Annals of African Medicine

Vol. 7, No.4; 2008: 200 – 204

Page | 200
OPINION
MANAGEMENT OF APPENDICEAL MASS

E. S. Garba and A. Ahmed

Division of General Surgery, Department of Surgery, Ahmadu Bello University Teaching Hospital Zaria, Nigeria
Reprint requests to:Dr. E. S. Garba, Department of Surgery, A. B. U. Teaching Hospital, Zaria, Kaduna State,
Nigeria. E-mail: esgarba@hotmail.com, Tel.: +234 803 3113763, +234 804 4118182

Abstract
Background: The management of appendiceal mass is surrounded with controversy. Traditonal
management has been conservative, with interval appendicectomy performed weeks after the mass
had resolved. This remains the most common approach at many centers in the world. Recently, an
increasing number of studies have challenged this approach. This article reviews some of the
controversial issues in the management of appendix mass, assesses current practce and suggests an
appropriate approach for the management of appendix mass.
Methods: A Medline, Pubmed and Cochrane database search were used to find such key words and
combinatons of: appendix, appendiceal, appendicular, interval, appendectomy, appendicectomy, mass,
abscess, phlegmon, and appendicits. Results were saved and managed by Reference manager 11. All
articles were cross-referenced by the authors.
Results: A conservative management is stll a highly acceptable approach for appendix mass. This
should be followed with interval appendicectomy especially in patents with persistent right iliac fossa
pain.
Conclusion: We recommend initally conservatve approach to the management of appendiceal mass
especially in our environment.

Keywords: Appendiceal mass, appendix abscess, appendix phlegmon, appendicits, interval

appendicectomy

Résumé
Contexte: La prise en charge du plastron appendiculaire est entoure de controverses. Le traitement
usuel a toujours été conservateur avec l’appendicectomie réalisée plusieurs semaines après la fonte de
la masse. C’est l’attitude la plus commune dans la plupart des centres à travers le monde. Récemment,
un nombre croissant d'études ont conteste cette approche. Cet article passe en revue certaines
controverses dans la prise en charge du plastron appendiculaire, présente les pratques actuelles, et
suggère une approche appropriée de la prise en charge du plastron appendiculaire.
Méthode: Une recherche dans les bases documentaires Medline, Pubmed et Cochrane ont été faites
par la recherche et la combinaison des mots clés que sont: appendice, appendiculaire, intervalle,
appendicectomie, masse, abcès, phlegmon et appendicite. Les résultats ont été sauvegardes et traites a
l’aide de Référence Manager 11. Tous les articles ont été recoupes par les auteurs.
Résultats: Un traitement conservateur est encore une approche très acceptable pour le plastron
appendiculaire. Cela devrait être suivi à distance par une appendicectomie particulièrement chez les
patents ayant une douleur persistante de la fosse iliaque droite.
Conclusion: Nous recommandons initalement une approche conservatrice pour la prise en charge du
plastron appendiculaire particulièrement dans notre contexte.

Mots clés: Masse appendiculaire, abcès appendiculaire, phlegmon appendiculaire, appendicite,

