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Intra abdominal abscess

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Intra abdominal abscess

  1. 1. Presenter: Dr. A R Shaan Moderator: Dr. S B Choudhary
  2. 2. Michael DeBakey & Alton Oschner
  3. 3. 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.
  4. 4. Types of Intra abdominal abscess  Intraperitoneal( Extravisceral)  Visceral  Retroperitoneal
  5. 5. Intraperitoneal spaces
  6. 6. Perihepatic Spaces
  7. 7. Extravisceral Abscess 2 situations: Resolution of diffuse peritonitis loculated infection Perforation of a viscous or Anastomotic Breakdown
  8. 8. Retroperitoneal spaces
  9. 9. 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
  10. 10. Bacterial Contamination Hyperemia Exudative fluid Macrophages Neutrophilic Exudate 2-4 hr Innate Immunity TNF-α IL-1 IL-6 IL-10 RESOLUTION of peritonitis Mast cells Mesothelial lining Cells Cytokines procagulants Fibrin COMPARTMENTALIZATION of peritonitis ABSCESS
  11. 11. Factors favouring abscess LOCAL FACTORS MICROBIAL FACTORS Local fibrin deposition Low pH Particulate stool Hypoxia Polymicrobial Flora Bacteroides fragilis Capsular polysaccharide
  12. 12. Clinical Features  High spiking fevers  Chills  Tachycardia  Tachypnoea  Leukocytosis  Localised abdominal pain  Anorexia  Delay in return of bowel function
  13. 13. Special Features  Subphrenic Abscess  Paracolic abscess  Pelvic abscess  Retroperitoneal Abscess
  14. 14. Diagnostic tests Xray CT Scan USG Scan MRI
  15. 15. Abdominal Xrays  Air fluid levels  Extraluminal gas  Soft tissue mass displacing the bowel  Elevated diaphragm  Collapse/consolidation at lung base
  16. 16. Diagnostic features in CT scan  Low CT attenuation  Mass effect displacing normal structures  “lucent centre with rim enhancement”  Gas in fluid collection
  17. 17. CT Scan vs USG Advantages 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
  18. 18. MRI Delineate the extent of an abscess Pregnancy
  19. 19. Management Adequate resuscitation and support Antimicrobial therapy Source control/ abscess drainage
  20. 20. Resuscitation & Support ABC Oral/enteric nutritional/ TPN
  21. 21. Antimicrobial Therapy 3 Categories:  community- acquired infections of mild to moderate severity  High risk/ severe community- acquired infections  Health care associated infections
  22. 22. Community acquired infections Mild-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 Cefazolin Cefuroxime Ceftriaxone Cefotaxime + Metronidazole Ciprofloxacin Levofloxacin Cefepime Ceftazidime + Metronidazole Ciprofolacin Levofloxacin
  23. 23. Health care associated infections Organism Carbepenem Piperacillin- tazobactum Ceftazidime/cef epime + metronidazole Aminoglycoside Vancomycin <20% Res. Pseudomonas ESBL Enterobacteracea, acenetobacter, MDR-GNB √ √ √ ESBL- Enterobacteraceae √ √ √ P. Aeruginosa>20% res ceftazidime √ √ √ MRSA √
  24. 24. 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
  25. 25. Amoebic Liver abscess  Metronidazole 750mg TID for 14 days  Chloroquine  Dihydromentine  Drainage ---- needle aspirations Percutaneous catheter drainage
  26. 26. Source Control Percutaneous Drainage Surgery
  27. 27. Prerequisites for percutaneous drainage  Anatomically safe route  Well defined unilocular abscess cavity  Surgical & radiological evaluation  Surgical backup for technical failure
  28. 28. Post-requisites for percutaneous drainage  Gram’s stain and culture  8-12f catheter  Closed drainage system  Irrigation of catheter once daily  Repeat CT
  29. 29. Complications with percutaneous drainage  Enterocutaneous fistula  Bacteremia  Sepsis  Vascular injury  Enteric puncture  Transpleural catheter placement
  30. 30. Criteria for removal of a Drain  Clinical resolution of septic parameters  Minimal drainage from the catheter  CT evidence of resolution
  31. 31. 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 mass Fungal abscess Infected hematoma Pancreatic necrosis  Small abscess (<4cm diameter)
  32. 32. Surgical Drainage  Failure of percutaneous drainage  Diffuse infection  Content of abscess is too thick  Access is impossible
  33. 33. Surgical approach  Transperitoneal approach  Extraperitoneal approach
  34. 34. Posterior Extraserous Approach
  35. 35. Anterior incisions
  36. 36. Every operation in surgery is an experiment in bacteriology -Berkeley Moynihan

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