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We performed US control of the pancreas lesions and upper abdominal abscesses and malignant according to 94 descriptive US images signs. We also used miniinvasive diagnostic involvements and small curative techniques. Diagnostic efficacy of US technology findings includes: sensitivity--90.5%, specificity--85.0% and accuracy--89.2%.
Computerized tomography or ultrasound-guided percutaneous drainage has replaced surgery as the preferred method of treatment for intra-abdominal abscesses and is generally regarded as safe. The authors, however, report a case of necrotizing fasciitis complicating percutaneous drainage of a postoperative intra-abdominal abscess. This potentially fatal complication illustrates that successful percutaneous drainage of an abscess does not eliminate the need to closely monitor the patient's subsequent clinical course. Successful treatment of necrotizing fasciitis depends on early recognition, radical debridement, aggressive fluid resuscitation, and diligent postoperative wound care.
Improvements in radiologic localization have made percutaneous catheter drainage (PCD) the initial procedure of choice for many intra-abdominal abscesses (IAA). During the past seven years 154 patients underwent PCD for treatment of abdominal abscesses. Fourteen of these patients had PCD as the initial treatment for IAA secondary to a perforated viscus and subsequently underwent an elective one-stage operation to treat the underlying disease. Etiologies of the abscesses included perforated appendicitis in six patients, sigmoid diverticulitis in three patients, Crohn's ileitis in two patients, and one case each of perforated gastric ulcer, perforated sigmoid carcinoma, and perforated gallbladder. Initial localization of the abscess was achieved by either CT or ultrasound. Seven abscesses were localized in the right lower quadrant, four were localized in the liver, and one was localized each in the left flank, right flank, subhepatic space, and pelvis. All patients subsequently underwent a definitive elective operation for their primary disease including six interval appendectomies, four sigmoid colectomies, two small-bowel resections, one subtotal gastrectomy and one cholecystectomy. There were no complications due to PCD and no deaths occurred. We conclude that PCD can be successfully performed as the initial treatment for IAA associated with a perforated viscus, obviating the first stage of the traditional two-stage surgical approach.
Macrophage procoagulant activity (PCA) has been proposed as a critical element in the formation of intra-abdominal abscesses. We tested the ability of local and systemic lipids (a known PCA inhibitor in vitro) to alter both peritoneal macrophage PCA and mixed Escherichia coli/Bacteroides fragilis intra-abdominal abscess formation in vivo. Lipids given intraperitoneally inhibited measured inducible peritoneal macrophage PCA for 8 h, and, in other animals, significantly decreased the number of abscesses formed and prevented abscesses in 29% of animals. Parallel experiments using subcutaneous intralipids did not show these effects. These results support the hypothesis that macrophage PCA produced locally is critical for intraperitoneal abscess formation.
We used computed tomography (CT) and ultrasonography for detection and localization of intra-abdominal abscesses. On the basis of these images, safe routes for diagnostic aspiration and percutaneous drainage were planned. Over these routes indwelling catheters were inserted to provide immediate decompression, evacuation, and continuous drainage until the abscess resolved. All patients received concomitant intravenous antibiotics. The treatment was used for 71 abscesses in 67 patients. Sixty-one abscesses (86 per cent) were satisfactorily drained. There were 11 complications (15 per cent). Six deaths were attributable to sepsis, three of which (4 per cent) were related to inadequate drainage. There was one recurrence (1 per cent) during a follow-up period ranging from one month to five years (means, 22.3 months). The mean duration of treatment was 20.2 days (range, five to 120 days). We conclude that percutaneous drainage is an effective method for treatment of abdominal abscesses and is indicated when sectional imaging demonstrates an accessible unilocular lesion.
The efficacy of trovafloxacin in treating Bacteroides fragilis and Escherichia coli infections was investigated and compared to the efficacy of combined clindamycin and gentamicin therapy in an experimental model of intra-abdominal abscesses in rats. Rats were treated with different doses of CP-116,517-27, a parenteral prodrug of trovafloxacin. Response to treatment was evaluated by mortality rate and elimination of infection (cure rate). Mortality in the control group was 85.4%, whereas in rats treated with trovafloxacin, it was close to 0%. The highest cure rate (89.3%) resulted from the administration of 40 mg of CP-116,517-27 per kg of body weight three times a day (TID) for 10 days (equivalent to 18.15 mg of active drug trovafloxacin per rat per day). The therapeutic response with trovafloxacin was comparable to that of a combination therapy of clindamycin (75 mg/kg) plus gentamicin (20 mg/kg) TID (cure rate, 74%; mortality rate, 5%). The measured peak levels of trovafloxacin in serum and abscess pus were 2.6 +/- 0.3 and 5.2 micrograms/ml, respectively. The tumor necrosis factor alpha levels in the untreated animals were high compared to those for rats treated with trovafloxacin or clindamycin plus gentamicin. These results demonstrate that trovafloxacin as a single agent appears to be as successful as clindamycin plus gentamicin in the treatment of experimental intra-abdominal abscesses in rats.
