t h e s u r g e o n x x x ( 2 0 1 6 ) 1 e7

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The Surgeon, Journal of the Royal Colleges
of Surgeons of Edinburgh and Ireland
www.thesurgeon.net

The evolving management of the appendix mass in

the era of laparoscopy and interventional radiology

James Forsyth*, Konstantinos Lasithiotakis, Mark Peter

Department of General Surgery, Scarborough General Hospital, York Teaching Hospitals NHS Foundation Trust, UK

article info abstract

Article history: Aim: An appendix mass is the result of a walled-off perforation of the appendix which
Received 27 June 2016 localises, resulting in a mass and it is encountered in up to 7% of patients presenting with
Received in revised form acute appendicitis. However, its management is controversial due to the lack of high level
11 August 2016 evidence. This review article sets out a rationale diagnostic and therapeutic strategy for the
Accepted 13 August 2016 appendix mass based upon up-to-date available evidence.
Available online xxx Methods: A literature review of the investigation and management of appendix mass/
complicated appendicitis was undertaken using PubMed, EMBASE and Google Scholar.
Keywords: Results/conclusion: No prospective studies were identified. The great majority of recent ev-
Appendix mass idence supports a conservative management approach avoiding urgent appendicectomy
Appendix abscess because of the high risk of major complications and bowel resection. Appendix abscesses
Appendix phlegmon over 5 cm in diameter and persistent abscesses should be drained percutaneously along
Appendicitis with antibiotics. Appendix phlegmon should be treated with antibiotics alone. Surgery is
reserved for patients who fail conservative treatment. Routine interval appendicectomy is
not recommended, but should be considered in the context of persistent faecolith, ongoing
right iliac fossa pain, recurrent appendicitis and appendix mass persistent beyond 2 weeks.
Clinicians should be particularly wary of patients with appendix mass aged over 40 and
those with features suggesting malignancy.
2016 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and
Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

omentum.2 It is being encountered in only 2%e7% of patients

Introduction
An appendix mass is the result of a walled-off perforation of
the appendix which localises, resulting in a mass. This
walled-off perforation varies in nature from a simple in-
flammatory mass to a pus-containing collection (an appen-
dix abscess).1 An inflammatory appendix mass (phlegmon)
includes complicated appendicitis and the joining of adja-
cent bowel loops and at times other viscera/greater
presenting with acute appendicitis3 but its incidence may
increase due to recent trends in the management of acute
appendicitis with antibiotics alone. Even though antibiotics
have been shown to be effective and safe as a primary
treatment for patients with uncomplicated appendicitis with
success rates up to 73%,4 they are associated with treatment
failures and crossover to surgery at 48 h in up to 50% of pa-
tients, and there is also a 23% risk of recurrent appendicitis

