Diagnostic and Therapeutic Management of Inflammatory Masses of Appendiceal Origin:
experience from a University Hospital in Montevideo, Uruguay
Abstract
Appendiceal inflammatory masses represent an uncommon but complex presentation of acute appendicitis, and their management remains controversial. They include appendiceal phlegmon with or without abscess formation and are defined by their pathological characteristics rather than by the duration of symptoms. The aim of this study was to analyze the diagnostic and therapeutic strategies adopted for patients with appendiceal inflammatory masses at a university hospital, evaluate their outcomes, and compare them with current international recommendations. A retrospective observational study was conducted including adult patients diagnosed with appendiceal inflammatory masses between 2020 and 2022. Clinical variables, diagnostic methods, treatment strategies, in-hospital outcomes, and outpatient followup were analyzed. In addition, a literature review was performed using international databases. During the study period, appendiceal inflammatory masses accounted for 4% of all cases of acute appendicitis. They occurred predominantly in middle-aged patients, mainly women with obesity, who presented with a longer clinical course and less evident physical findings. Computed tomography played a key role in confirming the diagnosis and guiding therapeutic decision-making. Non-operative management was the most frequently adopted strategy, being used in eleven patients, with favorable initial outcomes and a low complication rate. In contrast, early surgery was associated with greater technical difficulty, a higher need for conversion, and more extensive visceral resections. In conclusion, appendiceal inflammatory masses represent a diagnostic and therapeutic challenge that requires an individualized approach. Non-operative management is a safe and
effective alternative in selected patients, provided that adequate clinical follow-up is ensured.
Downloads
References
Di Saverio S, Podda M, De Simone B, Ceresoli M, Augustin G, Gori A, et al. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg Surg. 2020;15:27.
Wagner M, Tubre DJ, Asensio JA, Ahmed I, Deakin D, Parsons SL, et al. Evolution and current trends in the management of acute appendicitis. J Gastrointest Surg. 2018;22(5):1005-23.
Andersson RE, Petzold MG. Nonsurgical treatment of appendiceal abscess or phlegmon: a systematic review and meta-analysis. Ann Surg. 2007;246(5):741-8.
Lanterna W. Historia de la apendicitis en el Uruguay. Paysandú: Ed. Paysandú; 2005.
Deelder JD, Richir MC, Schoorl T, Schreurs WH. How to treat an appendiceal inflammatory mass: operatively or nonoperatively? J Gastrointest Surg. 2014;18(3):641-5.
Tekin A, Kurtoglu HC, Can I, Oztan S. Routine interval appendectomy is unnecessary after conservative treatment of appendiceal mass. Colorectal Dis. 2008;10(5):465-8.
Ahmed I, Deakin D, Parsons SL. Appendix mass: do we know how to treat it? Ann R Coll Surg Engl. 2005;87(3):191-5.
Deakin DE, Ahmed I. Interval appendicectomy after resolution of adult inflammatory appendix mass—is it necessary? Surgeon. 2007;5(1):45-50.
Universidad de la República, Facultad de Medicina, Hospital de Clínicas. Programa de Optimización de Antimicrobianos del Hospital de Clínicas: documento marco de funcionamiento del PROA (Internet). Montevideo:
Hospital de Clínicas; 2019 (citado 2024 Oct 15). Disponible en: https://www.proa.hc.edu.uy/images/documento_marco.pdf
Demetrashvili Z, Kenchadze G, Pipia I, Khutsishvili K, Loladze D, Ekaladze E, et al. Comparison of treatment methods of appendiceal mass and abscess: a prospective cohort study. Ann Med Surg (Lond). 2019;48:48-52.
Perez KS, Allen SR. Complicated appendicitis and considerations for interval appendectomy. JAAPA. 2018;31(9):35-41.
Rao PM, Rhea JT, Novelline RA, Mostafavi AA, McCabe CJ. Effect of computed tomography of the appendix on treatment of patients and use of hospital resources. N Engl J Med. 1998;338(3):141-6.
Jeffery RB Jr, Federle MP, Tolentino CS. Periappendiceal inflammatory masses: CT-directed management and clinical outcome in 70 patients. Radiology. 1988;167(1):13-6.
Fugazzola P, Ceresoli M, Agnoletti V, Agresta F, Amato B, Carcoforo P, et al. The SIFIPAC/WSES/SICG/SIMEU guidelines for diagnosis and treatment of acute appendicitis in the elderly. World J Emerg Surg. 2020;15:19.
ECCO Guidelines Committee. ECCO guidelines on therapeutics in Crohn’s disease: medical treatment. J Crohns Colitis.2020;14(Suppl 2):4-22.
Lichtenstein GR, Loftus EV Jr, Isaacs KL, Regueiro MD, Gerson LB, Sands BE, et al. ACG clinical guideline: management of Crohn’s disease in adults. Am J Gastroenterol. 2018;113(4):481-517.
