“INTERVAL APPENDECTOMY'S ROLE AND PROCEDURE IN TERTIARY

CARE FOLLOW-UP CASES OF APPENDICULAR MASS AND ABSCESS

IN KALABURAGI”

First Author DR.SANJEEV Y PATIL, Associate Professor,7210000891

Second Author DR. PALLAVI A.G, Post graduate,8088413950

Third Author DR.MOHD UMAR FAROOQUE, Post graduate,8147078203

Name of DR. PALLAVI A.G, Post graduate,8088413950

Corresponding
Author
DR.SANJEEV Y PATIL¹, DR. PALLAVI A.G², DR.MOHD UMAR FAROOQUE³
1. Associate Professor-Department of General Surgery, Basaveshwara Teaching and General Hospital, Attached
Mahadevappa Rampure Medical College, Kalaburagi.
2. Post graduate, Department of General Surgery, Basaveshwara Teaching and General Hospital, Attached
Mahadevappa Rampure Medical College, Kalaburagi.
3. Post graduate, Department of General Surgery, Basaveshwara Teaching and General Hospital, Attached
Mahadevappa Rampure Medical College, Kalaburagi.
ABSTRACT
Introduction: One of the most frequent side effects observed in individuals
who appear a few days following the onset of acute appendicitis is an
appendicular tumor. Appendectomy is seen to be the best course of action
for treating acute appendicitis; if this is not done, a number of complications,
including an appendicular mass, typically arise. Historically, the diagnosis of
acute appendicitis was primarily made through repeated physical
examinations following active observation, with minimal dependence on
laboratory testing. Increased dependence on putatively objective tools for
the diagnosis can delay the diagnosis and has changed the outlook for some
patients.
Complicated appendicitis develops from uncomplicated, basic acute
appendicitis due to delayed diagnosis. In a country where the majority of
people live in poverty and one person may provide all of the family's
income, reluctance to get surgery is prevalent. This is why some people find
it challenging to take time off from work. A significant contributing aspect is
that a large portion of the populace generally fears surgery.The absence of
medical facilities in isolated, underdeveloped locations is one of the
additional variables that leads to the development of an appendicular mass.
Instead of referring a patient to a higher-level hospital, general practitioners
in certain rural areas frequently maintain them on symptomatic therapy.
Aim of the Study: This dissertation aims to investigate the role of interval
appendicectomy by analyzing the follow-up cases of treated instances of
appendicular mass and abscess. to evaluate and contrast the clinical
outcomes of conservatively and surgically treated appendicular masses and
abscesses. to evaluate the function and advantages of interval
appendicectomy while these cases are being followed up on.

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Material and Methods: • Study location: Kalaburagi's,Basaveshwara
Teaching and General Hospital, which is attached to MahadevappaRampure
Medical College. • Research period: November 1, 2022–August 31, 2023 •
Prospective research is the study design. • Data analysis: Data will be
recorded into MS Excel, tabulated, and analyzed using the proper statistical
test. • Sample size: All patients admitted to various surgical wards during
the study period, diagnosed cases of appendicular mass and abscess are
considered.
Results:Because of its low conversion rate, lower recurrence, lower
complication rate, and shorter hospital stay, interval appendicectomy is seen
to be advantageous in cases of severe appendicitis that are treated
conservatively.

KEY WORDSAppendicectomy, Abscess, the lumen.