appendicectomie a distance
Page | Management of appendiceal mass. Garba E. S. and Ahmed A.
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Management of appendiceal mass. Garba E. S. and Ahmed A.
Introduction
An appendiceal mass is the end result of a walled-off
appendiceal perforaton and represents
pathological spectrum ranging from phlegmon to
1,2
abscess. It is a common surgical entty,
encountered in 2%-6% of patents presentng with
1-3
acute appendicits. Management of an appendiceal
mass is controversial with three general approaches
2-29
usually employed. 'Classical management' involves
inital conservatve management with broad-
spectrum antbiotcs and intravenous fluid untl the
inflammatory mass resolves. Patents are offered
interval appendicectomy following resoluton of
symptoms. More recently, the need for interval
appendicectomy has been questoned, with a
number of authors adopting semi conservative
approach with immediate appendicectomy or
entrely conservative approach without interval
4-6.
appendicectomy.
The semi-conservatve approach involves
performing immediate appendicectomy during the
inital admission after resolution of the inflammatory
mass. Advocates of immediate appendicectomy
mentoned advantages of avoiding the need for
readmission for interval appendicectomy, and the
exclusion of other pathologies masquerading as an
appendix mass.
4-7
while advocates of interval
appendicectomy described the advantages of
avoiding recurrence of symptoms and the
8,9
misdiagnosis of an appendix mass. They argue that
interval appendicectomy is a less hazardous and less
challenging operaton, compared with immediate
appendicectomy during the inital admission.
8,9
Proponents of an entrely conservatve approach
claim appendicectomy, whether interval (delayed) or
immediate (during initial admission), is
10-12
unnecessary.
None of these three approaches has gained total
universal acceptance. At our center at Ahmadu Bello
University Teaching Hospital Zaria, a classical
approach is stll favored by the majorities of the
consultants (personal communicatons). This article
aims to review the current available literatures
describing management of appendix mass and
suggest an acceptable approach based on available
local resources.
Materials and Methods
A Medline, Pubmed and Cochrane database search
was performed using reference manager 11 applying
search key words such as: appendicits, appendiceal
mass, interval, appendicectomy, abscess and
phlegmon. We also searched with the combinatons
of these key words using Boolean approach. Relevant
articles including case series, review articles and
individual case reports relating to adult appendix
Page |
202202202
mass were selected and saved into the reference
manager 11. Cases of children appendiceal masses
were excluded from this review. All articles were
a read by the two authors and cross-referenced.
Discussion
An Appendiceal mass range from phlegmon to
abscess and it develops in 2%-6% of cases following
2, 9-16.
acute appendicits For obvious cases of
appendiceal abscesses, there is no controversy as
regarding its management; immediate surgical
drainage (percutaneous or open) is the treatment of
choice by the majority of the authors of the articles
6
reviewed. For phlegmon, a number of treatment
optons ranging from conservative to aggressive
approaches are available. We compared the three
most popular approaches to the treatment of
appendix mass. This discussion shall be grouped
under the three main methods of approaches to
treatment of appendix mass.
Approach A
Initial conservative treatment followed by
interval
appendectomy six to eight weeks later
Oschner in 1901 proposed non-operative
management for treatment of appendix mass. 15, 16.
This approach involved the administraton of
intravenous fluids and antbiotcs while keeping the
patent on nil per oral. The aim of this approach was
to achieve complete resolution of the inflammatory
mass and the disappearance of symptoms in the
patent before any surgical interventon (Figure 1).
Some authors favor this approach on the ground that
16-18
it is effective in the majority of patents. What are
the reasons for justifying interval appendicectomy? It
is first to prevent recurrence of acute appendicitis
and second to avoid misdiagnosing an alternatve
12,14,16
pathology such as malignancy.
An article in favor of inital conservatve approach
2
published in 1993 by Nitecki et al reported a mean
incidence of recurrent acute appendicits in a meta-
analysis of 329 patents managed conservatvely as
13.7% (range 0%-20%). 14 Most recurrences occurred
within the first two years. There were also fewer
operatve difficulties in this group of patents and
there was a far less frequent need to extend the
incisions during surgery. As a result of these peculiar
advantages the operatve tme was significantly
shorter than other methods of treatment. There was
also no significant postoperative complicaton in this
group.
Approach B
Immediate appendicectomy following
inflammatory mass resolution
With the advent of antbiotcs designed to prevent
the growth of anaerobes, early appendectomy can
 19
now be carried out without complicaton Hence
emergency appendicectomy for appendix mass is
emerging as an alternatve to conventonal
conservatve treatment. It is said to be feasible, safe,
and cost-efectve, allowing early diagnosis and
18
treatment of unexpected pathology. However, the
appropriate tming for emergency surgery is
18
contentous.
One method involves immediate appendicectomy
as soon as there is resoluton of the mass before
patent is discharged home during the inital
admission. However some more aggressive surgeons
actually embark on right hemicolectomy for
2,5,8
appendiceal mass as soon as the patents present.
Immediate appendectomy has the advantages of
being safe, eliminates risk of recurrent appendicits
and eliminates the need for re-admission for interval
Figure 1. Algorithm for management of appendiceal mass
Appendiceal Mass
Inital conservative management
Abscess formaton
Resolved Drainage of Abscess
Interval Appendicectomy
Approach C
An entirely conservative approach
without interval appendicectomy in
patients with appendiceal mass
A school of thought argued that after a successful
conservatve management, interval appendicectomy
is not necessary and can safely be omitted, except in
patents with recurrent symptoms. In patents above
40 years of age, one must exclude other pathological
causes of right iliac fossa mass by further
investgatons such as barium enema, colonoscopy
and computerized tomography scan. A close follow
18
up is needed in this category of patents.
Obviously patents in Groups A and B above have
significantly longer duraton of hospital stay as well
20
as tme lost from work. Dixon et al reviewed the
characteristics of 32 patents who had recurrence of
20
symptoms following conservatve managemen.t
Mean tme to recurrence was five months following
5
appendectomy. It is generally reported to reduce
total hospital stay
2,8
However, it has a high
complicaton rate of about 36%, almost comparable
9
to that for perforated appendicits. Immediate
surgery leads to disseminaton of infection and
2
intestnal fistula formaton. This obviously seems to
obviate the advantages enumerated above. The
inflammatory appendiceal mass may be mistaken at
surgery for a malignant tumor, occasionally leading
to right hemicolectomy. A malignant mass may be
mistakenly under-treated by appendectomy. In view
of the above complicatons it is advisable not to
adopt this method in our environment, as this group
has significant complicatons and over treatment
compared to the traditonal inital conservative
method.
Persistent mass/pain
Further assessment and
investigatons
Resolved Persistent
Mass or pain
Laparotomy
the inital episode. They compared the clinical
characteristics of each patent at inital admission
with the same characteristics at recurrence. They
demonstrated that when recurrence of appendicitis
occurs this followed a milder clinical course. The
recurrences were treated successfully with both
operatve and non-operative approaches and were
not associated with any significant mortality or
morbidity. They also compared clinical and
demographic characteristcs of the recurrence group
to the non-recurrence group and found no significant
risk factors for recurrence, including the severity of
the inital presentaton. There is, therefore, good
evidence, first, that the risk of recurrent acute
appendicits following successful conservative
management is low; between 5% and 14%. Second,
in the minority of patents whose symptoms do recur,
this usually occurs within one year.
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