Abdominal Abscess - an overview (2023)

Intra-abdominal abscesses occur in 2% to 10% of all hepatic trauma and are related to the extent of the hepatic injury, other associated injuries (especially colonic), the number of transfusions, and the type of drainage.

From: Parkland Trauma Handbook (Third Edition), 2009

Related terms:

  • Appendectomy
  • Fistula
  • Abscess
  • Computer Assisted Tomography
  • Peritonitis
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Abdominal Abscesses and Gastrointestinal Fistulas

Mark Feldman MD, in Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 2021

Bacteriology

The microbiology of IAA depends on the stage of presentation, as well as the host in which the infection has occurred. Animal studies have shown that the composition of an intra-abdominal infection changes over time. In classic studies by Onderdonk etal.,Escherichia coli was shown to initially predominate in a rat model of abdominal sepsis.17 As peritonitis developed, many animals developedE. coli bacteremia and died. Of those animals who survived, IAAs developed withBacteroides fragilis as the predominant microbe. Thus, there is a fluid interplay between the bacterial species responsible for abdominal infection.

Formation of an IAA can be viewed as beneficial because it contains infection and prevents fatal sepsis and death.Bacteroides species are important microbes in the formation of IAA, so they have been studied extensively to better understand the process of abscess formation.B. fragilis is known to have 8 forms of capsular polysaccharides,18 some of which have a zwitterionic structure. Polysaccharide A (PSA) ofB. fragilis can stimulate either a proinflammatory or anti-inflammatory response in the digestive tract, dependent upon their location.19,20 This has been termed a “love-hate” relationship19 or the “yin-yang” of bacterial polysaccharides.20 On one side, PSA fromB. fragilis appears to have a vital role in induction of normal T cell–mediated immunity arising from normal commensal bacterial colonization in the gut, whereas on the other side, PSA introduced into the peritoneal cavity, in conjunction with lymphatic obstruction, induces abscess formation. The effect of PSA on abscess formation is through regulation of the T-helper 17 cells, which are needed for secretion of interleukin (IL)-17 and abscess formation,21 as well as Forkhead Box (FOX) transcription factor regulatory T cells and CD4+ CD45RBlow cells, both of which secrete IL-10, which promotes abscess formation.22,23 Interestingly, another source of IL-10 has been shown to be peritoneal macrophages, also vital to abscess formation.23 Recent research suggests the direct binding ofB. fragilis to fibrinogen and the activity of fibrinogenolytic proteases may circumvent abscess formation, giving rise to bacteremia and potentially sepsis.24 It is apparent there are extremely complex interactions that occur between bacteria and cells of the immune system to promote or prevent spread of bacteria. Indeed, the theory has been put forth by numerous authors that abscess formation may be considered a form of “bacteria apoptosis,” a means whereby extraintestinal commensals are sacrificed to circumvent sepsis and prevent death of the host organism, thereby ensuring the continued growth of the larger intraintestinal bacterial cohort.

Abdominal Abscess

Avinash Kambadakone, Peter R. Mueller, in Textbook of Gastrointestinal Radiology, 2-Volume Set (Fourth Edition), 2015

Patient Preparation

Percutaneous drainage of intra-abdominal abscess is often performed in hospitalized patients but can also be done on an outpatient basis. When it is performed on an outpatient basis, it might be necessary to admit the patient for overnight observation on the basis of the patient's clinical condition. Before the procedure, the patient should be fasting for at least 8 hours, and anticoagulant medications should be discontinued before the procedure. The patient should, however, continue other medications in the preoperative period. The procedure is mostly performed under intravenous conscious sedation, but general anesthesia should be considered in critically ill patients. Cardiorespiratory monitoring including electrocardiography, blood pressure, and pulse oximetry are crucial for monitoring of the patient during the procedure.

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Ultrasound-Guided Biopsy of Chest, Abdomen, and Pelvis

Carol M. Rumack MD, FACR, in Diagnostic Ultrasound, 2018

Abdominal and Pelvic Abscesses: General

Most abdominal and pelvic abscesses are secondary to underlying bowel disease or seen after surgery. Percutaneous abscess drainage for postoperative abdominal abscesses has become the accepted primary treatment of choice, with cure being the expected goal. Percutaneous drainage has also played a principal role in the treatment ofdiverticular, appendiceal, andCrohn disease–related abscesses.125-127 Drainage of abscesses in these acutely ill patients can help alleviate sepsis and allow the necessary curative surgery to be performed on an elective basis.

Drainage ofabdominal abscesses is often best performed with CT guidance, which allows the best visualization and avoids adjacent bowel loops. CT also provides an overview of the entire abdomen, to ensure all collections are drained. Ultrasound can provide excellent guidance for percutaneous abscess drainage; however, careful review of CT imaging assists in planning an optimal approach free of intervening bowel. Unlike CT, ultrasound is especially valuable in the treatment of critically ill patients who cannot be transported to the radiology department.

Pelvic abscesses are of variable origin and have been notoriously difficult to access because of their deep location, overlying bowel, blood vessels, and urinary bladder. Traditional approaches include ananterior transperitoneal approach or aposterior transgluteal approach. The transgluteal approach is relatively painful, and care must be taken to avoid the sciatic nerve. Small, deep pelvic abscesses may be difficult to access safely using traditional approaches.

