Multislice Computed Tomography Imaging with Clinical Outcome in Inflammatory Appendiceal Masses

Abstract

Introduction: Appendicular lump is a serious complication of appendicitis presenting clinically with right iliac fossa mass which has a range of differential diagnosis. Diagnosis of complicated appendicitis and appendicular lump is often difficult and challenging. Computed tomography imaging has an important role in diagnosis and differentiation of appendicular mass. Aim: The purpose of this study was to assess the computed tomography imaging features of inflammatory appendiceal masses. Materials and Methods: Multislice computed tomography (MSCT) images of total 56 patients of inflammatory appendiceal masses were retrospectively analyzed during the period of October 2011 to November 2015. Contiguous axial CT sections obtained before and after injection of iodinated intravenous contrast medium were analyzed. Oral and rectal contrast was also administered in all patients to opacify the bowel. Images were evaluated for inflammed appendix, appendicolith, extraluminal fluid collections, inflammatory phlegmon formation, extraluminal air, fat inflammation, fascial thickening, bowel aggregation, bowel wall thickening and enlarged lymph nodes. Results: Fifty six patients of inflammatory appendiceal masses with mean age 41-50 years were identified which included 31(55%) men and 25 (45%) women. The inflamed appendix could be identified in the inflammatory mass in 22 cases (39%) with appendicolith seen in 12 cases (21%). Extraluminal fluid collections were seen in 35 patients (62.5%) with walled-off collections with enhancing walls labelled as abscesses were seen in 26 cases (46%). Inflammatory phlegmonous mass was seen in 38 cases (68 %) while adjacent ileocecal wall thickening was seen 22 cases (39%). Omental thickening and fat inflammation was present in 46 out of 56 cases (82%) with adjoining aggregated small bowel loops were seen in 36 cases (64%). Extraluminal air pockets were seen in 31 patients (55%). Out of 35 patients with extraluminal fluid collections, 24 were drained percutaneously under image guidance which included 15 patients labelled as abscess. In five patients, the collections were small in size and resolved with conservative treatment. Nineteen patients including four patients with large abscesses and pelvic extensions underwent laparotomy. Conclusion: Appendicular mass is a serious complication resulting from perforation of inflammed appendix, showing inflammatory phlegmon and/or extraluminal fluid collection with associated imaging findings. Computed tomography is highly useful in diagnosis and differentiation of appendiceal masses and deciding the management approach.

Keywords

• abscess
• appendicular lump
• phlegmon