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Presenter: Dr. A R Shaan Moderator: Dr. S B Intra Abdominal Abscess

Intra abdominal abscess

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Page 1: Intra abdominal abscess

Presenter: Dr. A R Shaan Moderator: Dr. S B Choudhary

Intra Abdominal

Abscess

Page 2: Intra abdominal abscess

Michael DeBakey & Alton Oschner

Page 3: Intra abdominal abscess

Abdominal Abscess

“ well-defined collections of infected purulent material that are walled off from the rest of the peritoneal cavity by inflammatory adhesions, loops of intestines and their mesentry, the greater omentum or other abdominal viscera”

-Maingot’s 12th ed.

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Types of Intra abdominal abscess

Intraperitoneal( Extravisceral)

Visceral

Retroperitoneal

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Intraperitoneal spaces

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Perihepatic Spaces

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Extravisceral Abscess

2 situations:

Resolution of diffuse peritonitis loculated infection

Perforation of a viscous or Anastomotic Breakdown

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Retroperitoneal spaces

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Pathophysiology

3 major defense mechanisms of peritoneal cavity

Mechanical clearance via Diaphragmatic Lymphatics

Phagocytosis and destruction of adherent bacteria

Sequestration and walling off of bacteria, with delayed clearance

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Bacterial Contamination

HyperemiaExudative fluidMacrophages

Neutrophilic Exudate

2-4 hr

Innate Immunity

TNF-αIL-1IL-6IL-10

RESOLUTION of peritonitis

Mast cells Mesothelial lining Cells

Cytokinesprocagulants

FibrinCOMPARTMENTALIZATION of peritonitis

ABSCESS

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Factors favouring abscess

LOCAL FACTORS MICROBIAL FACTORS

Local fibrin deposition

Low pH

Particulate stool

Hypoxia

Polymicrobial Flora

Bacteroides fragilis

Capsular polysaccharide

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Clinical Features

High spiking fevers Chills Tachycardia Tachypnoea Leukocytosis Localised abdominal pain Anorexia Delay in return of bowel function

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Special Features

Subphrenic Abscess

Paracolic abscess

Pelvic abscess

Retroperitoneal Abscess

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Diagnostic testsXray

CT Scan

USG Scan

MRI

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Abdominal Xrays Air fluid levels

Extraluminal gas

Soft tissue mass displacing the bowel

Elevated diaphragm

Collapse/consolidation at lung base

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Diagnostic features in CT scan

Low CT attenuation

Mass effect displacing normal structures

“lucent centre with rim enhancement”

Gas in fluid collection

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CT Scan vs USGAdvantages of CT Disadvantages of CT

Not impaired in ileus

Wound dressings and stomas

Open abdomen

Retroperitoneal and pancreatic region

Absence of rim enhancement/ gas/ visible septations

High leucocyte and protein content

Loculated Abscess

Subphrenic and pulmonic fluid

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MRIDelineate the extent of an abscess

Pregnancy

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Management

Adequate resuscitation and support

Antimicrobial therapy

Source control/ abscess drainage

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Resuscitation & Support

ABC

Oral/enteric nutritional/ TPN

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Antimicrobial Therapy

3 Categories:

community- acquired infections of mild to moderate severity

High risk/ severe community- acquired infections

Health care associated infections

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Community acquired infectionsMild-moderate severity(perforated/ abscessed appendicitis and other infections of mild-moderate severity)

High Risk or Severe(severe physiological disturbance, advanced age, immunocompromised state)

Cefoxitin

Ertapenem

Moxifloxacin

Ticaricillin-clavulanic acid

Imipenem-cilastin

Meropenem

Doripenem

Piperacillin-tazobactum

CefazolinCefuroximeCeftriaxoneCefotaxime + Metronidazole

CiprofloxacinLevofloxacin

CefepimeCeftazidime + MetronidazoleCiprofolacinLevofloxacin

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Health care associated infectionsOrganism Carbepenem Piperacillin-

tazobactumCeftazidime/cefepime + metronidazole

Aminoglycoside

Vancomycin

<20% Res. PseudomonasESBL Enterobacteracea, acenetobacter, MDR-GNB

√ √ √

ESBL-Enterobacteraceae

√ √ √

P. Aeruginosa>20% res ceftazidime

√ √ √

MRSA √

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Pyogenic liver abscesses< 3cm

Single/multiple

Antibiotic therapy

PCD if not responding

> 3 cm

unilocular

antibiotics

PCD by needle aspiration or catheter

Surgical therapy if not responding

multilocular

antibiotics

Percutaneous drainage

Surgical therapy by resection / drainage if not responsive

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Amoebic Liver abscess Metronidazole 750mg TID for 14 days

Chloroquine

Dihydromentine

Drainage ---- needle aspirations Percutaneous catheter drainage

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Source Control

Percutaneous Drainage

Surgery

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Prerequisites for percutaneous drainage

Anatomically safe route

Well defined unilocular abscess cavity

Surgical & radiological evaluation

Surgical backup for technical failure

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Post-requisites for percutaneous drainage Gram’s stain and culture

8-12f catheter

Closed drainage system

Irrigation of catheter once daily

Repeat CT

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Complications with percutaneous drainage Enterocutaneous fistula

Bacteremia

Sepsis

Vascular injury

Enteric puncture

Transpleural catheter placement

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Criteria for removal of a Drain

Clinical resolution of septic parameters

Minimal drainage from the catheter

CT evidence of resolution

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Comparing outcome in different scenarios…. Single well defined bacterial abscess with no enteric communication

Abscess with enteric communication

Interloop abscess/ difficult to access abscess

Early post operative diffuse peritonitis

Infected tumour massFungal abscessInfected hematomaPancreatic necrosis

Small abscess (<4cm diameter)

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Surgical Drainage Failure of percutaneous drainage

Diffuse infection

Content of abscess is too thick

Access is impossible

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Surgical approach

Transperitoneal approach

Extraperitoneal approach

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Posterior Extraserous Approach

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Anterior incisions

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Thank You…..

Every operation in surgery is an experiment in bacteriology

-Berkeley Moynihan