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Intra abdominal abscess
This document discusses abdominal abscesses, including: - Definitions and types of abdominal abscesses - Pathophysiology, factors that favor abscess formation, and clinical features - Diagnostic tests including X-ray, CT scan, USG, and MRI - Management including adequate resuscitation, antimicrobial therapy, and source control through percutaneous or surgical drainage - Specific discussions of pyogenic liver abscesses, amoebic liver abscesses, prerequisites and complications of percutaneous drainage, and criteria for drain removal
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Presenter introductions with Dr. A R Shaan and Dr. S B Choudhary; Focus on Michael DeBakey and Alton Oschner.
Definition of abdominal abscess; Types include intraperitoneal, visceral, and retroperitoneal.
Overview of intraperitoneal and retroperitoneal spaces; Causes of extravisceral abscesses.
Defense mechanisms in the peritoneal cavity; Components involved include macrophages and cytokines.
Clinical symptoms like fever and localized pain; Highlights abscess types such as subphrenic.
Diagnostic methods include imaging via X-ray, CT, and MRI; Key features of diagnostics.
Management includes resuscitation, antimicrobial therapy, and source control.
Categories of antimicrobial therapy for community and healthcare-associated infections.
Management for pyogenic and amoebic liver abscesses including antibiotic and drainage strategies.
Techniques for percutaneous drainage; prerequisites and post-requisites for successful outcomes.
Complications during drainage include sepsis; Guidelines for drain removal based on clinical parameters.
Surgical options for abscess management; Insights on transperitoneal and extraperitoneal approaches.
Quote by Berkeley Moynihan reflecting on surgery's experimental nature in bacteriology.
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Intra abdominal abscess
- 1. Presenter: Dr. AR Shaan Moderator: Dr. S B Choudhary
- 2. Michael DeBakey &Alton Oschner
- 3. Abdominal Abscess “ well-definedcollections 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. Types of Intraabdominal abscess Intraperitoneal( Extravisceral) Visceral Retroperitoneal
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- 7. Extravisceral Abscess 2 situations: Resolutionof diffuse peritonitis loculated infection Perforation of a viscous or Anastomotic Breakdown
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- 9. Pathophysiology 3 major defensemechanisms of peritoneal cavity Mechanical clearance via Diaphragmatic Lymphatics Phagocytosis and destruction of adherent bacteria Sequestration and walling off of bacteria, with delayed clearance
- 10. Bacterial Contamination Hyperemia Exudative fluid Macrophages Neutrophilic Exudate 2-4hr 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. Factors favouring abscess LOCALFACTORS MICROBIAL FACTORS Local fibrin deposition Low pH Particulate stool Hypoxia Polymicrobial Flora Bacteroides fragilis Capsular polysaccharide
- 12. Clinical Features Highspiking fevers Chills Tachycardia Tachypnoea Leukocytosis Localised abdominal pain Anorexia Delay in return of bowel function
- 13. Special Features SubphrenicAbscess Paracolic abscess Pelvic abscess Retroperitoneal Abscess
- 14. Diagnostic tests Xray CT Scan USGScan MRI
- 15. Abdominal Xrays Airfluid levels Extraluminal gas Soft tissue mass displacing the bowel Elevated diaphragm Collapse/consolidation at lung base
- 16. Diagnostic features inCT scan Low CT attenuation Mass effect displacing normal structures “lucent centre with rim enhancement” Gas in fluid collection
- 17. CT Scan vsUSG 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. MRI Delineate the extentof an abscess Pregnancy
- 19. Management Adequate resuscitation andsupport Antimicrobial therapy Source control/ abscess drainage
- 20. Resuscitation & Support ABC Oral/entericnutritional/ TPN
- 21. Antimicrobial Therapy 3 Categories: community- acquired infections of mild to moderate severity High risk/ severe community- acquired infections Health care associated infections
- 22. Community acquired infections Mild-moderateseverity (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. Health care associatedinfections 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. 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. Amoebic Liver abscess Metronidazole 750mg TID for 14 days Chloroquine Dihydromentine Drainage ---- needle aspirations Percutaneous catheter drainage
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- 27. Prerequisites for percutaneousdrainage Anatomically safe route Well defined unilocular abscess cavity Surgical & radiological evaluation Surgical backup for technical failure
- 28. Post-requisites for percutaneousdrainage Gram’s stain and culture 8-12f catheter Closed drainage system Irrigation of catheter once daily Repeat CT
- 29. Complications with percutaneousdrainage Enterocutaneous fistula Bacteremia Sepsis Vascular injury Enteric puncture Transpleural catheter placement
- 30. Criteria for removalof a Drain Clinical resolution of septic parameters Minimal drainage from the catheter CT evidence of resolution
- 31. Comparing outcome indifferent 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. Surgical Drainage Failureof percutaneous drainage Diffuse infection Content of abscess is too thick Access is impossible
- 33. Surgical approach Transperitonealapproach Extraperitoneal approach
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- 36. Every operation insurgery is an experiment in bacteriology -Berkeley Moynihan