ORIGINAL ARTICLE

Nonoperative Management of Appendiceal Phlegmon

or Abscess with an Appendicolith in Children
Hai-Lan Zhang & Yu-Zuo Bai & Xin Zhou & Wei-Lin Wang
Received: 18 October 2012 / Accepted: 2 January 2013 / Published online: 12 January 2013
#2013 The Society for Surgery of the Alimentary Tract
Abstract
Background The optimal treatment of appendiceal phlegmon or abscess with an appendicolith is controversial. This study
aimed to evaluate outcomes and prognosis of nonoperative management of appendiceal phlegmon or abscess with an
appendicolith in children.
Methods From 2007 to 2011, 105 children with appendiceal phlegmon or abscess who were treated nonoperatively without
interval appendectomy were reviewed. Average follow-up of subjects was 2.4 years. Data were compared between subjects
with and without an appendicolith or persistent presence and disappearance of an appendicolith.
Results The success rate for nonoperative therapy for appendiceal phlegmon or abscess with appendicolith was 95.9 %. The
risk of recurrent appendicitis in appendiceal phlegmon or abscess with appendicolith (19.1 %) was higher than that without
appendicolith (8.9 %, P=0.132). The rate of appendicolith disappearance during follow-up was 80.9 %. The persistent
presence of an appendicolith was associated with a significantly higher recurrence rate (66.7 %) compared with appendicolith
disappearance (7.9 %, P<0.05).
Conclusion Appendiceal phlegmon or abscess with an appendicolith can be managed nonoperatively, and most appendico-
liths can be resolved. Persistent presence of an appendicolith is a significant risk factor for recurrent appendicitis. Interval
appendectomy is recommended for persistent presence of appendicolith, but is not indicated in cases without appendicolith or
appendicolith disappearance.
Keywords Appendiceal Phlegmon
.
Appendiceal Abscess
.
Appendicolith
.
Nonoperative Management
.
Children
Introduction
The symptoms and physical signs of acute appendicitis may
overlap with other gastrointestinal or genitourinary diseases
leading to a missed or delayed clinical diagnosis, especially
in children. The appendiceal phlegmon or abscess (APA) at
presentation occurs in about 30 to 60 % of children.
1, 2
The
presence of an appendicolith is closely associated with
APA.
3
Current researches on APA with an appendicolith
are rare and controversial. The debates predominantly focus
on the effects of an appendicolith, the success rate of nonop-
erative management, and the necessity of interval appendec-
tomy (IA). The presence of an appendicolith might predict
failure of nonoperative management of APA, and immediate
appendectomy may be a better choice.
4
However, some stud-
ies found no correlation between clinical outcomes and the
presence of appendicolith.
5
Recent studies
6, 7
indicated that an
appendicolith was a risk factor for recurrent appendicitis and
patients should receive IA; however, immediate appendecto-
my was not suggested considering the difficulty of technique
associated with appendectomy before the inflammatory pro-
cess completely subsided and the relatively mild course of
recurrent appendicitis.
It is important to study the relationship of APA with an
appendicolith in order to understand the clinical outcomes
of nonoperative treatment and the necessity of IA to prevent
recurrence. To our knowledge, confirming the persistent
presence or disappearance of appendicolith in APA by sub-
sequent computed tomography (CT) scans and development
of recurrent appendicitis has not been systematically
H.-L. Zhang
:
Y.-Z. Bai
:
X. Zhou
:
W.-L. Wang (*)
Department of Pediatric Surgery, Shengjing Hospital of China
Medical University, No. 36 Sanhao St., Heping District, Shenyang,
China 110004
e-mail: wangwl@sj-hospital.org
J Gastrointest Surg (2013) 17:766770
DOI 10.1007/s11605-013-2143-3
reported. The purposes of this study were to evaluate the
outcomes and prognosis of nonoperative treatment of APA
with an appendicolith in children, with emphasis on the
success rate and the need for IA.
Patients and Methods
This retrospective study was approved by the Ethics Com-
mittee at Shengjing Hospital of China Medical University.
From January 2007 to December 2011, 170 pediatric
patients (14 years old) presented to our hospital with a
clinical diagnosis of APA. Among them, 48 were treated by
immediate appendectomy or surgical drainage because of
extensive peritonitis, apparent intestinal obstruction, and
shorter duration of symptoms (3 days). Another 122 chil-
dren with APA who underwent attempted initial nonopera-
tive treatment were reviewed. Exclusion criteria included
children with incomplete follow-up and interval appendec-
tomy after successful nonoperative management. A total of
105 patients met the study criteria. Data collected included
demographics, duration of symptoms, common symptoms
(e.g., pain, fever, vomiting, diarrhea), physical signs (e.g.,
tenderness, rebound, rigidity), white blood cell (WBC)
counts, C-reactive protein (CRP) values, antibiotics admin-
istered, length of stay (LOS), ultrasonography (USG), and
CT scan findings.