Midgut organ, This poses cavity,
Abdominal a risk of
Mesoappendix appendix perforation.
INTRODUCTION
The omentum and small bowel
One of the most common acute
surround the inflamed appendix as
surgical diseases is acute
a natural defense mechanism,
appendicitis. An inflammatory trying to keep the infection from
mass or confined abscess, which spreading by separating the
frequently manifests as a palpable irritated organ from the remainder
mass a day after the onset of of the abdominal cavity. This type
symptoms, may occasionally be of defense system may have been
formed by the patient's own chosen due to an evolutionary
defense mechanism in cases of benefit.
acute appendicitis.
Typically, the patient has a right
In 2 to 7% of all episodes of iliac fossa painful mass along with
appendicitis, there is an fever, malaise, and anorexia. In the
appendicular mass. Children and event that this walling of
the elderly are more susceptible, mechanism fails, widespread
and their diagnosis of acute peritonitis could result. This is most
appendicitis may be missed or frequently observed in cases with
delayed. faecolith blockage of the
appendicular lumen,
48 to 72 hours following the onset immunocompromised patients,
of acute appendicitis symptoms is advanced age, diabetes mellitus,
when the mass often develops in and when the inflamed appendix is
the right iliac fossa. The mass lying freely in the pelvis and cannot
appears when ischemia necrosis be fully encircled by the omentum.
and gangrene of the appendicular
wall result in appendicitis, which is ANATOMY & EMBRYOLOGY
then produced by obstruction of At eight weeks of pregnancy, the
appendix-a midgut organ-is first

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identified as a little pouching of the these are fecal stasis and fecoliths,
cecum. As the pregnancy goes on, but other potential causes include
the cecum rotates medially and ascaris parasites, lymphoid
settles into the right lower hyperplasia, neoplasms, fruit and
quadrant of the belly, causing the vegetable debris, and barium
appendix to grow longer and more ingestion.
tubular.
Because of the columnar
epithelium, neuroendocrine cells,
and goblet cells that produce
mucin that line the tubular
structure, the appendiceal mucosa
has a colonic appearance. The
appendix is a midgut organ that
receives its blood supply from the
superior mesenteric artery. One of
the main named branches of the
superior mesenteric artery, the
ileocolic artery, is the source of the
appendiceal artery, which passes
through the mesoappendix. The Pathophysiology And
lymphatics of the appendix are also
located in the mesoappendix, and
they accompany the blood flow
from the superior mesenteric
artery to the ileocecal nodes.
Adults usually have an appendix
that is 9 cm long, though it can
vary in length from 5 to 35 cm.
Antibiotic treatment for
appendicitis-related infections
should consider both gram-
negative and gram-anemophilous
bacteria. These infections should
be considered polymicrobial.
Common isolates include
Escherichia coli, Bacteroides
fragilis, enterococci, Pseudomonas
aeruginosa, and others. There are
numerous causes of luminal
obstruction. The most common of

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Pathogenesis of The Ÿ Localized tenderness in right iliac
Appendicular Mass fossa
Following an acute episode of Ÿ Muscle guarding

appendicitis, the appendicular Ÿ Rebound tenderness

mass usually manifests as a sore SIGNS TO ELICIT APPENDICITIS

lump in the right iliac fossa, with a COPES PSOAS TESTPain on extension
size that can vary from a phlegmon of the right thigh: retroperitoneal
to an abscess (Brown CV et al retrocaecal appendix.
2003). It usually appears in
OBTURATOR TEST:- Pelvic appendix
patients who report later in the
pain on internal rotation in the
course of acute appendicitis
right thigh ROVSING SIGNWhen the
because the omentum and small
left iliac fossa is pressed, there is
bowel coils in the appendix area
pain in the right iliac fossa because
automatically seal off the inflamed
the intestinal loops are shifting and
appendix.
irritating the parietal peritoneum.
At first, this mass is made up of a DUNPHYS SIGN:- Coughing causes
confused mixture of granulation increased pain in the right iliac
tissue and an inflammatory fossa.
appendix (Brian W. Ellis and Simon
–Paterson Brown 2000). If the ARON SIGN: discomfort and pain in
barriers hold and the inflamed the epigastrium upon applying
appendix does not rupture, a pressure above McBurney's point.
clinically palpable painful mass THE BLUMBERG SIGN:release sign
develops in the right iliac fossa because an organ underneath it is
within 48 hours. If the appendix irritated.
ruptures or the defenses are
ALDER'S SIGN
unable to control the inflammation,
(DIAGNOSE APPENDICITIS IN
an appendicular abscess may PREGNANCY)
develop. Mark the area that is the most
Physical Examination tender first. When the patient is
CLINICAL PRESENTATION turned to the left, the appendix
SYMPTOMS pain stays in the same location, but
Ÿ Peri umbilical pain the uterine origin's tenderness will
Ÿ Pain shift to right iliac fossa change.
Ÿ Anorexia

