[size=20px]After completing a course of oral antibiotics following laparoscopic appendectomy for perforated appendicitis, an eight-year old returns with fever and abdominal pain. He is well appearing and tolerating a regular diet. His white blood cell count is 20,000 cells/µL. An ultrasound reveals a three centimeter pelvic abscess surrounded by bowel and no fecalith.

 

The most appropriate initial treatment for this patient with an abscess following appendectomy is

 

A second course of oral antibiotics.

 

B broad spectrum parenteral antibiotics.

 

C image guided drainage.

 

D laparoscopic drainage.

 

E open drainage.[/size]

D

B; as long as the abscess is small and not drainable, giving him another course of IV Abx is a good option

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B

correct answer

B broad spectrum parenteral antibiotics.

 

Postoperative abscesses occur in about two percent of all appendectomies. The rate is higher when perforation is present. Typical symptoms include fever, abdominal pain, abdominal distention, ileus, diarrhea and bowel obstruction. The white blood cell count and C-reactive protein levels are also usually elevated. Imaging by computerized tomography (CT) scan or ultrasound (US) is helpful in confirming the presence, location and nature of an abscess or abscesses. Scheduled imaging after an operation for a perforated appendix has not been shown to be predictive of symptomatic abscess formation by Ein [1]. Therefore, imaging is indicated in the presence of worsening symptoms that suggest an abscess.

 

Historically, the belief has been that drainage of an abscess is required to optimize and hasten treatment. Drainage has been done via CT- or US guided drain placement, operative drainage (either open or laparoscopically) or by a transrectal approach. However, multiple series suggest that medical therapy can accomplish successful treatment of these abscesses without drainage and without the complications that can occur with interventional therapy such as further adhesions or bowel or organ injury. When there is a small abscess (less than five cm) and/or no clear window for drainage, a trial of parental antibiotics should be the first line in treatment. There does appear to be agreement, however, that drainage is indicated if the patient has significant sepsis, there is the presence of a fecalith or antibiotic therapy is not succeeding. Medical therapy is considered successful when the fever and symptoms have resolved and imaging confirms significant reduction or resolution of the collection.

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B