CT scans were performed on a Siemens Sensation 64 CT
(Siemens Medical Solutions, Forchheim, Germany) or a Phi-
lips Brilliance 64 CT (Philips Medical Systems, Cleveland,
USA). In order to decrease childrens exposure to radiation,
our hospital keeps the radiation dose as low as possible
without comprising the quality of CTimages. Periappendiceal
abscesses were not generally drained unless the condition of
patients did not improve or abscesses gradually increased.
Nonoperative therapy was considered a failure in those
patients who received appendectomy during the initial hospi-
talization for nonsurgical therapy because of the deterioration
of clinical symptoms and signs or intestinal obstruction.
Based on the presence or absence of an appendicolith on
admission CT imaging, children were divided into two
groups: 49 patients with appendicolith (AC group) and 56
patients with no appendicolith (NA group). The conserva-
tively treated patients were given intravenous, broad-
spectrum antibiotics, and intrarectal suppositories (gentami-
cin and metronidazole). The therapy was continued for at
least 7 days. When the patients improved, USG or CT was
again performed and reexamined. The absence of an appen-
dicolith must be confirmed by CT imaging, even if USG
indicated no appendicolith of the appendix. If regression of
appendiceal inflammation was seen on USG or CT and
patients remained afebrile, with improved physical signs
and lower WBC and CRP, they were discharged home with
oral broad-spectrum antibiotics. The patients returned to our
pediatric clinic after 1, 2, and 3 or 4, 6, and 12 months,
respectively. After the first year, the patients were examined
once every year. Each child was followed for an average of
2.4 years in our clinic.
Statistical Analysis
Data are presented as mean standard deviation. The sta-
tistical analyses were performed using Students t test or chi-
square test with Fishers exact examination. A P value of
less than 0.05 was considered as significant. The statistical
calculations were performed using SPSS software version
13.0 (SPSS Inc., Chicago, IL, USA).
Results
Among 105 children who met the study criteria, 49 children
in the AC group and 56 in the NA group were treated
nonsurgically. The AC group included 24 males and 25
females with an average age of 7.13.7 years. The NA
group included 30 males and 26 females with an average
age of 6.43.5 years. Results are summarized in Table 1.
In the AC group, duration of symptoms was 9.3
4.8 days. No significant differences were found between
the AC and NA groups when comparing common symp-
toms such as abdominal pain (100 vs. 100 %), fever (81.6
vs. 80.4 %), vomiting (51.0 vs. 64.3 %), and diarrhea (42.9
vs. 37.5 %). Excluding two children who underwent appen-
dectomy because of intestinal obstruction, LOS was 12.5
Table 1 Clinical data between the AC group and NA group
AC (n=49) NA (n=56) P value
Sex (male/female) 24:25 15:13 0.639
Age (years) 7.13.7 6.43.5 0.316
Duration of symptoms 9.34.8 8.43.6 0.239
Pain 49 (100 %) 56 (100 %) 1.000
Fever 40 (81.6 %) 45 (80.4 %) 0.868
Localized peritonitis 35 (71.4 %) 3 1(55.4 %) 0.089
WBC 20.25.4 17.65.2 0.063
CRP 122.966.7 101.764.6 0.102
Inflammatory area (cm
2
) 34.523.4 26.618.8 0.062
Percutaneous drainage 2 (4.1 %) 1 (1.8 %) 0.597
LOS (excluding
appendectomy)
12.56.0 11.63.9 0.323
Overall success 47 (95.9 %) 56 (100 %) 0.215
Recurrent appendicitis
(excluding appendectomy)
9/47 (19.1 %) 5/56 (8.9 %) 0.132
AC appendicolith, NA no appendicolith
J Gastrointest Surg (2013) 17:766770 767
6.0 days in the AC group. The rate of localized peritonitis
was slightly higher in the AC group (71.4 %) than in the NA
group (55.4 %). Similarly, WBC (20.25.4 vs. 17.65.2)
and CRP (122.966.7 vs. 101.764.6) values were slightly
higher and mean inflammatory areas of APA (34.523.4 vs.
26.618.8) on USG or CT scan were slightly larger in the
AC group compared to those in the NA group. However,
these data did not reach statistical significance. Two patients
in the AC and one patient in the NA group underwent CT-
guided percutaneous drainage and received successful con-
servative therapy.
