![© 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
8 CRITICAL CARE 18 Intra-Abdominal Infection — 1
18 INTRA-ABDOMINAL INFECTION
Robert G. Sawyer, M.D., F.A.C.S., Jeffrey S. Barkun, M.D., F.A.C.S., Robert Smith, M.D.,T Chong, M.D., and George Tzimas, M.D.
ae
Recognition and Management of Intra-abdominal Infection
The basic principles of rapid diagnosis, timely physiologic sup- whereas a stable patient presenting with a chronic complaint can
port, and definitive intervention for intra-abdominal infections be evaluated in a more deliberate fashion.The specifics of the pre-
have remained unchanged over the past century. Specific manage- senting episode (e.g., the onset, location, and nature of the pain
ment of these conditions, however, has been transformed of late as and any changes in bowel habits) are undeniably crucial, but the
a result of numerous advances in technology. Improved radiologic patient’s medical and surgical histories, as well as any previous
and laboratory techniques have led to more precise preoperative similar illnesses, are equally critical. Many medical problems and
diagnoses, and newer procedures have led to treatment algorithms therapies are associated with abdominal pain or discomfort, and
that cause less morbidity and permit faster recovery. Whereas the an accurate accounting of previous surgical manipulation of the
pathophysiology of these infections remains largely unchanged, abdomen is vital for refining the differential diagnosis, as well as
their management is now marked by an ever-growing complexity. for prioritizing further tests.The question of whether a patient has
It is no longer true that the diagnosis of intra-abdominal infection, presented with similar symptoms before (particularly if those
even in association with a perforated viscus, necessitates urgent symptoms led to a diagnosis) may be important for determining
exploration, but it remains the case that decisions regarding the the timing of any intervention, as well as for putting the current
ultimate course of action for any individual patient are solely the complaint in the context of an ongoing condition. In fact, many
responsibility of the surgeon. patients arrive for medical treatment with a strong (and frequent-
ly correct) concept of the nature of their disease.
Clinical Evaluation PHYSICAL EXAMINATION
Once the history has been obtained, a thorough physical assess-
HISTORY
ment is performed, with the emphasis on the abdomen, the pelvis
The general approach to a patient sus- (including the vagina), and the rectum. The usual sequence—
pected of having an intra-abdominal inspection, auscultation, percussion, and palpation—should be
infection is much like that to a patient followed as traditionally taught.This sequence need not be exten-
with any other acute surgical condition. sively reviewed here; however, certain points should be empha-
Specific approaches to various intra- sized. With the advent of laparoscopy, inspection must include a
abdominal infections are addressed in more detail elsewhere [see careful search for scars indicating previous operations, given that
Infections of the Upper Abdomen and Infections of the Lower any laparoscopic procedure can be undertaken by way of a variety
Abdomen, below]. of trocar sites. Auscultation, though occasionally helpful, is also
The first step is an accurate history.To begin with, cases of peri- probably the least specific form of examination. Percussion is valu-
tonitis are broadly classified as primary, secondary, or tertiary; this able for assessing tenderness, as well as for differentiating abdom-
classification provides a useful framework for suggesting general inal distention caused by intraluminal gas or free air (signaled by
approaches to treatment. Primary peritonitis arises spontaneously, tympany) from that caused by fluid in the peritoneum, such as
without a demonstrable source of contamination, and is generally ascitic fluid or blood (signaled by dullness).
treated with antibiotics alone; an example is spontaneous bacteri- Proper and humane assessment of the abdomen for tenderness
al peritonitis in the setting of ascites. Secondary peritonitis is via palpation can be learned only through extensive experience.
caused by a breach in the GI tract that leads to contamination of Gaining the patient’s trust is fundamental: an anxious or dis-
a normally sterile space. Control of the source of infection via tressed examinee may respond in a hypersensitive manner, there-
drainage, resection, diversion, or some combination thereof is by hindering the acquisition of information. An individualized
imperative for optimizing outcome. Tertiary peritonitis is a poorly approach is essential as well. Palpation should not be performed in
defined entity associated with recurrence of intra-abdominal infec- a uniform manner from patient to patient; rather, the amount of
tion after the treatment of secondary peritonitis. It frequently fea- tenderness present ought to be judged by the degree of pressure
tures a diffuse infection in a critically ill patient and may be caused or indentation required to cause a given patient significant dis-
by any of a long list of nosocomial pathogens (e.g., Pseudomonas comfort. In the setting of severe abdominal pain, elicitation of
aeruginosa, Staphylococcus aureus, and Candida albicans). Manage- rebound tenderness by means of deep palpation followed by rapid
ment of tertiary peritonitis is complex and must be individualized release of pressure usually does not improve diagnostic accuracy
for each patient. or alter subsequent evaluation and should therefore be discour-
The acuteness and severity of the presenting symptoms may aged. Finally, administration of small doses of narcotics to patients
help localize the origin of the infection. More important, however, with abdominal pain is unlikely to alter an experienced examiner’s
they allow appropriate triage of these patients, who are frequently diagnostic ability for the worse.
seen in a crowded emergency department. For example, a patient Occasionally, a young patient whose history and physical exam-
with sudden onset of severe abdominal pain and physiologic ination (including vital signs) fit the classic clinical picture of
derangement must take precedence over almost all other patients, appendicitis may be taken to the OR without further assessment.](https://image.slidesharecdn.com/acs0818-intra-abdominalinfection-100726064008-phpapp01/75/Acs0818-Intra-Abdominal-Infection-1-2048.jpg)
![© 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
8 CRITICAL CARE 18 Intra-Abdominal Infection — 2
Recognition and Management of
Intra-abdominal Infection
Patient has suspected intra-abdominal
infection
Obtain history, including previous surgical
manipulation of abdomen.
Perform physical examination, focusing on
abdomen, pelvis and vagina, and rectum
(inspection, auscultation, percussion, palpation).
Order blood tests as appropriate.
• General tests of systemic response to
infection
• Specific tests to localize source or focus
of infection
On occasion, a young patient with classic
presentation of appendicitis may be taken to
OR without blood tests or imaging.
Order diagnostic imaging as appropriate.
Patient has “certain“ History and physical exam warrant Patient has upper abdominal All other patients
appendicitis exploration of abdomen for peritonitis, pain, elevated bilirubin level
but confirmation (free air) is needed or liver function test results, Order abdominal and pelvic
first; or index of suspicion for or history of biliary tract CT scans.
Resuscitate, give antibiotics,
peritonitis is very low disease Treat specific infection as
and take to OR.
appropriate [see Figure 9].
Order upper abdominal US.
Obtain plain abdominal films, including
upright chest film. Treat specific infection as
appropriate [see Figure 1].
Free peritoneal air is present No free peritoneal air is present, No free peritoneal air is present,
and index of suspicion for but index of suspicion for
Resuscitate, give antibiotics, peritonitis is low peritonitis is high
and take to OR.
Discharge from surgical care. Order abdominal and pelvic CT
scans (see above, right).](https://image.slidesharecdn.com/acs0818-intra-abdominalinfection-100726064008-phpapp01/75/Acs0818-Intra-Abdominal-Infection-2-2048.jpg)
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8 CRITICAL CARE 18 Intra-Abdominal Infection — 3
Practically speaking, however, almost all patients with significant abnormalities, and inflammatory changes. Now that significant
intra-abdominal infections undergo blood tests, and most also intra-abdominal infections—perhaps even in the setting of a per-
undergo some sort of radiologic evaluation. forated viscus—are no longer automatically considered to man-
date operative intervention, the ability of CT scanning to identify
the source and assess the chronicity of an infection is critical to
Investigative Studies effective modern management. Multiple common conditions have
now been defined for which an adequate CT scan allows nonop-
LABORATORY TESTS
erative management either as definitive therapy (e.g., expectant
Blood work can be divided into two treatment of a simple perforated duodenal ulcer) or as a means of
categories: (1) general tests designed to temporizing (e.g., percutaneous drainage of a periappendiceal or
assess the systemic response to infection peridiverticular abscess). In addition, in experienced hands, a neg-
and (2) specific tests designed to localize ative CT scan of the abdomen and the pelvis virtually excludes
the source or site of infection.The former any significant acute surgical illness.
category includes serum chemistries and hematology studies. The It must be noted, however, that a CT scan is not necessary in
latter category commonly includes amylase and lipase concentra- all patients with abdominal pain, and the decision whether to
tions (in patients suspected of having pancreatitis), bilirubin levels obtain one should be made on the basis of predefined guidelines
and liver function tests (to evaluate hepatic or biliary tract disease), or with the input of a general surgeon. When the need for opera-
and lactate levels (when an ischemic bowel is suspected). These tive intervention has already been determined, as in a classic case
tests are discussed further elsewhere, in connection with specific of appendicitis, imaging is unnecessary. In addition, some patients
infections (see below). Urinalysis, of course, is necessary whenever with an intra-abdominal infection amenable to nonoperative man-
urinary tract infection or urolithiasis is a possibility. agement (e.g., simple, mild diverticular disease that can be treat-
ed with oral antibiotics on an outpatient basis) do not necessarily
DIAGNOSTIC IMAGING
benefit from CT scanning.
The use of various radiologic studies In selected cases, other forms of imaging may be used.
in the diagnosis of intra-abdominal infec- Magnetic resonance imaging, though usually more difficult to
tion continues to evolve rapidly. Outside obtain in an emergency and logistically more complicated than
the setting of trauma, it is now very rare CT scanning, yields excellent tomographic images and has the
for patients to undergo operations or added benefit of imaging vascular structures and the pancreatico-
other major interventions without first biliary tree more precisely. Nonetheless, MRI has no significant
undergoing imaging. At one time, plain role in the evaluation of acute peritonitis. Nuclear medicine scans
films of the abdomen (including an and fluoroscopic studies, though occasionally useful adjuncts for
upright chest film) were routinely obtained whenever a significant evaluating biliary tract and upper GI disorders, also play no role
intra-abdominal infection was suspected, principally to detect free in the assessment of acute peritonitis.
peritoneal air, bowel obstruction, or fecaliths. Abdominal plain
films proved to lack sensitivity, specificity, and anatomic definition
in this setting and consequently have, in many cases, been sup- Options for Intervention
planted by abdominal and pelvic computed tomographic scanning. Once an intra-abdominal infection is diagnosed, there are mul-
There are, however, two circumstances in which plain films of the tiple options for intervention. Not infrequently, an approach com-
abdomen remain a reasonable first study for a patient with sus- bining several modalities is warranted. Occasionally, administration
pected peritonitis: (1) when the surgeon has almost decided, on the of systemic antibiotics is all that is necessary (or practical), as in
basis of the history and physical examination, to explore the patient cases of spontaneous primary bacterial peritonitis or of multiple
yet needs confirming evidence of perforation (i.e., free air), and (2) infected fluid collections that are small but too numerous to drain.
when the index of suspicion for peritonitis is so low that the plain Single abscesses, particularly those without thick or particulate
film studies are intended to rule out an unexpected positive finding contents, can be adequately treated with simple aspiration and a
and will not be followed by an abdominal CT scan if negative. short course of antibiotics. For discrete infected fluid collections in
Ultrasonography for intra-abdominal infection is useful only for almost any setting, placement of a percutaneous indwelling drain
focused examination of specific organ systems; it is inferior to CT (most commonly under radiologic guidance) is currently the treat-
scanning for generalized surveillance of the abdomen because of ment of choice. Operative management, either open or laparo-
the inability of sound waves to penetrate gas in the bowel. By far scopic, is employed for resection of damaged or inflamed and
the best-delineated use of ultrasonography is in the diagnosis of unsalvageable organs, diversion of enteric contents, or drainage of
liver and biliary tract disease, for which its ability to demonstrate collections that are too thick or numerous for percutaneous
cholelithiasis makes it superior to CT and for which it should drainage. Beyond these general guidelines, therapy for specific
almost always be the first radiologic test in the appropriate cir- intra-abdominal infections must be individualized (see below).
cumstances (e.g., a classic history of biliary colic or an elevated
serum bilirubin level). Ultrasonography also visualizes the spleen,
the kidneys, and the gynecologic pelvic organs well and has the Infections of the Upper Abdomen
additional benefit of using no ionizing radiation. Biliary tract and pancreatic infections present as a systemic sep-
The abdominal and pelvic CT scan, appropriately, has become tic response or as infections localized in the upper abdomen [see
the key diagnostic test for evaluating patients with suspected peri- Figure 1].Typical findings include abdominal pain, a tender upper
tonitis. This modality is widely available throughout much of the abdominal mass, fever and leukocytosis, and jaundice. Various
world, and newer scanners yield significantly higher resolution combinations of these symptoms may occur, but it is convenient
than older ones, with reduced scanning times and radiation expo- to consider three common clinical presentations. In each of the
sure. CT is highly sensitive for free air, fluid collections, bowel wall presentations, one or two symptoms dominate: (1) upper abdom-](https://image.slidesharecdn.com/acs0818-intra-abdominalinfection-100726064008-phpapp01/75/Acs0818-Intra-Abdominal-Infection-3-2048.jpg)
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8 CRITICAL CARE 18 Intra-Abdominal Infection — 4
Patient has clinical signs of upper abdominal infection,
or serum bilirubin or liver function tests are suggestive
Order abdominal US.
Upper abdominal pain and Fever and jaundice are Fever and abdominal
fever are dominant findings dominant findings mass are dominant
findings
US is normal Stones are seen in Evidence of acute Patient has choledocholithiasis
gallbladder without cholecystitis is apparent or biliary dilation consistent
evidence of with cholangitis
Consider nonbiliary
cholecystitis or If US is equivocal,
disease, especially Resuscitate, and give antibiotics.
choledocholithiasis consider nuclear
acute pancreatitis.
medicine scanning. Consider emergency
Consider abdominal Consider other endoscopic, radiologic, or
Resuscitate; take to OR
and pelvic CT scans. diagnoses. operative biliary drainage.
for urgent cholecystec-
Evaluate for elective tomy if patient is medi-
cholecystectomy. cally fit, or perform
percutaneous drainage
if not.
Patient has liver mass, with Patient has signs of Patient has splenic mass,
or without abscess pancreatic infection with or without abscess
Obtain travel history and Confirm diagnosis via abdominal Confirm diagnosis via abdominal
serologic tests to rule out amebic CT scan. CT scan.
and echinococcal abscesses. Resuscitate, and give antibiotics if Resuscitate, and give antibiotics.
For bacterial abscesses, infection is probable or necrosis Treat with splenectomy or
resuscitate, give antibiotics, is noted on CT. percutaneous drainage.
seek sources, and perform Discrete fluid collection: Aspirate
percutaneous drainage. or drain.
Phlegmon: Attempt medical
management. If unsuccessful and
percutaneous aspirate positive
for bacteria, perform open
Figure 1 Algorithm outlines approach to patient with drainage.
suspected upper abdominal infection.
inal pain and fever, (2) fever and jaundice, and (3) an upper abdominal ultrasound examination: an abnormal image of the
abdominal mass and fever. These clinical findings signal the need gallbladder or bile ducts supports a biliary etiology [see Figure 2].
for a battery of screening tests, including a complete blood count The differential diagnosis should include acute cholecystitis,
(CBC); routine blood tests of liver function; determination of biliary colic, acute pancreatitis, and acute cholangitis, each of
serum amylase level, prothrombin time (PT), and partial throm- which requires specific management [see Table 1]. For example, ini-
boplastin time (PTT); blood culture; chest and abdominal x-rays; tial management of biliary colic and mild acute pancreatitis is usu-
and abdominal ultrasonography. When considered together, the ally nonoperative, whereas severe acute cholangitis and acute
clinical findings and the test results allow early differentiation of cholecystitis are treated by means of surgical, endoscopic, or radi-
the three most common disease entities: acute cholecystitis, acute ologic intervention (see below). Clinical features and blood test
cholangitis, and acute pancreatitis. results, though helpful, may be inconclusive.The abdominal ultra-
sonogram may provide specific clues. Stones appear in biliary colic
UPPER ABDOMINAL PAIN AND FEVER
[see Figure 2]; stones and thickening of the gallbladder wall, in
Patients with upper abdominal sepsis may present with epigas- acute cholecystitis; gallstones and dilatation of the common bile
tric or right upper quadrant pain and fever. Only two thirds of duct (CBD), in acute cholangitis; and pancreatic enlargement and
these patients admitted with a working diagnosis of acute chole- sonolucency, in pancreatitis.
cystitis have acute biliary inflammation.1 In some patients, non-
surgical conditions (e.g., pneumonia, acute hepatitis, familial Pancreatitis
Mediterranean fever, herpes zoster of the intercostal nerves, and Diagnosis Differentiating acute pancreatitis from acute
gastroenteritis) can be distinguished clinically from biliary disease. cholecystitis may be difficult.The serum amylase level lacks speci-
The most important screening test for acute biliary infection is the ficity, but if the clinical findings suggest acute pancreatitis, an ele-](https://image.slidesharecdn.com/acs0818-intra-abdominalinfection-100726064008-phpapp01/75/Acs0818-Intra-Abdominal-Infection-4-2048.jpg)
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8 CRITICAL CARE 18 Intra-Abdominal Infection — 5
Table 2—Ranson’s Early Objective Signs
of Severity of Acute Pancreatitis2
On Admission After Initial 48 Hours
Age > 55 yr Serum Ca2+ < 8 mg/dl
Glucose > 200 mg/dl Arterial PO2 < 60 mm Hg
WBC > 16,000/mm3 Base deficit > 4 mEq/L
LDH > 350 IU/L BUN increase > 5 mg/dl
Hematocrit fall > 10%
AST > 250 Sigma Frankel U/dl
Fluid sequestration > 6,000 ml
Note: < 3 signs = mild pancreatitis; ≥ 3 signs = severe pancreatitis.
AST—aspartate aminotransferase—BUN—blood urea nitrogen—PO2—oxygen tension—
WBC—white blood cell
acute pancreatitis.5,6 Unless clinical findings and the results of bio-
chemical tests and ultrasonography are unequivocal, a contrast-
enhanced spiral abdominal CT scan is usually performed to estab-
lish the diagnosis and stage acute pancreatitis. It has been sug-
gested, however, that CT scanning should be reserved for patients
with clinically suspected severe acute gallstone pancreatitis, on the
grounds that the results would not change the recommended
course of action in other patients.7 Occasionally, a very mild pan-
creatitis may give rise to no findings on a CT scan, and a normal
technetium-99m (99mTc)–labeled HIDA (lidofenin) scan may help
differentiate this condition from acute cholecystitis.
Figure 2 Abnormal abdominal ultrasound examination shows Treatment Given that pancreatitis encompasses a wide
calculi in gallbladder casting shadows on underlying liver tissue. range of diseases with varying degrees of severity, treatment must
be individualized for each patient. Possible therapeutic strategies
range from outpatient management with temporary dietary mod-
vated level of serum amylase clinches the diagnosis. In one study, ification (for very mild cases) to open debridement and complex
the initial laboratory results in 100 patients with acute pancreati- intensive care (for severe cases). It is therefore useful to base pos-
tis were compared with those in 100 patients with acute abdomi- sible treatment approaches in particular cases on the cause and
nal pain caused by acute cholecystitis, perforated peptic ulcer, or severity of the pancreatitis.
acute appendicitis.2 The serum amylase concentrations were ele- Gallstone pancreatitis. Standard therapy for gallstone pancreatitis
vated in 95% of patients with acute pancreatitis but were normal includes I.V. fluids and narcotic analgesics. Nasogastric suction is
in 95% of patients with acute abdominal pain from other causes. useful in patients with significant ileus but need not be used rou-
These concentrations peak within the first 48 hours and are tinely.8 The use of systemic antibiotics is controversial; they are of
almost always elevated in biliary pancreatitis3; in fact, a serum benefit in the 10% to 34% of patients who have concomitant
amylase concentration above 1,000 U/L strongly suggests a biliary cholangitis.9 Other treatments suggested previously—including
origin of the pancreatitis.4 In addition, determination of serum total parenteral nutrition (TPN) and various pharmacologic agents
lipase levels has been shown to be more specific than and at least (e.g., cimetidine, somatostatin, glucagon, and insulin)—have not
as sensitive as determination of amylase levels for the detection of proved useful in all cases of gallstone pancreatitis.10 Continuous
intraduodenal infusion of an elemental diet has reduced exocrine
pancreatic secretions in animal experiments.11 Furthermore, enter-
Table 1—Diagnostic Indicators of al feeding has been shown to be beneficial and to decrease disease
Upper Abdominal Pain and Fever severity in patients with acute pancreatitis.12-14
In clinical practice, the need for further treatment depends on
Acute Acute the severity of the acute pancreatitis. Severity determines both the
Biliary Colic
Cholecystitis Pancreatitis risk of sepsis, which governs outcome, and the risk associated
with early cholecystectomy [see 5:21 Cholecystectomy and Bile Duct].
