Appendicular abscess is a delimited area of purulent inflammation of the peritoneum, resulting from the destruction of the vermiform process. It manifests itself on 5-6 days after the clinic of acute appendicitis with a sharp exacerbation of fever and pain syndrome, tachycardia, intoxication, dyspeptic phenomena. The diagnosis is established after studying the anamnesis, conducting a general blood test, ultrasound and radiography of the abdominal organs. An emergency operation is indicated – opening and drainage of the abscess. Antibacterial and detoxification therapy is prescribed; subsequently, an appendectomy is performed.
ICD 10
K35.1 Acute appendicitis with peritoneal abscess
Meaning
Appendicular abscess is a serious and dangerous complication of destructive acute appendicitis – its phlegmonous, apostematous, phlegmonous-ulcerative or gangrenous forms. Appendicular abscess may occur in the late period of the disease before surgery with suppuration of the appendicular infiltrate or in the postoperative period due to the delineation of the inflammatory process in peritonitis. According to experts in the field of abdominal surgery, the incidence of appendicular abscess in acute appendicitis is 1-3% of cases.
Causes of appendicular abscess
Appendicular abscess is usually caused by the association of E. coli, non-clostridial anaerobic microflora and cocci. Suppuration of the appendicular infiltrate with the development of an abscess is facilitated by the patient’s late treatment for medical help, untimely diagnosis of acute appendicitis. After appendectomy, a decrease in the immunological reactivity of the body, high virulence of microorganisms and their resistance to antibiotics used, and sometimes defects in surgical equipment can lead to the development of appendicular abscess.
Pathogenesis
The formation of an appendicular infiltrate usually occurs 2-3 days after the appearance of the first signs of acute appendicitis. Inflammation of the appendix does not extend to the entire abdominal cavity due to the protective physiological function of the peritoneum. The separation of the primary inflammatory focus in the caecum from the surrounding organs occurs due to the formation of fibrinous exudate, the development of the adhesive process and the fusion of the process itself with the loops of the large intestine, a section of the caecum, the large omentum and the parietal peritoneum.
The formed appendicular infiltrate with the attenuation of inflammation in the blind process (for example, after conservative therapy) can gradually resolve; with the destruction of the appendix and the spread of infection beyond its limits, it can fester with the formation of an abscess. The location of the appendicular abscess in the abdominal cavity depends on the localization of the blind process: more often – in the right iliac fossa, there may also be a retrocecal (retroperitoneal) or pelvic location of the abscess.
Symptoms of appendicular abscess
The onset of the disease is manifested by the clinic of acute appendicitis with a typical pain syndrome and an increase in body temperature. After 2-3 days from the onset of the attack, as a result of the delineation of inflammation in the blind process, acute phenomena subside, pain becomes dull, dragging, the temperature decreases, the normalization of the general condition is noted. During palpation, the abdominal wall is not tense, participates in the respiratory act, minor soreness and the presence of a sedentary seal without clear contours – appendicullary infiltrate is determined in the right iliac region.
The development of an appendicular abscess on the 5th-6th day of the disease is manifested by a deterioration in the general condition of the patient, sharp temperature rises (especially in the evening), chills and sweating, tachycardia, intoxication phenomena, poor appetite, intense pain syndrome of a pulsating nature in the right iliac region or lower abdomen, an increase in pain when moving, coughing, walking.
Palpation shows mild signs of irritation of the peritoneum: the abdominal wall is tense, sharply painful at the site of localization of the appendicular abscess (a positive symptom of Shchetkin-Blumberg), lags behind when breathing, painful elastic formation is felt in the lower right quadrant, sometimes with softening in the center and fluctuation.
The tongue is overlaid with a dense coating, dyspeptic phenomena are observed: stool disorders, vomiting, bloating; with an interstitial location of an appendicular abscess – the phenomena of partial intestinal obstruction, with pelvic – increased urge to urinate and bowel emptying, pain during defecation, mucus discharge from the anus. When an appendicular abscess breaks into the intestine, there is an improvement in well-being, a decrease in pain, a decrease in temperature, the appearance of liquid stool with a large amount of fetid pus.
