In a 21‑year‑old with 7‑day right iliac fossa pain, a palpable mass, leukocytosis and ultrasound showing an appendiceal phlegmon without collection, what is the appropriate management: non‑operative (conservative), laparoscopic appendectomy, open appendectomy, or exploratory laparotomy?

Management of Appendiceal Phlegmon Without Abscess

Initial non-operative management with broad-spectrum antibiotics is the appropriate treatment for this 21-year-old patient with an appendiceal phlegmon without collection 1, 2.

Rationale for Conservative Management

The World Journal of Emergency Surgery guidelines explicitly recommend non-operative management for appendiceal phlegmon, particularly when no drainable collection is present 1, 2. This approach includes:

• Broad-spectrum intravenous antibiotics covering enteric gram-negative organisms and anaerobes (E. coli, Bacteroides species) 2
• Recommended antibiotic regimens include single agents (ertapenem, meropenem, imipenem-cilastatin, or piperacillin-tazobactam) or combination therapy (ceftriaxone plus metronidazole, or ciprofloxacin plus metronidazole) 2
• Duration of 5-14 days depending on clinical response 2

Why Surgery Is NOT Indicated Initially

Conservative management of appendiceal phlegmon demonstrates significantly fewer complications compared to immediate appendectomy, including fewer wound infections, abdominal/pelvic abscesses, ileus, bowel obstruction, and additional surgeries 1.

Immediate surgery in this setting carries specific risks:

• 10% risk of requiring ileocecal resection or right hemicolectomy due to the inflammatory mass 1, 2
• Higher complication rates when operating in the acute inflammatory phase 1, 3
• No advantage in hospital stay compared to conservative management 1

Critical Monitoring Parameters

You must monitor for treatment failure within the first 24 hours 4. Indications to abandon conservative management and proceed to surgery include:

• Hemodynamic instability 4
• Diffuse peritonitis on examination 4
• Clinical deterioration despite antibiotics (persistent/worsening fever, tachycardia, increasing pain, rising inflammatory markers) 4
• Lack of clinical improvement within 24 hours mandates conversion to surgical therapy 1, 4

Follow-Up Considerations

After successful conservative treatment:

• No routine interval appendectomy is needed for patients under 40 years old 2
• Interval appendectomy is only indicated for recurrent symptoms (recurrence rate 12-24%) 1, 2
• For patients ≥40 years old, colonoscopy and interval CT scan are recommended to exclude underlying malignancy 2

Common Pitfalls to Avoid

• Do not persist with antibiotics beyond 24 hours without clear improvement – this delays necessary surgery and worsens outcomes 4
• Do not attempt immediate appendectomy unless the patient fails conservative management – the inflammatory mass makes surgery technically difficult with higher complication rates 1
• Do not confuse phlegmon (no collection) with abscess (collection present) – the latter may require percutaneous drainage if ≥3 cm and interventional radiology is available 2

Answer: A) Non-interventional (conservative management with antibiotics)