Short: 40%
Duration
< 1 hr
Persistent Persistent The most commonly used clinical prognostic index in North
America was developed by Ranson and reliably defines the sever-
Pathogenesis Visceral Somatic Retroperitoneal
ity of pancreatitis [see Table 2].2 In mild pancreatitis, one or two
Guarding and Guarding and Ranson signs are present; in more severe pancreatitis, three to five
Signs Tender
spasm spasm signs are present; and in very severe pancreatitis, more than five
Laboratory tests signs are present. This distinction serves to stratify further treat-
Liver function tests Occasionally Abnormal Abnormal ment. Other clinical prognostic scores, such as the APACHE-II
abnormal (Acute Physiology and Chronic Health Evaluation II) and
Serum amylase Normal Normal or slightly Increased APACHE-III scores and the Balthazar score, have been shown to
increased
Leukocyte counts Often normal Increased Increased
possess discriminatory value in identifying patients at high risk for
complications.15,16](https://image.slidesharecdn.com/acs0818-intra-abdominalinfection-100726064008-phpapp01/75/Acs0818-Intra-Abdominal-Infection-5-2048.jpg)
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8 CRITICAL CARE 18 Intra-Abdominal Infection — 6
Mild pancreatitis usually subsides within 1 week of onset. Most cholecystectomy has facilitated this approach safely without pro-
surgeons defer cholecystectomy until then; urgent operation should longing hospital stay.
be reserved for cases complicated by biliary sepsis, and it may Severe pancreatitis. Patients with three or more Ranson signs are
reveal acute cholecystitis in as many as 31% of patients.17 at particular risk for pancreatic sepsis.28 Repeated clinical and
An attack of acute gallstone pancreatitis is initiated by obstruc- radiologic evaluation is required in these patients to ensure early
tion at the confluence of the lower end of the CBD and the pan- detection of complications, because the outcome of an episode of
creatic duct by a stone or by edema at the ampulla of Vater result- pancreatitis depends on whether sepsis supervenes. When infec-
ing from stone migration. These stones may be found and tion occurs, operative debridement and drainage are required [see
removed in 63% to 78% of patients who undergo operation with- Fever and Abdominal Mass, below]. Some surgeons have attempt-
in 72 hours of admission17-19 [see 5:22 Biliary Tract Disease]; by ed to alter the course of severe disease by early operation; howev-
contrast, they are present in only 3% to 33% of patients explored er, urgent operation is associated with a high mortality in patients
after the first week.18-22 A randomized trial exploring the optimal with more than three Ranson signs.19,21,23,29 To avoid the mortali-
timing of surgery for gallstone pancreatitis showed that early ty associated with early operative intervention, some clinicians
surgery (within 48 hours after admission) was not associated with advocate early diagnosis by ERCP [see Figure 3], followed by bil-
a significant increase in morbidity or mortality in patients with iary decompression by means of endoscopic sphincterotomy and
mild pancreatitis but did not change prognosis.23 stone extraction. In a randomized trial comparing early ERCP and
Endoscopic retrograde cholangiopancreatography (ERCP). Early sphincterotomy with conservative therapy in patients with severe
ERCP and sphincterotomy [see 5:18 Gastrointestinal Endoscopy] has acute pancreatitis, ERCP and sphincterotomy decreased morbid-
been suggested as an alternative to surgery of the CBD in patients ity from 61% to 24% and lowered mortality from 18% to 4%.24
with mild pancreatitis. However, randomized trials comparing The results of this trial, however, have been the subject of debate,
endoscopic treatment with conservative treatment within the first and the success of this approach has been attributed by some
72 hours in patients with mild pancreatitis did not find that urgent authors to the treatment of a concomitant cholangitis rather than
endoscopic sphincterotomy improved outcome in this group of of the actual pancreatitis.25 A well-conducted trial that excluded
patients.24,25 Other studies showed that delaying surgery beyond 6 patients with concomitant cholangitis was published in 1997;
weeks may lead to a 32% to 57% risk of recurrent pancreatitis.26,27 unfortunately, this trial was unable to answer the question defini-
Therefore, cholecystectomy and cholangiography should be tively, because too few patients with severe pancreatitis had been
delayed only until just before patients are discharged from the hos- recruited.30 It appears that ERCP is warranted mainly in cases of
pital, 5 to 15 days after the onset of symptoms. Laparoscopic acute pancreatitis complicated by cholangitis and biliary sepsis.31,32
Use of peritoneal lavage in early severe pancreatitis was advo-
cated in one study to decrease morbidity and mortality.33 Use of
standard lavage over a 2-day period did not improve patient out-
come, but use of peritoneal lavage for 7 days (long peritoneal
lavage) yielded some improvement in outcome.34 Early use of
antibiotics and selective decontamination have been proposed as a
means of reducing septic complications, but neither has convinc-
ingly or reproducibly been shown to improve prognosis.35,36
Although prophylactic antibiotics have been shown to decrease the
rate of infectious complications in severe acute pancreatitis, they
have not clearly been shown to reduce overall disease mortali-
ty.35,37-40 Attempts have been made to modulate the initial systemic
inflammatory response seen in early severe acute pancreatitis to
reduce the risk of subsequent infection and improve overall prog-
nosis; somatostatin has exhibited limited success in this regard.41,42
Another drug in this category, the platelet-aggregating factor
(PAF) inhibitor lexipafant, initially yielded promising results in
animal models43,44 and in phase II trials45; however, a 2001 trial
using the same drug did not find it efficacious for treating severe
acute pancreatitis.46
Acute Cholecystitis
Diagnosis Acute cholecystitis is the most common diagnosis
in patients presenting with upper abdominal pain and fever and is
characterized by the clinical finding of a midinspiratory arrest on
palpation of the right upper quadrant (Murphy’s sign). As noted
(see above), with the widespread availability of ultrasonography,
acute cholecystitis can usually be diagnosed rapidly on the basis of
the findings of gallbladder wall thickening, pericholecystic fluid,
and stones. Occasionally, more complex cases must be evaluated
Figure 3 Endoscopic retrograde cholangiopancreatography with nuclear medicine scanning to look for cystic duct obstruc-
shows distal CBD stone in acute pancreatitis. Papillotome has tion. Concurrent acute obstructive cholangitis must also be con-
been placed through sphincter of Oddi in preparation for endo- sidered in all patients with acute cholecystitis. Supportive labora-
scopic sphincterotomy. tory data include a high serum bilirubin level and an increased](https://image.slidesharecdn.com/acs0818-intra-abdominalinfection-100726064008-phpapp01/75/Acs0818-Intra-Abdominal-Infection-6-2048.jpg)
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8 CRITICAL CARE 18 Intra-Abdominal Infection — 7
Table 3—Comparison of Acute Cholecystitis
and Emphysematous Cholecystitis
Emphysematous
Acute Cholecystitis
Cholecystitis
Gender 70% male 70% female
Stones 70% 90%
Bile culture positive 95% 66%
Clostridia found 46% 1.2%
Gangrenous gallbladder 75% 2.5%
Perforation of gallbladder 20% 4%
Mortality at age < 60 yr 15% 1.5%
Pathogenesis Ischemia, obstruction Obstruction
sustained narcotics therapy). In addition, focal inflammation may
cause biliary colonization or may activate coagulation factor XII,
thereby causing severe injury to the blood vessels in the gallblad-
der muscularis and serosa. A high index of suspicion is necessary.
Acute acalculous cholecystitis should be considered in any post-
operative or acutely ill patient with upper abdominal pain and
Figure 4 Air outlines gallbladder and bile ducts in emphysema-
fever or with unexplained fever and leukocytosis. It is particularly
tous cholecystitis.
common 2 to 4 weeks after injury. The diagnosis is confirmed by
findings on abdominal ultrasound examination [see Figure 5] and
99m
alkaline phosphatase level. Positive blood cultures and dilated Tc-labeled HIDA scanning coupled with infusion of cholecys-
biliary ducts on abdominal ultrasonography usually confirm the tokinin and morphine.52-54
diagnosis.
Emphysematous cholecystitis. An uncommon and insidious vari- Treatment Standard treatment of acute cholecystitis consists
ant of acute cholecystitis, emphysematous cholecystitis is charac- of I.V. fluid administration, analgesics, and cholecystectomy.
terized by gas in the gallbladder lumen or wall or in the perichole- Although the timing of operation is somewhat controversial in
cystic soft tissue and biliary ducts secondary to gas-forming bac- ordinary acute cholecystitis, cholecystectomy should be per-
teria.The key to the diagnosis is the presence of air on abdominal formed at the earliest opportunity [see 5:21 Cholecystecomy/Bile
x-ray [see Figure 4] or ultrasound examination. Three stages of Duct]. This approach has been confirmed by at least one ran-
emphysematous cholecystitis have been defined: (1) gas is seen domized trial comparing early with late laparoscopic cholecystec-
only in the lumen of the gallbladder, (2) a ring of gas is identified tomy.55 The delayed-surgery group had a greater need for conver-
in the wall of the gallbladder, and (3) gas is seen in the tissues adja- sion to open cholecystectomy (23% versus 11%), as well as a longer
cent to the wall. Compared with ordinary acute cholecystitis,
emphysematous cholecystitis is associated with a fivefold increase
in the risk of gallbladder perforation, as well as a 10-fold increase
in mortality in patients younger than 60 years [see Table 3].47
Studies from the 1960s noted an increased risk of gangrene and
perforation of the acutely inflamed gallbladder in patients with
diabetes mellitus.48,49 The mortality for acute cholecystitis was also
shown to be five to 10 times higher in patients with diabetes than
in other patients. Later studies, however, did not show an in-
creased mortality in patients with both diabetes and acute chole-
cystitis.50,51 Nevertheless, one third of patients with emphysema-
tous cholecystitis also have diabetes.This factor, coupled with the
current tendency to perform cholecystectomy early in most pa-
tients with acute cholecystitis, may account for the disparity be-
tween previous studies and later reports.
Acute acalculous cholecystitis. Another variant of acute cholecys-
titis is acalculous cholecystitis; though still rare, it became more
common from the 1950s through the 1990s.This disease was orig-
inally described as occurring after surgical treatment of unrelated
disease but was subsequently identified in patients with multiple Figure 5 Abnormal abdominal ultrasound examination con-
trauma, prolonged critical illness, and sepsis. Predisposing factors firms diagnosis of acute acalculous cholecystitis. When image is
include gallbladder ischemia (in patients with shock or trauma) compared with that in Figure 2, thickening of gallbladder wall
and biliary stasis (in prolonged fasting, hyperalimentation, and and intraluminal debris are obvious.](https://image.slidesharecdn.com/acs0818-intra-abdominalinfection-100726064008-phpapp01/75/Acs0818-Intra-Abdominal-Infection-7-2048.jpg)
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8 CRITICAL CARE 18 Intra-Abdominal Infection — 8
average total hospital stay and convalescence. Administration of jaundice, with pain a less marked component. Jaundice is almost
systemic antibiotics is not required; however, single-dose antibiot- always associated with obstruction of the biliary tree, either intra-
ic prophylaxis (e.g., cefazolin, 2 g I.V.) can be given at the start of hepatic or extrahepatic. The combination of fever with jaundice
the operation [see 1:1 Prevention of Postoperative Infection].56-58 always suggests acute cholangitis, a condition that can have a ful-
Some patients with acute cholecystitis are at high risk for gan- minant and fatal course if not treated promptly.
grene and perforation of the gallbladder. It is crucial to identify
these patients and perform cholecystectomy promptly because Acute Cholangitis
delay increases morbidity and mortality. Clinically, gangrene and Diagnosis If a patient presents with a temperature higher
perforation of the gallbladder in this high-risk population are sug- than 38.5º C (101.3º F) in conjunction with jaundice [see 5:3
gested by marked systemic toxicity or by the radiologic demon- Jaundice], the possibility of acute cholangitis should always be
stration of either emphysematous cholecystitis or acute acalculous investigated. If cholangitis is present, laboratory studies will reveal
cholecystitis. leukocytosis, and blood cultures will often be positive. A finding of
With ordinary acute cholecystitis, body temperature is slightly gallstones and dilated biliary ducts on abdominal ultrasound exam-
increased in most patients—averaging 37.8º C (100.04º F)—but ination supports the diagnosis. Reynolds’ pentad is present in the
is normal in 20% of patients. By comparison, the risk of gangrene full-blown syndrome.66 This syndrome includes upper abdominal
and perforation is reportedly higher in patients with marked sys- pain, fever and chills, jaundice, hypotension, and mental status
temic toxicity, manifested by a pulse rate greater than 120 changes. Acute cholangitis is usually related to choledocholithiasis,
beats/min, a body temperature higher than 39º C (102.2º F), and recent biliary manipulation, or biliary stenting performed for chron-
a left shift in the differential white blood cell count, showing more ic obstruction.
than 90% polymorphonuclear leukocytes. Unfortunately, findings Gallbladder infections. Gallbladder empyema can duplicate most
of systemic toxicity are frequently absent in elderly patients. of the findings associated with acute cholangitis. In this condition,
Patients with acute cholecystitis who have signs of systemic tox- acute cholecystitis is complicated by suppuration within the gall-
icity, emphysematous cholecystitis, or acalculous cholecystitis are bladder, which then becomes the focus of generalized sepsis. The
at high risk for gallbladder gangrene and perforation and therefore distended gallbladder may be palpable and tender.When jaundice
require prompt and aggressive treatment. I.V. antibiotic therapy is associated with empyema of the gallbladder, it is less likely to be
with a single agent (e.g., ceftriaxone, piperacillin, or a quinolone obstructive than when it is associated with acute cholangitis.True
such as ciprofloxacin or ofloxacin) can be given.59,60 Early chole- empyema of the gallbladder is rare. Treatment includes adminis-
cystectomy is the treatment of choice. Unfortunately, mortality tration of I.V. fluids, systemic antibiotic therapy, analgesics, and
may be as high as 20% to 30% with the traditional surgical ap- early cholecystectomy.
proach.61 If perforation and gangrene are not suspected but med- In some patients with jaundice and inflammation, a stone
ical illness poses a high risk of mortality from operation, nonoper- impacted in the cystic duct or in Hartmann’s pouch may suggest
ative supportive therapy may suffice. If this fails, another treatment choledocholithiasis, but preoperative diagnosis by ERCP shows an
option is cholecystostomy. extrinsic compression of the duct known as Mirizzi syndrome.Two
Percutaneous transhepatic cholecystostomy has been recom- types of Mirizzi syndrome exist. In type I, a stone impacted in the
mended for these high-risk patients,62 particularly where there is a cystic duct or Hartmann’s pouch compresses the common hepatic
low risk for perforation of the gallbladder.63 To determine the risk duct and causes inflammation, thereby leading to jaundice.
of gallbladder perforation, a risk score can be assigned to each of Treatment of this type consists of obliteration of the cystic duct and
seven findings that may be present on the preoperative abdominal careful partial cholecystectomy, with the neck of the gallbladder left
ultrasound examination: pericholecystic fluid, 7 points; distention in place. In type II, protrusion of the stone into the hepatic duct
of the gallbladder, 4 points; intraluminal membrane, 4 points; erodes the septum between the cystic duct and the hepatic duct
intraluminal debris, 3 points; round gallbladder, 3 points; sonolu- and causes a cholecystocholedochal fistula. Treatment of this type
cent zone in the gallbladder wall, 2 points; and a thick gallbladder involves internal biliary drainage to the wall of the cholecysto-
wall (> 3.5 mm), 1 point.63 A patient with a total risk score of 12 choledochal defect, usually with a choledochojejunostomy [see 5:22
or more points requires urgent cholecystectomy; one with a lower Biliary Tract Disease], in addition to cholecystectomy.67
score who does not respond to conservative treatment may be Primary sclerosing cholangitis. Patients with primary sclerosing
treated with percutaneous transhepatic cholecystostomy. cholangitis, especially those who have undergone internal or exter-
A 1997 review of 59 patients exhibiting the septic response who nal biliary drainage, are at high risk for recurrent bouts of ascend-
underwent successful percutaneous radiologic cholecystostomy ing cholangitis. Primary sclerosing cholangitis predominantly affects
defined predictors of a successful clinical outcome: localized right young males, particularly those with chronic ulcerative colitis.The
upper quadrant tenderness and gallstones, as well as gallstones diagnosis is suggested by the dominant cholestatic biochemical
and pericholecystic fluid on ultrasound examination.64 Patients profile—that is, elevation of the serum bilirubin concentration, the
with more equivocal findings may derive greater benefit from serum alkaline phosphatase level, and aspartate aminotransferase
more invasive techniques that can simultaneously be used for activity. Because of the concomitant hepatic scarring, ultrasonog-
diagnostic purposes (e.g., laparoscopy, which can even be per- raphy may not reveal the presence of dilated intrahepatic ducts.
formed at the ICU bedside65). Definitive diagnosis requires visualization of the beaded appear-
A few patients with acute cholecystitis will have concurrent ance of the biliary tree by means of cholangiography. Cholangio-
acute cholangitis. Cholecystostomy is contraindicated in these carcinoma and secondary sclerosing cholangitis in patients with
patients because of its high mortality; adequate drainage of the Caroli disease or choledochal cysts may mimic these clinical, bio-
CBD is required in such cases [see Fever and Jaundice, below]. chemical, and radiologic features, but this is an unusual occur-
rence and can be distinguished by careful follow-up of patients.
FEVER AND JAUNDICE
Currently, magnetic resonance cholangiopancreatography
An alternative presentation of upper abdominal infection (MRCP) is the imaging modality of choice for elective manage-
includes patients whose predominant symptoms are fever and ment of patients with primary sclerosing cholangitis, in that it yields](https://image.slidesharecdn.com/acs0818-intra-abdominalinfection-100726064008-phpapp01/75/Acs0818-Intra-Abdominal-Infection-8-2048.jpg)
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8 CRITICAL CARE 18 Intra-Abdominal Infection — 9
results comparable to those of ERCP without being invasive.68-71 decompression in these critically ill patients can result in a mor-
Other causes of cholangitis. An uncommon cause of recurrent tality of 30% to 40%.82-85 Furthermore, reoperation is required in
cholangitis in North America is Oriental cholangiohepatitis, which one third of survivors because important diagnostic information is
is characterized by intrahepatic duct scarring, biliary strictures, not available at the initial laparotomy. As a result, nonoperative
and hepatolithiasis, as demonstrated by cholangiography. Irrever- methods of biliary decompression, including percutaneous trans-
sible intrahepatic and extrahepatic liver damage may result be- hepatic biliary drainage (PTBD) and endoscopic sphincterotomy
cause of the overwhelming propensity of these patients to form at ERCP, have gained favor. PTBD was originally developed for
calcium bilirubinate stones. preoperative management of biliary obstruction without cholangi-
A few patients with cholangiocarcinoma causing bile duct ob- tis but has not been found to be beneficial in that setting. At pres-
struction or liver metastases causing intrahepatic bile duct obstruc- ent, it is mainly used for the management of proximal bile duct
tion may also present with a clinical picture suggestive of cholan- strictures or for the treatment of cases not amenable to ERCP; its
gitis. CT followed by MRCP can delineate the diagnosis in most complication rate is less than 10%.86
such cases.Treatment consists of I.V. antibiotics and biliary drain- Although PTBD can reduce the mortality associated with ini-
age by radiographic or surgical means. tial biliary decompression, many patients still require a definitive
operation. Consequently, endoscopic sphincterotomy [see 5:18 Gas-
Treatment Once acute cholangitis is diagnosed, resuscita- trointestinal Endoscopy] has been proposed for decompression of
tion is started with I.V. fluids and antibiotics, such as fluoro- the biliary tree in patients with acute cholangitis from choledo-
quinolones, mezlocillin, cefoperazone, or piperacillin,59,72-75 partic- cholithiasis [see Figure 6]. In a study of 82 patients with acute
ularly in patients with marked hyperbilirubinemia, in whom treat- cholangitis caused by CBD calculi, early operation was employed
ment with aminoglycosides may contribute to renal toxicity in up in 28 patients, endoscopic sphincterotomy in 43, and antibiotic
to 33% of cases [see 8:6 Renal Failure].76 These antibiotics are therapy alone in 11.87 Surgical mortality was 21% and morbidity
required to deal with the various aerobic bacteria, of which 57%; by comparison, mortality for endoscopic sphincterotomy
Escherichia coli, Klebsiella species, and enterococci are the most fre- was 5% and morbidity 28%. Others confirmed these findings.81 In
quently encountered in this setting. Anaerobes may be isolated in patients whose gallbladder is still in place, endoscopic sphincter-
15% to 30% of patients and are particularly likely to be present in otomy alone, without cholecystectomy, may even be a reasonable
diabetics, the elderly, and patients who have previously undergone long-term option. Of 23 patients whose gallbladders were left in
biliary manipulation. In patients with indwelling catheters, situ,87 only two required cholecystectomy in the 1- to 7-year fol-
Enterobacter, Pseudomonas, and Candida organisms are being isolat- low-up period: one for empyema of the gallbladder and one for
ed with increasing frequency. Indications of high risk include a recurrent cholangitis.
serum bilirubin concentration higher than 3 mg/dl. An increasingly recognized cause of cholangitis is biliary sepsis
Approximately 75% of patients with acute cholangitis respond after manipulation of the biliary tree with ERCP or PTBD.
to conservative measures,77 and supportive treatment is contin- Treatment includes I.V. fluids and antibiotics. To prevent this
ued. Subsequent investigations usually include CT followed by complication, prophylactic antibiotics should be administered be-
MRCP.78,79 Because of their invasive nature, ERCP and needle fore every biliary manipulation.88
percutaneous transhepatic cholangiography (PTC) are reserved
FEVER AND ABDOMINAL MASS
for cases in which a drainage procedure is anticipated or the infor-
mation from the MRCP is deemed inadequate. A third group of patients with upper abdominal infection pre-
For the 25% of patients who do not respond to conservative sent with fever and an upper abdominal mass identified either by
treatment, early recognition may improve their prognosis. In one clinical signs or through diagnostic imaging. Even if the mass is
study, patients who did not respond immediately to antibiotics only vaguely palpable, the mass effect is demonstrable on ultra-
had a mortality of 62%, compared with a mortality of 1.5% in sound examination of the abdomen. If the abdominal ultrasound
those who improved.80 In another study, indicators of high risk examination is technically unsatisfactory because of intestinal gas,
were an arterial blood pH less than 7.4, a serum bilirubin con- contrast-enhanced CT of the abdomen will facilitate the diagnosis.
centration above 9 mmol/L, a blood platelet count below The differential diagnosis is aided by the location of the mass.
150,000/mm3, and a serum albumin concentration lower than 3 A mass in the right upper quadrant usually indicates acute chole-
g/dl.102 These high-risk patients often have systemic hypotension, cystitis, though the possibility of a liver abscess must also be con-
mental confusion, a temperature higher than 39º C (102.2º F), or sidered. A mass in the epigastrium or in the left upper quadrant
hypothermia. Occasionally, acute cholangitis is complicated by dis- usually signals a pancreatic infection; in rare instances, a solitary
seminated intravascular coagulation (DIC), which manifests itself splenic abscess is found. Patients with an intra-abdominal abscess
as a tendency to bruise and bleed or merely as prolongation of the in the subphrenic space or an interloop abscess may also present
PT and the PTT, together with a fall in the blood platelet count in this manner.
[see 1:4 Bleeding and Transfusion]. If DIC is suspected, the diagno-
sis should be confirmed and treatment started before biliary Liver Abscess
decompression. Diagnosis In the setting of acute upper abdominal sepsis, a
Patients with refractory cholangitis who do not improve within tender mass in the right upper quadrant is most likely an enlarged,
24 hours require urgent biliary decompression. Urgent biliary inflamed gallbladder, possibly wrapped with omentum [see Upper
decompression had traditionally been accomplished via surgical Abdominal Pain and Fever, Acute Cholecystitis, above]. The next
exploration of the CBD and T-tube drainage [see 5:22 Biliary Tract most common cause of fever and abdominal mass in the right
Disease]. Cholecystostomy is an inadequate and often fatal upper quadrant, however, is liver abscess.
option in this context. Rarely, T-tube insertion alone may be life- Pyogenic abscess. Today, pyogenic liver abscess is most common-
saving in a desperately ill patient; generally, however, definitive ly related to biliary tract obstruction from gallstones or malignant
internal decompression is preferable. Unfortunately, any surgical disorders (35% of cases), and the ultrasound examination may](https://image.slidesharecdn.com/acs0818-intra-abdominalinfection-100726064008-phpapp01/75/Acs0818-Intra-Abdominal-Infection-9-2048.jpg)
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8 CRITICAL CARE 18 Intra-Abdominal Infection — 11
Blood cultures are positive in as many as 50% of patients with a decrease in the size of the abscess is apparent within 1 week on
pyogenic abscess, particularly in those with multiple abscesses; in ultrasonographic examination, though a small residual cavity may
fact, the presence of Streptococcus milleri in the blood suggests a vis- persist for as long as 2 years. If the patient’s condition does not
ceral abscess. improve, needle aspiration and culture are indicated. Secondary
infection is treated as a pyogenic abscess. Otherwise, oral emetine,
Treatment Pyogenic abscess. The preferred treatment of pyo- 65 mg/day, is added for up to 10 days.
genic abscess is closed continuous percutaneous drainage guided Echinococcal abscess. Symptomatic or secondarily infected echi-
by CT or ultrasonography, provided that it is technically feasible nococcal cysts are best treated by means of surgical excision or
and no other indication for laparotomy exists.94 More than one marsupialization. The use of oral anthelmintics (e.g., albendazole
catheter may be required for complete drainage. An alternative and mebendazole) has met with limited success. Nevertheless, pre-
treatment is repeated percutaneous needle aspiration, the results operative treatment with albendazole or mebendazole for 1 month,
of which are comparable to those of continuous drainage.95 One combined with postoperative treatment, is indicated to reduce the
advantage to repeated needle aspiration is the elimination of cum- risk of intraoperative seeding or postoperative recurrence.109,110
bersome, painful drainage tubes, which are prone to dislodgment.