* Corresponding author. Permanent address: Department of General Surgery, Scarborough General Hospital, Woodlands Drive,
Scarborough, YO12 6QL, UK. Fax: 44 01723 385 366.
E-mail addresses: jamesforsyth@nhs.net (J. Forsyth), konstantinos.lasithiotakis@nhs.net (K. Lasithiotakis), Mark.Peter@nhs.york.uk
(M. Peter).
http://dx.doi.org/10.1016/j.surge.2016.08.002
1479-666X/ 2016 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland.
Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Forsyth J, et al., The evolving management of the appendix mass in the era of laparoscopy and
interventional radiology, The Surgeon (2016), http://dx.doi.org/10.1016/j.surge.2016.08.002
2 t h e s u r g e o n x x x ( 2 0 1 6 ) 1 e7
within one year, which one can argue poses an increased risk
for complicated appendicitis and appendix mass.5,6 Neither
the diagnosis nor the management of the appendix mass is
standardised so far due to lack of relevant evidence from the
literature. In general there are three treatment approaches:
a. the classical management approach comprises initial
conservative management (antibiotics percutaneous
drainage of associated collections) followed by interval ap-
pendicectomy, b. immediate appendicectomy and c. an
entirely conservative approach that aims to completely avoid
appendicectomy. Two studies from the UK and Ireland
explored surgeon preferences with regard to management of
appendix mass, and they both found significant heteroge-
neity in management amongst surgical consultants and
registrars,7,8 with both studies concluding that there is a
significant need for clear guidelines and protocols to be
devised to streamline and improve practice. This paper rep-
resents an update of a previous review9 underlining more the
role of non-operative primary treatment of the appendix
mass. The proposed algorithm includes details on the man-
agement of related abscess, imaging in various patients
groups and the role of laparoscopic lavage as a damage
limitation measure in this setting.
Methods
A literature review of the investigation and management of
appendix mass/complicated appendicitis was undertaken
using PubMed, EMBASE and Google Scholar. We included
retrospective studies, randomised controlled trials, compar-
ative studies, systematic reviews, meta-analyses, review ar-
ticles and case series/reports. A search of the English
literature was conducted for appendix mass, appendix ab-
scess, appendix phlegmon, interval appendicectomy,
laparoscopic appendicectomy and complicated appendi-
citis. Further articles were obtained from cross-referencing of
the literature we reviewed.
Diagnosis of the appendix mass
A detailed history and examination is vital to differentiate
between the broad diagnoses that may be responsible for a
right iliac fossa (RIF) mass (Table 1). Patients with symptoms
suggestive of appendicitis lasting over 72 h are more likely to
have an appendix mass.2 Inflammatory markers will be
invariably increased. Proper radiological investigations are
essential for the diagnosis and differential of an appendix
mass, and if used appropriately should lead to a reduced
incidence of first diagnosis of the appendix mass at surgery/
under anaesthesia. Relevant imaging modalities are ultra-
sonography, computed tomography (CT) and magnetic
resonance imaging (MRI). Ultrasound is quick and safe and
often serves as the baseline investigation for patients with
RIF pain. It is also useful in women of childbearing age in
order to exclude gynaecological pathology, in pregnant
women and in children as it avoids radiation exposure. The
sensitivity of combined trans-abdominal and trans-vaginal
ultrasound for the diagnosis of acute appendicitis is 97%
Please cite this article in press as: Forsyth J, et al., The evolving management of the appendix mass in the era of laparoscopy and
interventional radiology, The Surgeon (2016), http://dx.doi.org/10.1016/j.surge.2016.08.002
with specificity of 91% but they are highly operator depen-
dent.10 CT has sensitivity and specificity for acute appendi-
citis that approaches 100%11 and it is excellent in
differentiating between simple perforation of the appendix,
appendiceal abscess and appendix phlegmon, and in the
setting of complicated appendicitis, CT may prevent surgical
complications and conversion to open surgery.12 CT is also
very useful for excluding other pathology in the RIF, partic-
ularly in patients over 40 (Table 1). MRI is indicated in pa-
tients with special radiation protection requirements, in
particular women of child bearing age, women in whom a
pregnancy cannot be ruled out in the emergency situation,
and pregnant women. The sensitivity and specificity of
conventional MRI for the diagnosis of acute appendicitis is
between 90% and 100%.13 Due to the longer examination
times, higher costs, and the limited availability, MRI of the
abdomen is not the first choice method in the case of clinical
suspicion of an appendix mass. However, it should be
considered in these groups of patients particularly if the ul-
trasound has not been contributory to the diagnosis of ap-
pendix mass (Fig. 1) (see Table 2).
Non-operative management of appendix mass
Percutaneous drainage
Image-guided percutaneous drainage in combination with
broad-spectrum antibiotics has been shown to be an effec-
tive, minimally invasive treatment of patients with appen-
dix abscess. Jamieson et al.14 reported a successful
treatment rate of 91% for appendix abscesses treated with
drainage and IV antibiotics. Similar results have been re-
ported for paediatric patients.15 On the other hand, in
certain situations percutaneous drainage is less likely to be
successful. A large, poorly defined peri-appendiceal abscess
and an appendicolith on pre-procedure CT images were in-
dependent predictors of clinical failure of percutaneous
drainage in both adult and paediatric patients.16 In these
instances, CT-guided percutaneous drainage might be suc-
cessful initially with resolution of the abscess cavity, but the
abscess will reform almost invariably following removal of
the catheter necessitating formal surgical drainage with
removal of the appendicolith in order to achieve a success-
ful outcome.16 Thus if percutaneous drainage is considered
as a primary management strategy, it is of particular
importance to inform the patient and the family regarding
the possibility of treatment failure and the need for further
surgical therapy.
The main complications of percutaneous drainage
include infection (superficial and intra-abdominal), bleeding
and non-target puncture.17 In the case of appendix mass, the
abscess may be deep in the pelvis, it can be technically
challenging to gain access and it may require careful plan-
ning. The sacrum, innominate bones, iliac crests, urinary
bladder and multiple bowel loops may be in the direct path of
the abscess, and dense pelvis vasculature further limits the
choice of route of access. In some patients access may need
to be via the trans-rectal/trans-vaginal route. In the paedi-
atric group percutaneous drainage may carry up to an 11%
 t h e s u r g e o n x x x ( 2 0 1 6 ) 1 e7 3

