1161

CT in the Management of
Periappendiceal Abscess

Jerome A. Barakos1 Abdominal CT was the primary diagnostic method used to evaluate 40 patients with
R. Brooke Jeffrey, Jr.2 suspected periappendiceal abscess. Its subsequent impact on patient management was
Michael P. Federle2 then analyzed for several categories of clinical presentation, including patients with and
without a palpable right-lower-quadrant mass and postoperative patients. CT was
Vivian W. Wing2
reliable in distinguishing penappendiceal abscesses from phlegmons; 17 of 18 patients
Faye C. Laing2
with phlegmons responded promptly to antibiotic therapy alone without need for surgery.
Daniel R. Hightower2
Patients with larger, poorly localized abscesses underwent early surgical drainage. CT
was successful in guiding percutaneous catheter drainage (nine patients) or aspiration
(one patient) of well-localized penappendiceal abscesses in 10 of I I patients. One
attempted catheter drainage guided by sonography was technically unsuccessful. In
patients without a palpable right-lower-quadrant mass, CT was helpful in establishing
the diagnosis of periappendiceal inflammation. However, there were three false-positive
diagnoses in patients with pericecal fluid collections including a ruptured cecal lym-
phoma, a ruptured cecal diverticulum, and a ruptured corpus luteum cyst. A diagnostic
approach with CT is presented in patients with suspected penappendiceal abscess.

Periappendiceal abscesses or phlegmons occur in 2%-7% of all patients with

acute appendicitis [1 -3]. In some patients the diagnosis is apparent on the basis
of a typical history for acute appendicitis and a palpable nght-lower-quadrant mass.
However, in patients without a palpable right-lower-quadrant mass, the diagnosis
is often less certain, and peniappendiceal abscess is only one of a number of
important diagnostic considerations.
The surgical management of patients with suspected periappendiceal abscess
and a palpable right-lower-quadrant mass remains quite controversial [1 -9]. Al-
though some surgeons prefer immediate surgical exploration with drainage and
appendectomy, others have emphasized the high frequency of postoperative
complications after early surgery [3, 7, 9] and prefer an initial trial of nonoperative
management with antibiotic therapy. A main factor in this controversy has been
the inability of surgeons to clinically distinguish a true periappendiceal abscess
from a phlegmon [i 0, 1 1 . A second factor has been the limited information provided
by barium enemas regarding the nature and extent of the penappendiceal inflam-
matory process [12].
CT has the potential advantage of directly imaging
the periappendiceal area, and
ReceivedNovember 25, 1985; accepted after
it can distinguish a phlegmon from a liquefied CT may provide a fuller
abscess.
revision January 29, 1986.
1 lktiversity of Southem California Medical assessment of the extent of periappendiceal inflammation by defining cul-de-sac
School, Los Angeles, CA 90033. and/or retropenitoneal extension. In patients without a palpable right-lower-quad-
2Department of Radiology, University of Califor- rant mass, CT may aid in resolving diagnostic dilemmas by demonstrating findings
nia, San Francisco, San Francisco General Hospital, of localized periappendiceal inflammation. In appropriate patients, CT may guide
1001 Potrero Ave., San Francisco, CA 94110. Ad- percutaneous drainage of periappendiceal abscesses as an alternative to surgical
dress reprint requests to A. B. Jeffrey, Jr.
drainage.
AJR 146:1161-1164 June 1986
0361 -803X/86/1 466-1161
The CT appearance of periappendiceal abscesses has previously been described
© American Roentgen Ray Society [13-15]. To better assess the role of CT in the management of patients with
ii 62 BARAKOS ET AL. AJR:146, June 1986

Fig. 1 .-Nonrotation of small bowel

with left-sided periappendiceal phlegmon
and abscess. Patient presented as diag-
nostic dilemma, owing to left-sided pain.
A, Large left-lower-quadrant phlegmon
(arrows). Note midline cecum (open ar-
row) and small intestine in right-lower
quadrant (asterisk). Scan 2cm caudal (B)
shows abscess (A) with well-defined low-
density areas and gas bubbles.

suspected penappendiceal abscesses, we reviewed our ex-

perience with 40 patients.

