3 cm is inadequate 1
- Routine use of intraoperative irrigation during the initial appendectomy does not prevent intra-abdominal abscess formation and may be avoided 2
Follow-up
- Clinical monitoring with serial imaging is recommended to ensure resolution of the abscess 1
- Interval appendectomy may not be necessary following initial non-operative treatment of complicated appendicitis, but should be performed for patients with recurrent symptoms 2
- Patients should be maintained on intravenous antibiotics until afebrile and without leukocytosis 5