Ÿ Nausea and vomiting

MURPHYS TRIAD
Ÿ Pain Differential Diagnosis Gastro-
Ÿ Vomiting intestinal
Ÿ Temperature Cholecystitis Diverticulitis The
SIGNS OF APPENDICITIS diverticulitis of Meckel Enteritis
Ÿ Pyrexia

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stomach ulcer Intussusception to the right; • Preperitoneal fat
intestinal lymphadenopathy widening; • Right lower quadrant
Enterocolitis with necrotizing mass indenting the caecum; •
Omentum Torsion Acute Blurring of the right psoas shape;
Pancreatitis Bowel perforation • Appendix gas
volvulus Neoplasm (carcinoid,
carcinoma, lymphoma) Ultrasound
GYNECOLOGICAL Unwanted For people experiencing
conception Endometriosis Torsion abdominal discomfort,
of the ovaries Inflammatory illness ultrasonography has a sensitivity
of the pelvis An ovarian cyst bursts of over 85% and a specificity of
ovarian tubo abscess over 90% when diagnosing acute
Systemic Cause appendicitis.
Acidosis keto in diabetics Porphyria Ultrasound Findings
Anemia with sickle cells Pleurisy
Genito-urinary prostatic and • A tubular structure that is blind and ends
pyelonephritic kidney stones at the tender point • Non-compressible
urinary tract infection infection of oedema of the caecal pole • Diameter 7
parasites mm or more •No peristalsis •Appendicolith
Abscess of Psoas Hematoma producing an acoustic shadow high
Torsion of the testicles echogenicity non-compressible
INVESTIGATIONS surrounding fat •Surrounding fluid or
abscess; •One assertion is that the
Lab Investigations sensitivity is approximately 90%. Recall
The overall count significantly that there are difficulties with diagnosing
rose, with a range of 8000 to appendicitis with ultrasonography.
14000/mm3. An increase in gangrenous or perforated appendicitis,
neutrophil counts (Shift to left) retrocaecal appendicitis, appendicitis of the
Increased CRP suggests appendiceal tip, and orgas loaded appendix
inflammation. Analyzing urine to are among the scenarios that can result in
rule out urinary tract infections. false-negative exams.

RADIOGRAPHIC STUDIES

Plain X-ray Film

•Sentinel loop: a fluid level in the
ileum with dilated atonic ileum;
dilated caecum; appendix
calculus measuring between 0.5
and 6 cm; right lower quadrant
hazy from fluid and edema •
Present scoliosis that is concave

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 appendectomy beneficial for both
gynecological disorders and young
girls

ALVARADO SCORE: To aid in

diagnosis, a variety of scoring
systems based on clinical and
laboratory settings have been
developed. The Alvarado score is
the most commonly utilized.
Alvarado Score

Computed Tomography (C.T)

Spiral CT scans are more accurate
than axial CT scans in
appendicitis. Comparing oral and
IV contrast to a non-contrast CT
scan yields more accurate results.
C.T. FINDINGS IN APPENDICITIS:
• Appendicolith is present •
Appendix diameter is greater than
6 mm • Oral contrast or air does
not fill the appendix • IV contrast
enhances the appendix wall Fluid,
thick caecum, appendicular mass,
Management-Medical
fat attenuation, gas in the extra
Management
luminal space, and swollen lymph
Ochsner Sherren Regime
nodes. 100% Specificity and
Historically, it was believed that
sensitivity are 100% blocked, with
because of edoema and the
the caecal lumen oriented brittleness of the structures,
towards the appendix's orifice. appendicular mass surgery was
dangerous and may lead to
potentially fatal consequences.
The necessary elements consist
of
Ÿ Positioning the patient to
enhance the exudates' gravity
flow towards the pelvis
Diagnostic Laparoscopy
Ÿ 0 for the first 48 hours per oral
It helps with cases that are unclear.
Ÿ intravenous liquids
Prevent unwarranted Ÿ intravenous antibiotics