Materials and Methods

Abdominal CT scans and medical records were reviewed in 40

patients evaluated by CT for suspected penappendiceal abscesses.
The ages of the ii female and 29 male patients ranged from 9 to 75
years (mean, 39 years). Thirty-one patients (77%) presented with
fever and right-lower-quadrant pain for more than 72 hr.
The patients in this series were divided into three categories based
on their clinical presentation. Group 1 consisted of 1 4 patients thought
to have a high probability for periappendiceal abscess based on a
typical history for appendicitis and the presence of a palpable right- Fig. 2.-Pericecal phiegmon. CT shows soft-tissue in-
flammatory mass (arrows) adjacent to cecal tip (C).
lower-quadrant mass. Group 2 consisted of 19 patients with a history
compatible with acute appendicitis and a penappendiceal abscess
but who lacked a palpable right-lower-quadrant mass. The diagnosis
of periappendiceal abscess remained uncertain in this group of pa- resolution of both the right-lower-quadrant mass and clinical
tients, and a number of other diagnostic possibilities were considered. symptoms. All four patients were then readmitted 4-6 weeks
Group 3 consisted of seven patients with suspected postoperative
later for elective appendectomy.
periappendiceal abscesses after routine appendectomy.
Six patients in Group 1 had CT evidence of localized
Patients were categorized as having either penappendiceal ab-
scesses or phlegmons. Patients demonstrating areas of both abscess periappendiceal abscesses. Five patients underwent either
formation and phlegmon were categorized as having abscesses (Figs. successful percutaneous catheter drainage (Figs. 3A and 3B)
1A and iB). The CT criteria for a penappendiceal abscess included or guided-needle aspiration (one patient with a small abscess).
the following: (1) a well-defined pericecal low-density area with CT In one patient undergoing percutaneous abscess drainage
numbers less than 20 H with or without gas bubbles, and (2) the guided by sonography, the back wall of the abscess cavity
presence of mass effect on the cecum and/or adjacent bowel loops was inadvertently perforated resulting in peritonitis and need
and an enhancing rim. Criteria for CT diagnosis of a periappendiceal for emergency laparotomy. The other five patients underwent
phiegmon included: (1) ill-defined soft-tissue density mass (greater elective appendectomy 4-6 weeks after being discharged.
than 20 H), and (2) no discrete low-density areas or gas bubbles
Four patients in Group 1 had CT evidence of extensive or
(Fig. 2).
poorly localized periappendiceal abscesses with either retro-
peritoneal or pelvic extension (Fig. 4). All four patients under-
Results went laparotomy within 24 hr of CT with confirmation of a
periappendiceal abscess.
Group 1: Palpable Right-Lower-Quadrant Mass

Among the 1 4 patients in Group 1 CT demonstrated , a

Group 2: No Palpable Right-Lower-Quadrant Mass
periappendiceal phlegmon in four patients, a localized periap-
pendiceal abscess in six patients, and poorly localized periap- Among the i 9 patients in Group 2, CT demonstrated per-
pendiceal abscess with either pelvic (three patients) or retro- iappendiceal inflammatory changes in 17 patients. In the
peritoneal (one patient) extension. All i 4 patients in Group 1 remaining two cases, CT excluded a periappendiceal abscess
were initially treated with IV antibiotic therapy. The four pa- and correctly diagnosed a ruptured ovarian cyst in one case
tients with CT evidence of a periappendiceal phlegmon were and a small bowel obstruction in another patient. Both these
successfully managed with antibiotic therapy with prompt diagnoses were confirmed at surgery. In one patient with a
AJR:146, June 1986 CT OF PERIAPPENDICEAL ABSCESS 1163

Fig. 3.-Percutaneous drainage of

penappendiceal abscess. A, Well-local-
ized abscess (arrow). B, After catheter
drainage, abscess cavity resolved.

