Management for Appendicular Mass

The appendix that is acutely inflamed may perforated and later wall off from the peritoneal cavity by omentum and adjacent bowel loop to form a tender, palpable right iliac fossa mass. It is a common surgical pathology which occur about 2-6% in patient who presented with acute appendicitis.

The initial school of thought regards this condition to be managed conservatively, with the famous one being the Ochsner-Sherren regimen. The idea behind this is that, surgery would be hazardous and increase the mortality rate.

Surgeon who hold with this choice differs in opinion whether there is a need for interval appendectomy which usually perform after 3-6 week after the conservative management. The idea behind the interval appendectomy is to prevent recurrence of acute appendicitis and to exclude other gastrointestinal pathology especially malignancy.

The recurrence rate of acute appendicitis in patient with appendicular mass who treated conservatively is around 5-13.7%. However, study shows that there is no justification for routine interval appendicectomy after successful conservative management in asymptomatic patient (D.E Deakin, 2007)

Meanwhile, in patients over 40 years of age, other pathological causes of right iliac mass must be excluded by further investigations (colonoscopy and computerized tomography scan), and a close follow-up is needed. ( Meshikhes AW, 2008).

The conservative management of appendicular mass can be summarized by mnemonic “ABCDEF” which is

A: Analgesic, Antibiotic, antipyretic

B: Bed rest

C: Charting (vital sign, size of the mass)

D: Diet (Keep Nil by Mouth)

E: Exploratory laparotomy KIV.

F: Fluid maintenance

In previous time, early operative management is not favored because of assumption that operating on this kind of patient will increase the morbidity and mortality. However, current trend shows that early operation is acceptable and associated with low morbidity, reduced hospital stay, low cost, and increase patient compliance.

Therefore, early surgery is now regards as a preferred method. Laparoscopic appendicectomy is safe and should be a preferred method compared to open surgery even though in emergency setting.

As a conclusion, three methods are proposed for management of appendicular mass which are 1) Conservative management, 2) Interval appendectomy, 3) Early surgical intervention. The selection of methods depends on surgeon preference and patient’s condition.

Reference

1) Cunnigaiper Nd, Raj P, Ganeshram P, Venkatesan V, "Does Ochsner-Sherren Regimen Still Hold True In The Management Of Appendicular Mass?", Ulus Travma Acil Cerrahi Derg. 2010 Jan;16(1):43-6.

2) D.E Deakin & I. Ahmed, " Interval Appendicectomy After Resolution Of Adult Inflammatory Appendix Mass- Is It Necessary?", Surgeon 5:1:45-50, The Royal Colleges Of Surgeons Of Edinburgh And Ireland, 2007.

3) De U, Ghosh S, "Acute Appendicectomy For Appendicular Mass: A Study Of 87 Patients.", Ceylon Med J. 2002 Dec;47(4):117-8, Pubmed

4) E. Charles Brunicardi Et Al, "Schwartz's Manual Of Surgery 8th Ed", The Mcgraw Hill Companies, 2006.

5) E. S. Garba And A. Ahmed, "Management Of Appendicealmass", Annals Of African Medicine, Vol. 7, No.4; 2008: 200 – 204

6) Malik Arshad, Laghari A. Aziz, Mallah Qasim, Et Al" Early Appendicectomy In Appendicular Mass—A Liaquat University Hospital Experience", J Ayub Med Coll Abbottabad 2008;20 (1)

7) M.A. Bahram, Evaluation Of Early Surgical Management Of Complicated Appendicitis By Appendicular Mass", International Journal Of Surgery 9 (2011) 101-103, Elsevier

8) Meshikhes Aw, "Management Of Appendiceal Mass: Controversial Issues Revisited.", J Gastrointest Surg. 2008 Apr;12(4):767-75. Epub 2007 Nov 13, Pubmed.

9) Safir Ullah, Mumtaz Khan, Siddique Ahmad, Naeem Mumtaz, "Conservative Treatment Of Appendicular Mass Without Interval Appendicectomy: Is It Justified?", JPMI Vol 21, No 1:55-59, 2007