Although initial studies showed a good response rate with repeat- Pancreatic Infection
ed needle aspiration,96 the results were not duplicated in a subse- Diagnosis When the mass is located in the epigastrium or the
quent randomized trial.97 left upper quadrant, a pancreatic source is most likely. Prompt and
The abscess cavity dimensions are followed by serial imaging accurate diagnosis is crucial because severe pancreatic infection is
until the cavity collapses, and the catheter can usually be removed fatal if left untreated.The key to successful treatment is early diag-
2 to 3 weeks later. Continuous percutaneous drainage has been nosis of infected pancreatic necrosis, infected pseudocyst, and pan-
associated with a complication rate of 4% and a failure rate of creatic abscess. A high index of suspicion is required to diagnose
15%.98 However, operative drainage is the treatment of choice in these three infectious processes and to differentiate them from a
patients with an identified intra-abdominal focus of infection and pancreatic inflammatory mass or phlegmon,28 in which pancreatic
in patients in whom percutaneous drainage is not feasible or has edema and inflammation are present without necrosis or infection.
failed.99 Operative drainage, especially via a laparoscopic approach, Correct diagnosis and treatment of infected pancreatic necrosis,
is a highly effective treatment option that is associated with low infected pseudocyst, and pancreatic abscess require an under-
mortality and morbidity.100 In some patients, a limited hepatic standing of their pathophysiology. It is generally assumed that
resection [see 5:23 Hepatic Resection] may be required to eliminate infected pancreatic necrosis develops as a transmural, transductal,
multiple abscesses, particularly when an underlying intrahepatic lymphatic, or hematogenous infection of a necrotic region of the
stricture is the source.101 pancreas. Infection develops in 40% of cases of pancreatic necro-
Treatment of pyogenic liver abscess should include systemic sis, usually in week 2 or 3 after development of the acute pancre-
antibiotic therapy. Approximately 70% of pyogenic liver abscesses atitis.111 Surgical debridement is required in these cases to prevent
yield polymicrobial isolates,102 and 25% to 45% of the organisms death. Pancreatic abscesses form by liquefaction of infected necro-
are anaerobic.103 Multiple anaerobic isolates suggest the colon as a sis.They usually occur after week 5 of pancreatitis, when the acute
source, whereas a single isolate of E. coli suggests a nidus in the bil- phase of the disease has subsided.112 Pancreatic abscesses are asso-
iary tree. Antibiotic treatment should include initial coverage of ciated with a lower mortality than infected pancreatic necrosis.
both aerobes and anaerobes with either a single agent or multiple Like pancreatic abscesses, infected pancreatic collections and
agents.The need to cover enterococci has been debated, but these pseudocysts present late in the course of pancreatitis. They are
organisms clearly are increasingly important nosocomial patho- associated with a lower mortality than pancreatic abscesses.
gens. An acceptable initial treatment regimen consists of a single Caused by infection in 13% of localized collections resulting from
broad-spectrum agent (e.g., ticarcillin-clavulanate or meropenem). ductal blowout, infected pancreatic collections and pseudocysts
It should be noted that significant changes have occurred in the eti- may occur in the pancreas itself, in contiguous peripancreatic tis-
ology, bacteriology, and treatment of liver abscesses. There is a sue, or in remote (extrapancreatic) tissue.
trend toward a higher incidence of pseudomonal and streptococcal Clinical evaluation alone is generally insufficient to diagnose
infections, and the frequency of fungal infection is increasing as pancreatic infection. A clearly defined upper abdominal mass is
well.104 The mortality from this disease remains high, and appropri- palpable in only 50% to 75% of cases.28 In most patients, the
ate antibiotic coverage with drainage is of paramount importance. screening battery of tests reveals leukocytosis with leukocyte
The duration of antibiotic therapy is controversial105; according counts greater than 15,000/mm3. Blood cultures are positive in
to one set of guidelines, antibiotics should be continued for 3 to 4 50% of cases. CT-guided percutaneous aspiration with Gram stain
weeks when the abscess has been excised, 4 to 8 weeks when a soli- and culture provides the best method of diagnosing pancreatic
tary abscess has been drained, and 6 to 8 weeks when multiple infection. In one study of 75 patients with clinical toxicity sugges-
macroscopic abscesses have been drained.106 Multiple microscopic tive of pancreatic sepsis, infection was confirmed in only 40%.113
abscesses usually require that a biliary source also be treated.85 The In another study of 21 patients with pancreatic infection, only five
overall prognosis for multiple small hepatic abscesses is not as good had specific signs on abdominal CT scan.114 CT-guided diagnos-
as that for solitary abscesses, and the development of a pyogenic tic needle aspiration leads to a correct diagnosis within 72 hours
abscess in a patient with an underlying hepatobiliary or pancreatic in two thirds of patients, and the mortality associated with opera-
malignancy has been identified as a preterminal event associated with tive intervention is 19%; however, CT-guided needle aspiration is
a hospital mortality of 28% and survival of less than 6 months.107 beneficial only if pancreatic infection is suspected and if the tech-
Amebic abscess. Medical treatment is now the standard approach nique is used early in the course of disease.
to management of amebic liver abscesses. Metronidazole, 750 mg Several laboratory markers of pancreatic necrosis have been
orally three times a day for 10 days, is a highly effective regimen.108 investigated, such as serum methemalbumin, serum ribonuclease,
A favorable response to treatment occurs within 4 to 5 days, and and C-reactive protein. Most of these markers are too insensitive](https://image.slidesharecdn.com/acs0818-intra-abdominalinfection-100726064008-phpapp01/75/Acs0818-Intra-Abdominal-Infection-11-2048.jpg)
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8 CRITICAL CARE 18 Intra-Abdominal Infection — 12
for routine clinical practice. However, serum levels of C-reactive pseudocysts can usually be treated nonoperatively. In one prospec-
protein above 10 mg/dl have been reported to be 95% accurate in tive study, percutaneous and surgical drainage were equally suc-
predicting necrosis.115 cessful in treating infected pancreatic fluid collections and pseudo-
Currently, the best indicators of infected pancreatic necrosis or cysts.124 Clinical signs of progress rather than CT findings are the
abscess are a combination of Ranson’s objective prognostic signs best indicators of the need for intervention, and nonoperative
[see Table 2] and dynamic abdominal CT scan findings. In Ranson’s methods should be attempted before open surgery is planned.
series, the pancreatic findings on CT were graded in five categories Adjunctive procedures. In the past, debridement and sump
[see Figure 7]116: (a) normal, (b) pancreatic enlargement alone, (c) drainage were accompanied by the so-called triple ostomy tech-
inflammation of the pancreas and peripancreatic fat, (d) one peri- nique, which involved cholecystostomy, gastrostomy, and jejunos-
pancreatic fluid collection, and (e) two or more peripancreatic fluid tomy. The role of these ancillary procedures, however, is contro-
collections. Only category e was associated with a high (61%) inci- versial at best, and currently, cholecystostomy is employed only if
dence of pancreatic abscess. The number of objective prognostic gallstones are detected.
signs present also predicted the subsequent development of an Other operative procedures may be required to manage gastric
abscess: fewer than three signs, 12.5%; three to five signs, 31.8%; or colonic complications. Gastric bleeding, gastric outlet obstruc-
and more than five signs, 80%. However, the value of this method tion, and gastric fistula necessitating reoperation are relatively
was limited because only five of the 83 patients evaluated had more infrequent in this setting. By contrast, colonic necrosis and fistula
than five prognostic signs. By combining the objective prognostic formation are relatively common and occur either spontaneously
signs with positive abdominal CT findings, the investigators identi- or as complications of treatment. The usual site of involvement is
fied 30 patients who had three or more objective signs and were the splenic flexure or upper descending colon.Treatment consists
graded as category c, d, or e on abdominal CT scan; in these of colonic resection or a diverting colostomy [see 5:34 Laparo-
patients, the incidence of pancreatic abscess was 56.7%. By con- scopic Coloctomy].
trast, no patient with fewer than three prognostic signs and graded Antibiotic therapy.The role of systemic antibiotic therapy in the
as category a or b on abdominal CT scan had a pancreatic abscess. prophylaxis of pancreatic abscess is controversial. Experimental
evidence suggests that antibiotics may sometimes decrease the
Treatment Once pancreatic infection is diagnosed, support- severity of pancreatitis,125 and endoscopic cannulation of the
ive measures are initiated, including nasogastric suction, with- pancreatic duct has yielded bacteria in pancreatic secretions of
holding of oral feedings, meticulous attention to respiratory care patients with acute pancreatitis.126 In patients with pancreatic
and fluid and electrolyte balance, systemic antibiotic therapy, and abscess, bacteriologic cultures are usually polymicrobial, the
nutritional support. The key to successful treatment, however, is most common organisms being E. coli, enterococci, Klebsiella
surgical, radiologic, or endoscopic drainage. pneumoniae, P aeruginosa, S. aureus, Bacteroides fragilis, and Clos-
.
Pancreatic necrosis. Sterile pancreatic necrosis alone is not an tridium perfringens. There is a growing trend toward early use of
indication for surgical debridement. In one prospective study, 11 prophylactic antibiotics in cases of pancreatic necrosis, even
patients with sterile pancreatic necrosis were all followed success- though there are no data that convincingly demonstrate a clini-
fully with conservative treatment.117 However, once infected pan- cal benefit. This trend may be partly responsible for the increas-
creatic necrosis is confirmed by Gram stain or culture, surgical ing prevalence of Candida species in pancreatitis-related sepsis; a
debridement is required to remove the characteristically thick 1996 report stated that Candida infection was detected in 21%
necrotic material; radiologic or endoscopic methods alone are not of patients.127
as effective for this purpose. Nutrition. Nutritional support of patients with pancreatic abs-
The choice of drainage technique is nevertheless controversial. cesses usually consists of TPN, though small bowel feeding may
Many clinicians prefer operative debridement and sump drainage. be attempted occasionally.These patients have high metabolic de-
The mortality associated with extensive operative debridement (so- mands and may experience glucose intolerance or hyperlipi-
called necrosectomy) and sump drainage may range from 30% to demia. Nevertheless, they generally tolerate I.V. feeding well. A
40%,118 and this technique may be associated with a 30% to 40% 10-fold increase in mortality (from 2.5% to 21%) was reported
reoperation rate because of sepsis or GI complications.28,119 in patients in whom a positive nitrogen balance could not be
Open drainage. To reduce the frequency of reoperation and to achieved.128
lower mortality, some clinicians opt for open drainage or marsu-
pialization of the infected pancreas. One modification involves the Splenic Abscess
use of a prosthetic mesh and a zipper to facilitate reexploration in Diagnosis A splenic abscess should be considered in patients
patients with severe intra-abdominal abscess.120 A 1991 meta- who present with fever and a left upper quadrant mass, though it
analysis of published surgical studies on infected pancreatic necro- remains a rare cause of these symptoms. Most splenic abscesses
sis found statistically better results with debridement and lavage or encountered in clinical practice are solitary; multiple abscesses are
debridement and open packing than with extensive debridement usually covert and are typically found at autopsy in patients with
and sump drainage.121 However, surgical treatment should be cus- disseminated malignancy, collagen vascular disease, or chronic
tomized for each patient. In one study, open packing was used for debility.
massive necrosis (more than 100 g removed by debridement at Because splenic abscess is rare, correct diagnosis requires a high
operation or CT evidence of at least 50% pancreatic necrosis) or index of suspicion.The main clue is the clinical setting: both bactere-
for extrapancreatic necrosis, whereas conventional debridement mia and local splenic disease are required to produce splenic abscess.
and sump drainage were used in other cases; the overall mortality In the preantibiotic period, this combination was seen most frequent-
in this study was only 14%.122 ly in patients with bacterial endocarditis and typhoid. Even today,
Pancreatic abscess. Pancreatic abscess resulting from liquefaction more than three quarters of splenic abscesses occur in patients who
of necrosis is also best treated by surgical drainage because resid- already have an infection elsewhere in the body; splenic abscesses
ual necrosis may cause failure of treatment by percutaneous meth- can also occur in patients with splenic infarcts, splenic hematomas,
ods.123 On the other hand, infected pancreatic fluid collections and or local splenic disease caused by hemoglobinopathies.](https://image.slidesharecdn.com/acs0818-intra-abdominalinfection-100726064008-phpapp01/75/Acs0818-Intra-Abdominal-Infection-12-2048.jpg)
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8 CRITICAL CARE 18 Intra-Abdominal Infection — 13
a Pancreas b Pancreas
c Pancreas d
Pancreas
Fluid
e Fluid Pancreas f Abscess
Fluid
Figure 7 Pancreatic findings on CT scan have been graded by Ranson into five categories: grade A—normal pancreas
(a); grade B—diffuse enlargement of pancreas and nonhomogeneous density of gland (b); grade C—diffuse enlargement
of pancreas associated with peripancreatic inflammation (c); grade D—high-density fluid collection in left anterior
pararenal space (only head of pancreas is visualized at this level) (d); and grade E—diffuse enlargement of pancreas
with several intrapancreatic small fluid collections and poorly defined fluid collections adjacent to tail and head of pan-
creas (e). In final CT scan (f), pancreatic abscess is demonstrated; partially encapsulated fluid collection containing
bubbles of air represents large abscess.
The diagnosis of splenic abscess may be supported by indirect tion or abdominal CT scan is required. The abdominal CT scan,
radiologic signs, such as an elevated left hemidiaphragm or the enhanced with I.V. or oral contrast material, is preferred [see Figure
finding of a left upper quadrant air-fluid level (mimicking the stom- 8].129 This technique provides a direct image of the spleen, on
ach). To clinch the diagnosis, an abdominal ultrasound examina- which abscesses appear as low-density areas that may contain gas.](https://image.slidesharecdn.com/acs0818-intra-abdominalinfection-100726064008-phpapp01/75/Acs0818-Intra-Abdominal-Infection-13-2048.jpg)
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8 CRITICAL CARE 18 Intra-Abdominal Infection — 14
Mass
Figure 8 Abdominal CT scan, enhanced by contrast material, confirms diagnosis of splenic abscess.
Infections of the Lower Abdomen
Treatment Treatment of splenic abscess includes I.V. admin-
istration of antibiotics and splenectomy [see 5:25 Although enteric perforations, like pancreatitis and cholecystitis,
Splenectomy].The usual pathogenic organisms found are staphylo- present most commonly with pain and fever, their diagnosis differs
cocci and streptococci, though gram-negative bacilli and anaer- from that of upper abdominal infections of the solid organs.The pain
obes may also be present.When splenic abscesses are not drained, associated with enteric perforation frequently is not well localized;
mortality approaches 100%. At one time, splenotomy was the pre- consequently, CT scanning is used more frequently than ultra-
ferred operative treatment, but splenectomy is currently the pre- sonography because it is superior for evaluating the entire abdomen
ferred approach. Percutaneous catheter drainage is being per- [see Figure 9]. Moreover, a perforated viscus may present more acute-
formed with increasing frequency and appears to be as effective as ly than other forms of infection do, and it is a common indication
operative drainage.8,130.131 for emergency exploration. Thus, in the setting of a possible lower
Patient does not have "certain" appendicitis, signs of
upper abdominal infection are not present, and abdominal
plain films are not indicated
Order abdominal and pelvic CT scans.
Diffuse infection is Free peritoneal air is Evidence of duodenal Localized infection
Scans are normal
observed; infection seen without evidence perforation is seen, with or is seen
is uncontrolled, and of controlled leak without free peritoneal air
Consider nonsurgical
source is unclear (duodenal ulcer,
diagnoses. Treat operatively; if upper GI
periappendiceal or
Consider esophago- diverticular abscess) study shows perforation is
Resuscitate, give
gastroduodenoscopy. sealed, consider nonoperative
antibiotics, and take
to OR. Resuscitate, give treatment.
antibiotics, and take
to OR.
No discrete fluid collection is Discrete fluid collection is
present (pancreatitis, present (periappendiceal or
diverticulitis) diverticular abscess)
Provide nonoperative management, Resuscitate and give antibiotics.
including resuscitation and Treatment options:
antibiotic therapy (antibiotics are • percutaneous drainage with
unnecessary for bland pancreatitis delayed resection
Figure 9 Algorithm outlines approach to patient with without necrosis). • immediate open resection and
suspected lower abdominal infection. drainage
• diversion and drainage only](https://image.slidesharecdn.com/acs0818-intra-abdominalinfection-100726064008-phpapp01/75/Acs0818-Intra-Abdominal-Infection-14-2048.jpg)
![© 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
8 CRITICAL CARE 18 Intra-Abdominal Infection — 15
a b
c
Figure 10 (a) Upright chest x-ray of patient with
sudden onset of diffuse abdominal pain demonstrates
free peritoneal air underneath both diaphragms
(black arrows). Emergency exploration was carried
out without further studies, and perforated gastric
ulcer was excised. (b) Abdominal CT scan of patient
with history of ulcer disease and 1-week history of
increasing abdominal pain shows retrogastric fluid
collection with air that appears to be in communica-
tion with duodenum (white arrow). Patient under-
went laparotomy, and perforated duodenal ulcer was
repaired. (c) Abdominal CT scan of patient with 2- to
3-day history of worsening abdominal pain demon-
strates extravasation of oral contrast from anterolat-
eral aspect of duodenum (white arrow). Patient
underwent laparoscopic omental patch closure.
abdominal infection, the diagnostic emphasis is on confirming or a role for H. pylori infection in the pathogenesis of these perfora-
ruling out the presence of an acute condition necessitating opera- tions as well.136
tion, rather than on fine localization of a more chronic illness.
Diagnosis
PEPTIC ULCER PERFORATION
A patient with a perforated peptic ulcer will complain of the
The incidence of peptic ulcer perforation has decreased signifi- sudden onset of intense abdominal pain and will often be able to
cantly as a consequence of the changes in disease progression and pinpoint the exact time when the symptoms began. If the perfora-
incidence of intractable ulcers brought about by the advent of H2 tion has not spontaneously sealed or been managed with operative
receptor antagonists and proton pump inhibitors (PPIs). Still, a closure, the clinical picture can progress to florid sepsis and shock.
significant percentage of all hospital admissions are secondary to Evidence of free air on plain upright and left lateral decubitus radi-
perforated peptic ulcers, and the patient population is becoming ographs will be seen in as many as 70% of cases [see Figure 10a].137
older and more evenly balanced between men and women, pre- Endoscopy should be avoided in the evaluation of peptic ulcer per-
sumably because of increased use of nonsteroidal anti-inflamma- foration, but equivocal cases or spontaneously sealed perforations
tory drugs and cigarettes.132 can be evaluated with water-soluble contrast studies. CT scanning
Several studies found a high (80% to 92%) incidence of can be used to localize an infection to the duodenum, particular-
Helicobacter pylori infection in patients with perforated peptic ly if communication of air or fluid with the duodenum is estab-
ulcers.133,134 Although the prevalence of H. pylori infection in this lished [see Figure 10b] or if extravasation of contrast is seen [see
population is well established, the causal role that such infection Figure 10c].
plays in peptic ulcer perforations has been questioned.135 In a 1999
study involving 50 patients with juxtapyloric perforations related to Treatment
crack cocaine use who were successfully managed with simple Surgical management centers on control of the site of perfora-
omental patch closure, the investigators found that approximately tion (via surgical closure or spontaneous sealing), with or without
80% of the patients who underwent antral mucosal biopsy at the an acid-reducing procedure [see 5:20 Gastric Duodenal Disease]. Be-
time of closure had a positive urease test, a finding that suggested fore this is done, I.V. fluids should be given, metabolic derange-](https://image.slidesharecdn.com/acs0818-intra-abdominalinfection-100726064008-phpapp01/75/Acs0818-Intra-Abdominal-Infection-15-2048.jpg)
![© 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
8 CRITICAL CARE 18 Intra-Abdominal Infection — 17
[see 5:29 Intestinal Anastomosis]. For patients with Crohn disease,
perforation (usually presenting as a fistula) is a risk factor for post-
operative disease recurrence156; accordingly, close postoperative
follow-up is indicated.
There are two additional issues regarding small bowel perfora-
tions that warrant special mention. The first has to do with small
bowel perforation secondary to obstruction. When this event
occurs, it is important not only that the perforated segment be
resected but also that the cause of obstruction be identified to pre-
vent recurrence. The second issue has to do with anastomotic
leakage. Not all leaks call for surgical intervention. If the leak is a
late complication, it is likely to have walled itself off into an
abscess, in which case CT-guided drainage of the abscess is the
treatment of choice. Efforts at reducing the luminal transport are
also made to improve healing.