The authors report their experience with 19 percutaneous drainages of abdominal abscesses in 19 patients. Six collections were in the subphrenic spaces, 6 in the liver, 1 in the infracolic space, 2 in the psoas muscle, 3 within the abdominal wall, and 1 in the pararenal space. Their etiology was abdominal surgery in 10 patients, biliary obstruction in 1, and trauma in 2; in the extant patients a hematogenous infection was supposed. The procedures were performed under combined US and fluoroscopic guidance, following Seldinger technique in all but two cases. Van Sonnenberg double-lumen sump catheter was successfully employed in all cases. After a review of the technique the authors discuss the advantages of US-fluoroscopic over CT guidance. The latter is preferred if the collection is not well demonstrated by US and in the cases where a posterior approach is needed. The economic advantages of US-fluoroscopic over CT guidance are also stressed.
BACKGROUND: Percutaneous drainage (PD) of complex postoperative abscesses associated with a variety of factors such as multiple location or enteric fistula remains a matter of debate. Accordingly, this retrospective study was designed to determine the predictive factors for failure of PD of postoperative abscess, in order to better select the patients who may benefit from PD. METHODS: From 1992 to 2000, the data of 73 patients who underwent computed tomography (CT)-guided PD for postoperative intra-abdominal abscess, were reviewed. PD was considered as failure when clinical sepsis persisted or subsequent surgery was needed. The possible association between failure of PD and 27 patient-, abscess-, surgical-, and drainage-related variables were assessed using univariate and multivariate analysis. RESULTS: Successful PD was achieved in 59 of 73 (81%) patients. The overall mortality was 3% but no patient died after salvage surgery. Multivariate analysis showed that only an abscess diameter of less than 5 cm (P = 0.042) and absence of antibiotic therapy (P = 0.01) were significant predictive variables for failure of PD. CONCLUSIONS: CT-guided PD associated with antibiotic therapy could be attempted as the initial treatment of postoperative abdominal abscesses even in complex cases such as loculated abscess or abscess associated with enteric fistula.
In a 23-year-old woman, an intramuscular abscess of the ventral abdominal wall in the right iliac fossa was found to have an extraperitoneal fistula to a focus of asymptomatic osteomyelitis of the iliac ala. Pelvic osteomyelitis should be suspected in cases of abdominal wall abscess without pathologic intra-abdominal findings.
An animal model has been developed to study the evolution of intra-abdominal abscesses. Gelatin capsules containing pooled colonic contents and barium sulfate were prepared in an anaerobic chamber and implanted into the pelvic region of Wistar rats. The natural course of the ensuing disease was studied in various groups according to the source of the inoculum and sex of the recipient. Colonic contents derived from rats fed a grain diet produced a highly lethal disease with an 80% mortality rate for males and 100% for females. Most deaths occurred within 3 days of implantation, and autopsies showed generalized peritonitis. The addition of blood to the inoculum caused a rapidly fatal peritonitis in all animals. With an inoculum derived from meat-fed rats implanted in male recipients, there was a biphasic disease. Initially, there was peritonitis associated with 43% mortality. All animals that survived this acute period developed discrete intra-abdominal abscesses by the seventh postoperative day. The latter stage was characterized by an indolent course and progressive enlargement of abscesses.
We have characterized splanchnic blood flows in a rat model of antibiotic-controlled, intra-abdominal abscess (ACIA) in normoxic and hyperoxic environments. Abscesses (1.5 ml average volume) were established by implanting a fecal-agar pellet containing known numbers and strains of live Escherichia coli and Bacteroides fragilis into the peritoneal cavity of rats via a midline incision. Sham-operated rats (SR) served as controls. Cannulas (PE-50) were placed into the left ventricle of both SR and ACIA rats for injection of tracer microspheres (MS) and into the tail artery for a reference withdrawal site. Blood flow measurements were made in conscious unrestrained rats before, during, and after hyperoxic exposure by using MS labelled with either 51Cr or 85Sr or 141Ce. No change in cardiac output (CO), heart rate (HR), or mean arterial pressure (MAP) was seen between ACIA and SR groups. The administration of hyperoxia diminished the fractional distribution of CO to the liver (portal), stomach, cecum, colon, and pancreas in both groups. The percent CO to the liver (arterial), small intestine, and spleen did not change in either group. The blood flow to all splanchnic organs, except liver (arterial), was diminished during hyperoxia in both groups and recovered after hyperoxia. In conclusion, central hemodynamics and splanchnic blood flows are not altered by the presence of a large intra-abdominal abscess controlled by antibiotics. Splanchnic blood flows are diminished by hyperoxia.