percutaneous drainage. Appendix phlegmon should be

Table 1 e Differential diagnoses for right iliac fossa mass
and respective clinical features.
Condition Clinical features
Appendix mass Short history, tender right iliac fossa
(RIF) mass, signs of sepsis.
Caecal malignancy RIF mass (tender if closed loop large
bowel obstruction or perforation),
weight loss, change in bowel habit,
rectal bleeding, anaemia, poor
appetite, fatigue.
Crohn's disease Previous bowel problems, mouth
ulceration, eye and skin signs, perianal
pathology, diarrhoea, rectal bleeding,
family history.
Diverticular mass Lower abdominal mass, tender, signs
of sepsis, patient typically >40,
Western diet.
Psoas abscess Fever, abdominal/flank/hip pain,
nausea, malaise, weight loss,
associated with intravenous drug
abuse/immunosuppression.
Tubo-ovarian Lower abdominal/pelvic tender mass,
abscess fever, signs of sepsis, vaginal
discharge, sexual history.
Intussusception Paediatric: periodic cramping
abdominal pain, nausea, vomiting,
pulling legs to chest area, rectal
bleeding, sausage-shaped mass,
association with Henoch-Schonlein
purpura. Adults: non-specific features,
nausea, vomiting, gastrointestinal
bleeding, constipation, abdominal
distension, palpable mass.
Transplanted kidney Renal failure patient, scar and mass in
RIF, evidence of previous fistula use.
Lymphoma Abdominal pain, palpable mass,
weight loss, lymphadenopathy,
hepatosplenomegaly, skin lesions.
Ileocaecal Chronic symptoms (possibly for years),
tuberculosis period colicky abdominal pain,
diarrhoea, previous pulmonary
tuberculosis/foreign travel, night
sweats, weight loss.
risk of major complications (major complications being
defined as severe and potentially fatal complications
comprising death and those requiring re-operation) and in
the adult group up to 6%.18 With consideration of such po-
tential complications it has been suggested that abscesses
less than 5 cm should be treated primarily with antibiotics
alone, and those over 5 cm should be considered for
treated with antibiotics.18
Antibiotic therapy
There are no specific guidelines on antibiotic therapy for ap-
pendix mass. We recommend commencing patients on
intravenous antibiotics according to local guidelines for intra-
abdominal infection/sepsis, and continuing intravenous
therapy until the patient significantly improves both clinically
and biochemically, and is apyrexial for 24 h. Further repeat
imaging is another option to assess the response to conser-
vative therapy. Blood culture results and culture results of any
pus drained percutaneously should tailor ongoing antibiotic
therapy, in conjunction with expert microbiology advice. Once
suitable, patients should be stepped down to appropriate oral
antibiotics.
Operative management of appendix mass
Urgent appendicectomy
In the literature there is a significant body of opinion that does
not support urgent appendicectomy in the context of appen-
dix mass, but instead favours conservative management.
Indeed, the conservative approach for appendix mass is not a
new idea and its history goes back to the beginning of the last
century.19,20
Urgent appendicectomy has been associated with
increased surgical site infections, increased overall compli-
cations, abdominal/pelvic abscesses, ileus/bowel obstructions
and re-operations.21,22 The risk of intestinal resection ranges
between 25% and 30%.18,23 Guida et al.24 retrospectively
studied six children with appendix mass; three were treated
with immediate appendicectomy, with an average hospital
stay of 11 days, two of them developed a wound infection, and
1 patient developed a retro-bladder abscess which required a
further 4 days of IV antibiotics. In the conservatively managed
group the average total length of stay was shorter (7 days),
with no complications reported. Unfortunately, there are no
studies with larger number of paediatric patients comparing
surgery versus non-operative treatment in paediatric patient
and this represents an excellent field for future research. Up to
now, the main body of literature as mentioned above suggests
better outcomes when a non-operative management is
adopted primarily, with surgery reserved for those who fail
conservative management.