Group 3: Suspected Postoperative Abscesses

Five patients in Group 3 had CT evidence of postoperative

periappendiceal phlegmons without an In four of
abscess.
these patients, symptoms were relieved with antibiotic ther-
apy without surgical intervention. One patient on antibiotics
who had persistent low-grade fever and pain underwent
surgical exploration, which revealed no evidence of an ab-
scess and only a phlegmon with pencecal adhesions. This
patient ultimately responded to antibiotic therapy and no
further surgery was performed.
Two patients had localized postoperative penappendiceal
abscesses after appendectomy. Both patients successfully
Fig. 4.-Large pelvic extension from ruptured appendix. CT
underwent percutaneous catheter drainage under CT guid-
shows periappendiceal abscess (arrow) with pelvic extension
(asterisk). ance.

history compatible with a penappendiceal abscess and left-

Discussion
lower-quadrant pain, CT demonstrated nonrotation of the
small bowel with a left-lower-quadrant abscess adjacent to Localized perforations of the appendix may become walled
the cecum located in the midabdomen. A correct diagnosis of off from the rest of the pentoneal cavity by adjacent omentum
a left-sided penappendiceal abscess was made and confirmed and small-bowel loops resulting in a palpable right-lower-
by surgery (Fig. 1). quadrant mass. Surgical management of patients with an
Nine patients in Group 2 had CT evidence of a periappen- appendiceal mass remains controversial, and several authors
diceal phlegmon. All nine patients responded to antibiotic have noted that it is virtually impossible to distinguish a
therapy alone. Elective appendectomy was then performed in penappendiceal phlegmon from a true abscess on clinical
seven patients 4-6 weeks after they were discharged; the grounds alone [7, 1 0]. This is underscored by the fact that in
other two patients were lost to follow-up. recent surgical series early operation for “appendiceal ab-
Of the remaining eight patients, three had well-localized scess” in fact revealed no evidence of drainable pus and only
penappendiceal abscesses that were successfully drained a phlegmon in 45% of patients at laparotomy [3]. Because of
percutaneously with CT guidance. Two patients underwent an unacceptably high complication rate with early surgery (up
elective appendectomy 4-6 weeks after they were dis- to 36% in some series) [3, 7, 9], many surgeons prefer initial
charged, and one patient was lost to follow-up. nonoperative management with antibiotic therapy followed by
Five patients had extensive or poorly defined periappendi- interval appendectomy 4-6 weeks later.
ceal abscesses with pelvic extension diagnosed by CT. All CT appears to be a reliable method for distinguishing
five patients underwent surgical exploration within 24 hr of penappendiceal abscesses from phlegmons. Of the 18 pa-
CT. Surgery confirmed penappendiceal abscesses in two tients with CT evidence of penappendiceal phlegmons, i7
patients. However, in the remaining three patients surgery responded to antibiotic therapy alone without the need for
revealed a ruptured cecal diverticulum with a pencecal ab- surgical or percutaneous intervention. In the one remaining
scess, a ruptured cecal lymphoma with a pencecal abscess, patient with persistent low-grade fever and right-lower-quad-
and a ruptured corpus luteum cyst with sterile pericecal fluid, rant pain, surgery revealed only pencecal adhesions and no
respectively. evidence of an abscess.
1164 BARAKOS ET AL. AJR:146, June 1986

Twenty patients in the series had CT evidence of a periap- of a penappendiceal abscess was uncertain. In this group,
pendiceal abscess. This was confirmed in 1 8 patients (89%) CT may help to establish the diagnosis by demonstrating a
by either percutaneous drainage, aspiration, or surgery. Two periappendiceal inflammatory process. As with a barium
additional patients had abscesses in the region of the appen- enema, however, false-positive diagnoses may be encoun-
dix that were not caused by appendiceal perforation but by tered in a few patients [12]. CT also was valuable in excluding
other disorders of the cecum. One patient had a ruptured periappendiceal inflammation in two patients and in success-
cecal lymphoma and another had a ruptured cecal diverticu- fully diagnosing a small-bowel obstruction in one patient and
lum both mimicking the CT appearance of a penappendiceal a ruptured ovarian cyst in another. In patients with postop-
abscess. A third patient had a ruptured corpus luteum cyst erative complications after appendectomy, CT may be useful
with sterile pericecal fluid and no evidence of an abscess. in again demonstrating either periappendiceal abscesses or
Therefore, it is important to emphasize that the mere dem- phlegmons and in guiding postoperative drainage of localized
onstration of an abscess or fluid collection in the region of the abscesses.
cecum is not conclusive evidence for a penappendiceal ab-
scess. Despite the CT errors in these three patients, two
patients nonetheless required surgical intervention for drain-
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