Nutritional support plays a major supportive role in the treat-
ment of patients with small bowel perforation. Many of these
patients, either because of their underlying pathology (e.g., Crohn
disease) or because of their hypermetabolic state (e.g., from trau-
ma), lose some of their innate ability to heal and prevent anasto-
motic breakdown.The presence of a knowledgeable nutrition staff
can dramatically enhance patient recovery in this setting. Figure 11 Pelvic CT scan of patient with distant history of right
lower quadrant abdominal pain with recurrent acute attack
demonstrates inflamed and thickened appendix with surrounding
Antibiotic therapy The small bowel flora is typically sparse
fat stranding (white arrow). Gangrenous appendix was removed
(103 to 104/ml), with salivary organisms predominating. In condi- laparoscopically.
tions of stasis, obstruction, or impaired motility, however, colonic
flora can proliferate, with E. coli, enterococci, and obligate anaer-
obes the dominant organisms. In the distal ileum, there are typi- from 39% to 8%, and one retrospective study found that the use
cally about 106 colony-forming units/ml, with an increasing pro- of diagnostic CT lowered the rate of misdiagnosis to 7%.162 CT
portion of enteric organisms and anaerobic bacteria, presumably scanning is reported to be 93% to 98% in diagnosing appendici-
as a result of backwash through the ileocecal valve.157 Although tis, with significantly improved accuracy achieved by using an
there are generally far fewer bacteria in the small intestine than in appendicitis protocol after retrograde water-soluble contrast
the colon (which contains about 1012 organisms/ml), the standard administration.163 CT findings suggestive of appendicitis [see
antimicrobial therapy remains broad-spectrum coverage (e.g., flu- Figure 11] include enlargement and dilation of the appendix (to
oroquinolone plus an antianaerobic agent for 5 days).158 > 6 mm), nonfilling of the appendix, and periappendiceal inflam-
mation (fat stranding, abscess, phlegmon, and dependent fluid
APPENDICITIS collections); these findings do not differ significantly between
Obstruction of the appendiceal lumen by a fecalith, a hyper- acute appendicitis and chronic, recurrent appendicitis.164,165
plastic lymph node, or a foreign body is typically the inciting event Current evidence supports the role of CT scanning in the diag-
in the pathogenesis of appendicitis. Luminal obstruction with con- nostic evaluation of patients with suspected appendicitis. Studies
tinued secretion results in progressive distention, proliferation of have demonstrated decreases both in the incidence of normal
luminal microorganisms, ischemia, gangrene, and subsequent per- appendectomies and in the incidence of prolonged, unnecessary
foration. The clinical history during this evolution is marked by observations.166,167 Furthermore, alterations in patient manage-
diffuse epigastric pain with anorexia, nausea, and vomiting. The ment attributable to diagnostic CT have been shown to decrease
pain typically progresses first to the periumbilical region and then overall hospital and patient costs. Nevertheless, the utility of CT in
to the right lower quadrant (at McBurney’s point). Patients have a young men whose history, physical examination, and laboratory
low-grade fever and exhibit direct tenderness at McBurney’s point test results fit the classic picture of appendicitis remains unproven;
but may also manifest rebound tenderness, guarding, rigidity, and this subset of patients may be managed without confirmatory
marked temperature elevation if the appendix perforates and CT.166 On the other hand, CT scanning appears to be quite useful
results in diffuse peritonitis. As the viscera and the omentum local- for diagnosing appendicitis in women, in which setting it decreases
ize and sequester the perforation, the symptoms may subside to a the incidence of normal appendectomies and facilitates diagnosis
degree, with localized pain and a palpable abdominal mass the pri- of other causes of the symptoms.168,169 Preoperative CT scanning
mary manifestations remaining. assists in planning an operation, identifying a periappendiceal
abscess that may delay immediate appendectomy, and recognizing
Diagnosis other sources of intra-abdominal pathology.
Classically, the diagnosis of appendicitis has been made pri-
marily through clinical examination, with laboratory tests consis- Treatment
tent with inflammation (i.e., an elevated leukocyte count with a Initial management consists of fluid resuscitation, appropriate
left shift and an elevated C-reactive protein level) serving as con- prophylactic antibiotics, and preparation for surgery. Currently,
firmation. In as many as 20% of patients with appendicitis, how- acute nonperforated appendicitis, gangrenous appendicitis, and
ever, the incorrect diagnosis is made, and the incidence of removal perforated appendicitis without an associated abscess are man-
of a normal appendix can approach 40%.159-161 Early diagnosis of aged with urgent appendectomy [see 5:26 Appendectomy]. The
appendicitis can decrease the risk of postoperative complications main dilemmas in management center on the appropriate use of](https://image.slidesharecdn.com/acs0818-intra-abdominalinfection-100726064008-phpapp01/75/Acs0818-Intra-Abdominal-Infection-17-2048.jpg)
![© 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
8 CRITICAL CARE 18 Intra-Abdominal Infection — 18
laparoscopic appendectomy and the role of conservative manage- currence and progression to chronic appendicitis supports the use
ment for periappendiceal masses with interval appendectomy. of interval appendectomy in young patients, but in adults, the de-
cision algorithm must also consider the incidental diagnosis of tumor.
Laparoscopic versus open appendectomy In several Interval appendectomy is typically performed between 6 weeks
prospective, randomized clinical trials that compared laparoscop- and 3 months after percutaneous intervention and clinical resolu-
ic with open appendectomy, the consensus was that the former tion [see Figure 12]. The risk of recurrence is greatest after the 6-
was associated with a lower incidence of wound infection, month point in the clinical progression of acute appendicitis man-
decreased utilization of pain medication, earlier return to normal aged conservatively.183 In several retrospective analyses, interval
activities, and reduced cost of hospitalization (though the data appendectomy proved to be a safe management plan, but to date,
were conflicting on this last point).170-173 On the other hand, the there have been no randomized, prospective trials evaluating its
trials found the laparoscopic approach to be associated with sig- role in management.184,185
nificantly longer operating time, equivalent duration of hospital-
ization, and a possible increased risk of abscess formation. A ret- Antibiotic therapy The pathogenic organisms recovered in
rospective review published in 2000, however, found that when a peritoneal cultures derive from the colon and consist of aerobic or
dedicated laparoscopic service was established for patients with facultative bacteria and anaerobes. The most frequently isolated
appendicitis, the rates of intra-abdominal abscess formation after organisms are E. coli, enterococci, viridans streptococci, B. fragilis,
laparoscopic appendectomy decreased to levels equivalent to those Lactobacillus species, Prevotella melaninogenica, and Bilophila
reported after open appendectomy.174 wadsworthia.186,187 It is noteworthy that the use of intraoperative
Although laparoscopic appendectomy is associated with a high- peritoneal cultures has not been shown to affect the incidence of
er incidence of intra-abdominal abscess formation in the setting of wound infection, abscess formation, or small bowel obstruction if
perforated appendicitis, it is not associated with a higher incidence patients are presumptively managed with antibiotics that cover
of wound infection or abscess in patients with gangrenous or non- gram-negative bacteria and enteric anaerobes.188
perforated appendicitis.175 Furthermore, a prospective, random- Appropriate coverage can be obtained with any of the following:
ized trial found that laparoscopic appendectomy was associated ampicillin-sulbactam, piperacillin-tazobactam, ticarcillin-clavu-
with reduced overall cost of hospitalization, decreased use of pain lanate, cefoxitin, cefotetan, and ciprofloxacin plus metronida-
medication, and earlier return to functional status in patients with zole.189-192 In a trial involving children with perforated appendici-
uncomplicated appendicitis.170 tis, conversion to oral therapy after parenteral therapy was equiv-
Two groups of patients clearly benefit from laparoscopic appen- alent to parenteral therapy alone.193 In a study of patients with
dectomy: women and obese patients. In women, laparoscopy aids acute nonperforated appendicitis, preoperative administration of
in the diagnosis of other pelvic pathologic conditions and lowers cefoxitin was superior to placebo in reducing the incidence of
the incidence of negative appendectomies; in obese patients, it wound infection.190 In a study of children with acute nonperforat-
results in less postoperative pain and a shorter recovery time, even ed appendicitis, prolonged antibiotic administration (5 days) had
though it does not significantly reduce the postoperative compli- no advantage over a single preoperative dose with respect to the
cation rate.176,177 Patients who present with evidence of perforated incidence of wound infection or subsequent abscess formation.194
or complicated appendicitis may be better managed with the tra- The duration and timing of antibiotic administration in patients
ditional open approach to minimize the risk of postoperative with nonperforated gangrenous appendicitis have not been shown
abscess formation.178 Improvements in laparoscopic techniques, to correlate with the wound infection rate.195
however, may eventually reduce the incidence of this complication
COLONIC PERFORATION
to a level comparable to that seen with open management.
Periappendiceal abscess and interval appendectomy Diagnosis
The mainstays of conservative management have been parenteral Diagnostic strategies for identifying colon lesions associated
antibiotics, supportive fluid resuscitation, and percutaneous with intra-abdominal infection follow the general approach out-
drainage of radiographically amenable fluid collections. In a 2001 lined earlier [see Clinical Evaluation and Investigative Studies,
review of 155 patients with periappendiceal abscesses, the compli- above]. For unstable patients with generalized peritonitis, there is
cation rate was 36% for patients managed with surgical incision no need to delay operative intervention to wait for radiologic con-
and drainage and appendectomy, compared with 17% for patients firmation: the pathologic condition will be identified in the course
managed nonoperatively.179 The recurrence rate was 8% in the of the operation. However, for patients who have localized peri-
conservatively managed patients, and nonoperative management tonitis or those who are stable and whose physical examination is
failed in five patients. Patients with perforated appendicitis and not conclusive for peritonitis, radiologic evaluation is pivotal in
abscess or phlegmon diagnosed by CT scanning but without a planning treatment.
palpable mass were safely managed with conservative therapy. In Although plain films may reveal free air in the abdomen and
a 2002 study, immediate appendectomy was associated with a prompt surgical intervention, CT scanning may be a more valu-
higher postoperative complication rate and an increased incidence able first study because of its ability to delineate the bowel wall and
of more extensive initial operations (e.g., ileocecal resection, right surrounding soft tissues with remarkable accuracy. In a 2002
hemicolectomy, and temporary ileostomy).180 study comparing abdominal radiography with CT for the evalua-
The recurrence rate after conservative management ranges tion of acute nontraumatic abdominal pain in the ED, the former
from 10% to 20%. In one study of patients managed with interval was not nearly as diagnostically sensitive as the latter (a nonspe-
appendectomy for periappendiceal mass, histologic evaluation cific diagnosis in 68%, compared with a specific diagnosis in
revealed that a significant majority of samples had a patent appen- 80%).196 The investigators concluded that CT was the initial radi-
diceal lumen and were at risk for recurrent appendicitis.181 In a ographic modality of choice for patients with acute abdominal
2002 report, 45.8% of interval appendectomy pathologic samples pain in the ED. Another study found that CT scans frequently
showed evidence of chronic active inflammation.182 The risk of re- changed physicians’ initial diagnoses, increased diagnostic certain-](https://image.slidesharecdn.com/acs0818-intra-abdominalinfection-100726064008-phpapp01/75/Acs0818-Intra-Abdominal-Infection-18-2048.jpg)
![© 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
8 CRITICAL CARE 18 Intra-Abdominal Infection — 19
a b
Figure 12 (a) Pelvic CT scan of young patient with a 5-day history of right lower quadrant abdominal
pain shows fluid collection containing air adjacent to appendix and consistent with appendiceal perfora-
tion and abscess formation (white arrow). (b) Pelvic CT scan of same patient after percutaneous ultra-
sound-guided placement of drainage catheter shows evacuation of air and much fluid. Patient underwent
uneventful interval appendectomy 6 weeks later.
ty, and led to more appropriate treatment in patients with acute management, including broad-spectrum antibiotics and bowel
abdominal pain in the ED.197 rest.The patient can be evaluated for definitive surgical treatment
In view of the relatively high cost of CT scanning, the con- later, after the episode resolves and the patient is in better condi-
comitant radiation exposure, and the use of I.V. contrast agents to tion for surgery. For larger abscesses or stage II disease [see Figure
enhance the scans, some have suggested using ultrasonography to 13b], the standard of care is CT-guided percutaneous abscess
make diagnoses. However, the well-documented dependency of drainage, if feasible. After drainage, resuscitation, and bowel prep-
this modality on the skill of the individual technician makes it less aration, a one-stage colectomy can be done (resection of the dis-
attractive to the broader health care community, where full-time eased segment with primary anastomosis) so as to avoid the poten-
sonographers are not always available. Finally, it should be noted tial increased morbidity of a two-stage procedure.205
that there is no role for MRI in the acute setting. Although it is For patients who have abscesses that are inaccessible to percu-
both sensitive and specific, the logistic hindrances associated with taneous drainage or who experience persistent symptoms despite
its use greatly limit its applicability. drainage, operative correction is required. If adequate bowel pre-
paration can be carried out, primary anastomosis at the time of
Treatment surgery should be considered. If adequate bowel preparation is not
Diverticulitis Diverticular disease ranges in severity from possible, a two-stage approach, including a Hartmann procedure
minor to serious. The focus of our discussion will be on manage- and subsequent stoma reversal, should be considered. Alterna-
ment of complicated (perforated) diverticular disease, for which tively, depending on the patient’s condition, resection with prima-
resection should be considered after only one attack. ry anastomosis may be attempted. There is some evidence that
In the past, treatment of perforated diverticular disease involved a employing intraoperative colonic lavage to reduce the fecal col-
multistage surgical approach whereby the patient underwent three umn and thus allow primary anastomosis may reduce morbidity,
separate procedures: one for fecal diversion and drainage of the especially in patients with stage I or II disease.206-208 However, the
infection, a second for resection of the diseased segment, and a third studies supporting this view are not conclusive enough for such a
for closure of the colostomy.This three-stage approach proved to be regimen to be considered standard; further investigation is war-
associated with high morbidities, high cumulative mortalities, and ranted before it is generally accepted. Finally, whether to add a
prolonged hospitalizations.198-200 Since then, CT -guided percuta- covering stoma to a primary anastomosis is a case-by-case decision
neous drainage, primary resection of the diseased segment, and that is usually guided by the presence of risk factors such as poor
improved patient selection for resection and primary anastomosis nutritional status, inadequate bowel preparation, blood loss, or
have improved patient outcomes dramatically. Few adequately pow- intraoperative hypotension.209
ered multicenter, prospective, randomized trials evaluating treat-
ment of complicated diverticular disease have been done; accord-
ingly, many of the current treatment standards have been derived by
consensus on the basis of thorough review of the literature. Table 4—Hinchey System for Classification
Therapy for perforated diverticular disease depends greatly on of Perforated Diverticulitis201
the patient’s condition at the time of presentation and on the stage
of the disease.The Hinchey staging system201 [see Table 4] classifies Stage Description
perforated diverticular disease according to the associated inflam-
Stage I Pericolic or mesenteric abscess
matory process and is used to guide and compare treatment
Stage II Pelvic or retroperitoneal abscess that is walled off
options.202-204
Stage III Purulent peritonitis
In stage I disease, a small pericolic abscess [see Figure 13a] in a Stage IV Feculent peritonitis
stable and otherwise healthy patient may resolve with conservative](https://image.slidesharecdn.com/acs0818-intra-abdominalinfection-100726064008-phpapp01/75/Acs0818-Intra-Abdominal-Infection-19-2048.jpg)
![© 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
8 CRITICAL CARE 18 Intra-Abdominal Infection — 21
a b
Figure 14 (a) Abdominal CT scan of elderly patient with history of vascular disease and worsening
abdominal pain over a 3-day period shows diffuse inflammation and right upper quadrant extraluminal
air (white arrow). Patient underwent emergency exploration, and ischemic perforation of cecum was
found. Right hemicolectomy and temporary diverting ileostomy were performed. (b) Abdominal CT
scan of patient with history of Crohn disease and worsening abdominal pain demonstrates thickening of
colonic wall with both intramural and extramural air (white arrow). Patient was treated with emergency
total abdominal colectomy for pancolitis with creation of temporary diverting ileostomy.
dures.Two studies from the early 1990s suggested improved long- [see Table 5] that cannot be attributed to another cause.To reduce
term mortality after primary resection.226,227 A subsequent study, undue treatment-associated morbidity, additional criteria are sup-
however, suggested that the improved mortality associated with plied to aid in specifying precisely who should receive treatment.
primary resection was secondary to preselection and therefore Treatment of PID, according to the CDC, includes broad-spec-
could not be considered conclusive proof of the superiority of this trum antibiotics directed toward Neisseria gonorrhoeae, Chlamydia
approach.The authors of this latter study concluded that primary trachomatis, anaerobes, gram-negative facultative bacteria, and
resection was appropriate for a select patient population with min- streptococci [see Table 6]. Hospitalization is suggested when surgi-
imal comorbidity and that staged resection was beneficial for cal emergencies (e.g., appendicitis) cannot be excluded or when
patients with a high degree of acute illness and comorbidity (e.g., the patient is pregnant; does not respond clinically to oral antimi-
elderly patients).228 crobial therapy; cannot follow or tolerate an outpatient oral regi-
Less common causes of colonic perforation. Other diagnoses associ- men; has severe illness, nausea and vomiting, or high fever; or has
ated with colonic perforation and peritonitis (localized or diffuse) a tubo-ovarian abscess. Surgical intervention for PID is generally
are ischemic necrosis as a result of vasculopathology [see Figure limited to patients with symptomatic pelvic masses, ruptured
14a] or volvulus, missed traumatic injury, and IBD [see Figure 14b].
Except for IBD, the standard therapy is excision of the affected seg-
ment and reanastomosis, with or without a covering stoma. For
patients with numerous comorbidities, a high degree of feculent Table 5—CDC Guidelines for Diagnosis of
contamination, or very severe illness necessitating an extremely
abbreviated operating time, a Hartmann procedure with a mucous
Pelvic Inflammatory Disease230
fistula or an oversewn distal segment is the primary treatment. Minimal symptoms
Because perforation associated with IBD is typically a self-limited Uterine/adnexal tenderness
disease, treatment is directed at the underlying pathophysiology Cervical motion tenderness
and excision of the diseased segment is not always indicated.229 Additional supportive criteria (enhance specificity of minimal symptoms)
Oral temperature >101° F (> 38.3° C)
Abnormal cervical or vaginal mucopurulent discharge
Other Abdominal Infections Presence of white blood cells on saline microscopy of vaginal
secretions
PELVIC INFLAMMATORY DISEASE Elevated erythrocyte sedimentation rate
Elevated C-reactive protein
Because of the diverse clinical presentations of pelvic inflam- Laboratory documentation of cervical infection with Neisseria gonorrhoeae
matory disease (PID) and the significant sequelae associated with or Chlamydia trachomatis
delayed diagnosis, women with this condition can pose a major Most specific criteria
diagnostic dilemma in the ED. In 2002, the Centers for Disease Endometrial biopsy with histopathologic evidence of endometritis
Control and Prevention (CDC) updated their established diag- Transvaginal sonography or magnetic resonance imaging techniques
nostic guidelines for initiating therapy in patients with suspected showing thickened, fluid-filled tubes with or without free pelvic fluid or
PID.230 According to these guidelines, empirical treatment should tubo-ovarian complex
Laparoscopic abnormalities consistent with PID
be started if a young sexually active woman or any woman at risk
for sexually transmitted diseases presents with minimal symptoms](https://image.slidesharecdn.com/acs0818-intra-abdominalinfection-100726064008-phpapp01/75/Acs0818-Intra-Abdominal-Infection-21-2048.jpg)
![© 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice
8 CRITICAL CARE 18 Intra-Abdominal Infection — 25
approach works because of the liver’s luxurious dual blood supply. response to the original insult. Such deaths are still attributed to
On the other hand, multiple peritoneal fluid collections (with- overwhelming sepsis, to multiple organ dysfunction syndrome, or
out a natural blood supply) are not infrequently seen even after to any number of other terms used to describe an irreversible
successful management of diffuse or fecal peritonitis yet can occa- sequence of organ failure and death [see 8:13 Multiple Organ
sionally be managed without drainage. Even if these collections Dysfunction Syndrome].
are subsequently proved to be infected, they may be too numer- Multiple attempts over the years to alter this downward trajec-
ous to approach percutaneously, and ongoing inflammation of the tory by using novel therapies to target this generalized inflamma-
bowel may render an operative approach unsafe. Again, drainage tory response proved unsuccessful. In the past few years, however,
of the largest accessible collection to establish a diagnosis and both recombinant human activated protein C and corticosteroid
guide antibiotic management, followed by long-term antibiotic replacement therapy (for those with sepsis-associated adrenal
therapy, is the most feasible course. In this case, sampling is imper- insufficiency) were shown to improve survival in randomized,
ative because a hospital-acquired intra-abdominal infection is placebo-controlled trials involving mixed populations of patients
more likely to involve less common but more resistant pathogens, with sepsis. Although the number of patients with intra-abdomi-
including fungi. Regardless of the situation, though, the optimal nal infection was relatively small in each study, there was no indi-
duration of antibiotic therapy for small undrained abscesses cation that these agents would not be similarly effective in this spe-
remains to be established. cific subgroup. The overall benefit of each of these treatments
appears to be small, but the results of these trials are highly
ADJUNCTIVE MEDICAL THERAPIES
encouraging in that they suggest that related agents might be able
Until recently, it could be said that advances in surgical therapy to achieve further decreases in mortality.These possibilities, com-
for intra-abdominal infection were outpacing other aspects of bined with significant improvements in general critical care, por-
patient management. Too often, operations were technically suc- tend a future in which significant reductions in mortality may be
cessful, yet patients died afterward as a result of their systemic realized even in the most severely infected patients.
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- 1. © 2004 WebMDInc. All rights reserved. ACS Surgery: Principles and Practice 8 CRITICAL CARE 18 Intra-Abdominal Infection — 1 18 INTRA-ABDOMINAL INFECTION Robert G. Sawyer, M.D., F.A.C.S., Jeffrey S. Barkun, M.D., F.A.C.S., Robert Smith, M.D.,T Chong, M.D., and George Tzimas, M.D. ae Recognition and Management of Intra-abdominal Infection The basic principles of rapid diagnosis, timely physiologic sup- whereas a stable patient presenting with a chronic complaint can port, and definitive intervention for intra-abdominal infections be evaluated in a more deliberate fashion.The specifics of the pre- have remained unchanged over the past century. Specific manage- senting episode (e.g., the onset, location, and nature of the pain ment of these conditions, however, has been transformed of late as and any changes in bowel habits) are undeniably crucial, but the a result of numerous advances in technology. Improved radiologic patient’s medical and surgical histories, as well as any previous and laboratory techniques have led to more precise preoperative similar illnesses, are equally critical. Many medical problems and diagnoses, and newer procedures have led to treatment algorithms therapies are associated with abdominal pain or discomfort, and that cause less morbidity and permit faster recovery. Whereas the an accurate accounting of previous surgical manipulation of the pathophysiology of these infections remains largely unchanged, abdomen is vital for refining the differential diagnosis, as well as their management is now marked by an ever-growing complexity. for prioritizing further tests.The question of whether a patient has It is no longer true that the diagnosis of intra-abdominal infection, presented with similar symptoms before (particularly if those even in association with a perforated viscus, necessitates urgent symptoms led to a diagnosis) may be important for determining exploration, but it remains the case that decisions regarding the the timing of any intervention, as well as for putting the current ultimate course of action for any individual patient are solely the complaint in the context of an ongoing condition. In fact, many responsibility of the surgeon. patients arrive for medical treatment with a strong (and frequent- ly correct) concept of the nature of their disease. Clinical Evaluation PHYSICAL EXAMINATION Once the history has been obtained, a thorough physical assess- HISTORY ment is performed, with the emphasis on the abdomen, the pelvis The general approach to a patient sus- (including the vagina), and the rectum. The usual sequence— pected of having an intra-abdominal inspection, auscultation, percussion, and palpation—should be infection is much like that to a patient followed as traditionally taught.This sequence need not be exten- with any other acute surgical condition. sively reviewed here; however, certain points should be empha- Specific approaches to various intra- sized. With the advent of laparoscopy, inspection must include a abdominal infections are addressed in more detail elsewhere [see careful search for scars indicating previous operations, given that Infections of the Upper Abdomen and Infections of the Lower any laparoscopic procedure can be undertaken by way of a variety Abdomen, below]. of trocar sites. Auscultation, though occasionally helpful, is also The first step is an accurate history.To begin with, cases of peri- probably the least specific form of examination. Percussion is valu- tonitis are broadly classified as primary, secondary, or tertiary; this able for assessing tenderness, as well as for differentiating abdom- classification provides a useful framework for suggesting general inal distention caused by intraluminal gas or free air (signaled by approaches to treatment. Primary peritonitis arises spontaneously, tympany) from that caused by fluid in the peritoneum, such as without a demonstrable source of contamination, and is generally ascitic fluid or blood (signaled by dullness). treated with antibiotics alone; an example is spontaneous bacteri- Proper and humane assessment of the abdomen for tenderness al peritonitis in the setting of ascites. Secondary peritonitis is via palpation can be learned only through extensive experience. caused by a breach in the GI tract that leads to contamination of Gaining the patient’s trust is fundamental: an anxious or dis- a normally sterile space. Control of the source of infection via tressed examinee may respond in a hypersensitive manner, there- drainage, resection, diversion, or some combination thereof is by hindering the acquisition of information. An individualized imperative for optimizing outcome. Tertiary peritonitis is a poorly approach is essential as well. Palpation should not be performed in defined entity associated with recurrence of intra-abdominal infec- a uniform manner from patient to patient; rather, the amount of tion after the treatment of secondary peritonitis. It frequently fea- tenderness present ought to be judged by the degree of pressure tures a diffuse infection in a critically ill patient and may be caused or indentation required to cause a given patient significant dis- by any of a long list of nosocomial pathogens (e.g., Pseudomonas comfort. In the setting of severe abdominal pain, elicitation of aeruginosa, Staphylococcus aureus, and Candida albicans). Manage- rebound tenderness by means of deep palpation followed by rapid ment of tertiary peritonitis is complex and must be individualized release of pressure usually does not improve diagnostic accuracy for each patient. or alter subsequent evaluation and should therefore be discour- The acuteness and severity of the presenting symptoms may aged. Finally, administration of small doses of narcotics to patients help localize the origin of the infection. More important, however, with abdominal pain is unlikely to alter an experienced examiner’s they allow appropriate triage of these patients, who are frequently diagnostic ability for the worse. seen in a crowded emergency department. For example, a patient Occasionally, a young patient whose history and physical exam- with sudden onset of severe abdominal pain and physiologic ination (including vital signs) fit the classic clinical picture of derangement must take precedence over almost all other patients, appendicitis may be taken to the OR without further assessment.