Ultrasound-guidedtransvaginal drainage has been established as a viable alternative to these traditional approaches128,129 (Fig. 17.17). Needle guides are available for endovaginal probes that help guide the needle into the fluid collection (Videos 17.6 and17.7

). This transvaginal approach can be used to drain tubo-ovarian abscesses unresponsive to medical treatment. The trocar technique may also be used successfully for transvaginal drain placement.Transrectal ultrasound-guided drainage has also been described in the drainage of pelvic fluid collections,130 but such an approach is infrequently used.

Fornonpurulent pelvic collections, immediate catheter drainage is not necessarily indicated. Many of these patients respond to a one-step aspiration, lavage, and antibiotic therapy based on results of cultures of the aspirates.131,132

Enteric abscesses often have communication with the GI tract. For these abscesses to be drained successfully, the GI communication first must be recognized, then allowed to heal and close before removal of the catheter. Fistulas will not close if there is distal obstruction, tumor, or persistent infection. Even with the most aggressive techniques, however, success in treating abscesses with enteric communication is lower than for noncommunicating abscesses.133,134 A particular challenge exists in the percutaneous treatment of Crohn disease–related abscesses. Obviating surgery in the short term can only be achieved in about 50% of patients, with a much lower success rate in patients with preexisting bowel fistulas.127,135Enterocutaneous fistulas may develop along the drain tract in these patients.

Paediatric bowel and mesentery

Marilyn J. Siegel, Edward Y. Lee, in Clinical Ultrasound (Third Edition), 2011

Inflammatory disease

Abdominal abscesses in children are usually the result of intestinal perforation secondary to appendicitis or Crohn's disease, but they may also follow pelvic surgery or trauma or be a sequel of pelvic inflammatory disease. Patients typically present with fever, leukocytosis and abdominal pain. The characteristic ultrasound appearance of intraperitoneal abscess is an echo-poor mass (see Fig. 70.33) with a reflective rim. Occasionally fluid/debris levels, septations or gas can be encountered. Gas can be recognised as intensely reflective foci, usually with acoustic shadowing. Careful observation while holding the transducer still may show the mobile gas bubbles in anaerobic abscesses.

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Surgical Infections and Antibiotic Use

Courtney M. Townsend JR., MD, in Sabiston Textbook of Surgery, 2022

Definition, Etiology, and Classification of Intraabdominal Abscess

Intraabdominal abscess refers to a localized walled-off collection of infected fluid within the confines of the abdomen (peritoneal cavity, retroperitoneum, and pelvic cavity) that occurs as a result of the protective containment of the host’s intraabdominal defense mechanisms. Failure of the host intraabdominal defense mechanisms to wall off and localize the infection leads to an uncontained infection with acute diffuse peritonitis and systemic infection associated with a high morbidity and mortality.

An abscess can develop at a later stage of what was previously uncontained intraabdominal “free-floating infection.” With the intraabdominal host defense mechanisms against infection in effect, there is, then, the development of a capsular wall around the inflammatory fluid or infected fluid for containment, resulting in a walled-off abscess. A previously uninfected fluid collection that becomes walled off may later become secondarily infected from systemic bacteremia or from external translocation via a drain or instrumentation, for example, secondary infection of a post pancreatitis pseudocyst (Fig. 11.2).

On the other hand, intra-abdominal fluid may already be infected at the onset and then become walled off (e.g. purulent fluid from ruptured acute appendicitis or leaked hollow viscus contaminated fluid like in a colonic anastomotic leak) (Table 11.4).

Intraabdominal abscesses can, therefore, be classified into the following categories based on location, etiology, and severity (Box 11.3).

Bacteroides, Prevotella, Porphyromonas, and Fusobacterium Species (and Other Medically Important Anaerobic Gram-Negative Bacilli)

Wendy S. Garrett, Andrew B. Onderdonk, in Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases (Eighth Edition), 2015

Intra-abdominal Infections

Intra-abdominal abscesses can occur after frank perforation stemming from a trauma, surgical procedure of the intestine or biliary tract, or intestinal cancer. Abscesses also form in the setting of inflammatory or infectious processes such as appendicitis, inflammatory bowel disease, diverticulitis, cholecystitis, or pancreatitis. B. fragilis is the prototypic anaerobe associated with intra-abdominal abscesses. Escherichia coli is also a common isolate. The facultative anaerobe E. coli and B. fragilis can act synergistically and are often both isolated from intra-abdominal abscesses. It is the host response to the capsular polysaccharides of B. fragilis that results in abscess formation. Studies in mouse models using intraperitoneal injection of B. fragilis have provided valuable insight into how adaptive and innate immune cell subsets, as well as mesothelial cells, contribute to intra-abdominal abscess formation. It speaks to the unique biology of B. fragilis that this organism, which makes up less than 0.5% of the intestinal microflora, is responsible for the vast majority of intra-abdominal abscesses.

