Complications of acute appendicitis

Appendicular mass. In majority of cases as soon as the appendix becomes gangrenous, omentum and coils of small intestine cover the appendix all around. There is no discrete collection of pus inside. This is an attempt of the nature to prevent general peritonitis even if rupture of the appendix occurs. Usually such appendicular mass develops on die 3^rd day after the commencement of an attack of acute appendicitis. This is a tender mass on the right iliac fossa. This mass usually resolves by conservative treatment. In untreated cases when the patient does not react to the conservative treatment such appendicular mass may turn into an appendicular abscess and becomes larger in size.

Treatment of the appendicular mass. In these cases conservative treatment should be started immediately. Surgery at this stage is difficult and dangerous as it is difficult to find appendix due to adhesions and ultimately faecal fistula may form.

Conservative treatment includes intravenous fluid with dextrose saline and Ringer solution as and when required; nasogastric aspiration; antibiotic therapy. A broad - spectrum antibiotic should be given intramuscularly. Metronidazole may be given intravenously.

The conditions for stopping the conservative treatment are: a) arising pulse rate; b) vomiting or increase in gastric aspiration; c) increasing abdominal pain – suggesting spreading peritonitis; d) mass becomes larger in size.

About 90% of cases resolve without any problem. The patient is kept under observation for further 4 to 5 days after resolution of the mass. Patient is instructed to have appendectomy 6 to 8 weeks after his discharge.

Appendicular abscess. A progressive supportive process in an appendicular mass forms an appendicular abscess walled off by the omentum, inflamed caecum and coils of small intestine. Such abscess may follow rupture of the appendix. The most common site of the abscess is in the lateral part of the iliac fossa (from retrocaecal appendicitis). The second common position is in the pelvis. In untreated cases lethal form of peritonitis is produced by secondary rupture of appendicular abscess.

At abscessing of infiltrate the condition of a patient gets worse, the symptoms of acute appendicitis become more expressed, the temperature of body, which in most cases gains hectic character, rises, the fever appears. Next to that, pain in the right iliac region increases. Painful formation is felt there. In the blood test high leukocytosis is present with the acutely expressed change of leukocyte formula to the left. The temperature of body rises to 38.0–39.0 °С. During the rectal examination the weakened sphincter of anus is found. The front wall of rectum at first is only painful, and then its overhanging is observed as dense painful infiltrate.

Treatment of appendicular abscess. Immediate drainage under antibiotic cover is the treatment of choice. Appendectomy is not performed. A pelvic abscess may be drained in the female into the vagina and in the male into the rectum. If the appendix is not removed when the abscess is drained, interval of appendectomy should be carried out 6 to 8 weeks after.

Pylephlebitis. Ascending septic thrombophlebitis of portal venous system (pylethrombophlebitis) is a grave but rare complication of gangre­nous appendicitis. Septic clots from involved mesenteric veins produce multiple pyogenic abscesses in the liver. It is more frequent in patients with acute retrocaecal appendicitis. It is heralded by chills, hectic fever, right upper quadrant pain and jaundice. Pylephlebitis is a complication of both appendicitis and after-operative period of appendectomy.

In case with rapid passing of disease the icterus appears, the liver is increased, kidney-hepatic insufficiency makes progress, and patients die in 7–10 days from the beginning of disease.

At gradual subacute development of pathology the liver and spleen is increased in size, and after the septic state of organism ascites arises.

Peritonitis. Peritonitis is happened when bacterial and other contents of the appendix leak into the abdomen.