- 2. © 2004 WebMDInc. All rights reserved. ACS Surgery: Principles and Practice 8 CRITICAL CARE 18 Intra-Abdominal Infection — 2 Recognition and Management of Intra-abdominal Infection Patient has suspected intra-abdominal infection Obtain history, including previous surgical manipulation of abdomen. Perform physical examination, focusing on abdomen, pelvis and vagina, and rectum (inspection, auscultation, percussion, palpation). Order blood tests as appropriate. • General tests of systemic response to infection • Specific tests to localize source or focus of infection On occasion, a young patient with classic presentation of appendicitis may be taken to OR without blood tests or imaging. Order diagnostic imaging as appropriate. Patient has “certain“ History and physical exam warrant Patient has upper abdominal All other patients appendicitis exploration of abdomen for peritonitis, pain, elevated bilirubin level but confirmation (free air) is needed or liver function test results, Order abdominal and pelvic first; or index of suspicion for or history of biliary tract CT scans. Resuscitate, give antibiotics, peritonitis is very low disease Treat specific infection as and take to OR. appropriate [see Figure 9]. Order upper abdominal US. Obtain plain abdominal films, including upright chest film. Treat specific infection as appropriate [see Figure 1]. Free peritoneal air is present No free peritoneal air is present, No free peritoneal air is present, and index of suspicion for but index of suspicion for Resuscitate, give antibiotics, peritonitis is low peritonitis is high and take to OR. Discharge from surgical care. Order abdominal and pelvic CT scans (see above, right).
- 3. © 2004 WebMDInc. All rights reserved. ACS Surgery: Principles and Practice 8 CRITICAL CARE 18 Intra-Abdominal Infection — 3 Practically speaking, however, almost all patients with significant abnormalities, and inflammatory changes. Now that significant intra-abdominal infections undergo blood tests, and most also intra-abdominal infections—perhaps even in the setting of a per- undergo some sort of radiologic evaluation. forated viscus—are no longer automatically considered to man- date operative intervention, the ability of CT scanning to identify the source and assess the chronicity of an infection is critical to Investigative Studies effective modern management. Multiple common conditions have now been defined for which an adequate CT scan allows nonop- LABORATORY TESTS erative management either as definitive therapy (e.g., expectant Blood work can be divided into two treatment of a simple perforated duodenal ulcer) or as a means of categories: (1) general tests designed to temporizing (e.g., percutaneous drainage of a periappendiceal or assess the systemic response to infection peridiverticular abscess). In addition, in experienced hands, a neg- and (2) specific tests designed to localize ative CT scan of the abdomen and the pelvis virtually excludes the source or site of infection.The former any significant acute surgical illness. category includes serum chemistries and hematology studies. The It must be noted, however, that a CT scan is not necessary in latter category commonly includes amylase and lipase concentra- all patients with abdominal pain, and the decision whether to tions (in patients suspected of having pancreatitis), bilirubin levels obtain one should be made on the basis of predefined guidelines and liver function tests (to evaluate hepatic or biliary tract disease), or with the input of a general surgeon. When the need for opera- and lactate levels (when an ischemic bowel is suspected). These tive intervention has already been determined, as in a classic case tests are discussed further elsewhere, in connection with specific of appendicitis, imaging is unnecessary. In addition, some patients infections (see below). Urinalysis, of course, is necessary whenever with an intra-abdominal infection amenable to nonoperative man- urinary tract infection or urolithiasis is a possibility. agement (e.g., simple, mild diverticular disease that can be treat- ed with oral antibiotics on an outpatient basis) do not necessarily DIAGNOSTIC IMAGING benefit from CT scanning. The use of various radiologic studies In selected cases, other forms of imaging may be used. in the diagnosis of intra-abdominal infec- Magnetic resonance imaging, though usually more difficult to tion continues to evolve rapidly. Outside obtain in an emergency and logistically more complicated than the setting of trauma, it is now very rare CT scanning, yields excellent tomographic images and has the for patients to undergo operations or added benefit of imaging vascular structures and the pancreatico- other major interventions without first biliary tree more precisely. Nonetheless, MRI has no significant undergoing imaging. At one time, plain role in the evaluation of acute peritonitis. Nuclear medicine scans films of the abdomen (including an and fluoroscopic studies, though occasionally useful adjuncts for upright chest film) were routinely obtained whenever a significant evaluating biliary tract and upper GI disorders, also play no role intra-abdominal infection was suspected, principally to detect free in the assessment of acute peritonitis. peritoneal air, bowel obstruction, or fecaliths. Abdominal plain films proved to lack sensitivity, specificity, and anatomic definition in this setting and consequently have, in many cases, been sup- Options for Intervention planted by abdominal and pelvic computed tomographic scanning. Once an intra-abdominal infection is diagnosed, there are mul- There are, however, two circumstances in which plain films of the tiple options for intervention. Not infrequently, an approach com- abdomen remain a reasonable first study for a patient with sus- bining several modalities is warranted. Occasionally, administration pected peritonitis: (1) when the surgeon has almost decided, on the of systemic antibiotics is all that is necessary (or practical), as in basis of the history and physical examination, to explore the patient cases of spontaneous primary bacterial peritonitis or of multiple yet needs confirming evidence of perforation (i.e., free air), and (2) infected fluid collections that are small but too numerous to drain. when the index of suspicion for peritonitis is so low that the plain Single abscesses, particularly those without thick or particulate film studies are intended to rule out an unexpected positive finding contents, can be adequately treated with simple aspiration and a and will not be followed by an abdominal CT scan if negative. short course of antibiotics. For discrete infected fluid collections in Ultrasonography for intra-abdominal infection is useful only for almost any setting, placement of a percutaneous indwelling drain focused examination of specific organ systems; it is inferior to CT (most commonly under radiologic guidance) is currently the treat- scanning for generalized surveillance of the abdomen because of ment of choice. Operative management, either open or laparo- the inability of sound waves to penetrate gas in the bowel. By far scopic, is employed for resection of damaged or inflamed and the best-delineated use of ultrasonography is in the diagnosis of unsalvageable organs, diversion of enteric contents, or drainage of liver and biliary tract disease, for which its ability to demonstrate collections that are too thick or numerous for percutaneous cholelithiasis makes it superior to CT and for which it should drainage. Beyond these general guidelines, therapy for specific almost always be the first radiologic test in the appropriate cir- intra-abdominal infections must be individualized (see below). cumstances (e.g., a classic history of biliary colic or an elevated serum bilirubin level). Ultrasonography also visualizes the spleen, the kidneys, and the gynecologic pelvic organs well and has the Infections of the Upper Abdomen additional benefit of using no ionizing radiation. Biliary tract and pancreatic infections present as a systemic sep- The abdominal and pelvic CT scan, appropriately, has become tic response or as infections localized in the upper abdomen [see the key diagnostic test for evaluating patients with suspected peri- Figure 1].Typical findings include abdominal pain, a tender upper tonitis. This modality is widely available throughout much of the abdominal mass, fever and leukocytosis, and jaundice. Various world, and newer scanners yield significantly higher resolution combinations of these symptoms may occur, but it is convenient than older ones, with reduced scanning times and radiation expo- to consider three common clinical presentations. In each of the sure. CT is highly sensitive for free air, fluid collections, bowel wall presentations, one or two symptoms dominate: (1) upper abdom-
- 4. © 2004 WebMDInc. All rights reserved. ACS Surgery: Principles and Practice 8 CRITICAL CARE 18 Intra-Abdominal Infection — 4 Patient has clinical signs of upper abdominal infection, or serum bilirubin or liver function tests are suggestive Order abdominal US. Upper abdominal pain and Fever and jaundice are Fever and abdominal fever are dominant findings dominant findings mass are dominant findings US is normal Stones are seen in Evidence of acute Patient has choledocholithiasis gallbladder without cholecystitis is apparent or biliary dilation consistent evidence of with cholangitis Consider nonbiliary cholecystitis or If US is equivocal, disease, especially Resuscitate, and give antibiotics. choledocholithiasis consider nuclear acute pancreatitis. medicine scanning. Consider emergency Consider abdominal Consider other endoscopic, radiologic, or Resuscitate; take to OR and pelvic CT scans. diagnoses. operative biliary drainage. for urgent cholecystec- Evaluate for elective tomy if patient is medi- cholecystectomy. cally fit, or perform percutaneous drainage if not. Patient has liver mass, with Patient has signs of Patient has splenic mass, or without abscess pancreatic infection with or without abscess Obtain travel history and Confirm diagnosis via abdominal Confirm diagnosis via abdominal serologic tests to rule out amebic CT scan. CT scan. and echinococcal abscesses. Resuscitate, and give antibiotics if Resuscitate, and give antibiotics. For bacterial abscesses, infection is probable or necrosis Treat with splenectomy or resuscitate, give antibiotics, is noted on CT. percutaneous drainage. seek sources, and perform Discrete fluid collection: Aspirate percutaneous drainage. or drain. Phlegmon: Attempt medical management. If unsuccessful and percutaneous aspirate positive for bacteria, perform open Figure 1 Algorithm outlines approach to patient with drainage. suspected upper abdominal infection. inal pain and fever, (2) fever and jaundice, and (3) an upper abdominal ultrasound examination: an abnormal image of the abdominal mass and fever. These clinical findings signal the need gallbladder or bile ducts supports a biliary etiology [see Figure 2]. for a battery of screening tests, including a complete blood count The differential diagnosis should include acute cholecystitis, (CBC); routine blood tests of liver function; determination of biliary colic, acute pancreatitis, and acute cholangitis, each of serum amylase level, prothrombin time (PT), and partial throm- which requires specific management [see Table 1]. For example, ini- boplastin time (PTT); blood culture; chest and abdominal x-rays; tial management of biliary colic and mild acute pancreatitis is usu- and abdominal ultrasonography. When considered together, the ally nonoperative, whereas severe acute cholangitis and acute clinical findings and the test results allow early differentiation of cholecystitis are treated by means of surgical, endoscopic, or radi- the three most common disease entities: acute cholecystitis, acute ologic intervention (see below). Clinical features and blood test cholangitis, and acute pancreatitis. results, though helpful, may be inconclusive.The abdominal ultra- sonogram may provide specific clues. Stones appear in biliary colic UPPER ABDOMINAL PAIN AND FEVER [see Figure 2]; stones and thickening of the gallbladder wall, in Patients with upper abdominal sepsis may present with epigas- acute cholecystitis; gallstones and dilatation of the common bile tric or right upper quadrant pain and fever. Only two thirds of duct (CBD), in acute cholangitis; and pancreatic enlargement and these patients admitted with a working diagnosis of acute chole- sonolucency, in pancreatitis. cystitis have acute biliary inflammation.1 In some patients, non- surgical conditions (e.g., pneumonia, acute hepatitis, familial Pancreatitis Mediterranean fever, herpes zoster of the intercostal nerves, and Diagnosis Differentiating acute pancreatitis from acute gastroenteritis) can be distinguished clinically from biliary disease. cholecystitis may be difficult.The serum amylase level lacks speci- The most important screening test for acute biliary infection is the ficity, but if the clinical findings suggest acute pancreatitis, an ele-
- 5. © 2004 WebMDInc. All rights reserved. ACS Surgery: Principles and Practice 8 CRITICAL CARE 18 Intra-Abdominal Infection — 5 Table 2—Ranson’s Early Objective Signs of Severity of Acute Pancreatitis2 On Admission After Initial 48 Hours Age > 55 yr Serum Ca2+ < 8 mg/dl Glucose > 200 mg/dl Arterial PO2 < 60 mm Hg WBC > 16,000/mm3 Base deficit > 4 mEq/L LDH > 350 IU/L BUN increase > 5 mg/dl Hematocrit fall > 10% AST > 250 Sigma Frankel U/dl Fluid sequestration > 6,000 ml Note: < 3 signs = mild pancreatitis; ≥ 3 signs = severe pancreatitis. AST—aspartate aminotransferase—BUN—blood urea nitrogen—PO2—oxygen tension— WBC—white blood cell acute pancreatitis.5,6 Unless clinical findings and the results of bio- chemical tests and ultrasonography are unequivocal, a contrast- enhanced spiral abdominal CT scan is usually performed to estab- lish the diagnosis and stage acute pancreatitis. It has been sug- gested, however, that CT scanning should be reserved for patients with clinically suspected severe acute gallstone pancreatitis, on the grounds that the results would not change the recommended course of action in other patients.7 Occasionally, a very mild pan- creatitis may give rise to no findings on a CT scan, and a normal technetium-99m (99mTc)–labeled HIDA (lidofenin) scan may help differentiate this condition from acute cholecystitis. Figure 2 Abnormal abdominal ultrasound examination shows Treatment Given that pancreatitis encompasses a wide calculi in gallbladder casting shadows on underlying liver tissue. range of diseases with varying degrees of severity, treatment must be individualized for each patient. Possible therapeutic strategies range from outpatient management with temporary dietary mod- vated level of serum amylase clinches the diagnosis. In one study, ification (for very mild cases) to open debridement and complex the initial laboratory results in 100 patients with acute pancreati- intensive care (for severe cases). It is therefore useful to base pos- tis were compared with those in 100 patients with acute abdomi- sible treatment approaches in particular cases on the cause and nal pain caused by acute cholecystitis, perforated peptic ulcer, or severity of the pancreatitis. acute appendicitis.2 The serum amylase concentrations were ele- Gallstone pancreatitis. Standard therapy for gallstone pancreatitis vated in 95% of patients with acute pancreatitis but were normal includes I.V. fluids and narcotic analgesics. Nasogastric suction is in 95% of patients with acute abdominal pain from other causes. useful in patients with significant ileus but need not be used rou- These concentrations peak within the first 48 hours and are tinely.8 The use of systemic antibiotics is controversial; they are of almost always elevated in biliary pancreatitis3; in fact, a serum benefit in the 10% to 34% of patients who have concomitant amylase concentration above 1,000 U/L strongly suggests a biliary cholangitis.9 Other treatments suggested previously—including origin of the pancreatitis.4 In addition, determination of serum total parenteral nutrition (TPN) and various pharmacologic agents lipase levels has been shown to be more specific than and at least (e.g., cimetidine, somatostatin, glucagon, and insulin)—have not as sensitive as determination of amylase levels for the detection of proved useful in all cases of gallstone pancreatitis.10 Continuous intraduodenal infusion of an elemental diet has reduced exocrine pancreatic secretions in animal experiments.11 Furthermore, enter- Table 1—Diagnostic Indicators of al feeding has been shown to be beneficial and to decrease disease Upper Abdominal Pain and Fever severity in patients with acute pancreatitis.12-14 In clinical practice, the need for further treatment depends on Acute Acute the severity of the acute pancreatitis. Severity determines both the Biliary Colic Cholecystitis Pancreatitis risk of sepsis, which governs outcome, and the risk associated with early cholecystectomy [see 5:21 Cholecystectomy and Bile Duct]. Short: 40% Duration < 1 hr Persistent Persistent The most commonly used clinical prognostic index in North America was developed by Ranson and reliably defines the sever- Pathogenesis Visceral Somatic Retroperitoneal ity of pancreatitis [see Table 2].2 In mild pancreatitis, one or two Guarding and Guarding and Ranson signs are present; in more severe pancreatitis, three to five Signs Tender spasm spasm signs are present; and in very severe pancreatitis, more than five Laboratory tests signs are present. This distinction serves to stratify further treat- Liver function tests Occasionally Abnormal Abnormal ment. Other clinical prognostic scores, such as the APACHE-II abnormal (Acute Physiology and Chronic Health Evaluation II) and Serum amylase Normal Normal or slightly Increased APACHE-III scores and the Balthazar score, have been shown to increased Leukocyte counts Often normal Increased Increased possess discriminatory value in identifying patients at high risk for complications.15,16
- 6. © 2004 WebMDInc. All rights reserved. ACS Surgery: Principles and Practice 8 CRITICAL CARE 18 Intra-Abdominal Infection — 6 Mild pancreatitis usually subsides within 1 week of onset. Most cholecystectomy has facilitated this approach safely without pro- surgeons defer cholecystectomy until then; urgent operation should longing hospital stay. be reserved for cases complicated by biliary sepsis, and it may Severe pancreatitis. Patients with three or more Ranson signs are reveal acute cholecystitis in as many as 31% of patients.17 at particular risk for pancreatic sepsis.28 Repeated clinical and An attack of acute gallstone pancreatitis is initiated by obstruc- radiologic evaluation is required in these patients to ensure early tion at the confluence of the lower end of the CBD and the pan- detection of complications, because the outcome of an episode of creatic duct by a stone or by edema at the ampulla of Vater result- pancreatitis depends on whether sepsis supervenes. When infec- ing from stone migration. These stones may be found and tion occurs, operative debridement and drainage are required [see removed in 63% to 78% of patients who undergo operation with- Fever and Abdominal Mass, below]. Some surgeons have attempt- in 72 hours of admission17-19 [see 5:22 Biliary Tract Disease]; by ed to alter the course of severe disease by early operation; howev- contrast, they are present in only 3% to 33% of patients explored er, urgent operation is associated with a high mortality in patients after the first week.18-22 A randomized trial exploring the optimal with more than three Ranson signs.19,21,23,29 To avoid the mortali- timing of surgery for gallstone pancreatitis showed that early ty associated with early operative intervention, some clinicians surgery (within 48 hours after admission) was not associated with advocate early diagnosis by ERCP [see Figure 3], followed by bil- a significant increase in morbidity or mortality in patients with iary decompression by means of endoscopic sphincterotomy and mild pancreatitis but did not change prognosis.23 stone extraction. In a randomized trial comparing early ERCP and Endoscopic retrograde cholangiopancreatography (ERCP). Early sphincterotomy with conservative therapy in patients with severe ERCP and sphincterotomy [see 5:18 Gastrointestinal Endoscopy] has acute pancreatitis, ERCP and sphincterotomy decreased morbid- been suggested as an alternative to surgery of the CBD in patients ity from 61% to 24% and lowered mortality from 18% to 4%.24 with mild pancreatitis. However, randomized trials comparing The results of this trial, however, have been the subject of debate, endoscopic treatment with conservative treatment within the first and the success of this approach has been attributed by some 72 hours in patients with mild pancreatitis did not find that urgent authors to the treatment of a concomitant cholangitis rather than endoscopic sphincterotomy improved outcome in this group of of the actual pancreatitis.25 A well-conducted trial that excluded patients.24,25 Other studies showed that delaying surgery beyond 6 patients with concomitant cholangitis was published in 1997; weeks may lead to a 32% to 57% risk of recurrent pancreatitis.26,27 unfortunately, this trial was unable to answer the question defini- Therefore, cholecystectomy and cholangiography should be tively, because too few patients with severe pancreatitis had been delayed only until just before patients are discharged from the hos- recruited.30 It appears that ERCP is warranted mainly in cases of pital, 5 to 15 days after the onset of symptoms. Laparoscopic acute pancreatitis complicated by cholangitis and biliary sepsis.31,32 Use of peritoneal lavage in early severe pancreatitis was advo- cated in one study to decrease morbidity and mortality.33 Use of standard lavage over a 2-day period did not improve patient out- come, but use of peritoneal lavage for 7 days (long peritoneal lavage) yielded some improvement in outcome.34 Early use of antibiotics and selective decontamination have been proposed as a means of reducing septic complications, but neither has convinc- ingly or reproducibly been shown to improve prognosis.35,36 Although prophylactic antibiotics have been shown to decrease the rate of infectious complications in severe acute pancreatitis, they have not clearly been shown to reduce overall disease mortali- ty.35,37-40 Attempts have been made to modulate the initial systemic inflammatory response seen in early severe acute pancreatitis to reduce the risk of subsequent infection and improve overall prog- nosis; somatostatin has exhibited limited success in this regard.41,42 Another drug in this category, the platelet-aggregating factor (PAF) inhibitor lexipafant, initially yielded promising results in animal models43,44 and in phase II trials45; however, a 2001 trial using the same drug did not find it efficacious for treating severe acute pancreatitis.46 Acute Cholecystitis Diagnosis Acute cholecystitis is the most common diagnosis in patients presenting with upper abdominal pain and fever and is characterized by the clinical finding of a midinspiratory arrest on palpation of the right upper quadrant (Murphy’s sign). As noted (see above), with the widespread availability of ultrasonography, acute cholecystitis can usually be diagnosed rapidly on the basis of the findings of gallbladder wall thickening, pericholecystic fluid, and stones. Occasionally, more complex cases must be evaluated Figure 3 Endoscopic retrograde cholangiopancreatography with nuclear medicine scanning to look for cystic duct obstruc- shows distal CBD stone in acute pancreatitis. Papillotome has tion. Concurrent acute obstructive cholangitis must also be con- been placed through sphincter of Oddi in preparation for endo- sidered in all patients with acute cholecystitis. Supportive labora- scopic sphincterotomy. tory data include a high serum bilirubin level and an increased
- 7. © 2004 WebMDInc. All rights reserved. ACS Surgery: Principles and Practice 8 CRITICAL CARE 18 Intra-Abdominal Infection — 7 Table 3—Comparison of Acute Cholecystitis and Emphysematous Cholecystitis Emphysematous Acute Cholecystitis Cholecystitis Gender 70% male 70% female Stones 70% 90% Bile culture positive 95% 66% Clostridia found 46% 1.2% Gangrenous gallbladder 75% 2.5% Perforation of gallbladder 20% 4% Mortality at age < 60 yr 15% 1.5% Pathogenesis Ischemia, obstruction Obstruction sustained narcotics therapy). In addition, focal inflammation may cause biliary colonization or may activate coagulation factor XII, thereby causing severe injury to the blood vessels in the gallblad- der muscularis and serosa. A high index of suspicion is necessary. Acute acalculous cholecystitis should be considered in any post- operative or acutely ill patient with upper abdominal pain and Figure 4 Air outlines gallbladder and bile ducts in emphysema- fever or with unexplained fever and leukocytosis. It is particularly tous cholecystitis. common 2 to 4 weeks after injury. The diagnosis is confirmed by findings on abdominal ultrasound examination [see Figure 5] and 99m alkaline phosphatase level. Positive blood cultures and dilated Tc-labeled HIDA scanning coupled with infusion of cholecys- biliary ducts on abdominal ultrasonography usually confirm the tokinin and morphine.52-54 diagnosis. Emphysematous cholecystitis. An uncommon and insidious vari- Treatment Standard treatment of acute cholecystitis consists ant of acute cholecystitis, emphysematous cholecystitis is charac- of I.V. fluid administration, analgesics, and cholecystectomy. terized by gas in the gallbladder lumen or wall or in the perichole- Although the timing of operation is somewhat controversial in cystic soft tissue and biliary ducts secondary to gas-forming bac- ordinary acute cholecystitis, cholecystectomy should be per- teria.The key to the diagnosis is the presence of air on abdominal formed at the earliest opportunity [see 5:21 Cholecystecomy/Bile x-ray [see Figure 4] or ultrasound examination. Three stages of Duct]. This approach has been confirmed by at least one ran- emphysematous cholecystitis have been defined: (1) gas is seen domized trial comparing early with late laparoscopic cholecystec- only in the lumen of the gallbladder, (2) a ring of gas is identified tomy.55 The delayed-surgery group had a greater need for conver- in the wall of the gallbladder, and (3) gas is seen in the tissues adja- sion to open cholecystectomy (23% versus 11%), as well as a longer cent to the wall. Compared with ordinary acute cholecystitis, emphysematous cholecystitis is associated with a fivefold increase in the risk of gallbladder perforation, as well as a 10-fold increase in mortality in patients younger than 60 years [see Table 3].47 Studies from the 1960s noted an increased risk of gangrene and perforation of the acutely inflamed gallbladder in patients with diabetes mellitus.48,49 The mortality for acute cholecystitis was also shown to be five to 10 times higher in patients with diabetes than in other patients. Later studies, however, did not show an in- creased mortality in patients with both diabetes and acute chole- cystitis.50,51 Nevertheless, one third of patients with emphysema- tous cholecystitis also have diabetes.This factor, coupled with the current tendency to perform cholecystectomy early in most pa- tients with acute cholecystitis, may account for the disparity be- tween previous studies and later reports. Acute acalculous cholecystitis. Another variant of acute cholecys- titis is acalculous cholecystitis; though still rare, it became more common from the 1950s through the 1990s.This disease was orig- inally described as occurring after surgical treatment of unrelated disease but was subsequently identified in patients with multiple Figure 5 Abnormal abdominal ultrasound examination con- trauma, prolonged critical illness, and sepsis. Predisposing factors firms diagnosis of acute acalculous cholecystitis. When image is include gallbladder ischemia (in patients with shock or trauma) compared with that in Figure 2, thickening of gallbladder wall and biliary stasis (in prolonged fasting, hyperalimentation, and and intraluminal debris are obvious.
