Abdominal Abscess


Article Author:
Nisarg Mehta


Article Editor:
Eddie Copelin II


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Saifur Rehman
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
7/31/2019 12:17:28 AM

Introduction

An abdominal abscess is a collection of cellular debris, enzymes, and liquefied remains which can be from an infection or non-infectious source. An intra-abdominal abscess usually signals that something serious is happening to the patient. An abscess can develop almost anywhere in the abdomen but are usually confined to some part of the peritoneal cavity. In many cases, the omentum, viscera, or mesentery may wall off an intraabdominal abscess. An abdominal abscess is quite common and is a serious condition. To avoid the high morbidity and mortality, the condition must be promptly diagnosed and treated. In general, sepsis that occurs after perforation in the upper gastrointestinal (GI) tract or leak is often associated with less morbidity and mortality compared to leaks that result from a colonic perforation or injury.[1][2][3]

Etiology

The most common organisms involved in an abdominal abscess include a mixture of aerobic and anaerobic bacteria that originate from the gastrointestinal tract. Causes of an intraabdominal abscess include perforation of a gastric ulcer, perforated appendicitis, diverticulitis, ischemic bowel disease, pancreatic necrosis, or gangrenous cholecystitis. Other common causes include penetrating abdominal trauma, surgical trauma, anastomotic leaks, volvulus, intussusception, or a missed gallstone during a cholecystectomy. Less frequently sterile abscess can result from the injection of a drug.[4]

Organisms involved in an abdominal abscess include the following:

  • Escherichia coli
  • Bacteroides
  • Neisseria
  • Chlamydia
  • Candida

Epidemiology

In most cases, intra-abdominal abscesses derive from an intra-abdominal organ and often develop after operative procedures. It is estimated that about 70% are postsurgical and that 6% of patients undergoing colorectal surgery may develop a postoperative abscess. Hepatic abscesses account for 13% of all intra-abdominal abscesses. Most hepatic abscesses involve the right lobe, probably due to the larger size and greater blood supply.

Pathophysiology

An intra-abdominal abscess may be confined or generalized within the peritoneal cavity. Localized collections of pus may have a barrier that may include adhesions, omentum or other adjacent viscera. In almost all cases, abdominal abscesses contain a polymicrobial collection of both aerobic and anaerobic organisms from the GI tract. The bacteria usually incite an inflammatory reaction that often results in a hypertonic environment that continues to expand as an abscess cavity. If left untreated, an abdominal abscess can lead to septic shock.[5][6]

History and Physical

Patients with an intra-abdominal abscess may present with abdominal pain, fever anorexia, tachycardia or prolonged ileus. The presence of a palpable mass may or may not be present. If the presentation is delayed, some individuals may appear in septic shock.

If the abscess is retroperitoneal or located deep in the pelvis, there may be no clinical signs. In such cases, the only suspicion may be a fever, mild liver dysfunction, or prolonged ileus.

In post surgery patients, the diagnosis of an abdominal abscess is difficult because of analgesia and antibiotics which often mask the signs of an infection.

A subphrenic abscess may present with shoulder tip pain, hiccups, or atelectasis.

Most patients with an abdominal abscess will show signs of dehydration, oliguria, tachycardia, tachypnea, and respiratory alkalosis.

Evaluation

Blood work is not specific for an intra-abdominal abscess but may reveal leukocytosis, abnormal liver function, anemia or thrombocytopenia. These are features that signal an infection. Blood cultures are often negative but when positive may reveal predominantly anaerobic organisms, the most common being Bacteroides fragilis.

Plain abdominal x-rays are not sensitive for identifying an intraabdominal abscess and hence a CT scan is required and is considered to be the most definitive test to rule out an intra-abdominal abscess. A CT scan can reveal the location, size, and presence of bowel thickening, thumbprinting, and ileus. Intra-abdominal abscess almost always requires intravenous (IV) antibiotics. If the abscess is localized, CT-guided aspiration can be performed to drain the abscess. CT scan has the advantage that it avoids general anesthesia and wound complications. It also prevents contamination of other parts of the abdominal cavity.[7][8][9]

In some patients, ultrasound may help identify abdominal abscess.

