A 32-year-old man comes to the emergency department complaining of right lower quadrant ab… — USMLE Step 3

A 32-year-old man comes to the emergency department complaining of right lower quadrant abdominal pain that has been progressively worsening over the past 5 days. He also reports nausea, decreased appetite, and subjective fever. His temperature is $38.8^\circ\text{C}$ ( $101.8^\circ\text{F}$ ), blood pressure is $110/70\text{ mmHg}$ , pulse is $105/\text{min}$ , and respirations are $18/\text{min}$ . Physical examination reveals focal tenderness and a palpable fullness in the right lower quadrant, with localized guarding. Laboratory studies show a leukocyte count of $18,000/\text{mm}^3$ with a left shift. Intravenous fluids and broad-spectrum antibiotics are initiated. A computed tomography scan of the abdomen and pelvis with intravenous contrast reveals a ruptured appendix with an adjacent $6.5\text{-cm}$ fluid collection demonstrating an enhancing rim. Which of the following is the most appropriate next step in the management of this patient?

Percutaneous image-guided drain placementCevap
B
Urgent laparoscopic appendectomy
C
Early colonoscopy to evaluate for inflammatory bowel disease
D
Discharge home with a 14-day course of oral antibiotics
E
Magnetic resonance imaging of the abdomen and pelvis

Cevap

The correct answer is percutaneous image-guided drain placement.

This patient presents with delayed-onset appendicitis complicated by a large (

6.5\text{-cm}

) periappendiceal abscess. The standard of care for appendicitis complicated by a well-demarcated abscess larger than

3\text{ to }4\text{ cm}

is initial conservative management with intravenous antibiotics and percutaneous image-guided drainage. This approach allows the severe localized inflammation to subside, significantly reducing the risk of surgical complications such as bowel injury or the need for an extensive bowel resection (e.g., ileocecectomy). An interval appendectomy may be considered several weeks later, though some guidelines suggest it can be omitted if the patient remains asymptomatic.

Adım Adım Çözüm

Identify the diagnosis from the clinical presentation and imaging.

The patient has delayed-presentation acute appendicitis complicated by a

6.5\text{-cm}

periappendiceal abscess.

Recognizing that this is a complicated appendicitis (perforation with well-formed abscess) rather than early, uncomplicated appendicitis is essential for determining the correct treatment pathway.

Determine the standard management guidelines for an appendiceal abscess of this size.

Guidelines recommend initial non-operative management consisting of intravenous antibiotics and percutaneous drainage for abscesses larger than

3\text{ cm}

Immediate appendectomy in the setting of severe local inflammation and a large abscess carries a high risk of significant surgical complications, such as iatrogenic bowel injury.

Select the corresponding intervention from the options provided.

Percutaneous image-guided drain placement is the definitive next step.

This procedure provides necessary source control while allowing the acute inflammation to subside, potentially followed by an interval appendectomy several weeks later.

Anahtar Kavram

Management of acute appendicitis complicated by a large periappendiceal abscess via percutaneous drainage and intravenous antibiotics.

Soru

Cevap

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