Table 2 e Key points for the management of an appendix mass.

 Urgent appendicectomy for appendix mass carries increased risk of major complications and bowel resection and should be avoided if
possible.
 If required, the laparoscopic approach is preferred for urgent appendicectomy.
 Conservative management of appendix mass with antibiotics percutaneous drainage is a safe and effective and is strongly recommended as
the primary management strategy.
 Interval imaging/endoscopy should be performed at 4e6 weeks.
 Routine interval appendicectomy is not recommended, but should be considered in patients with persistent faecolith, ongoing RIF pain,
recurrent appendicitis, persistent mass at 2 weeks, and patient anxiety and desire for appendicectomy.
 Clinicians need to be cautious not to miss important pathology, particularly colorectal neoplasia in patients over 40.

Please cite this article in press as: Forsyth J, et al., The evolving management of the appendix mass in the era of laparoscopy and
interventional radiology, The Surgeon (2016), http://dx.doi.org/10.1016/j.surge.2016.08.002
4 t h e s u r g e o n x x x ( 2 0 1 6 ) 1 e7

Fig. 1 e Flowchart for the management of appendix mass.

Suggested surgical approach for urgent appendicectomy
If the surgeon does decide to pursue urgent appendicectomy
for appendix mass, then the laparoscopic approach is gener-
ally recommended. Even in the paediatric group, the laparo-
scopic approach has been associated with reduced parenteral
analgesia requirements, earlier commencement of feeding,
shorter length of hospital stay, lower rate of wound infections,
and a lower incidence of bowel obstruction/ileus.25e27 In
adults, studies have again shown positive results with
significantly reduced mean hospital stay, reduced analgesia
requirements, fewer abdominal wall complications, reduced
surgical blood loss, reduced pulmonary complications, lower
rates of bowel obstruction/ileus, and comparative operative
times and length of stay.28e32 There are also two very recent
randomised controlled trials that have again supported lapa-
roscopic appendicectomy as safe and feasible in the setting of
complicated appendicitis.33,34 Given these generally positive
results, the laparoscopic approach should be the primary
surgical strategy to deal with appendix mass, with open con-
version if necessary.
However, one must acknowledge that data regarding
laparoscopic management of appendix mass is fairly scarce
and further investigation with large-scale randomised
controlled trials is warranted. It also has to be underlined here
that laparoscopic appendicectomy for appendix mass or ab-
scess can be very challenging and might be associated with
higher conversion rates28,29 and morbidity. In particular, evi-
dence suggests that the laparoscopic approach in complicated
appendicitis can lead to a potentially higher incidence of
intra-abdominal abscesses, and as such the use of endobags
and careful irrigation of the abdomen is recommended.35 Pa-
tient and family should be made aware of the increased risks
before the operation. Despite the fact that the laparoscopic
approach is recommended when surgery is indicated, it
should be expected to be a difficult operation with higher
conversion rates and complications including bowel resec-
tion. Laparoscopic views might be limited by distended bowel
loops, adhesions and inflammation with bleeding tendency,
whilst bowels are often plastronized, inflamed and more
prone to inadvertent enterotomy. Therefore, it should be
performed by senior laparoscopists or with their support,
otherwise a low threshold for conversion to open surgery is
warranted or even a primarily open approach.
Interval appendicectomy
Interval appendicectomy is supposed to prevent recurrence of
appendicitis, and enable histopathological confirmation of
disease. However, most of the recent literature does not sup-
port routine interval appendicectomy, with results demon-
strating rates of successful long term conservative
management for appendix mass of up to 97%,36 with relatively
low recurrence rates of 7.4%.37 In these studies, the rates of
detection of malignant disease is low (1.2%) and important
benign diseases are discovered in only 0.7% of the patients
during follow-up.37 These findings provide the argument by
many authors to suggest that interval appendicectomy is
unnecessary in the majority of cases.38,39 On the other hand,
there are certain situations where interval appendicectomy
should be more strongly considered. Recurrent episodes of
appendicitis or persistence of symptoms in the right iliac fossa

