Jebmh.com Original Research Article

Appendicular Mass - Our Experience in a Tertiary Care Hospital, Andhra Pradesh, India

Ashok Prasadula1, Sree Lakshmi Prasanna Garapati2, Ankolu V. V. Siva Prasad3, Naveen Kumar Podili4, Paila Bhagyasri5

1Assistant Professor, Department of General Surgery, King George Hospital, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India. 2Postgraduate, Department of General Surgery, King George Hospital, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India. 3Postgraduate, Department of General Surgery, King George Hospital, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India. 4Postgraduate, Department of Urology, St. John’s Medical College, Bangalore, Karnataka. 5Postgraduate, Department of General Surgery, King George Hospital, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India.

ABSTRACT

BACKGROUND Appendicular mass is a well-known complication of acute appendicitis. It is Corresponding Author: conventionally treated conservatively followed by interval appendectomy. This Dr. Sree Lakshmi Prasanna Garapati, Pragathi Brundhavanam Apartments, prospective clinical study was done to evaluate the various ways of presentation, Penthouse, Kirlampudi, etiological evaluation and management of appendicular mass. Beside Ambica Sea Green Hotel, Visakhapatnam, Andhra Pradesh. METHODS E-mail: [email protected] A prospective, nonrandomized study was conducted over a 3-year period DOI: 10.18410/jebmh/2019/652 evaluating 272 cases of appendicular masses. All cases were evaluated from their Financial or Other Competing Interests: first appearance in emergency department till the end of appropriate treatment. None. They were subjected to early resuscitation, laboratory evaluation and imaging of condition with ultrasound abdomen. How to Cite This Article: Prasadula A, Garapati SLP, Sivaprasad RESULTS AVV, et al. Appendicular mass - our Among the 272 cases, 39 were diagnosed as abscess for which emergency experience in a tertiary care hospital, Andhra Pradesh, India. J. Evid. Based drainage was done. One forty-two cases were managed by conservative Med. Healthc. 2019; 6(50), 3114-3117. management followed by interval appendicectomy. Non resolving appendicular DOI: 10.18410/jebmh/2019/652 masses were evaluated for tuberculosis or malignancy by CECT abdomen, colonoscopy. Among these non-resolving masses, 67 were diagnosed to have Submission 19-11-2019, tuberculosis of ileocecal junction leading to appendicular mass, 23 were diagnosed Peer Review 25-11-2019, Acceptance 04-12-2019, to have adenocarcinoma of cecum and appendix. We noticed only one case of Published 10-12-2019. carcinoid tumour which belonged to non-resolved group. Mortality is zero.

CONCLUSIONS Appendicular mass is one of the commonest presentations of various aetiologies that affect ileocecal junction. Because of endemicity of tuberculosis and risk of malignancy in certain age groups, these should be kept in mind while evaluating these patients.

KEYWORDS Appendicular Mass, Conservative Management, Interval Appendicectomy, Tuberculosis of Ileocecal Junction

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Jebmh.com Original Research Article

BACKGROUND postoperative ward records, and death records. Data

includes gender, age, date of admission, date of surgery, Acute appendicitis i.e. acute inflammation of the appendix date of discharge or death, date of onset, and type of from mild inflammation of mucous membrane to gangrene, symptoms, presence of guarding, rebound tenderness, or perforation and peritonitis is the most common acute rigidity, abdominal quadrant (s) affected, vital signs on surgical condition.1,2,3 Regardless of the cause it is presentation including heart rate, blood pressure, and associated with definite morbidity and mortality if not respiratory rate, operative diagnosis, and surgical managed properly. These complications are more at the procedure. The results of initial complete blood counts, extremes of age and in immunocompromised patients.3,4 results of abdominal ultrasound, x-ray erect abdomen, The definite treatment of acute appendicitis is biochemical values (creatinine and potassium values) were appendicectomy to avoid complications.4 If timely also taken into consideration. Cases not resolved by initial appendicectomy is not done due to any reason 2-6% of the non operative management were evaluated by CECT patients develop a mass as one of the early complications.4 abdomen and colonoscopy in view of malignancy and On the third day (rarely sooner) of commencement of acute tuberculosis. appendicitis, a tender mass can frequently be felt in right

iliac fossa. This mass is composed of omentum, oedematous caecal wall and oedematous loop of ileum. The treatment of RESULTS

this appendicular mass is controversial and there are several 5 management options. Traditionally, those patients are Of the 272 cases that were studied, mean age of managed conservatively followed by interval presentation was 29.35 years (range from 7 to 89 years) appendicectomy 4 to 6 weeks later, believing that an early with majority of patients being males 152 (55.88%) and the appendicectomy in these cases is hazardous, time remaining 120 (47.61%) being females. The male consuming and may lead to life threatening complications predominance over female in ratio of male/female-1.2: 1. 6 such as faecal fistula. Others prefer an operative Majority of the patients 131/272 were in 21-30 years age intervention, including the drainage of the mass and group (48.16%) followed by 74/272(29.36%) in >40 years conservative treatment, and later an interval age group and 37/272 (13.60%) were in age group 10-20 appendicectomy depending on the results of colonoscopy or years. (Figure 1). barium enema which could help in excluding other underlying lesions.7 The purpose of this study is to highlight the salient causes of appendicular masses and its outcome in terms of morbidity and mortality.

