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Appendicular abscess

Case contributed by Mohamed Mahmoud Elthokapy
Diagnosis certain

Presentation

Severe right iliac fossa pain with fever and rigidity not relieved by pain killers. TLC about 27 mg/dl.

Patient Data

Age: 25 years
Gender: Female

Initial CT study

ct

Rather thickened wall of the appendix showing heterogeneous enhancement after post-contrast series with markedly smudged surrounding fat planes and prominent regional mesenteric lymph nodes with reactive thickening of the adjacent terminal ileum and ileocecal junction.

Moreover, clusters of gases foci are seen intimately related to appendiceal tip with marked smudging of surrounding fat planes, minimal surrounding fluid smearing, and mesenteric fat sealing amalgamating with it.

Mild hepatomegaly is incidentally seen.

The patient received medical treatment (antibiotics and analgesics) yet no improvement with marked increasing pain after the 5th day, hence prompted to do CT again.

5 days later

ct

Limited non-enhanced CT revealed a large right iliac fossa heterogenous walled-off collection containing multiple air foci and air-fluid levels (abscess formation) in the vicinity of the inflamed and thickened appendix. The Appendix could not be defined separately from the collection. This is associated with marked stranding of the surrounding fat planes and minimal heterogeneous free fluid collection. Reactive thickening of small bowel loops, cecum, and ascending colon was also noticed.

ultrasound

Right iliac fossa ultrasound scanning revealed heterogenous amalgamated thickened bowel loops with a thick heterogenous collection showing increased echogenicity and debris.

Ultrasound-guided pigtail insertion and evacuation of the collection were done.

ct

Post appendicular abscess drainage using image-guided with pigtail insertion and evacuation of the collection.

Case Discussion

These findings described at the level of the right iliac fossa are compatible with complicated acute appendicitis not improved on medical treatment, presented 5 days later with large appendicular abscess.

Appendicular abscess is the most common complication of acute appendicitis following perforation of the inflamed and distended appendix. The appearance of multiloculated heterogeneous collection is identified with air/fluid levels. The related mesentery and peritoneum show thickening and smudging giving the possibility of perforated appendicitis with a large abscess formation.  

An appendicular abscess can be managed by either surgical drainage or better by image-guided percutaneous drainage as in this case.

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