Lamb CA, Kennedy NA, Raine T, Hendy PA, Smith PJ, Limdi JK, et al. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut. 2019;68(Suppl 3):s1-s106.
Marenco C, Fontes MG. Rol de la enterorresonancia en la enfermedad de Crohn. Rev Imagenol. 2019;22(2):45-54.
Hidalgo LH, Moreno EA, Arranz JC, Alonso RC, Martínez V, Fernández DV. Enterorresonancia magnética: revisión de la técnica para el estudio de la enfermedad de Crohn. Radiologia. 2011;53(5):421-33.
Huete Á, Craig J, Vial C, Farías M, Cuello M. Rol de la imagenología en el proceso diagnóstico de la patología ginecológica benigna. Rev Chil Obstet Ginecol. 2016;81(1):63-85.
Bizer LS. Acute appendicitis is rarely the initial presentation of cecal cancer in the elderly patient. J Surg Oncol.1993;54(1):45-6.
Hori T, Machimoto T, Kadokawa Y, Hata T, Ito T, Kato S, et al. Laparoscopic appendectomy for acute appendicitis: how to discourage surgeons using inadequate therapy. World J Gastroenterol. 2017;23(32):5849-59.
Agresta F, Ansaloni L, Catena F, De Simone B, Coccolini F, et al. Laparoscopic approach to acute abdomen from the Consensus Development Conference of the Società Italiana di Chirurgia Endoscopica e Nuove
Tecnologie (SICE), Associazione Chirurghi Ospedalieri Italiani (ACOI), Società Italiana di Chirurgia (SIC), Società Italiana di Chirurgia d’Urgenza e del Trauma (SICUT), Società Italiana di Chirurgia nell’Ospedalità Privata (SICOP)
and the European Association for Endoscopic Surgery (EAES). Surg Endosc. 2012;26(8):2134-64.
Salom A. Valor diagnóstico y terapéutico de la laparoscopía y la videocirugía en la apendicitis aguda. Cir Urug.2002;72(2):124-36.
Mansilla S, Pouy A, Brito N, Muniz N, Misa R. Manejo terapéutico de las masas inflamatorias de origen apendicular. Cir Esp. 2024;102:58-60.
Bailey H. The Ochsner-Sherren (delayed) treatment of acute appendicitis: indications and technique. Br Med J.1930;2:140-3.
Mirilas P, Skandalakis JE. Not just an appendix: Sir Frederick Treves. Arch Dis Child. 2003;88(6):549-52.
Rodríguez A, Pereyra S, Chaparro C, Bianchi N. Manejo percutáneo de la apendicitis aguda complicada en forma de absceso en edad no pediátrica. Rev Imagenol. 2017;20(2):65-8.
Helling TS, Soltys DF, Seals S. Operative versus non-operative management in the care of patients with complicated appendicitis. Am J Surg. 2017;214:1-6.
Mentula P, Sammalkorpi H, Leppäniemi A. Laparoscopic surgery or conservative treatment for appendiceal abscess in adults? A randomized controlled trial. Ann Surg. 2015;262(2):237-42.
Maxfield MW, Schuster KM, Bokhari J, McGillicuddy EA, Davis KA. Predictive factors for failure of nonoperative management in perforated appendicitis. J Trauma Acute Care Surg. 2014;76(4):976-81.
Young KA, Neuhaus NM, Fluck M, Blans JA, Hunsinger MA, Shabahang MM, et al. Outcomes of complicated appendicitis: is conservative management as smooth as it seems? Am J Surg. 2018;215(4):586-92.
Sadakari Y, Date S, Murakami S, Ichimiya S, Nishimura S, Kawaji H. Prediction of negative outcomes in non-surgical treatment for appendiceal abscess in adults. J Anus Rectum Colon. 2018;2(2):59-65.
Frías-Gonzales V, Castillo-Angeles M, Rodríguez-Castro M, Borda-Luque G. Manejo de la masa apendicular inflamatoria en el paciente adulto en el Hospital Nacional Cayetano Heredia. Rev Gastroenterol Perú. 2012;32(3):267- 72.
Dixon MR, Haukoos JS, Park IU, et al. An assessment of the severity of recurrent appendicitis. Am J Surg. 2003;186(6):718-22.
De Jonge J, Bolmers MDM, Musters GD, Van Rossem CC, Bemelman WA, Van Geloven AAW. Predictors for interval appendectomy in non-operatively treated complicated appendicitis. Int J Colorectal Dis. 2019;34(8):1325-32.
Copyright (c) 2026 Sofia Mansilla, Camila Haro, Mario Almada, Noelia Brito, Nicolas Muniz, Pablo Santiago, Justino Zeballos
This work is licensed under a Creative Commons Attribution 4.0 International License.
The authors retain their copyright and assign to the journal the right of first publication of their work, which will be simultaneously subject to the Creative Commons Attribution 4.0 International License. that allows sharing the work as long as the initial publication in this magazine is indicated.