Please cite this article in press as: Forsyth J, et al., The evolving management of the appendix mass in the era of laparoscopy and
interventional radiology, The Surgeon (2016), http://dx.doi.org/10.1016/j.surge.2016.08.002
 t h e s u r g e o n x x x ( 2 0 1 6 ) 1 e7
should stimulate discussion with the patient about sur-
gery.40,41 Moreover, the persistence of an appendicolith on
imaging represents another relative indication for interval
appendicectomy because of the increased risk of recurrence.42
Swarnkar et al.43 in their study of 26 patients with appendix
mass managed conservatively found that in 2 cases the mass
persisted beyond two weeks and at operation caecal carci-
noma was identified. The authors therefore concluded that
when appendix mass persists after 2 weeks, it is a strong
reason to have surgical intervention earlier. Patients with
imaging features raising suspicion for cancer or concerning
clinical features (e.g. change in bowel habit, rectal bleeding,
anaemia) should undergo thorough investigation with
endoscopy and repeat scan in 4e6weeks before they are
considered for surgical intervention. This will allow for
appropriate surgical planning by colorectal specialists,
informed patient decisions and a modern multidisciplinary
approach.
Interval imaging/endoscopy
There are three main reasons to carry out further interval
investigations in the context of appendix mass: firstly to
assess the response of the mass/abscess to conservative
management, secondly to see if there is a persistent faecolith,
and thirdly to avoid missing other diagnoses. According to
Olsen et al.,18 repeat ultrasound/CT should be performed after
4e6 weeks (plus colonoscopy particularly in adults over 40).
We would recommend ultrasonography as the most appro-
priate initial imaging for paediatric patients; in younger adults
either ultrasound or CT and in adults over 40 CT followed by
colonoscopy.
Patient counselling for interval appendicectomy
Patients with appendix mass managed conservatively should
have outpatient follow-up after interval investigations. An
open and frank discussion should be held with the patient,
explaining the pros, cons and indications of interval appen-
dicectomy, with the specific mentioning that not removing
the appendix may result in recurrent appendicitis, and that
there is a small risk of missing other appendicular pathology.
Ongoing associated pain, recurrent appendicitis, faecolith,
persistent mass beyond two weeks, and patient anxiety/desire
for the appendix to be removed should naturally steer the
clinician towards surgery. However, routine interval ap-
pendicectomy should not necessarily be a strict policy. Each
case should be judged individually, and a joint decision made
between both the patient and clinician.
Laparoscopic assisted drainage and washout without resection
If percutaneous drainage is not possible and urgent appendi-
cectomy is deemed to be too hazardous because of anatomical
distortion due to the inflammatory process, there is also the
option of laparoscopic lavage and drainage of the appendix
abscess without appendicectomy.44,45 The patient can then
have interval investigations as mentioned above, and de-
cisions can be made at a later date about the requirement for
interval appendicectomy.
Please cite this article in press as: Forsyth J, et al., The evolving management of the appendix mass in the era of laparoscopy and
interventional radiology, The Surgeon (2016), http://dx.doi.org/10.1016/j.surge.2016.08.002
5
Appendix mass and colon cancer
The link between appendicitis and colon cancer, particularly
in the older population, is well known. Patients older than 40
years with appendicitis/appendix mass have higher colorectal
