A 22-year-old woman presents with 36 hours of right iliac fossa pain with a palpable mass in the RIF on CT (appendix not visualised; heterogeneous inflammatory fat stranding with a central 3 cm fluid collection adjacent to the caecum). Her temperature is 37.8°C and WCC 14,000/μL. She is haemodynamically stable. According to the 'APPAC' trial evidence and WSES guidelines, the most appropriate initial management is:
- A Emergency appendicectomy to prevent perforation
- B Interval appendicectomy always at 6–8 weeks after conservative treatment
- C Non-operative management (IV antibiotics ± CT-guided drainage of the collection) with interval appendicectomy considered only if symptomatic recurrence occurs ✓
- D Immediate laparoscopic right hemicolectomy to exclude Crohn's disease or carcinoma
Explanation
For appendiceal mass (phlegmon or periappendiceal abscess), the WSES guidelines and evidence from multiple studies (including the APPAC randomised trial for uncomplicated appendicitis managed non-operatively) support initial non-operative management: IV antibiotics and CT-guided percutaneous drainage for abscesses >3 cm. The majority of patients (approximately 80%) resolve without surgery. Interval appendicectomy is no longer universally recommended; it is performed selectively only for patients with recurrent symptoms or findings suggesting an underlying neoplasm. The recurrence rate after successful conservative management is approximately 15–20% over 5 years. Emergency surgery through an inflammatory mass risks enterotomy and complex procedures.
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.