In the AC group, two children underwent appendectomy
and surgical drainage because of aggravated intestinal ob-
struction occurring between 8 and 12 days after initial
nonsurgical management. All children in the NA group were
treated successfully with nonoperative treatment. There
were no statistically significant differences between the
AC and NA groups (95.9 vs. 100 %) in the overall success
rate for nonoperative management of APA.
All children were followed up for an average of 2.4 years
(range, 0.5 to 5.5 years). There was no significant difference in
the average follow-up time between the NA and AC groups
(2.51.4 vs. 2.21.5, P=0.358). Five patients had recurrent
appendicitis in the NA group between 2 months and 2 years
after initial conservative treatment. Of these, one patient had
another APA and was treated nonoperatively again, receiving
IAafter 3 months. In the ACgroup, nine patients had recurrent
appendicitis between 1 and 10 months after initial treatment.
Of these, four children had another APA. Two patients with
second APAs received appendectomy immediately, whereas
the remaining two patients had IA between 2 and 3 months
after another course of conservative treatment. Two cases had
appendicoliths outside the appendix in the appendectomy. The
risk of recurrence in the AC group (19.1 %) was higher than
that in the NA group (8.9 %), but without statistical
significance.
In the AC group, the appendicolith disappeared in 38
children and presented persistently in APA in nine children
during the follow-up period. Excluding two patients who
underwent appendectomy because of intestinal obstruction,
the rate of disappeared appendicolith was 80.9 %. Based on
whether appendicolith disappeared or persisted, the patients
in the AC group were divided into two subgroups: appendi-
colith disappearance and appendicolith persistent presence.
Among the appendicolith disappearance group, 57.9 % of
appendicoliths (22/38) disappeared during the initial hospital-
ization (Figs. 1 and 2). The earliest appendicolith resolution
was the fourth day of conservative management, while most
appendicoliths resolved within 614 days. The disappearance
of an appendicolith in 15 children was found in the first month
of follow-up and another appendicolith disappeared in the
fourth month of follow-up (Fig. 3). Under similar circum-
stances of age, symptomatic duration and mean inflammatory
area, risk of localized peritonitis, WBC and CRP values, and
LOS were slightly higher in the appendicolith persistent pres-
ence subgroup than in the appendicolith disappearance sub-
group (Table 2). Three patients with appendicolith
disappearance had recurrent appendicitis, for a 7.9 % recur-
rence rate. However, two patients with persistent appendico-
lith had recurrent appendicitis and four recurrent APAs. The
Fig. 1 a The admission CT
scan of a 13-year-old boy
showed an appendiceal phleg-
mon formation and a dilated
appendix with an appendicolith.
b An appendicolith disappeared
after 12 days of nonoperative
management
Fig. 2 a The initial CT image with intravenous contrast medium of a
2-year-old girl showed an appendicolith within a multilocular appen-
diceal abscess. b Intravenous contrast CT scan revealed that the
appendiceal abscess was absorbed and the appendicolith was resolved
after 17 days of nonoperative management
768 J Gastrointest Surg (2013) 17:766770
persistent presence of an appendicolith was associated with a
significantly higher rate of recurrent appendicitis (66.7 %)
compared with appendicolith disappearance, representing a
statistically significant difference (P<0.05).
Discussion
An appendicolith, or fecalith, is composed of inspissated fecal
material, mucus with entrapped calcium phosphate, and inor-
ganic salts. With the increased use of CT scans, the appendi-
coliths are detected in 40 to 50 %of children who present with
a clinical suspicion of acute appendicitis.
8, 9
The appendicolith
has long been implicated as an important cause of acute
appendicitis, especially in APA.
10, 11
Current surgical guide-
lines advise nonoperative management of APA in children.
However, the optimal treatment of APAwith an appendicolith
is not well established.
When an appendicolith is present in APA, it was believed
to predict failure of conservative therapy and immediate
appendectomy was suggested.
4
However, in our review of
children with an appendicolith in APA, the success rate of
nonoperative treatment was 95.9 %, without a statistically
significant difference compared to the NA group. This
indicates that APA with an appendicolith can be nonsurgi-
cally managed and immediate appendectomy is not neces-
sary. Our results are consistent with other studies of APA in
children,
1214
and immediate appendectomy might encoun-
ter difficulties because of distorted anatomy, inflammatory
adhesion, closing the appendiceal stump, and severe post-
operative complications.
During the mean 2.4 years of follow-up, the recurrence
rate of the AC group was 19.1 %. This is similar to previous
research on the mean risk of recurrent appendicitis after the
conservative management of APA in children.
