The Korean J ournal of Inte rnal Medicine Vol. 14, No. 2, J uly, 1999 Ep ig a s t r ic Ap p e n d ic e a l Ab s c e s s w it h S p o n t a n e o u s Dr a in a g e in t o t h e S t o m a c h J u n g W o o k He r , M .D., J a e S e o k Hw a n g , M .D., S u n g Ho o n A h n , M .D. S o o n g Ko o k Pa rk, M .D. a n d Ho n g Kim , M .D.* Div is io n of Gast ro e nte ro logy , De p a rt m e nt of Inte rna l M e d ic ine a nd De p a rt m e nt of Rad io logy *, Ke im y u ng Un iv e rs ity S c ho o l of M e d ic ine a nd Inst it ute f o r M e d ica l S c ie nce , T aeg u, Ko re a T he ap p e nd ice a l a bs ce s s is a co m m o n co m p licat io n of ac ute ap p e nd ic it is a nd us ua lly is lo cate d in t he rig ht low e r q uad ra nt of t he abd o m e n . A n e p ig ast ric ap p e nd ice a l a bs ce s s has nev e r be e n re p o rte d at a n u n us ua l lo cat io n . W e ex p e rie nce d a n u n us ua l cas e of a 4 9 -y e a r-o ld m a n w it h a n e p ig ast ric ap p e nd ice a l abs ce s s . In it ia lly , t h is a bs ce s s w as s us p e cte d to be a p a nc re at ic a bs ce s s . A bd o m ina l CT s ca n a nd ba riu m e ne m a d e m o nst rate d a hy p e rrotate d ce c u m w it h a n ap p e nd ice a l a bs ce s s in t he lef t up p e r q uad ra nt of t he abd o m e n . A n g ast ro s co py rev e a le d a s m a ll f ist u la - like le s io n w it h p u ru le nt co at ing at t he b u lg ing p o s te rio r g ast ric w a ll. T he a bs ce s s re s o lv e d s p o nta ne o us ly . W e be lie v e t hat t he abs ce s s d ra ine d into t he sto m ac h t h ro ug h a s m a ll f is t u la betw e e n t he sto m ac h a nd abs ce s s cav ity . T he re w as no re c u rre nce f o r ov e r 6 m o nt hs . ──────────────────────────────────────────────── Ke y W o rd s : Ep ig ast ric ap p e nd ice a l abs ce s s INT RO DUCT IO N CA S E REP O RT Appendiceal abscesses represent 2.3% of all the A 49-year- old man was referred to our institution for cases of acute appendicitis 1 ) and usually present a mass further evaluation and management of an intraabdominal in the right lower quadrant2 ) . Occasionally, abscesses abscess with the air- fluid level located outside of the develop in the right subhepatic space, right greater curvature of the stomach, demonstrated on the subdiaphragmatic space and right pararenal space or abdominal CT scan checked 5 days before the referral liver3 ) . However, an appendiceal abscess located in the (Fig 1). He experienced left upper quadrant abdominal epigastric space has never been reported. The pain with fever and chills for 15 days without any management of appendiceal abscess is controversial4 ) . preceding trauma and was managed at a private clinic Recently, the ultrasonic or CT guided percutaneous without improvement of symptoms. Upon abdominal puncture technique has offered an alternative to examination, an adult fist- sized, ill- defined, round, conventional surgical treatment3 , 5 ) . We experienced a nonmovable and tender mass was palpated at the left patient with an epigastric appendiceal abscess, epigastrium. No abnormalities were observed in CBC, demonstrated by abdominal CT scan and barium enema, urinalysis, stool examination, serum amylase and liver which resolved spontaneously. chemistry. We treated the patient with intravenous antibiotics and bed rest. On the second day of hospitalization, an gastroscopy was performed which Address reprint requests to : Jung Wook Her, M.D., showed a bulging external mass effect with adherent Division of Gastroenterology, Department of Internal purulent material and mucosal friability around a Medicine, Keimyung University School of Medicine, 194 fistula- like lesion at the posterior wall of the mid- gastric Dongsan-Dong, Chung- Gu, Taegu 700-712, Korea body (Fig. 2). We took biopsy specimens which showed 82 EPIGAS TRIC APPENDICEAL ABSCESS WITH SPONTANEOUS DRAINAGE INTO THE S TOMACH Fig . 3 . A barium enema shows a hyperrotated cecum in the left upper quadrant and nonvisualization of the Fig . 