Appendicular lump
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Appendicular Lump
Definition
An appendicular lump is a tender, fixed mass that develops in the right iliac fossa (RIF) 2-3 days after the onset of acute appendicitis. It is the body's natural attempt to wall off the inflamed appendix and prevent generalized peritonitis. The lump may be either:
- Appendicular mass - inflamed appendix surrounded by omentum, oedematous caecal wall, and matted coils of small intestine bound together by fibrin/lymph. Contains no pus.
- Appendicular abscess - same process but the appendix has perforated and pus has collected within the walled-off cavity. Contains pus.
Pathogenesis
The inflammatory appendix is walled off by:
- Greater omentum
- Oedematous caecal wall
- Coils of small intestine matted together with lymph
This forms a protective barrier preventing spread to the general peritoneal cavity, even if the appendix perforates.
Clinical Features
Symptoms
- Preceding history of periumbilical pain shifting to RIF (Murphy's syndrome: pain → vomiting → fever)
- Diarrhoea may occur with pelvic appendicitis or abscess
- Fever - variable pyrexia
Signs
| Feature | Appendicular Mass | Appendicular Abscess |
|---|---|---|
| Tenderness | Present | More marked |
| Pus | Absent | Present |
| Pyrexia | Mild | Variable, higher |
| WBC | Mildly elevated | Elevated with polymorphonuclear leucocytosis |
| Abdominal wall signs | Rigidity may obscure lump | Redness + oedema of overlying skin as abscess approaches surface |
| Percussion | May be tympanic | Similar |
The lump is characteristically:
- Irregular
- Firm
- Tender
- Fixed
- May be tympanic on percussion (patient may not tolerate)
- Limits can be marked on skin with a pencil and monitored serially
In children, an appendicular lump is rarely seen because of a short omentum and poor inflammatory response - hence early perforation and peritonitis are more common.
Management
Conservative (Ochsner-Sherren Regime)
This is the standard initial treatment when the patient's condition is satisfactory. The rationale is that the inflammatory process is already localized and operating in this setting is technically difficult and potentially dangerous (risk of faecal fistula, inability to find the appendix).
Components:
- IV fluids with fluid balance monitoring
- IV antibiotics (covering Gram-negative bacilli and anaerobes)
- Nil by mouth / bowel rest
- 4-hourly temperature and pulse recording
- Serial abdominal examination with skin pencil marking of lump edges
- Contrast-enhanced CT abdomen
- Radiological drainage if abscess is confirmed
Expected outcome: ~90% of cases resolve without incident. Clinical improvement is usually evident within 24-48 hours.
Criteria to STOP conservative treatment (operate)
- Rising pulse rate
- Increasing or spreading abdominal pain
- Increasing size of the mass
- Signs of peritonitis (indication for early laparotomy)
Interval Appendicectomy
This remains debated. The majority of patients will not develop recurrent appendicitis. However:
- In patients over 40 years, interval appendicectomy deserves careful consideration because studies have found unexpectedly high rates of underlying appendiceal neoplasm (up to 29% in one RCT terminated early for this reason)
- Low-grade appendiceal mucinous neoplasms (LAMNs) accounted for 42% of unexpected tumours in this group
- At minimum: follow-up CT or MRI to confirm complete resolution + colonoscopy in all patients over 40
Differential Diagnosis of a RIF Lump (when appendicular lump does not resolve)
Think of 4 conditions when an appendicular lump fails to resolve with conservative treatment:
- Crohn's disease - history of intestinal colic, diarrhoea, anal complications (fissure, fistula, skin tags); caecum remains in normal position
- Ileocaecal tuberculosis - recurrent abdominal pain, diarrhoea, blind loop syndrome features (anaemia, weight loss, steatorrhoea), evening pyrexia; caecum pulled up on barium meal
- Actinomycosis
- Carcinoma of the caecum - elderly, occult blood in stool, anaemia, rapid weight loss, hard irregular lump
Other RIF swellings to exclude: renal (unascended), ovarian, uterine, undescended testis, pelvic abscess, iliopsoas abscess, carcinoma of the caecum (commonest malignant cause)
Additional differentials for the acute presentation:
- Acute cholecystitis (right hypochondrium, Charcot's triad)
- Mesenteric adenitis
- Ovarian torsion / acute salpingitis
- Ectopic pregnancy (in females of reproductive age)
Key Points Summary
| Point | Detail |
|---|---|
| Timing of lump formation | 2-3 days after acute appendicitis |
| Mass vs abscess | No pus vs pus; pyrexia + leucocytosis higher in abscess |
| Standard treatment | Ochsner-Sherren regime (conservative) |
| Resolution rate | ~90% with conservative management |
| Failure to resolve | Think: Crohn's, TB, actinomycosis, carcinoma |
| Age >40 | Higher risk of underlying appendiceal neoplasm - consider interval appendicectomy |
| Children | Appendicular lump rare (short omentum) - early peritonitis more common |
- S Das A Manual on Clinical Surgery, 13th Edition, pp. 473, 476, 538
- Bailey and Love's Short Practice of Surgery, 28th Edition, p. 1365
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