Complications
The opening of an appendicullary abscess into the abdominal cavity leads to the development of peritonitis, accompanied by septicopemia – the appearance of secondary purulent foci of various localization, an increase in signs of intoxication, tachycardia, fever. Among the complications there are retroperitoneal or pelvic phlegmons, purulent paracolitis and paranephritis, liver abscess, subdiaphragmatic abscess, purulent thrombophlebitis of the portal vein, adhesive intestinal obstruction, urinary tract infections, abdominal wall fistulas.
Diagnostics
In the recognition of an appendicular abscess, the data of anamnesis, general examination and the results of special diagnostic methods are important. During vaginal or rectal finger examination, the abdominal surgeon sometimes manages to palpate the lower pole of the abscess as a painful protrusion of the vaginal arch or the anterior wall of the rectum. The results of a general blood test for appendicular abscess show an increase in leukocytosis with a shift of the leukocyte formula to the left, a significant increase in ESR.
Ultrasound of the abdominal cavity is performed to clarify the localization and size of the appendicular abscess, to detect fluid accumulation in the area of inflammation. An overview abdominal x-ray organs determines a homogeneous darkening in the iliac region on the right and a slight displacement of the intestinal loops towards the median line; in the area of the appendicular abscess, the level of fluid and the accumulation of gases in the intestine (pneumatosis) is detected. Appendicular abscess must be differentiated with a torsion of the ovarian cyst, spilled purulent peritonitis, a tumor of the cecum.
Treatment for appendicular abscess
At the infiltration stage, emergency surgery for acute appendicitis is contraindicated, it is treated conservatively in a hospital setting: strict bed rest is prescribed, cold on the stomach for the first 2-3 days, then heat, a sparing diet, antibiotic therapy. Laxatives and narcotic drugs are excluded. Sometimes paranephral novocaine blockades are prescribed for the purpose of resorption of the infiltrate. With complete resorption of the appendicular infiltrate, a planned appendectomy is performed after 1-2 months, since repeated attacks of acute appendicitis, the development of infiltrate, abscess and severe complications are possible.
Treatment of the formed appendicullary abscess is operative: the abscess is opened and drained, access depends on the location of the abscess. In some cases, with an appendicular abscess, its percutaneous drainage can be performed under the control of ultrasound using local anesthesia. Operative opening and emptying of the abscess is carried out under general anesthesia by right-sided lateral extraperitoneal access.
With a pelvic appendicular abscess, it is opened in men through the rectum, in women – through the posterior arch of the vagina with a preliminary test puncture. The purulent contents of the appendicular abscess are aspirated or removed with tampons, the cavity is washed with antiseptics and drained using two-light tubes. Removal of the blind process is preferable, but if there is no such possibility, it is not removed because of the danger of spreading pus into the free abdominal cavity, injury to the inflamed intestinal wall forming the wall of the appendicular abscess.
In the postoperative period, careful drainage care, flushing and aspiration of the contents of the cavity, antibiotic therapy (a combination of aminoglycosides with metronidazole), detoxification and restorative therapy are carried out. Drainage remains until the purulent contents are separated from the wound. After removal of the drainage tube, the wound heals by secondary tension. If an appendectomy has not been performed, it is performed as planned 1-2 months after the inflammation subsides.
Prognosis and prevention
In the absence of treatment, an appendicullary abscess can spontaneously open into the lumen of the intestine, abdominal cavity or retroperitoneal space, sometimes into the bladder or vagina, very rarely through the abdominal wall to the outside. The prognosis is serious, the outcome of the disease is determined by the timeliness and adequacy of surgical intervention. Prevention of appendicular abscess consists in early recognition of acute appendicitis and appendectomy in the first 2 days.