- 8. © 2004 WebMDInc. All rights reserved. ACS Surgery: Principles and Practice 8 CRITICAL CARE 18 Intra-Abdominal Infection — 8 average total hospital stay and convalescence. Administration of jaundice, with pain a less marked component. Jaundice is almost systemic antibiotics is not required; however, single-dose antibiot- always associated with obstruction of the biliary tree, either intra- ic prophylaxis (e.g., cefazolin, 2 g I.V.) can be given at the start of hepatic or extrahepatic. The combination of fever with jaundice the operation [see 1:1 Prevention of Postoperative Infection].56-58 always suggests acute cholangitis, a condition that can have a ful- Some patients with acute cholecystitis are at high risk for gan- minant and fatal course if not treated promptly. grene and perforation of the gallbladder. It is crucial to identify these patients and perform cholecystectomy promptly because Acute Cholangitis delay increases morbidity and mortality. Clinically, gangrene and Diagnosis If a patient presents with a temperature higher perforation of the gallbladder in this high-risk population are sug- than 38.5º C (101.3º F) in conjunction with jaundice [see 5:3 gested by marked systemic toxicity or by the radiologic demon- Jaundice], the possibility of acute cholangitis should always be stration of either emphysematous cholecystitis or acute acalculous investigated. If cholangitis is present, laboratory studies will reveal cholecystitis. leukocytosis, and blood cultures will often be positive. A finding of With ordinary acute cholecystitis, body temperature is slightly gallstones and dilated biliary ducts on abdominal ultrasound exam- increased in most patients—averaging 37.8º C (100.04º F)—but ination supports the diagnosis. Reynolds’ pentad is present in the is normal in 20% of patients. By comparison, the risk of gangrene full-blown syndrome.66 This syndrome includes upper abdominal and perforation is reportedly higher in patients with marked sys- pain, fever and chills, jaundice, hypotension, and mental status temic toxicity, manifested by a pulse rate greater than 120 changes. Acute cholangitis is usually related to choledocholithiasis, beats/min, a body temperature higher than 39º C (102.2º F), and recent biliary manipulation, or biliary stenting performed for chron- a left shift in the differential white blood cell count, showing more ic obstruction. than 90% polymorphonuclear leukocytes. Unfortunately, findings Gallbladder infections. Gallbladder empyema can duplicate most of systemic toxicity are frequently absent in elderly patients. of the findings associated with acute cholangitis. In this condition, Patients with acute cholecystitis who have signs of systemic tox- acute cholecystitis is complicated by suppuration within the gall- icity, emphysematous cholecystitis, or acalculous cholecystitis are bladder, which then becomes the focus of generalized sepsis. The at high risk for gallbladder gangrene and perforation and therefore distended gallbladder may be palpable and tender.When jaundice require prompt and aggressive treatment. I.V. antibiotic therapy is associated with empyema of the gallbladder, it is less likely to be with a single agent (e.g., ceftriaxone, piperacillin, or a quinolone obstructive than when it is associated with acute cholangitis.True such as ciprofloxacin or ofloxacin) can be given.59,60 Early chole- empyema of the gallbladder is rare. Treatment includes adminis- cystectomy is the treatment of choice. Unfortunately, mortality tration of I.V. fluids, systemic antibiotic therapy, analgesics, and may be as high as 20% to 30% with the traditional surgical ap- early cholecystectomy. proach.61 If perforation and gangrene are not suspected but med- In some patients with jaundice and inflammation, a stone ical illness poses a high risk of mortality from operation, nonoper- impacted in the cystic duct or in Hartmann’s pouch may suggest ative supportive therapy may suffice. If this fails, another treatment choledocholithiasis, but preoperative diagnosis by ERCP shows an option is cholecystostomy. extrinsic compression of the duct known as Mirizzi syndrome.Two Percutaneous transhepatic cholecystostomy has been recom- types of Mirizzi syndrome exist. In type I, a stone impacted in the mended for these high-risk patients,62 particularly where there is a cystic duct or Hartmann’s pouch compresses the common hepatic low risk for perforation of the gallbladder.63 To determine the risk duct and causes inflammation, thereby leading to jaundice. of gallbladder perforation, a risk score can be assigned to each of Treatment of this type consists of obliteration of the cystic duct and seven findings that may be present on the preoperative abdominal careful partial cholecystectomy, with the neck of the gallbladder left ultrasound examination: pericholecystic fluid, 7 points; distention in place. In type II, protrusion of the stone into the hepatic duct of the gallbladder, 4 points; intraluminal membrane, 4 points; erodes the septum between the cystic duct and the hepatic duct intraluminal debris, 3 points; round gallbladder, 3 points; sonolu- and causes a cholecystocholedochal fistula. Treatment of this type cent zone in the gallbladder wall, 2 points; and a thick gallbladder involves internal biliary drainage to the wall of the cholecysto- wall (> 3.5 mm), 1 point.63 A patient with a total risk score of 12 choledochal defect, usually with a choledochojejunostomy [see 5:22 or more points requires urgent cholecystectomy; one with a lower Biliary Tract Disease], in addition to cholecystectomy.67 score who does not respond to conservative treatment may be Primary sclerosing cholangitis. Patients with primary sclerosing treated with percutaneous transhepatic cholecystostomy. cholangitis, especially those who have undergone internal or exter- A 1997 review of 59 patients exhibiting the septic response who nal biliary drainage, are at high risk for recurrent bouts of ascend- underwent successful percutaneous radiologic cholecystostomy ing cholangitis. Primary sclerosing cholangitis predominantly affects defined predictors of a successful clinical outcome: localized right young males, particularly those with chronic ulcerative colitis.The upper quadrant tenderness and gallstones, as well as gallstones diagnosis is suggested by the dominant cholestatic biochemical and pericholecystic fluid on ultrasound examination.64 Patients profile—that is, elevation of the serum bilirubin concentration, the with more equivocal findings may derive greater benefit from serum alkaline phosphatase level, and aspartate aminotransferase more invasive techniques that can simultaneously be used for activity. Because of the concomitant hepatic scarring, ultrasonog- diagnostic purposes (e.g., laparoscopy, which can even be per- raphy may not reveal the presence of dilated intrahepatic ducts. formed at the ICU bedside65). Definitive diagnosis requires visualization of the beaded appear- A few patients with acute cholecystitis will have concurrent ance of the biliary tree by means of cholangiography. Cholangio- acute cholangitis. Cholecystostomy is contraindicated in these carcinoma and secondary sclerosing cholangitis in patients with patients because of its high mortality; adequate drainage of the Caroli disease or choledochal cysts may mimic these clinical, bio- CBD is required in such cases [see Fever and Jaundice, below]. chemical, and radiologic features, but this is an unusual occur- rence and can be distinguished by careful follow-up of patients. FEVER AND JAUNDICE Currently, magnetic resonance cholangiopancreatography An alternative presentation of upper abdominal infection (MRCP) is the imaging modality of choice for elective manage- includes patients whose predominant symptoms are fever and ment of patients with primary sclerosing cholangitis, in that it yields
- 9. © 2004 WebMDInc. All rights reserved. ACS Surgery: Principles and Practice 8 CRITICAL CARE 18 Intra-Abdominal Infection — 9 results comparable to those of ERCP without being invasive.68-71 decompression in these critically ill patients can result in a mor- Other causes of cholangitis. An uncommon cause of recurrent tality of 30% to 40%.82-85 Furthermore, reoperation is required in cholangitis in North America is Oriental cholangiohepatitis, which one third of survivors because important diagnostic information is is characterized by intrahepatic duct scarring, biliary strictures, not available at the initial laparotomy. As a result, nonoperative and hepatolithiasis, as demonstrated by cholangiography. Irrever- methods of biliary decompression, including percutaneous trans- sible intrahepatic and extrahepatic liver damage may result be- hepatic biliary drainage (PTBD) and endoscopic sphincterotomy cause of the overwhelming propensity of these patients to form at ERCP, have gained favor. PTBD was originally developed for calcium bilirubinate stones. preoperative management of biliary obstruction without cholangi- A few patients with cholangiocarcinoma causing bile duct ob- tis but has not been found to be beneficial in that setting. At pres- struction or liver metastases causing intrahepatic bile duct obstruc- ent, it is mainly used for the management of proximal bile duct tion may also present with a clinical picture suggestive of cholan- strictures or for the treatment of cases not amenable to ERCP; its gitis. CT followed by MRCP can delineate the diagnosis in most complication rate is less than 10%.86 such cases.Treatment consists of I.V. antibiotics and biliary drain- Although PTBD can reduce the mortality associated with ini- age by radiographic or surgical means. tial biliary decompression, many patients still require a definitive operation. Consequently, endoscopic sphincterotomy [see 5:18 Gas- Treatment Once acute cholangitis is diagnosed, resuscita- trointestinal Endoscopy] has been proposed for decompression of tion is started with I.V. fluids and antibiotics, such as fluoro- the biliary tree in patients with acute cholangitis from choledo- quinolones, mezlocillin, cefoperazone, or piperacillin,59,72-75 partic- cholithiasis [see Figure 6]. In a study of 82 patients with acute ularly in patients with marked hyperbilirubinemia, in whom treat- cholangitis caused by CBD calculi, early operation was employed ment with aminoglycosides may contribute to renal toxicity in up in 28 patients, endoscopic sphincterotomy in 43, and antibiotic to 33% of cases [see 8:6 Renal Failure].76 These antibiotics are therapy alone in 11.87 Surgical mortality was 21% and morbidity required to deal with the various aerobic bacteria, of which 57%; by comparison, mortality for endoscopic sphincterotomy Escherichia coli, Klebsiella species, and enterococci are the most fre- was 5% and morbidity 28%. Others confirmed these findings.81 In quently encountered in this setting. Anaerobes may be isolated in patients whose gallbladder is still in place, endoscopic sphincter- 15% to 30% of patients and are particularly likely to be present in otomy alone, without cholecystectomy, may even be a reasonable diabetics, the elderly, and patients who have previously undergone long-term option. Of 23 patients whose gallbladders were left in biliary manipulation. In patients with indwelling catheters, situ,87 only two required cholecystectomy in the 1- to 7-year fol- Enterobacter, Pseudomonas, and Candida organisms are being isolat- low-up period: one for empyema of the gallbladder and one for ed with increasing frequency. Indications of high risk include a recurrent cholangitis. serum bilirubin concentration higher than 3 mg/dl. An increasingly recognized cause of cholangitis is biliary sepsis Approximately 75% of patients with acute cholangitis respond after manipulation of the biliary tree with ERCP or PTBD. to conservative measures,77 and supportive treatment is contin- Treatment includes I.V. fluids and antibiotics. To prevent this ued. Subsequent investigations usually include CT followed by complication, prophylactic antibiotics should be administered be- MRCP.78,79 Because of their invasive nature, ERCP and needle fore every biliary manipulation.88 percutaneous transhepatic cholangiography (PTC) are reserved FEVER AND ABDOMINAL MASS for cases in which a drainage procedure is anticipated or the infor- mation from the MRCP is deemed inadequate. A third group of patients with upper abdominal infection pre- For the 25% of patients who do not respond to conservative sent with fever and an upper abdominal mass identified either by treatment, early recognition may improve their prognosis. In one clinical signs or through diagnostic imaging. Even if the mass is study, patients who did not respond immediately to antibiotics only vaguely palpable, the mass effect is demonstrable on ultra- had a mortality of 62%, compared with a mortality of 1.5% in sound examination of the abdomen. If the abdominal ultrasound those who improved.80 In another study, indicators of high risk examination is technically unsatisfactory because of intestinal gas, were an arterial blood pH less than 7.4, a serum bilirubin con- contrast-enhanced CT of the abdomen will facilitate the diagnosis. centration above 9 mmol/L, a blood platelet count below The differential diagnosis is aided by the location of the mass. 150,000/mm3, and a serum albumin concentration lower than 3 A mass in the right upper quadrant usually indicates acute chole- g/dl.102 These high-risk patients often have systemic hypotension, cystitis, though the possibility of a liver abscess must also be con- mental confusion, a temperature higher than 39º C (102.2º F), or sidered. A mass in the epigastrium or in the left upper quadrant hypothermia. Occasionally, acute cholangitis is complicated by dis- usually signals a pancreatic infection; in rare instances, a solitary seminated intravascular coagulation (DIC), which manifests itself splenic abscess is found. Patients with an intra-abdominal abscess as a tendency to bruise and bleed or merely as prolongation of the in the subphrenic space or an interloop abscess may also present PT and the PTT, together with a fall in the blood platelet count in this manner. [see 1:4 Bleeding and Transfusion]. If DIC is suspected, the diagno- sis should be confirmed and treatment started before biliary Liver Abscess decompression. Diagnosis In the setting of acute upper abdominal sepsis, a Patients with refractory cholangitis who do not improve within tender mass in the right upper quadrant is most likely an enlarged, 24 hours require urgent biliary decompression. Urgent biliary inflamed gallbladder, possibly wrapped with omentum [see Upper decompression had traditionally been accomplished via surgical Abdominal Pain and Fever, Acute Cholecystitis, above]. The next exploration of the CBD and T-tube drainage [see 5:22 Biliary Tract most common cause of fever and abdominal mass in the right Disease]. Cholecystostomy is an inadequate and often fatal upper quadrant, however, is liver abscess. option in this context. Rarely, T-tube insertion alone may be life- Pyogenic abscess. Today, pyogenic liver abscess is most common- saving in a desperately ill patient; generally, however, definitive ly related to biliary tract obstruction from gallstones or malignant internal decompression is preferable. Unfortunately, any surgical disorders (35% of cases), and the ultrasound examination may
- 10. © 2004 WebMDInc. All rights reserved. ACS Surgery: Principles and Practice 8 CRITICAL CARE 18 Intra-Abdominal Infection — 10 Figure 6 Endoscopic sphincterotomy for acute biliary decompression in acute obstructive cholangitis is shown. At left, stone is visible in common hepatic duct, and papillotome has been passed through sphincter of Oddi. At right, stone is held within a Dormia basket before extraction. reveal both the abscess and the dilated biliary ducts. Previously, isoenzyme analysis, Entamoeba histolytica–specific antigen detec- portal pyemia from diverticulitis, inflammatory bowel disease tion, or even polymerase chain reaction (PCR) is preferred to con- (IBD), or perforated appendicitis had been the most common firm the diagnosis of amebiasis.91 cause; it now accounts for 20% of cases. Even less common is Echinococcal abscess. The diagnosis of echinococcal liver abscess hematogenous spread via the hepatic artery. Approximately 20% can be confirmed by means of elevated indirect hemagglutination of hepatic abscesses are cryptogenic. Ultrasonographic imaging of (IHA) titers (> 250). In the late 1980s, a combination of tests that the liver may demonstrate lesions as small as 2 cm in the liver sub- included IHA for Echinococcus granulosus and enzyme-linked im- stance. CT scanning, however, is superior to ultrasonography for munosorbent assay (ELISA) using E. multilocularis antigen yielded evaluating the presence of air and abscesses as small as 0.5 cm in an 89% species-specific diagnosis of echinococcal disease.92 Later diameter, especially near the hemidiaphragms.89 Abdominal CT is work indicated that IgG ELISA and IHA were the best tests for also the diagnostic modality of choice in the postoperative follow-up after resection of the abscess. In patients with a favor- patient.90 ERCP and PTC are indicated only when gallstone dis- able clinical outcome, the specific IgG level decreased toward the ease or a biliary malignancy is the potential source of the abscess. end of the first year, though in some cases, a positive serologic Most liver abscesses occur in the right lobe: 40% are 1.5 to 5 cm result persisted beyond 6 years.93 Diagnostic aspiration is indicat- in diameter, 40% are 5 to 8 cm in diameter, and 20% are greater ed when a diagnosis of pyogenic or amebic abscess is in doubt, but than 8 cm in diameter. not in echinococcal disease. Aspiration may also be beneficial in Amebic abscess. Although pyogenic abscesses are commonly patients with left-side abscesses and abscesses greater than 10 cm multiple, no imaging technique can reliably differentiate them in diameter. The chest x-ray is abnormal in as many as 50% of from amebic abscesses.The best indication of a parasitic infection cases of amebic abscess, and the plain abdominal x-ray may show is a history of travel to an endemic area (e.g., Mexico, Central calcification of an echinococcal cyst with secondary pyogenic America, or Southeast Asia). However, when a hepatic abscess is infection. detected by an imaging technique, serologic tests should be per- It is essential to differentiate infected echinococcal cysts from formed to rule out active amebiasis or echinococcal infection. pyogenic abscess: special precautions are required for drainage of Examination of stool for amebae is insensitive; consequently, echinococcal cysts because of the risk of spillage and anaphylaxis.