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Intraabdominal Abscess

Christopher M. Watson, Robert G. Sawyer, in Netter’s Infectious Diseases, 2012

Prognosis

If IAA is treated appropriately and early, the prognosis is good; most IAAs resolve quickly, drains can be removed after days to weeks, and the patient can be followed clinically. These good results are probably related to the fact that abscess formation itself indicates that a robust immune response has occurred and that the infection has already been naturally contained, unlike the pathophysiology seen with diffuse peritonitis. Recurrence, which can occur in up to 25% of cases, can usually be treated with another catheter placed into the collection and a new course of antimicrobials. Of course, repeat cultures should be obtained because the likelihood of a resistant pathogen being present is higher with a recurrence.

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Stenosis, Terminal Ileum

In Expertddx: Abdomen and Pelvis (Second Edition), 2017

Helpful Clues for Less Common Diagnoses

Abdominal Abscess

Pus from any abdominal or pelvic source (appendicitis, diverticulitis, adnexal abscess)

May bathe distal ileum, causing wall thickening & spasm

Fold thickening & luminal narrowing simulates primary SB inflammation

Cecal Carcinoma

May extend into distal SB wall, serosa

CT may shows peritoneal & liver metastases

Carcinoid Tumor

Common in appendix, distal SB

CT: Mesenteric mass (± calcification) usually more evident than primary tumor

Primary tumor and metastases are usually hypervascular

Marked desmoplastic infiltration of SB mesentery

Tuberculosis

May involve cecum & terminal ileum

Look for signs of peritonitis & caseated nodes on CT

Radiation Enteritis

Usually pelvic SB loops, not terminal ileum

Small Bowel Carcinoma

Short segment stricture with overhanging edges (apple core)

Mass is soft tissue density

Not hypervascular (unlike carcinoid)

Typically results in SB obstruction

Regional nodal & liver metastases

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Postoperative control: Complications and management in critical care units

Susana López Piñeiro, in Foundations of Colorectal Cancer, 2022

Intraabdominal abscess

An intraabdominal abscess is usually located in subphrenic, paracolic, or pelvic spaces. It should be suspected in patients with persistent fever, prolonged ileus, and a slower recovery than expected after surgery. The increased leukocyte count, plus data provided from the ultrasound and, preferably the CT scan, will lead us to the diagnosis. The treatment consists of controlling the focus by means of drainage, controlling the cause, and systemic antibiotic therapy. Percutaneous drainage or using endoscopic ultrasonography (EUS)6 inside of the intestinal lumen can be chosen in single and well-located abscesses. Those located in the pelvis, apparent in a rectal or vaginal exam, can be drained by directly targeting that area.7 Deep-rooted abscesses, associated with suture dehiscence, will be dealt with by means of a laparotomy. In this new surgery, the deposit will be drained and the continuity solution will be repaired by means of an ileostomy or colostomy, with or without a mucous fistula.

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CROHN'S DISEASE OF THE SMALL BOWEL

Scott A. Strong MD, in Current Therapy in Colon and Rectal Surgery (Second Edition), 2005

Abscess

Most abdominal abscesses in ileocecal or small bowel Crohn's disease arise from penetrating fissures or ulcers. Although some surgeons advocate primary management by laparotomy, an enteroparietal abscess is usually best treated by preliminary CT-guided external drainage if the cavity is accessible or surgical drainage if the abscess is unapproachable despite imaging guidance. Subsequent resection of the diseased intestinal source is carried out when the abscess has resolved. Recent reports have challenged the notion that an abscess ultimately mandates laparotomy with resection. In one series, more than half of persons undergoing a CT-guided drainage procedure avoided subsequent operative intervention, and most of these patients had evaded surgery and remained asymptomatic after 3 years of follow-up.

Intramesenteric abscesses arise when a mesenteric ulcer penetrates the bowel wall, and the abscess spreads between the leaves of the mesentery, extending toward the mesenteric root. Resection of the bowel with a mesenteric cuff risks secondary peritoneal contamination and difficulty with vascular pedicle ligation. These pedicles are particularly fragile and slippage or premature erosion of the ligature can instigate major secondary hemorrhage. Instead, the abscess should be identified by intraoperative needle localization, and emptied by needle aspiration as well as manual compression of the mesenteric leaves. The bowel associated with the affected mesentery is then excluded by dividing the intestine on either side, creating proximal and distal mucous fistulas, and constructing an enteroenterostomy to restore bowel continuity. The excluded segment is resected 6 months later.

Posterior or retroperitoneal perforation of the ileocecal area may be well circumscribed or poorly localized because of deep extension behind the psoas fascia. A small simple abscess is managed by CT-guided drainage followed by elective resection of the diseased segment. A larger multiloculated abscess is best treated by surgical drainage. An incision is created over the site, the oblique muscles are separated, the abscess is localized with a large-bore needle, the pyogenic membrane is incised, and loculations are disrupted. Then, a catheter is inserted and remains until the cavity has collapsed as evidenced by sinography. If an unsuspected psoas abscess is identified at laparotomy, the ileocecal segment is mobilized, the bowel is resected, an anastomosis is completed, the abscess is unroofed and drained extraperitoneally, and omentum is interposed between the bowel and the residual cavity.

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