A 55-year-old woman presents with right iliac fossa pain for 3 days. CT abdomen shows a perforated appendix with a well-defined right iliac fossa abscess measuring 4.5 cm. She is hemodynamically stable and afebrile on antibiotics. The most appropriate management per current WSES 2020 appendicitis guidelines for this presentation is:

• A Emergency appendicectomy with peritoneal lavage
• B Interval appendicectomy after 6-8 weeks of IV antibiotics alone
• C Conservative management with oral antibiotics only; no drainage
• D CT-guided percutaneous drainage of the abscess + antibiotics; interval appendicectomy at 6-8 weeks is optional and guided by clinical course ✓

Explanation

For appendiceal abscess/phlegmon (peri-appendiceal collection, hemodynamically stable), WSES 2020 and EAST guidelines recommend non-operative management: percutaneous drainage if abscess ≥3-4 cm + IV antibiotics, followed by interval appendicectomy at 6-8 weeks. Meta-analyses show that interval appendicectomy may not be mandatory in all patients (10-20% recurrence rate in 5 years without it) — risk-benefit must be discussed with the patient. Emergency appendicectomy for a contained abscess increases complication rates significantly. The key indication for urgent surgery is diffuse peritonitis or hemodynamic instability, not a contained abscess.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.