- 11. © 2004 WebMDInc. All rights reserved. ACS Surgery: Principles and Practice 8 CRITICAL CARE 18 Intra-Abdominal Infection — 11 Blood cultures are positive in as many as 50% of patients with a decrease in the size of the abscess is apparent within 1 week on pyogenic abscess, particularly in those with multiple abscesses; in ultrasonographic examination, though a small residual cavity may fact, the presence of Streptococcus milleri in the blood suggests a vis- persist for as long as 2 years. If the patient’s condition does not ceral abscess. improve, needle aspiration and culture are indicated. Secondary infection is treated as a pyogenic abscess. Otherwise, oral emetine, Treatment Pyogenic abscess. The preferred treatment of pyo- 65 mg/day, is added for up to 10 days. genic abscess is closed continuous percutaneous drainage guided Echinococcal abscess. Symptomatic or secondarily infected echi- by CT or ultrasonography, provided that it is technically feasible nococcal cysts are best treated by means of surgical excision or and no other indication for laparotomy exists.94 More than one marsupialization. The use of oral anthelmintics (e.g., albendazole catheter may be required for complete drainage. An alternative and mebendazole) has met with limited success. Nevertheless, pre- treatment is repeated percutaneous needle aspiration, the results operative treatment with albendazole or mebendazole for 1 month, of which are comparable to those of continuous drainage.95 One combined with postoperative treatment, is indicated to reduce the advantage to repeated needle aspiration is the elimination of cum- risk of intraoperative seeding or postoperative recurrence.109,110 bersome, painful drainage tubes, which are prone to dislodgment. Although initial studies showed a good response rate with repeat- Pancreatic Infection ed needle aspiration,96 the results were not duplicated in a subse- Diagnosis When the mass is located in the epigastrium or the quent randomized trial.97 left upper quadrant, a pancreatic source is most likely. Prompt and The abscess cavity dimensions are followed by serial imaging accurate diagnosis is crucial because severe pancreatic infection is until the cavity collapses, and the catheter can usually be removed fatal if left untreated.The key to successful treatment is early diag- 2 to 3 weeks later. Continuous percutaneous drainage has been nosis of infected pancreatic necrosis, infected pseudocyst, and pan- associated with a complication rate of 4% and a failure rate of creatic abscess. A high index of suspicion is required to diagnose 15%.98 However, operative drainage is the treatment of choice in these three infectious processes and to differentiate them from a patients with an identified intra-abdominal focus of infection and pancreatic inflammatory mass or phlegmon,28 in which pancreatic in patients in whom percutaneous drainage is not feasible or has edema and inflammation are present without necrosis or infection. failed.99 Operative drainage, especially via a laparoscopic approach, Correct diagnosis and treatment of infected pancreatic necrosis, is a highly effective treatment option that is associated with low infected pseudocyst, and pancreatic abscess require an under- mortality and morbidity.100 In some patients, a limited hepatic standing of their pathophysiology. It is generally assumed that resection [see 5:23 Hepatic Resection] may be required to eliminate infected pancreatic necrosis develops as a transmural, transductal, multiple abscesses, particularly when an underlying intrahepatic lymphatic, or hematogenous infection of a necrotic region of the stricture is the source.101 pancreas. Infection develops in 40% of cases of pancreatic necro- Treatment of pyogenic liver abscess should include systemic sis, usually in week 2 or 3 after development of the acute pancre- antibiotic therapy. Approximately 70% of pyogenic liver abscesses atitis.111 Surgical debridement is required in these cases to prevent yield polymicrobial isolates,102 and 25% to 45% of the organisms death. Pancreatic abscesses form by liquefaction of infected necro- are anaerobic.103 Multiple anaerobic isolates suggest the colon as a sis.They usually occur after week 5 of pancreatitis, when the acute source, whereas a single isolate of E. coli suggests a nidus in the bil- phase of the disease has subsided.112 Pancreatic abscesses are asso- iary tree. Antibiotic treatment should include initial coverage of ciated with a lower mortality than infected pancreatic necrosis. both aerobes and anaerobes with either a single agent or multiple Like pancreatic abscesses, infected pancreatic collections and agents.The need to cover enterococci has been debated, but these pseudocysts present late in the course of pancreatitis. They are organisms clearly are increasingly important nosocomial patho- associated with a lower mortality than pancreatic abscesses. gens. An acceptable initial treatment regimen consists of a single Caused by infection in 13% of localized collections resulting from broad-spectrum agent (e.g., ticarcillin-clavulanate or meropenem). ductal blowout, infected pancreatic collections and pseudocysts It should be noted that significant changes have occurred in the eti- may occur in the pancreas itself, in contiguous peripancreatic tis- ology, bacteriology, and treatment of liver abscesses. There is a sue, or in remote (extrapancreatic) tissue. trend toward a higher incidence of pseudomonal and streptococcal Clinical evaluation alone is generally insufficient to diagnose infections, and the frequency of fungal infection is increasing as pancreatic infection. A clearly defined upper abdominal mass is well.104 The mortality from this disease remains high, and appropri- palpable in only 50% to 75% of cases.28 In most patients, the ate antibiotic coverage with drainage is of paramount importance. screening battery of tests reveals leukocytosis with leukocyte The duration of antibiotic therapy is controversial105; according counts greater than 15,000/mm3. Blood cultures are positive in to one set of guidelines, antibiotics should be continued for 3 to 4 50% of cases. CT-guided percutaneous aspiration with Gram stain weeks when the abscess has been excised, 4 to 8 weeks when a soli- and culture provides the best method of diagnosing pancreatic tary abscess has been drained, and 6 to 8 weeks when multiple infection. In one study of 75 patients with clinical toxicity sugges- macroscopic abscesses have been drained.106 Multiple microscopic tive of pancreatic sepsis, infection was confirmed in only 40%.113 abscesses usually require that a biliary source also be treated.85 The In another study of 21 patients with pancreatic infection, only five overall prognosis for multiple small hepatic abscesses is not as good had specific signs on abdominal CT scan.114 CT-guided diagnos- as that for solitary abscesses, and the development of a pyogenic tic needle aspiration leads to a correct diagnosis within 72 hours abscess in a patient with an underlying hepatobiliary or pancreatic in two thirds of patients, and the mortality associated with opera- malignancy has been identified as a preterminal event associated with tive intervention is 19%; however, CT-guided needle aspiration is a hospital mortality of 28% and survival of less than 6 months.107 beneficial only if pancreatic infection is suspected and if the tech- Amebic abscess. Medical treatment is now the standard approach nique is used early in the course of disease. to management of amebic liver abscesses. Metronidazole, 750 mg Several laboratory markers of pancreatic necrosis have been orally three times a day for 10 days, is a highly effective regimen.108 investigated, such as serum methemalbumin, serum ribonuclease, A favorable response to treatment occurs within 4 to 5 days, and and C-reactive protein. Most of these markers are too insensitive
- 12. © 2004 WebMDInc. All rights reserved. ACS Surgery: Principles and Practice 8 CRITICAL CARE 18 Intra-Abdominal Infection — 12 for routine clinical practice. However, serum levels of C-reactive pseudocysts can usually be treated nonoperatively. In one prospec- protein above 10 mg/dl have been reported to be 95% accurate in tive study, percutaneous and surgical drainage were equally suc- predicting necrosis.115 cessful in treating infected pancreatic fluid collections and pseudo- Currently, the best indicators of infected pancreatic necrosis or cysts.124 Clinical signs of progress rather than CT findings are the abscess are a combination of Ranson’s objective prognostic signs best indicators of the need for intervention, and nonoperative [see Table 2] and dynamic abdominal CT scan findings. In Ranson’s methods should be attempted before open surgery is planned. series, the pancreatic findings on CT were graded in five categories Adjunctive procedures. In the past, debridement and sump [see Figure 7]116: (a) normal, (b) pancreatic enlargement alone, (c) drainage were accompanied by the so-called triple ostomy tech- inflammation of the pancreas and peripancreatic fat, (d) one peri- nique, which involved cholecystostomy, gastrostomy, and jejunos- pancreatic fluid collection, and (e) two or more peripancreatic fluid tomy. The role of these ancillary procedures, however, is contro- collections. Only category e was associated with a high (61%) inci- versial at best, and currently, cholecystostomy is employed only if dence of pancreatic abscess. The number of objective prognostic gallstones are detected. signs present also predicted the subsequent development of an Other operative procedures may be required to manage gastric abscess: fewer than three signs, 12.5%; three to five signs, 31.8%; or colonic complications. Gastric bleeding, gastric outlet obstruc- and more than five signs, 80%. However, the value of this method tion, and gastric fistula necessitating reoperation are relatively was limited because only five of the 83 patients evaluated had more infrequent in this setting. By contrast, colonic necrosis and fistula than five prognostic signs. By combining the objective prognostic formation are relatively common and occur either spontaneously signs with positive abdominal CT findings, the investigators identi- or as complications of treatment. The usual site of involvement is fied 30 patients who had three or more objective signs and were the splenic flexure or upper descending colon.Treatment consists graded as category c, d, or e on abdominal CT scan; in these of colonic resection or a diverting colostomy [see 5:34 Laparo- patients, the incidence of pancreatic abscess was 56.7%. By con- scopic Coloctomy]. trast, no patient with fewer than three prognostic signs and graded Antibiotic therapy.The role of systemic antibiotic therapy in the as category a or b on abdominal CT scan had a pancreatic abscess. prophylaxis of pancreatic abscess is controversial. Experimental evidence suggests that antibiotics may sometimes decrease the Treatment Once pancreatic infection is diagnosed, support- severity of pancreatitis,125 and endoscopic cannulation of the ive measures are initiated, including nasogastric suction, with- pancreatic duct has yielded bacteria in pancreatic secretions of holding of oral feedings, meticulous attention to respiratory care patients with acute pancreatitis.126 In patients with pancreatic and fluid and electrolyte balance, systemic antibiotic therapy, and abscess, bacteriologic cultures are usually polymicrobial, the nutritional support. The key to successful treatment, however, is most common organisms being E. coli, enterococci, Klebsiella surgical, radiologic, or endoscopic drainage. pneumoniae, P aeruginosa, S. aureus, Bacteroides fragilis, and Clos- . Pancreatic necrosis. Sterile pancreatic necrosis alone is not an tridium perfringens. There is a growing trend toward early use of indication for surgical debridement. In one prospective study, 11 prophylactic antibiotics in cases of pancreatic necrosis, even patients with sterile pancreatic necrosis were all followed success- though there are no data that convincingly demonstrate a clini- fully with conservative treatment.117 However, once infected pan- cal benefit. This trend may be partly responsible for the increas- creatic necrosis is confirmed by Gram stain or culture, surgical ing prevalence of Candida species in pancreatitis-related sepsis; a debridement is required to remove the characteristically thick 1996 report stated that Candida infection was detected in 21% necrotic material; radiologic or endoscopic methods alone are not of patients.127 as effective for this purpose. Nutrition. Nutritional support of patients with pancreatic abs- The choice of drainage technique is nevertheless controversial. cesses usually consists of TPN, though small bowel feeding may Many clinicians prefer operative debridement and sump drainage. be attempted occasionally.These patients have high metabolic de- The mortality associated with extensive operative debridement (so- mands and may experience glucose intolerance or hyperlipi- called necrosectomy) and sump drainage may range from 30% to demia. Nevertheless, they generally tolerate I.V. feeding well. A 40%,118 and this technique may be associated with a 30% to 40% 10-fold increase in mortality (from 2.5% to 21%) was reported reoperation rate because of sepsis or GI complications.28,119 in patients in whom a positive nitrogen balance could not be Open drainage. To reduce the frequency of reoperation and to achieved.128 lower mortality, some clinicians opt for open drainage or marsu- pialization of the infected pancreas. One modification involves the Splenic Abscess use of a prosthetic mesh and a zipper to facilitate reexploration in Diagnosis A splenic abscess should be considered in patients patients with severe intra-abdominal abscess.120 A 1991 meta- who present with fever and a left upper quadrant mass, though it analysis of published surgical studies on infected pancreatic necro- remains a rare cause of these symptoms. Most splenic abscesses sis found statistically better results with debridement and lavage or encountered in clinical practice are solitary; multiple abscesses are debridement and open packing than with extensive debridement usually covert and are typically found at autopsy in patients with and sump drainage.121 However, surgical treatment should be cus- disseminated malignancy, collagen vascular disease, or chronic tomized for each patient. In one study, open packing was used for debility. massive necrosis (more than 100 g removed by debridement at Because splenic abscess is rare, correct diagnosis requires a high operation or CT evidence of at least 50% pancreatic necrosis) or index of suspicion.The main clue is the clinical setting: both bactere- for extrapancreatic necrosis, whereas conventional debridement mia and local splenic disease are required to produce splenic abscess. and sump drainage were used in other cases; the overall mortality In the preantibiotic period, this combination was seen most frequent- in this study was only 14%.122 ly in patients with bacterial endocarditis and typhoid. Even today, Pancreatic abscess. Pancreatic abscess resulting from liquefaction more than three quarters of splenic abscesses occur in patients who of necrosis is also best treated by surgical drainage because resid- already have an infection elsewhere in the body; splenic abscesses ual necrosis may cause failure of treatment by percutaneous meth- can also occur in patients with splenic infarcts, splenic hematomas, ods.123 On the other hand, infected pancreatic fluid collections and or local splenic disease caused by hemoglobinopathies.
- 13. © 2004 WebMDInc. All rights reserved. ACS Surgery: Principles and Practice 8 CRITICAL CARE 18 Intra-Abdominal Infection — 13 a Pancreas b Pancreas c Pancreas d Pancreas Fluid e Fluid Pancreas f Abscess Fluid Figure 7 Pancreatic findings on CT scan have been graded by Ranson into five categories: grade A—normal pancreas (a); grade B—diffuse enlargement of pancreas and nonhomogeneous density of gland (b); grade C—diffuse enlargement of pancreas associated with peripancreatic inflammation (c); grade D—high-density fluid collection in left anterior pararenal space (only head of pancreas is visualized at this level) (d); and grade E—diffuse enlargement of pancreas with several intrapancreatic small fluid collections and poorly defined fluid collections adjacent to tail and head of pan- creas (e). In final CT scan (f), pancreatic abscess is demonstrated; partially encapsulated fluid collection containing bubbles of air represents large abscess. The diagnosis of splenic abscess may be supported by indirect tion or abdominal CT scan is required. The abdominal CT scan, radiologic signs, such as an elevated left hemidiaphragm or the enhanced with I.V. or oral contrast material, is preferred [see Figure finding of a left upper quadrant air-fluid level (mimicking the stom- 8].129 This technique provides a direct image of the spleen, on ach). To clinch the diagnosis, an abdominal ultrasound examina- which abscesses appear as low-density areas that may contain gas.
- 14. © 2004 WebMDInc. All rights reserved. ACS Surgery: Principles and Practice 8 CRITICAL CARE 18 Intra-Abdominal Infection — 14 Mass Figure 8 Abdominal CT scan, enhanced by contrast material, confirms diagnosis of splenic abscess. Infections of the Lower Abdomen Treatment Treatment of splenic abscess includes I.V. admin- istration of antibiotics and splenectomy [see 5:25 Although enteric perforations, like pancreatitis and cholecystitis, Splenectomy].The usual pathogenic organisms found are staphylo- present most commonly with pain and fever, their diagnosis differs cocci and streptococci, though gram-negative bacilli and anaer- from that of upper abdominal infections of the solid organs.The pain obes may also be present.When splenic abscesses are not drained, associated with enteric perforation frequently is not well localized; mortality approaches 100%. At one time, splenotomy was the pre- consequently, CT scanning is used more frequently than ultra- ferred operative treatment, but splenectomy is currently the pre- sonography because it is superior for evaluating the entire abdomen ferred approach. Percutaneous catheter drainage is being per- [see Figure 9]. Moreover, a perforated viscus may present more acute- formed with increasing frequency and appears to be as effective as ly than other forms of infection do, and it is a common indication operative drainage.8,130.131 for emergency exploration. Thus, in the setting of a possible lower Patient does not have "certain" appendicitis, signs of upper abdominal infection are not present, and abdominal plain films are not indicated Order abdominal and pelvic CT scans. Diffuse infection is Free peritoneal air is Evidence of duodenal Localized infection Scans are normal observed; infection seen without evidence perforation is seen, with or is seen is uncontrolled, and of controlled leak without free peritoneal air Consider nonsurgical source is unclear (duodenal ulcer, diagnoses. Treat operatively; if upper GI periappendiceal or Consider esophago- diverticular abscess) study shows perforation is Resuscitate, give gastroduodenoscopy. sealed, consider nonoperative antibiotics, and take to OR. Resuscitate, give treatment. antibiotics, and take to OR. No discrete fluid collection is Discrete fluid collection is present (pancreatitis, present (periappendiceal or diverticulitis) diverticular abscess) Provide nonoperative management, Resuscitate and give antibiotics. including resuscitation and Treatment options: antibiotic therapy (antibiotics are • percutaneous drainage with unnecessary for bland pancreatitis delayed resection Figure 9 Algorithm outlines approach to patient with without necrosis). • immediate open resection and suspected lower abdominal infection. drainage • diversion and drainage only
- 15. © 2004 WebMDInc. All rights reserved. ACS Surgery: Principles and Practice 8 CRITICAL CARE 18 Intra-Abdominal Infection — 15 a b c Figure 10 (a) Upright chest x-ray of patient with sudden onset of diffuse abdominal pain demonstrates free peritoneal air underneath both diaphragms (black arrows). Emergency exploration was carried out without further studies, and perforated gastric ulcer was excised. (b) Abdominal CT scan of patient with history of ulcer disease and 1-week history of increasing abdominal pain shows retrogastric fluid collection with air that appears to be in communica- tion with duodenum (white arrow). Patient under- went laparotomy, and perforated duodenal ulcer was repaired. (c) Abdominal CT scan of patient with 2- to 3-day history of worsening abdominal pain demon- strates extravasation of oral contrast from anterolat- eral aspect of duodenum (white arrow). Patient underwent laparoscopic omental patch closure. abdominal infection, the diagnostic emphasis is on confirming or a role for H. pylori infection in the pathogenesis of these perfora- ruling out the presence of an acute condition necessitating opera- tions as well.136 tion, rather than on fine localization of a more chronic illness. Diagnosis PEPTIC ULCER PERFORATION A patient with a perforated peptic ulcer will complain of the The incidence of peptic ulcer perforation has decreased signifi- sudden onset of intense abdominal pain and will often be able to cantly as a consequence of the changes in disease progression and pinpoint the exact time when the symptoms began. If the perfora- incidence of intractable ulcers brought about by the advent of H2 tion has not spontaneously sealed or been managed with operative receptor antagonists and proton pump inhibitors (PPIs). Still, a closure, the clinical picture can progress to florid sepsis and shock. significant percentage of all hospital admissions are secondary to Evidence of free air on plain upright and left lateral decubitus radi- perforated peptic ulcers, and the patient population is becoming ographs will be seen in as many as 70% of cases [see Figure 10a].137 older and more evenly balanced between men and women, pre- Endoscopy should be avoided in the evaluation of peptic ulcer per- sumably because of increased use of nonsteroidal anti-inflamma- foration, but equivocal cases or spontaneously sealed perforations tory drugs and cigarettes.132 can be evaluated with water-soluble contrast studies. CT scanning Several studies found a high (80% to 92%) incidence of can be used to localize an infection to the duodenum, particular- Helicobacter pylori infection in patients with perforated peptic ly if communication of air or fluid with the duodenum is estab- ulcers.133,134 Although the prevalence of H. pylori infection in this lished [see Figure 10b] or if extravasation of contrast is seen [see population is well established, the causal role that such infection Figure 10c]. plays in peptic ulcer perforations has been questioned.135 In a 1999 study involving 50 patients with juxtapyloric perforations related to Treatment crack cocaine use who were successfully managed with simple Surgical management centers on control of the site of perfora- omental patch closure, the investigators found that approximately tion (via surgical closure or spontaneous sealing), with or without 80% of the patients who underwent antral mucosal biopsy at the an acid-reducing procedure [see 5:20 Gastric Duodenal Disease]. Be- time of closure had a positive urease test, a finding that suggested fore this is done, I.V. fluids should be given, metabolic derange-
- 16. © 2004 WebMDInc. All rights reserved. ACS Surgery: Principles and Practice 8 CRITICAL CARE 18 Intra-Abdominal Infection — 16 ments corrected, appropriate antibiotics and an H2 receptor blocker or Both of these studies, however, were performed before PPIs PPI administered, and a nasogastric tube placed for decompression. became routinely available. Some 40% of patients with duodenal perforation treated with Operative versus conservative management Several simple closure may experience recurrent duodenal ulcer. A 1995 studies have shown nonoperative management to be safe and series associated such recurrence with H.pylori infection.146 To fur- effective for perforations that have sealed spontaneously. A 1989 ther study the role of H. pylori eradication in ulcer recurrence after study evaluated 35 patients with acute duodenal perforations— peptic ulcer perforation, a randomized study was done in which excluding those with a history of chronic ulcer disease who ulti- patients with perforated duodenal ulcers and H. pylori infection mately went on to primary repair and acid-reducing surgery—who after simple closure received either quadruple anti–H. pylori ther- were managed nonoperatively after evidence of a sealed perfora- apy (1 week of bismuth, tetracycline, and metronidazole with 4 tion was noted on a water-soluble upper GI study. The investiga- weeks of omeprazole) or omeprazole alone.133 After 1 year, 38.1% tors reported one death, in a patient with a history of metastatic of patients managed with PPIs alone experienced ulcer recur- breast cancer, and one intra-abdominal abscess.138 In a 1989 rence, compared with 4.8% of patients managed with PPIs and H. prospective trial of 83 patients with perforated peptic ulcers ran- pylori eradication. A similar study followed patients with perforat- domly assigned to either conservative or operative management, ed duodenal ulcers for up to 2 years after simple closure and ran- the two groups experienced similar morbidity and mortality domization to either short-term H2 receptor blockers or H2 block- (~5%), and 73% of the patients in the conservatively managed ers with quadruple therapy; ongoing H. pylori infection correlated group experienced full resolution of their symptoms.139 The only with recurrent ulcers for up to 2 years.147 significant difference between the groups was in the length of hos- On the basis of these findings, definitive acid-reducing proce- pital stay. It has been suggested that patients with evidence of a dures should be reserved for (1) patients in whom medical man- sealed perforation confirmed by a Gastrografin upper GI study agement of peptic ulcers and H. pylori fails, (2) patients whose can be managed conservatively with a low incidence of reperfora- ulcer symptoms have persisted for longer than 3 months, and (3) tion and intra-abdominal abscess formation.140 These patients patients with otherwise complicated ulcers (e.g., lesions that are must undergo repeated clinical examination and receive support- bleeding or causing obstruction).148 ive therapy until clinical symptoms resolve. Antibiotic therapy In fasting persons, gastric juice contains Laparoscopic versus open repair A prospective, random- as many as 103 organisms/ml.These organisms are typically facul- ized trial of perforated peptic ulcers to either open or laparoscopic tative gram-positive salivary bacteria (e.g., lactobacilli and strepto- suture omental patch repair concluded that for perforations small- cocci) and fungi (e.g., Candida species). In induced states of er than 10 mm, laparoscopic repair was associated with reduced achlorhydria (e.g., from treatment with H2 receptor blockers or operating times, less need for analgesics, fewer postoperative chest PPIs), there is an increase in the total number of organisms, infections, earlier return to normal activities, and shorter hospital- including enterococci and nitrate-reducing organisms. This phe- izations.141 An earlier study also demonstrated reduced analgesic nomenon suggests a proliferation of salivary and enteric organ- times and earlier return to normal activities but reported longer isms, but its clinical relevance is unknown.149 operating times.142 These studies confirm that small perforations Eradication of H. pylori in patients with uncomplicated ulcers can be adequately managed laparoscopically without exacerbation and bleeding ulcers is now the standard of care.150,151 Infection with of bacterial sepsis. It must be emphasized, however, that biopsy of this organism is associated with a 1% per year risk of peptic ulcer perforated gastric ulcers is critical for ruling out malignancies, and disease, a level of risk approximately 10 times that seen in unin- laparoscopic repair of the perforation may preclude biopsy. fected patients. Eradication of H. pylori with medical management typically results in resolution of the ulcer, and recurrence is rare. Simple repair with medical management versus repair Consequently, acid-reducing procedures are not often required.152 with acid-reducing procedure Definitive surgical manage- SMALL INTESTINAL PERFORATION ment of ulcer disease during repair of a perforated peptic ulcer is contraindicated in patients who are hemodynamically unstable, have diffuse peritonitis, have an abscess, or have multiple under- Diagnosis lying comorbid conditions.143 The significant side effects associ- Small intestinal perforation is a very difficult entity to diagnose, ated with definitive surgery (dumping and diarrhea) and the suc- in large part because of its relative rarity.There are certain clinical cess of medical management (PPIs, H2 receptor blockers, and scenarios (e.g., strangulated hernia and Crohn disease) in which H. pylori eradication) have further contributed to the reduced the likelihood of this condition is heightened, but in the setting of popularity of proximal vagotomy at the time of repair. Now that blunt small intestinal injury, the low incidental occurrence of per- fewer acid-reducing operations are being performed, there is foration (~1%153) and the complexity of the presentation fre- some justifiable concern that younger surgeons will not be able to quently lead to a delay in diagnosis. Such delay is associated with obtain the degree of training they would need to perform a defin- increases in the morbidity and mortality directly attributable to the itive operation (highly selective vagotomy) in an urgent or emer- injury.154 The radiographic modality most useful in diagnosis is gency scenario. CT scanning.155 A 1987 study found that simple closure with a Graham patch, without a concurrent operation to reduce ulcer recurrence, result- Treatment ed in a higher recurrence rate than closure with proximal gastric The basics of treatment are the same for small bowel perfora- vagotomy did (52% versus 16%; median follow-up, 54 months).144 tion as for all perforations: isolation and control of the source of In a subsequent study of patients with acute perforations who contamination. In the acute setting, this is accomplished through were randomly assigned to undergo either simple closure or sim- laparotomy and excision of the disease segment, whether the per- ple closure with proximal vagotomy, ulcer recurrence rates in the foration is the result of ischemic necrosis, of blunt injury, or of two groups after 2 years were 36.6% and 10.6%, respectively.145 IBD. Primary reanastomosis is generally accepted in these patients