1. An abdominal CT scan demonstrates an abscess appendix with mucosal irregularity and focal with the air- fluid level located outside the greater narrowing at the surrounding distal transverse curvature of the stomach (arrow). colon on the prone position (arrow). abscess pocket had subsided with surrounding inflammatory change only(Fig. 5). The patient was discharged on the tenth day of hospitalization and has remained well for over 6 months. Fig . 2 . A gastroscopy shows a bulging external mass effect with purulent coating and mucosal friability around a fistula- like lesion (arrow) at the posterior wall of the gastric body. necrotic tissues along with an intact gastric mucosa. Fig . 4 . A follow- up gastroscopy demonstrates focal regen- On the third day of hospitalization, a barium enema erating edematous mucosa without the bulging was performed and showed a hyperrotated cecum in the mass effect. left upper quadrant and nonvisualization of the appendix with mucosal irregularity and focal luminal narrowing at the surrounding distal transverse colon on prone position DIS C US S IO N film consistent with a hyperrotated cecum and appendiceal abscess(Fig. 3). The palpable mass associated with acute appendicitis On the fifth day of hospitalization, after conservative may consist of phlegmon or abscesses of various sizes4 ) . management, the tender mass subsided. A follow- up 2- 3% of the patients with appendicitis who are admitted gastroscopy. showed a focal regenerating edematous to the hospital have abdominal masses 4 ,6 - 8 ) and mucosa without the bulging effect noted in the initial appendiceal abscesses represent 50-89% of the patients examination (Fig. 4). A follow- up CT scan disclosed the with an appendiceal mass 4 , 9 - 1 2 ) . Complicating abscesses 83 J.W. HER, J.S. HWANG, S.H. AHN, S.K. PARK, H. KIM rather than early surgery7 , 1 1 , 1 3 ) . Initial conservative management with intravenous antibiotics, with or without percutaneous drainage of the abscess, is prudent, safe and effective 17 ) and shows a high success rate (80-90%) and low morbidity rate (15%)7 , 1 2 , 18 ) compared to the high complication rate of early surgery (15- 50%)2 , 4 , 7 , 9 ) . Guided percutaneous drainage is an effective alternative to surgical drainage3 , 5 ) . Nonoperative treatment and, if possible, ultrasonic percutaneous drainage of a verified abscess are safe procedures with few complications and late sequelae 1 2 ) . Recently, the ultrasonic percutaneous puncture technique has offered an almost atraumatic alternative to conventional surgical treatment1 4 , 19 ) . Also, CT guided percutaneous abscess drainage is an effective Fig . 5 . A follow- up CT scan shows that the abscess alternative to surgery7 , 1 7 ) . pocket subsided with only surrounding inflam- The recurrence of appendicitis after conservative matory change (arrow). treatment is between 4-80%2 ) or 0-20%1 3 ) . Sixty- six have been reported in 2.3% of all cases of acute percent of the recurrent cases occurred within 2 years of 1 3 ) appendicitis 1 ) . the initial attack . The abscess often spontaneously 1 4 ) The main manifestations of acute appendicitis are resolves or drains into the intestine with a low 1 1) fever, a palpable mass and leukocytosis4 ) . Patients often recurrence rate . have a palpable mass in the right lower quadrant (the Our case exhibited fever, chills and an epigastric appendix mass )2 ) . Rarely does the abscess form in the abscess. At first, we suspected a pancreatic abscess right subhepatic space, right subdiaphragmatic space, because of its location, and managed initially with liver or posterior pararenal space distant to the right lower antibiotics and planned percutaneous drainage. However, quadrant. Therefore, the value of aggressive radiologic the radiological studies, especially the CT scan and the work- up and follow- up can not be overemphasized in barium enema, revealed an appendiceal abscess in the suspected appendiceal abscesses, especially those left upper quadrant of the abdomen due to a hyperrotated present in locations remote from the appendix5 ) .