15
In our
research, the recurrence rate was slightly higher compared
to that of the NA group but without statistical significance.
During the follow-up period, we were surprised that the
higher recurrence rate was closely associated with the per-
sistent presence of an appendicolith in APA, but not with its
disappearance.
In the AC group, the appendicolith disappeared on sub-
sequent CT scans in 38 of 47 children who had the presence
of appendicolith on admission CT exams. Among them, the
appendicoliths of 22 (57.9 %) patients were absent at the
end of the initial hospitalization. Until first month of follow-
up, 97.4 % (37/38) of appendicoliths were resolved. Hence,
the first month of follow-up was vital when the patient was
discharged with the presence of appendicolith at last reex-
amination. The interesting aspect was that the appendicolith
in APA most likely resolved spontaneously just as in simple
appendicitis or normal appendix.
10
The appendicolith still
existed in the appendiceal lumen even if the appendix in
most cases had perforated with APA. As seen in our results,
the perforated appendix should likely be able to expel an
appendicolith from its lumen depending on peristaltic
movement.
The rate of recurrent appendicitis after appendicolith
disappearance was 7.9 %, which was similar to the recur-
rence rate of the NA group. Several reviews also indicated
that IA was not necessary because of a lower recurrence
rate.
1517
When IA is performed, patients are exposed to an
1118 % complication risk in order to prevent a recurrence
of appendicitis in less than 10 % of patients.
17, 18
Also,
patients who experience recurrent appendicitis usually
Fig. 3 a The initial intravenous contrast image of a 7-year-old boy
showed an appendicolith within the multilocular gas-containing appen-
diceal abscess with an enhancing rim. b The abscess was smaller and
the appendicolith was still present on contrast-enhanced image after
7 days when he was discharged. c The inflammatory change of the
right lower quadrant and the appendicolith disappeared on the CT scan
at the fourth month of follow-up
Table 2 Clinical data between the appendicolith persistent presence
subgroup and appendicolith disappearance subgroup
APs (n=9) ADs (n=38) P value
Age (years) 6.73.5 7.33.7 0.682
Duration of symptoms 9.75.3 9.44.8 0.904
Localized peritonitis 8 (88.9 %) 25 (65.8 %) 0.244
WBC 22.23.4 19.95.8 0.258
CRP 143.577.0 116.959.7 0.262
Inflammatory area (cm
2
) 34.621.0 34.224.7 0.960
LOS 16.19.9 11.74.5 0.223
Recurrent appendicitis 6 (66.7 %) 3 (7.9 %) 0.001*
APs appendicolith persistent presence subgroup, ADs appendicolith
disappearance subgroup
*P<0.05
J Gastrointest Surg (2013) 17:766770 769
exhibit a milder clinical course at recurrence.
19
In the no
appendicolith and appendicolith disappearance groups, only
one child had another APA and IA after receiving conser-
vative management again. The other children with recurrent
appendicitis received appendectomy immediately with zero
morbidity.
Nine children in our series had persistent presence of an
appendicolith during the follow-up period. Among them,
two patients had recurrent appendicitis and four had recur-
rent APA. The recurrence rate was 66.7 % in the appendi-
colith persistent presence subgroup, which was a 8.4 relative
risk (66.7 vs. 7.9 %) for recurrent appendicitis compared
with the appendicolith disappearance with APA, and recur-
rent APAwas accounting for 66.7 %. The four children with
recurrent APA returned on months 3, 4, 3, and 7, respec-
tively. This indicated that IA was able to prevent recurrent
complicated appendicitis because the recurrence was often
after 3 months of initial conservative management. These
data suggest that the persistent presence of an appendicolith
increases recurrent risk in children with APA. IA was rec-
ommended to prevent recurrence in patients with persistent
presence of appendicolith in APA.
Our study has some limitations. One limitation is that the
data were retrospectively collected. This may have resulted
in some degree of bias. Another limitation is that the number
of patients with persistent appendicolith was lower than
expected because most cases resolved. Further large-scale,
prospective trials are needed to validate our conclusion
about the optimal treatment of APA with an appendicolith.
Conclusion
APA with an appendicolith can be managed nonoperatively
without immediate appendectomy. Most appendicoliths pres-
ent on admission CT scans will resolve. The persistent pres-
ence of an appendicolith rather than appendicolith presence
alone was a significant risk factor for recurrent appendicitis in
APA. IA was recommended for the persistent presence of an
appendicolith in APA, but IA is not indicated in APA cases
without appendicolith or disappearance of appendicolith.
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