METHODS

This study was conducted at King George Hospital (KGH) in Visakhapatnam, the capital of North Coastal Andhra Pradesh, during the calendar years 2013-2015. KGH is a 1085 bedded tertiary care hospital rendering services to the Figure 1. Age and Sex Distribution people of North Coastal Andhra Pradesh and adjacent districts of Orissa and Chhattisgarh. The hospital has a 24 Majority of the patients (218/272) presented with hours casualty department, 20-bedded surgical intensive classical pain of acute appendicitis, 154 patients with care unit, several open wards with capacity for around 250 vomiting, fever in 218, abdominal distension in 180 and surgical patients, and equipped with two emergency altered bowel habits in 42, and 12 patients presented with operating rooms.8 A retrospective study of 272 patients of shock due to septicaemia. 11 patients gave past history appendicular mass was done over a period of last two years tuberculosis all are which is treated according principles of (September 2016 - August 2019). RNTCP. Patients diagnosed to have acute appendicitis which is complicated by appendicular mass diagnosed by clinical Clinical Presentation Patients Affected examination and abdominal ultrasound examination were Classical migratory pain of abdomen 218 Fever 218 included. Patients with acute appendicitis in its early stages Vomiting 154 Altered bowel hobbits 42 without mass were not included. Other causes of right iliac Abdominal distension 180 fossa masses were excluded. Table 1. Clinical Presentation All cases were studied in terms of clinical presentation, radiological evaluation, operative findings and postoperative All cases of appendicular mass were initially treated course. Data was collected from outpatient department, according Ochsner Sheeren regimen. The regimen includes casualty records, emergency operation theatre, regular clinical evaluation of symptoms and vitals,

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Jebmh.com Original Research Article assessment of abdominal lump size. Patient was put on predominance is found. Majority of the patients who liquid diet and parental broad-spectrum antibiotics covering presented with lump had symptoms between 4-10 days. In gram negative and anaerobes. other studies, it was found to be 3-4 days. Reason might be Among the 272 cases, 142 were successfully treated the patient in our region coming from distant places and with Ochsner Sheeren regimen alone. And all these patients habit of getting treatment by local practitioner.9 During the were undergone interval appendectomy after 6 weeks of conservative management, appendicular abscess may resolution. The non-resolving cases (130/272) were further develop in few cases.10 In the present study, appendicular evaluated with ultrasound and CECT abdomen, colonoscopy abscess developed in 39(14.3%) of the patients who were in view of tuberculosis and malignancy. managed with either ultrasound guided drainage or Thirty-nine cases (39/130) of non-resolving cases were laparotomy drainage. In our study, 30(11.02%) cases diagnosed to have appendicular abscess as a complication returned with repeat attack of acute appendicitis and all of of appendicitis. These cases were diagnosed with ultrasound them underwent successful appendicectomy. A meta- abdomen as a failure of non-operative management. All analysis conducted over a 13 years period, including 1012 these cases underwent emergency drainage of abscess patients concluded that the interval appendicectomy was not followed by interval appendicectomy. Emergency justified, as the majority (95%) of the patients managed appendicectomy was not done in these cases because of conservatively will not develop recurrence.3 The success rate high chances of postoperative fistula and other of initial conservative management varies between 76-97%. complications. In our study 142 patients (52.22%) out of 272 were Sixty-seven cases of appendicular masses which belong successfully treated conservatively. So our success rate of to non-resolving group were diagnosed to have tuberculosis conservative management was 52.22% was not comparable as aetiology of mass by CECT abdomen and colonoscopy to other studies because of high incidence of tuberculosis in biopsy. All were put on anti-tubercular regimen for 6 months our area.11 According to the results of our study, most of the under RNTCP guidelines. Eleven of these 67 cases were patients were managed successfully by conservative known case of Koch aetiology and were treated for 9 months approach with only few needing surgery for complications. under category 2 of RNTCP. Out of these 130 cases of non-resolving group 24 were

diagnosed to have malignant pathology on biopsy and CONCLUSIONS

imaging. All these underwent right hemicolectomy.

Postoperative pathology shows 20 were having Conservative management of an appendicular mass is a adenocarcinoma of cecum and 1 case was diagnosed to have well-known entity. The patient is put on Ochsner Sherren carcinoid tumour and 3 were diagnosed to have chronic Regime and stays in the hospital for 7 to 10 days. All the inflammatory pathology. patients do not respond uniformly. In a significant number of patients, the regimen fails, and surgical intervention has Outcomes of Treatment Number of Patients to be made rather in a difficult situation. Misdiagnosis in the Resolved by Conservative Management 142 Non-Resolving Cases 130 form of ileocaecal tuberculosis, carcinoma of caecum and Appendicular abscess 39 intussusceptions is another enigma. Tubercular pathology 67 Malignant pathology 21 Table 2. Outcomes of Appendicular Masses

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Jebmh.com Original Research Article

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