A 35-year-old woman presents with 3-day history of RIF pain, nausea, and low-grade fever. CT shows a periappendiceal phlegmon with a 4 cm abscess. WBC 14,000/μL, CRP 180 mg/L. She is haemodynamically stable. According to CODA trial data and current guidelines, which is the most appropriate initial management?
- A Emergency open appendicectomy and drainage of abscess
- B Percutaneous image-guided drainage + antibiotics; interval appendicectomy at 6-8 weeks ✓
- C Antibiotics alone without drainage; interval appendicectomy at 12 weeks only if symptoms persist
- D Immediate laparoscopic appendicectomy with intraperitoneal lavage
Explanation
A periappendiceal abscess > 3 cm is best managed non-operatively with CT-guided percutaneous drainage plus IV antibiotics, avoiding immediate surgery which carries risks of inadvertent bowel injury, fistula, and right hemicolectomy. After complete resolution (usually 4-6 weeks), interval appendicectomy at 6-8 weeks is performed to prevent recurrence (recurrence rate ~15-20% without interval procedure) and to exclude an underlying neoplasm (caecal or appendiceal tumour causing obstruction should be excluded, especially in patients > 40 years). The CODA trial showed antibiotics alone were non-inferior to appendicectomy for uncomplicated appendicitis, but for complicated disease with abscess, drainage remains the standard.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.