Nuclear scans are rarely used today to detect abscesses because the technique is time-consuming and has a high rate of false positives.

Treatment / Management

Broad-spectrum antibiotics and hydration are essential. Once cultures become, available one can use specific antibiotics as noted by their sensitivity. Intravenous hydration is required. A nasogastric tube may help decompress bowel and lower the emesis.[10][11][12]

Percutaneous CT guided drainage is widely used to drain abdominal abscesses. The procedure can be done under local anesthesia and decreases the duration of hospitalization. In most patients, improve occurs within 48 hours after drainage. In localized abscesses, CT-guided drainage has a success rate of over 90%.

If the patients fail to improve within 24 to 48 hours, surgical consultation is required. Both laparoscopic, interventional radiology and open procedures can be used to evacuate the abdominal abscess. However, if surgery is required, the necrotic tissue will be removed, and all adhesions can be lysed. Most of these patients require monitoring in the intensive care unit (ICU) and need aggressive resuscitation with fluids. If the abscess is localized and promptly treated, the prognosis is good.

Abscesses located in the pelvis may be drained transrectally or transvaginally, and the results are excellent.

Open surgery for an abdominal abscess is a difficult undertaking and can be difficult because of adhesions and lack of proper anatomical pathways to separate bowel.

Differential Diagnosis

  • Prolonged ileus
  • Fever of unknown origin
  • Crohn disease
  • Ulcerative colitis

Prognosis

The prognosis of patients with an abdominal abscess prior to the era of the CT scan was very high. Today, with the availability of CT scans the diagnosis is made much earlier, and in fact in many cases, CT guided drainage has helped lower the morbidity. However, if an abdominal abscess is misdiagnosed and not treated, the mortality is very high. Risk factors that increase mortality and morbidity include the following:

  • Advanced age 
  • Multi-organ failure
  • Multiple recent surgeries
  • Complex abscess
  • Delay in diagnosis

Complications

An abdominal abscess can lead to the following complications:

  • Multiorgan failure
  • Formation of fistula
  • Septic shock
  • Both CT-guided drainage and surgery can lead to bowel perforation
  • Death
  • Deep vein thrombosis
  • Malnutrition

Postoperative and Rehabilitation Care

Patients with an abdominal abscess usually require a stay in the hospital. Repeat imaging is often done to ensure that there is no more residual abscess after treatment.

Depending on the complexity of the abscess, some patients may require total parenteral nutrition.

Because the patients are often frail, physical therapy is recommended to help recover muscle strength and flexibility.

Consultations

Once a diagnosis of an abdominal abscess is done, a general surgeon and a radiologist should be consulted.

Pearls and Other Issues

Those with gross contamination of the abdominal cavity can develop multiorgan failure and consequently have a high mortality rate.

Today with the availability of CT scan, both diagnosis and drainage can be accomplished with very low morbidity.

A complex abscess may require a laparoscopic or an open approach.

Enhancing Healthcare Team Outcomes

An abdominal abscess is not an uncommon presentation on the general surgery ward or to the emergency department. Because of its vague clinical presentation, the disorder is best managed by an interprofessional group of health professional that includes a surgeon, dietitian, pharmacist, radiologist, gastroenterologist, and a wound care nurse. An abdominal abscess has significant morbidity and can rapidly become fatal if left untreated. To improve outcomes, communication between the interprofessional team is highly recommended.

While initial antibiotics are broad-spectrum, the pharmacist and clinicians need to watch the blood cultures to determine the type of organisms growing and their sensitivity. In many cases, patients with an abdominal abscess may not be able to eat and may require peripheral or central parenteral nutrition and hence, a dietary consult should be involved. While there are no universal guidelines on the management of an abdominal abscess, the current consensus indicates that percutaneous drainage by a radiologist has low morbidity compared to an open procedure.