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 Ÿ Calculating the mass's laparoscopy has become more
dimensions After six weeks, if the common. By allowing for a quicker
patient continues to progress, hospital stay and an earlier return
orals are recommended along to work, laparoscopic operations
with an interval appendicectomy. reduce the number of lost earning
Ÿ If therapy doesn't work, surgery days. Because the majority of them
is done. are daily wage workers in India, it
is helpful there.
Operative Management
An appendicectomy is the therapy DISCUSSION
for appendicitis. Preoperative work  Both complicated and
up should be done correctly. uncomplicated acute
1. IV fluid administration should start. appendicitis are the most
monitoring of blood pressure, common cause of severe
pulse, and urine production. Any abdominal pain.
irregularities in electrolytes should  An appendix inflammation may
be rectified. sometimes be accompanied with
a restricted abscess or an
2. Antibiotics ought to be inflammatory phlegmon. The
administered prior to the half-hour best course of action for these
mark of anesthetic induction. patients is up for debate.
Treatment for these patients is
3. Antibiotic should cover both gram-
either conservative or surgical.
negative bacteria and anaerobes
 In order to assess the
4. There should not be any delay in effectiveness of interval
surgery to minimize the chances of appendicectomy and its
perforation. necessity, this study will follow
patients who have been
Numerous researches have been diagnosed with appendicular
carried out globally; some have mass or abscess and are
endorsed and bolstered undergoing either conservative
laparoscopy, while others have not. or surgical treatment (drainage).
Laparoscopy can be used to treat  The study includes all patients
acute appendicitis in the majority diagnosed with appendicular
of cases. Compared to open mass or abscess who are
appendicectomy, laparoscopic admitted to surgical wards.
appendicectomy is less risky and  Without undergoing an
has less pain and morbidity after appendicectomy, patients in this
surgery. A laparoscopic group are treated conservatively
appendicectomy can shorten or with surgical drainage.
hospital stay, allow for an early  About fifty individuals with
return to work, and result in fewer complex appendicitis were
problems. Due to improved training advised to have surgical
drainage or conservative therapy
in minimum access surgery,
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 in this study. These people were in the following order based on
watched for around three the duration of their stay.
months. Some of the patients 7 3
got interval appendicectomy Days
during the procedure, while 6 6
others underwent conservative Days
line of treatment. 5Days 16
 Of the fifty patients that were 4 7
part of the trial, twenty-one were Days
female and 29 were male. The 3 8
majority of hospitalized patients Days
with appendicitis were between
the ages of 20 and 30 (about  Of the 42 cases, six interval
54%), then between 30 and 40 appendicectomy patients had
(28%), and finally older than 40 postoperative complications like
and younger than 20. Out of the fever, wound infection, and
50 patients admitted, 28 wound gaping. Furthermore, it
patients had an appendicular was found that five patients had
mass identified either normal histology findings
radiologically or clinically; demonstrating total infection
roughly 22 people had this remission, demonstrating the
diagnosis. Every patient with efficacy of cautious antibiotic
appendicular abscesses treatment. The incidence of
underwent surgical drainage and complications was somewhat
underwent three months of higher than in cases involving
follow-up care. traditional appendicectomy.
 The following is the breakdown  Of the eight participants who did
of the procedures performed on not get interval appendicectomy,
the about 42 patients who had there was no record of
interval appendicectomy. A recurrence.
conservative course of treatment  With all of this information,
was continued for the eight interval appendicectomy might
patients who remained. 33 not be required in a case of
patients had laparoscopy; 2 had severe appendicitis that is
open surgery; and 7 had lap treated conservatively.
conversion to open surgery.
 The conversion rate from
laparoscopic appendicectomy to CONCLUSION
open method was slightly In our study, conservative care
greater than in individuals with with interval appendectomy for the
acute appendicitis. management of appendiceal
 The hospital stays varied in mass/abcess shown a lower
duration from three to seven incidence of recurrence and
days. The patients are arranged negligible consequences.

8
Considering all of these data, resolution of an appendiceal mass questioned.
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