In 56 patients with abdominal abscess typical radiological abscess sings were analized to establish a rational and stepwise use of imaging procedures. Plain radiographs of the abdomen should be carried out at first because of their large diagnostic possibilities and standardized practicability. In addition with ultrasonography the diagnosis is possible in almost 90% of the cases. Contrast medium examination are rarely of diagnostic value. Computed tomography should be used in the remaining unclear cases and for planning of further surgical treatment.
PURPOSE: Early detection of occult abscesses is important in patients with persistent fever after colorectal surgery. In this study, the authors evaluated the relative merits of computed tomographic (CT) and Ga-67 scans in the detection of intra-abdominal abscesses in patients who had just undergone colorectal surgery. MATERIALS AND METHODS: Thirty-four patients who underwent colorectal surgery were enrolled in the study. Ga-67 and CT scans were obtained in all patients. Ga-67 scintigraphy was performed 24 hours, and later as needed, after the injection of 111 MBq (3 mCi) Ga-67 citrate. RESULTS: Intra-abdominal abscesses were diagnosed in 16 of the 34 (47%) patients who had colorectal surgery. For CT scans, the overall accuracy, sensitivity, and specificity rates were 97.1%, 93.7%, and 100%, respectively. For the Ga-67 scans, the diagnostic accuracy, sensitivity, and specificity rates were 91.2%, 100%, and 95.2%, respectively. In addition, the whole-body Ga-67 scans successfully detected two cases of extra-abdominal infection, one case of pneumonia, and one case of cellulitis. CONCLUSIONS: Computed tomographic and Ga-67 scans offer complementary information and play an important role in the investigation of sources of infection in patients after colorectal surgery.
Computed tomography and, to a lesser extent, ultrasonography provide detailed anatomic localization of intra-abdominal abscesses that permit precise percutaneous placement of catheters large enough to effect drainage. Using routes similar to surgical approaches, the authors have used this technique as definitive therapy for intra-abdominal abscesses. To assess its efficacy, the results in the 27 patients treated percutaneously over the last five years have been compared with the results in the 43 patients treated by operative intervention over the past ten years. In the percutaneous group, complications (4%), inadequate drainage (11%), and duration of drainage (17 days) were less than in the operative group (16%, 21% and 29 days respectively). These results indicate that percutaneous drainage is at least as efficacious as operative drainage and avoids the risks of a major operative procedure.
The sonographic-radiological diagnosis of abdominal abscesses is discussed; these are divided into intraparenchymal, extra-parenchymal-intraperitoneal and extraparenchymal-extraperitoneal lesions. The results of grey scle sonography are most informative and are correlated with the radiological and scintigraphic findings in 25 patients. In addition to the advantages of economy and of a non-invasive method, ultrasound permits aimed fine-needle aspiration of pathological abdominal processes such as abscesses.
Primary peritonitis that tends to occur especially in children, and cirrhotic spontaneous bacterial peritonitis are well recognized clinical entities. At the University College Hospital, Ibadan, cases of intra-abdominal abscess that do not fit the recognized criteria for primary peritonitis have been seen. These patients were neither cirrhotic nor nephrotic and all the intra-abdominal organs at operation appeared normal. This "idiopathic" intra-abdominal abscess seems to occur mainly in the tropics and is a strong differential diagnosis of typhoid perforation. Treatment consists of exploratory laparotomy, thorough irrigation of the abdominal cavity with sterile saline solution, and systemic administration of broad spectrum antibiotics.
Abdominal wall abscess is a rare presentation of intra-abdominal disease. We describe a 69-year-old woman with a locally advanced carcinoma of the sigmoid colon presenting as abdominal wall abscess. The diagnosis was suggested by computed tomography of the abdomen. She was treated with resection of the tumor with closure of the rectal stump and proximal end colostomy. No adjuvant therapy was undertaken considering the extent of the disease. She survived for four months after the operation.
The technique of computed tomographic guided drainage of abdominal abscesses is simple, and is becoming increasingly available. Obvious advantages include the avoidance of general anaesthesia and major surgery. Three illustrative cases of the drainage of abscesses in different locations are presented together with a description of the technique.