A 27-year-old man presents to the emergency department with a 5-day history of abdominal p… — USMLE Step 3

A $27$ -year-old man presents to the emergency department with a $5$ -day history of abdominal pain. The pain initially began around his umbilicus and was associated with nausea and two episodes of nonbloody emesis. Three days ago, the pain migrated to the right lower quadrant and became more constant. Yesterday, he felt slightly better, but today he developed a fever and worsening, severe right lower quadrant pain. Temperature is $38.8^\circ\text{C}$ ( $101.8^\circ\text{F}$ ), blood pressure is $122/78\text{ mmHg}$ , pulse is $112/\text{min}$ , and respirations are $18/\text{min}$ . Physical examination reveals a palpable, tender, $6\text{ cm}$ mass in the right lower quadrant. Bowel sounds are hypoactive. Laboratory studies show a leukocyte count of $17,200/\text{mm}^3$ with a neutrophil predominance. Computed tomography of the abdomen and pelvis with intravenous contrast reveals a ruptured appendix with an adjacent $5.2\text{ cm}$ rim-enhancing periappendiceal fluid collection. Which of the following is the most appropriate next step in management?

Intravenous antibiotics and percutaneous fluid drainageAnswer
B
Immediate laparoscopic appendectomy
C
Colonoscopy with random mucosal biopsies
D
Magnetic resonance imaging of the abdomen and pelvis
E
Discharge home with a $14$ -day course of oral antibiotics

Answer

Intravenous antibiotics and percutaneous fluid drainage

The correct approach to a patient presenting with appendicitis symptoms for more than

5

days and a confirmed abscess larger than

3\text{ cm}

is nonoperative management with intravenous antibiotics and percutaneous image-guided drainage. In delayed presentations, the body has walled off the perforation, creating a mass of inflamed tissue and adherent bowel loops (phlegmon or abscess). Attempting an immediate appendectomy in this setting is technically difficult and carries a high complication rate, including iatrogenic enterotomy and the unintended need for an ileocecectomy or right hemicolectomy. After successful percutaneous drainage and resolution of the acute infection, the patient can be evaluated for an elective interval appendectomy several weeks later.

Step-by-Step Solution

Analyze the clinical presentation and timeline.

The patient has a

5

-day history of RLQ pain, fever, tachycardia, and a palpable mass, suggesting a delayed presentation of appendicitis with complication.

Establishing the timeline of appendicitis is critical, as management changes significantly if symptoms have been present for

>5

days.

Interpret the imaging findings.

CT scan confirms a ruptured appendix with a

5.2\text{ cm}

abscess.

Fluid collections

>3\text{ cm}

require different management than small phlegmons or early, uncomplicated appendicitis.

Select the appropriate procedural intervention.

Choose percutaneous CT-guided drainage combined with IV antibiotics over immediate surgery.

Immediate surgery in the setting of a large, late-presenting abscess carries a high risk of bowel injury and the need for ileocecal resection due to severe inflammation.

Key Concept

Management of late-presentation appendiceal abscess

Estimated Time:1m 0s

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