cancer incidence rates.46e48 The percentage of patients pre-
senting with appendicitis who also have colonic carcinoma
ranges from 1 to 8%, and that carcinoma masquerading as
appendicitis occurs more often than is generally realized, and
will be seen more frequently as the ageing population in-
creases.49 Studies have shown an even greater incidence of
colorectal malignancy in patients with appendiceal mass,
between 5.9% and 8%.23,43,50 Given such strong links between
colorectal cancer and appendicitis, and even greater risk with
appendix mass, it is vitally important to bear this possibility in
mind, particularly in patients over 40 or when red flag symp-
toms are present (i.e. change in bowel habit, iron deficiency
anaemia, weight loss, poor appetite, rectal bleeding), and
considering further investigation (i.e. CT/colonoscopy/barium
enema). Although we do specifically recommend CT/colo-
noscopy for patients aged over 40 with appendiceal mass, we
do not suggest routine investigation of other patients with
uncomplicated appendicitis or other age groups with appen-
diceal mass unless there are clinical hints suggesting under-
lying malignancy. Clinical discretion is advised.
Right iliac fossa mass and Crohn's disease
Patients with Crohn's disease may present with RIF pain and/
or a mass. In such a context it can be clinically difficult to
decide if such a presentation is due to underlying Crohn's, or
if it is a case of complicated appendicitis. It is important to
investigate the patient appropriately before deciding on any
surgical intervention. According to Gatta et al.51 in the setting
of Crohn's, visualisation of the RIF/terminal ileum via ultra-
sound has the highest sensitivities as opposed to other areas
of the gastrointestinal tract, henceforth ultrasound is a good
initial diagnostic tool. However, clinicians should interpret
ultrasound reports with discretion, appreciating that the ac-
curacy of ultrasound is highly dependent on factors such as
experience level of the examining radiographer/severity of
disease etc. If the ultrasound report is not conclusive, then a
further CT scan is indicated. If ultrasound/CT imaging sup-
port a diagnosis of Crohn's mass, then ideally this should be
primarily managed conservatively/medically in a stable
patient.
Conclusion
Management for appendix mass is controversial, with much
heterogeneity in surgical practice. The classical manage-
ment is conservative followed by interval appendicectomy,
however many advocate immediate appendicectomy, and a
more modern approach is purely conservative that aims to
avoid appendicectomy altogether. This article encourages a
more reserved approach to the management of appendix
mass. Urgent appendicectomy should ideally be avoided
6 t h e s u r g e o n x x x ( 2 0 1 6 ) 1 e7
because of the significantly increased risk of major compli-
cations, but if it is required then the laparoscopic approach is
recommended. We do not recommend routine interval ap-
pendicectomy, but would support it in the context of persis-
tent faecolith, ongoing right iliac fossa pain, recurrent
appendicitis, appendix mass persistent beyond 2 weeks, along
with patient anxiety and desire for the diseased appendix to
be removed. Finally we have emphasized the importance of
identifying underlying malignancy or Crohn's disease in the
context of a suspected appendix mass. Clinicians should be
particularly wary of patients with appendix mass aged over 40
and those with atypical and/or red flag features. In such in-
stances it is recommended to further investigate such patients
appropriately with CT/colonoscopy.
Sources of financial support
Not relevant.
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