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Presenter: Dr. A R Shaan Moderator: Dr. S B Choudhary
Intra Abdominal
Abscess
Michael DeBakey & Alton Oschner
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.
Types of Intra abdominal abscess
Intraperitoneal( Extravisceral)
Visceral
Retroperitoneal
Intraperitoneal spaces
Perihepatic Spaces
Extravisceral Abscess
2 situations:
Resolution of diffuse peritonitis loculated infection
Perforation of a viscous or Anastomotic Breakdown
Retroperitoneal spaces
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
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
Factors favouring abscess
LOCAL FACTORS MICROBIAL FACTORS
Local fibrin deposition
Low pH
Particulate stool
Hypoxia
Polymicrobial Flora
Bacteroides fragilis
Capsular polysaccharide
Clinical Features
High spiking fevers Chills Tachycardia Tachypnoea Leukocytosis Localised abdominal pain Anorexia Delay in return of bowel function
Special Features
Subphrenic Abscess
Paracolic abscess
Pelvic abscess
Retroperitoneal Abscess
Diagnostic testsXray
CT Scan
USG Scan
MRI
Abdominal Xrays Air fluid levels
Extraluminal gas
Soft tissue mass displacing the bowel
Elevated diaphragm
Collapse/consolidation at lung base
Diagnostic features in CT scan
Low CT attenuation
Mass effect displacing normal structures
“lucent centre with rim enhancement”
Gas in fluid collection
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
MRIDelineate the extent of an abscess
Pregnancy
Management
Adequate resuscitation and support
Antimicrobial therapy
Source control/ abscess drainage
Resuscitation & Support
ABC
Oral/enteric nutritional/ TPN
Antimicrobial Therapy
3 Categories:
community- acquired infections of mild to moderate severity
High risk/ severe community- acquired infections
Health care associated infections
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
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 √
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
Amoebic Liver abscess Metronidazole 750mg TID for 14 days
Chloroquine
Dihydromentine
Drainage ---- needle aspirations Percutaneous catheter drainage
Source Control
Percutaneous Drainage
Surgery
Prerequisites for percutaneous drainage
Anatomically safe route
Well defined unilocular abscess cavity
Surgical & radiological evaluation
Surgical backup for technical failure
Post-requisites for percutaneous drainage Gram’s stain and culture
8-12f catheter
Closed drainage system
Irrigation of catheter once daily
Repeat CT
Complications with percutaneous drainage Enterocutaneous fistula
Bacteremia
Sepsis
Vascular injury
Enteric puncture
Transpleural catheter placement
Criteria for removal of a Drain
Clinical resolution of septic parameters
Minimal drainage from the catheter
CT evidence of resolution
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)
Surgical Drainage Failure of percutaneous drainage
Diffuse infection
Content of abscess is too thick
Access is impossible
Surgical approach
Transperitoneal approach
Extraperitoneal approach
Posterior Extraserous Approach
Anterior incisions
Thank You…..
Every operation in surgery is an experiment in bacteriology
-Berkeley Moynihan