All patients with an abdominal abscess need close monitoring as they can quickly become septic. The nursing responsibility lies with measuring vital signs, urine output, pressure sore prevention, DVT prophylaxis, ambulation, and timely antibiotics. Any change in the patient's clinical status should be immediately communicated to the clinician.

There should not be any delay in consulting with the surgeon, as delay can lead to adverse outcomes and significant healthcare costs. Many of these patients also develop wound infections that do not heal. Hence a consult with a wound care nurse for daily dressings is necessary.

The progress and monitoring of patients with an abdominal abscess are made by regular physical exams, vital signs, and imaging tests. Often these patients have drainage devices that also need to be monitored for the type and amount of fluid discharge. Only through a systematic clinical interprofessional team approach can the morbidity and mortality of an abdominal abscess be lowered. [13][14](Level III)

Outcomes

The outcomes after an abdominal abscess depend on patient morbidity, the cause, extent of contamination and age. When multiple organs are involved and the patient is septic, the outcomes are poor. However, for localized abscesses from a rupture of an appendix or sigmoid diverticulitis, the outcomes are good. Many of these patients have significant comorbidity which affects their long-term survival. The key to improving mortality is an interprofessional approach with prompt diagnosis, close monitoring, and early treatment. [15][4] (Level V)


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Abdominal Abscess - Questions

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A 65-year-old female has a left hemicolectomy for cancer. On postoperative day seven, she develops a temperature of 39.2 C. Physical examination shows clear lungs, no evidence of wound or line infections, and her calves are soft and nontender. Chest radiograph shows mild bibasilar atelectasis. Two days later, blood cultures grow Bacteroides fragilis and Escherichia coli, while urine culture is negative. Which of the following is the most appropriate approach to this patient?



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Which of the following is the best test for the diagnosis of both intraperitoneal abscess and intra-abdominal infection?



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A 76-year-old male from a nursing home presents with abdominal distension and vague pain. The nurse states that he has not been hungry for the past several days. His past medical history reveals sarcoidosis for which he was taking oral prednisone, hypertension managed with metoprolol, gout managed with allopurinol and type 2 diabetes managed with metformin. Vitals reveals a heart rate of 125 bpm, blood pressure 90/60 mmHg, respiratory rate 28 breaths per minute and temperature 101.4 F. The abdominal exam reveals a distended abdomen with diffuse tenderness and guarding. The white blood cell count is 12,300 cells per cubic millimeter with a leftward shift. Which of the following tests has the highest false-positive rate?



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A 68-year-old had an iatrogenic perforation of the sigmoid colon during a colonoscopy. The gastroenterologist repaired the 1 cm perforation with an intraluminal clip and admitted the patient for observation. Two days later, the nurse noted that the patient was having abdominal pain, and the surgeon was notified. Which of the following is a common feature of an abdominal abscess?



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A 17-year-old male presented 48 hours after developing right lower quadrant pain, anorexia, and a low-grade fever. Laparoscopy revealed a ruptured appendix, which was managed with irrigation and closure of the stump. Three days later, he presents with lower abdominal pain, fever, diarrhea, and anorexia. Computed tomography (CT) scan revealed a collection in the left pelvis. CT guided drainage was done which revealed the presence of a high number of anaerobes. Which of the following antibiotic should be administered to the patient?



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Two days after a difficult appendectomy that was converted from a laparoscopic approach to an open procedure, the patient developed a high fever of 102 F. The patient has been anorexic and not gotten out of bed for the past 48 hours. The provider on call is notified who notes that the patient has a blood pressure of 95/65 mmHg, respiratory rate 28 breaths per minute, pulse of 120 bpm and the room air pulse oximetry of 91%. Except for mild pain around the incision, the exam is unrevealing. Which of the following may help establish his pathology?



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Abdominal Abscess - References

References

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