- 17. © 2004 WebMDInc. All rights reserved. ACS Surgery: Principles and Practice 8 CRITICAL CARE 18 Intra-Abdominal Infection — 17 [see 5:29 Intestinal Anastomosis]. For patients with Crohn disease, perforation (usually presenting as a fistula) is a risk factor for post- operative disease recurrence156; accordingly, close postoperative follow-up is indicated. There are two additional issues regarding small bowel perfora- tions that warrant special mention. The first has to do with small bowel perforation secondary to obstruction. When this event occurs, it is important not only that the perforated segment be resected but also that the cause of obstruction be identified to pre- vent recurrence. The second issue has to do with anastomotic leakage. Not all leaks call for surgical intervention. If the leak is a late complication, it is likely to have walled itself off into an abscess, in which case CT-guided drainage of the abscess is the treatment of choice. Efforts at reducing the luminal transport are also made to improve healing. Nutritional support plays a major supportive role in the treat- ment of patients with small bowel perforation. Many of these patients, either because of their underlying pathology (e.g., Crohn disease) or because of their hypermetabolic state (e.g., from trau- ma), lose some of their innate ability to heal and prevent anasto- motic breakdown.The presence of a knowledgeable nutrition staff can dramatically enhance patient recovery in this setting. Figure 11 Pelvic CT scan of patient with distant history of right lower quadrant abdominal pain with recurrent acute attack demonstrates inflamed and thickened appendix with surrounding Antibiotic therapy The small bowel flora is typically sparse fat stranding (white arrow). Gangrenous appendix was removed (103 to 104/ml), with salivary organisms predominating. In condi- laparoscopically. tions of stasis, obstruction, or impaired motility, however, colonic flora can proliferate, with E. coli, enterococci, and obligate anaer- obes the dominant organisms. In the distal ileum, there are typi- from 39% to 8%, and one retrospective study found that the use cally about 106 colony-forming units/ml, with an increasing pro- of diagnostic CT lowered the rate of misdiagnosis to 7%.162 CT portion of enteric organisms and anaerobic bacteria, presumably scanning is reported to be 93% to 98% in diagnosing appendici- as a result of backwash through the ileocecal valve.157 Although tis, with significantly improved accuracy achieved by using an there are generally far fewer bacteria in the small intestine than in appendicitis protocol after retrograde water-soluble contrast the colon (which contains about 1012 organisms/ml), the standard administration.163 CT findings suggestive of appendicitis [see antimicrobial therapy remains broad-spectrum coverage (e.g., flu- Figure 11] include enlargement and dilation of the appendix (to oroquinolone plus an antianaerobic agent for 5 days).158 > 6 mm), nonfilling of the appendix, and periappendiceal inflam- mation (fat stranding, abscess, phlegmon, and dependent fluid APPENDICITIS collections); these findings do not differ significantly between Obstruction of the appendiceal lumen by a fecalith, a hyper- acute appendicitis and chronic, recurrent appendicitis.164,165 plastic lymph node, or a foreign body is typically the inciting event Current evidence supports the role of CT scanning in the diag- in the pathogenesis of appendicitis. Luminal obstruction with con- nostic evaluation of patients with suspected appendicitis. Studies tinued secretion results in progressive distention, proliferation of have demonstrated decreases both in the incidence of normal luminal microorganisms, ischemia, gangrene, and subsequent per- appendectomies and in the incidence of prolonged, unnecessary foration. The clinical history during this evolution is marked by observations.166,167 Furthermore, alterations in patient manage- diffuse epigastric pain with anorexia, nausea, and vomiting. The ment attributable to diagnostic CT have been shown to decrease pain typically progresses first to the periumbilical region and then overall hospital and patient costs. Nevertheless, the utility of CT in to the right lower quadrant (at McBurney’s point). Patients have a young men whose history, physical examination, and laboratory low-grade fever and exhibit direct tenderness at McBurney’s point test results fit the classic picture of appendicitis remains unproven; but may also manifest rebound tenderness, guarding, rigidity, and this subset of patients may be managed without confirmatory marked temperature elevation if the appendix perforates and CT.166 On the other hand, CT scanning appears to be quite useful results in diffuse peritonitis. As the viscera and the omentum local- for diagnosing appendicitis in women, in which setting it decreases ize and sequester the perforation, the symptoms may subside to a the incidence of normal appendectomies and facilitates diagnosis degree, with localized pain and a palpable abdominal mass the pri- of other causes of the symptoms.168,169 Preoperative CT scanning mary manifestations remaining. assists in planning an operation, identifying a periappendiceal abscess that may delay immediate appendectomy, and recognizing Diagnosis other sources of intra-abdominal pathology. Classically, the diagnosis of appendicitis has been made pri- marily through clinical examination, with laboratory tests consis- Treatment tent with inflammation (i.e., an elevated leukocyte count with a Initial management consists of fluid resuscitation, appropriate left shift and an elevated C-reactive protein level) serving as con- prophylactic antibiotics, and preparation for surgery. Currently, firmation. In as many as 20% of patients with appendicitis, how- acute nonperforated appendicitis, gangrenous appendicitis, and ever, the incorrect diagnosis is made, and the incidence of removal perforated appendicitis without an associated abscess are man- of a normal appendix can approach 40%.159-161 Early diagnosis of aged with urgent appendectomy [see 5:26 Appendectomy]. The appendicitis can decrease the risk of postoperative complications main dilemmas in management center on the appropriate use of
- 18. © 2004 WebMDInc. All rights reserved. ACS Surgery: Principles and Practice 8 CRITICAL CARE 18 Intra-Abdominal Infection — 18 laparoscopic appendectomy and the role of conservative manage- currence and progression to chronic appendicitis supports the use ment for periappendiceal masses with interval appendectomy. of interval appendectomy in young patients, but in adults, the de- cision algorithm must also consider the incidental diagnosis of tumor. Laparoscopic versus open appendectomy In several Interval appendectomy is typically performed between 6 weeks prospective, randomized clinical trials that compared laparoscop- and 3 months after percutaneous intervention and clinical resolu- ic with open appendectomy, the consensus was that the former tion [see Figure 12]. The risk of recurrence is greatest after the 6- was associated with a lower incidence of wound infection, month point in the clinical progression of acute appendicitis man- decreased utilization of pain medication, earlier return to normal aged conservatively.183 In several retrospective analyses, interval activities, and reduced cost of hospitalization (though the data appendectomy proved to be a safe management plan, but to date, were conflicting on this last point).170-173 On the other hand, the there have been no randomized, prospective trials evaluating its trials found the laparoscopic approach to be associated with sig- role in management.184,185 nificantly longer operating time, equivalent duration of hospital- ization, and a possible increased risk of abscess formation. A ret- Antibiotic therapy The pathogenic organisms recovered in rospective review published in 2000, however, found that when a peritoneal cultures derive from the colon and consist of aerobic or dedicated laparoscopic service was established for patients with facultative bacteria and anaerobes. The most frequently isolated appendicitis, the rates of intra-abdominal abscess formation after organisms are E. coli, enterococci, viridans streptococci, B. fragilis, laparoscopic appendectomy decreased to levels equivalent to those Lactobacillus species, Prevotella melaninogenica, and Bilophila reported after open appendectomy.174 wadsworthia.186,187 It is noteworthy that the use of intraoperative Although laparoscopic appendectomy is associated with a high- peritoneal cultures has not been shown to affect the incidence of er incidence of intra-abdominal abscess formation in the setting of wound infection, abscess formation, or small bowel obstruction if perforated appendicitis, it is not associated with a higher incidence patients are presumptively managed with antibiotics that cover of wound infection or abscess in patients with gangrenous or non- gram-negative bacteria and enteric anaerobes.188 perforated appendicitis.175 Furthermore, a prospective, random- Appropriate coverage can be obtained with any of the following: ized trial found that laparoscopic appendectomy was associated ampicillin-sulbactam, piperacillin-tazobactam, ticarcillin-clavu- with reduced overall cost of hospitalization, decreased use of pain lanate, cefoxitin, cefotetan, and ciprofloxacin plus metronida- medication, and earlier return to functional status in patients with zole.189-192 In a trial involving children with perforated appendici- uncomplicated appendicitis.170 tis, conversion to oral therapy after parenteral therapy was equiv- Two groups of patients clearly benefit from laparoscopic appen- alent to parenteral therapy alone.193 In a study of patients with dectomy: women and obese patients. In women, laparoscopy aids acute nonperforated appendicitis, preoperative administration of in the diagnosis of other pelvic pathologic conditions and lowers cefoxitin was superior to placebo in reducing the incidence of the incidence of negative appendectomies; in obese patients, it wound infection.190 In a study of children with acute nonperforat- results in less postoperative pain and a shorter recovery time, even ed appendicitis, prolonged antibiotic administration (5 days) had though it does not significantly reduce the postoperative compli- no advantage over a single preoperative dose with respect to the cation rate.176,177 Patients who present with evidence of perforated incidence of wound infection or subsequent abscess formation.194 or complicated appendicitis may be better managed with the tra- The duration and timing of antibiotic administration in patients ditional open approach to minimize the risk of postoperative with nonperforated gangrenous appendicitis have not been shown abscess formation.178 Improvements in laparoscopic techniques, to correlate with the wound infection rate.195 however, may eventually reduce the incidence of this complication COLONIC PERFORATION to a level comparable to that seen with open management. Periappendiceal abscess and interval appendectomy Diagnosis The mainstays of conservative management have been parenteral Diagnostic strategies for identifying colon lesions associated antibiotics, supportive fluid resuscitation, and percutaneous with intra-abdominal infection follow the general approach out- drainage of radiographically amenable fluid collections. In a 2001 lined earlier [see Clinical Evaluation and Investigative Studies, review of 155 patients with periappendiceal abscesses, the compli- above]. For unstable patients with generalized peritonitis, there is cation rate was 36% for patients managed with surgical incision no need to delay operative intervention to wait for radiologic con- and drainage and appendectomy, compared with 17% for patients firmation: the pathologic condition will be identified in the course managed nonoperatively.179 The recurrence rate was 8% in the of the operation. However, for patients who have localized peri- conservatively managed patients, and nonoperative management tonitis or those who are stable and whose physical examination is failed in five patients. Patients with perforated appendicitis and not conclusive for peritonitis, radiologic evaluation is pivotal in abscess or phlegmon diagnosed by CT scanning but without a planning treatment. palpable mass were safely managed with conservative therapy. In Although plain films may reveal free air in the abdomen and a 2002 study, immediate appendectomy was associated with a prompt surgical intervention, CT scanning may be a more valu- higher postoperative complication rate and an increased incidence able first study because of its ability to delineate the bowel wall and of more extensive initial operations (e.g., ileocecal resection, right surrounding soft tissues with remarkable accuracy. In a 2002 hemicolectomy, and temporary ileostomy).180 study comparing abdominal radiography with CT for the evalua- The recurrence rate after conservative management ranges tion of acute nontraumatic abdominal pain in the ED, the former from 10% to 20%. In one study of patients managed with interval was not nearly as diagnostically sensitive as the latter (a nonspe- appendectomy for periappendiceal mass, histologic evaluation cific diagnosis in 68%, compared with a specific diagnosis in revealed that a significant majority of samples had a patent appen- 80%).196 The investigators concluded that CT was the initial radi- diceal lumen and were at risk for recurrent appendicitis.181 In a ographic modality of choice for patients with acute abdominal 2002 report, 45.8% of interval appendectomy pathologic samples pain in the ED. Another study found that CT scans frequently showed evidence of chronic active inflammation.182 The risk of re- changed physicians’ initial diagnoses, increased diagnostic certain-
- 19. © 2004 WebMDInc. All rights reserved. ACS Surgery: Principles and Practice 8 CRITICAL CARE 18 Intra-Abdominal Infection — 19 a b Figure 12 (a) Pelvic CT scan of young patient with a 5-day history of right lower quadrant abdominal pain shows fluid collection containing air adjacent to appendix and consistent with appendiceal perfora- tion and abscess formation (white arrow). (b) Pelvic CT scan of same patient after percutaneous ultra- sound-guided placement of drainage catheter shows evacuation of air and much fluid. Patient underwent uneventful interval appendectomy 6 weeks later. ty, and led to more appropriate treatment in patients with acute management, including broad-spectrum antibiotics and bowel abdominal pain in the ED.197 rest.The patient can be evaluated for definitive surgical treatment In view of the relatively high cost of CT scanning, the con- later, after the episode resolves and the patient is in better condi- comitant radiation exposure, and the use of I.V. contrast agents to tion for surgery. For larger abscesses or stage II disease [see Figure enhance the scans, some have suggested using ultrasonography to 13b], the standard of care is CT-guided percutaneous abscess make diagnoses. However, the well-documented dependency of drainage, if feasible. After drainage, resuscitation, and bowel prep- this modality on the skill of the individual technician makes it less aration, a one-stage colectomy can be done (resection of the dis- attractive to the broader health care community, where full-time eased segment with primary anastomosis) so as to avoid the poten- sonographers are not always available. Finally, it should be noted tial increased morbidity of a two-stage procedure.205 that there is no role for MRI in the acute setting. Although it is For patients who have abscesses that are inaccessible to percu- both sensitive and specific, the logistic hindrances associated with taneous drainage or who experience persistent symptoms despite its use greatly limit its applicability. drainage, operative correction is required. If adequate bowel pre- paration can be carried out, primary anastomosis at the time of Treatment surgery should be considered. If adequate bowel preparation is not Diverticulitis Diverticular disease ranges in severity from possible, a two-stage approach, including a Hartmann procedure minor to serious. The focus of our discussion will be on manage- and subsequent stoma reversal, should be considered. Alterna- ment of complicated (perforated) diverticular disease, for which tively, depending on the patient’s condition, resection with prima- resection should be considered after only one attack. ry anastomosis may be attempted. There is some evidence that In the past, treatment of perforated diverticular disease involved a employing intraoperative colonic lavage to reduce the fecal col- multistage surgical approach whereby the patient underwent three umn and thus allow primary anastomosis may reduce morbidity, separate procedures: one for fecal diversion and drainage of the especially in patients with stage I or II disease.206-208 However, the infection, a second for resection of the diseased segment, and a third studies supporting this view are not conclusive enough for such a for closure of the colostomy.This three-stage approach proved to be regimen to be considered standard; further investigation is war- associated with high morbidities, high cumulative mortalities, and ranted before it is generally accepted. Finally, whether to add a prolonged hospitalizations.198-200 Since then, CT -guided percuta- covering stoma to a primary anastomosis is a case-by-case decision neous drainage, primary resection of the diseased segment, and that is usually guided by the presence of risk factors such as poor improved patient selection for resection and primary anastomosis nutritional status, inadequate bowel preparation, blood loss, or have improved patient outcomes dramatically. Few adequately pow- intraoperative hypotension.209 ered multicenter, prospective, randomized trials evaluating treat- ment of complicated diverticular disease have been done; accord- ingly, many of the current treatment standards have been derived by consensus on the basis of thorough review of the literature. Table 4—Hinchey System for Classification Therapy for perforated diverticular disease depends greatly on of Perforated Diverticulitis201 the patient’s condition at the time of presentation and on the stage of the disease.The Hinchey staging system201 [see Table 4] classifies Stage Description perforated diverticular disease according to the associated inflam- Stage I Pericolic or mesenteric abscess matory process and is used to guide and compare treatment Stage II Pelvic or retroperitoneal abscess that is walled off options.202-204 Stage III Purulent peritonitis In stage I disease, a small pericolic abscess [see Figure 13a] in a Stage IV Feculent peritonitis stable and otherwise healthy patient may resolve with conservative
- 20. © 2004 WebMDInc. All rights reserved. ACS Surgery: Principles and Practice 8 CRITICAL CARE 18 Intra-Abdominal Infection — 20 a b Figure 13 (a) Pelvic CT scan of elderly patient with left lower quadrant abdominal pain of 2 days’ duration shows diverticulitis with small amount of extraluminal air (white arrow). Patient was treated acutely with resuscitation and antibiotics alone and was discharged home without complications. (b) Pelvic CT scan of middle-aged patient with 1-week history of constipation and moderate pelvic pain shows left lower quadrant fluid collection consistent with peridiverticular abscess (white arrow). Proximal bowel is seen anterior to abscess, distal bowel posterior. Percutan- eous drain was placed, and elective colectomy with primary reanastomosis was performed 12 days later. Stage III or IV diverticulitis is a surgical emergency that calls for it affects annually, which translates into small series reported in the prompt resuscitation and administration of broad-spectrum anti- literature. In the course of follow-up, it is important that these biotics, followed rapidly by surgical treatment. The Hartmann patients undergo thorough evaluation for colon cancer. procedure is the most widely accepted operation for this presenta- Antibiotic therapy. Appropriate antibiotic administration is an tion.210-212 It is associated with a substantially lower mortality than integral part of standard therapy for diverticular disease and is drainage followed by colostomy as a separate, delayed procedure started at diagnosis. The most frequently isolated organisms are (12% versus 28%).213 In certain circumstances, with appropriate anaerobes, including Bacteroides,Peptostreptococcus,Clostridium,and patient selection and low feculent contamination, primary anasto- Fusobacterium species. Gram-negative aerobes (predominantly E. mosis, with or without a covering stoma, may be feasible.214-216 coli) and facultative gram-positive bacteria (predominantly strep- The goals of resection are to remove the focus of infection and tococci) are also associated with these infections.223 Parenterally to prevent recurrent attacks. Recurrent diverticulitis after resection administered broad-spectrum antibiotics are standard. A particu- is the result of incomplete removal of the diseased segment, espe- larly common regimen is ciprofloxacin plus metronidazole, but cially at the rectosigmoid junction. Therefore, when the diseased there are other regimens that are equally efficacious for treatment. segment is resected, the entire sigmoid must be removed, and the According to a 2002 report from the Surgical Infection Society, distal resection margin must extend below the confluence of the the duration of therapy for complicated intra-abdominal infec- taeniae coli and onto pliable rectum.217 Proximally, the colon is tions should be no longer than 5 to 7 days.158 If ongoing infection mobilized until a margin of uninflamed bowel is identified. It is not, is suspected at termination of treatment, investigation into a however, necessary to remove the entire colon affected by diverticuli. potential source of infection is warranted. Laparoscopy. Laparoscopic treatment of diverticular disease is becoming more common but remains controversial. Many feel Other colon lesions associated with perforation and peri- that there is no place for laparoscopic-assisted colectomy in the tonitis A number of colonic conditions besides diverticular dis- treatment of stage III or IV disease,202 but there is growing accep- ease may be manifested by colonic perforation and secondary tance of this approach in the treatment of stage I and II disease. A peritonitis.Whatever the specific cause, the general goals of thera- review of several small studies concluded that laparoscopic colec- py remain the same: (1) to identify and control the source of bac- tomy had a high potential for reducing hospitalization time and terial contamination, (2) to reduce the level of peritoneal contam- operative morbidity; however, the cost analysis data were conflict- ination, and (3) to prevent recurrent infections. ing, and some of the trials reported very high conversion rates.218 Colon cancer. After diverticular disease, colon cancer is the next Right-side disease. Particular mention should be made of right- leading cause of colonic perforation in uninjured patients. In gen- side diverticulitis. In the past, this condition was often misdiag- eral, perforated colon cancer carries a high mortality,224,225 and the nosed as appendicitis before exploration, but today, with the operative technique of choice is controversial. Perforation typical- increased use of CT scanning, this error is less frequently made. ly occurs at the site of the lesion but can also occur proximally Given that diagnosis is difficult and the disease is surgically curable, (e.g., at the cecum) as a result of luminal obstruction. some authors suggest that it should be treated with aggressive Generally, perforations at the site of cancer in the ascending and resection, ranging from simple diverticulectomy to right hemi- transverse colon are treated with primary resection and anasto- colectomy.219,220 Others argue that the disease is relatively benign in mosis, with or without a diverting stoma, regardless of whether the absence of perforation and suggest leaving the diseased bowel localized or diffuse peritonitis is present.When perforations occur in situ, performing an incidental appendectomy, and then treating at the site of cancer in the descending and sigmoid colon, howev- the patient conservatively.221,222 There is no standard therapy for er, there is some debate over the appropriate surgical approach, cecal diverticulitis, mainly because of the small number of patients with some advocating primary resection and others staged proce-
- 21. © 2004 WebMDInc. All rights reserved. ACS Surgery: Principles and Practice 8 CRITICAL CARE 18 Intra-Abdominal Infection — 21 a b Figure 14 (a) Abdominal CT scan of elderly patient with history of vascular disease and worsening abdominal pain over a 3-day period shows diffuse inflammation and right upper quadrant extraluminal air (white arrow). Patient underwent emergency exploration, and ischemic perforation of cecum was found. Right hemicolectomy and temporary diverting ileostomy were performed. (b) Abdominal CT scan of patient with history of Crohn disease and worsening abdominal pain demonstrates thickening of colonic wall with both intramural and extramural air (white arrow). Patient was treated with emergency total abdominal colectomy for pancolitis with creation of temporary diverting ileostomy. dures.Two studies from the early 1990s suggested improved long- [see Table 5] that cannot be attributed to another cause.To reduce term mortality after primary resection.226,227 A subsequent study, undue treatment-associated morbidity, additional criteria are sup- however, suggested that the improved mortality associated with plied to aid in specifying precisely who should receive treatment. primary resection was secondary to preselection and therefore Treatment of PID, according to the CDC, includes broad-spec- could not be considered conclusive proof of the superiority of this trum antibiotics directed toward Neisseria gonorrhoeae, Chlamydia approach.The authors of this latter study concluded that primary trachomatis, anaerobes, gram-negative facultative bacteria, and resection was appropriate for a select patient population with min- streptococci [see Table 6]. Hospitalization is suggested when surgi- imal comorbidity and that staged resection was beneficial for cal emergencies (e.g., appendicitis) cannot be excluded or when patients with a high degree of acute illness and comorbidity (e.g., the patient is pregnant; does not respond clinically to oral antimi- elderly patients).228 crobial therapy; cannot follow or tolerate an outpatient oral regi- Less common causes of colonic perforation. Other diagnoses associ- men; has severe illness, nausea and vomiting, or high fever; or has ated with colonic perforation and peritonitis (localized or diffuse) a tubo-ovarian abscess. Surgical intervention for PID is generally are ischemic necrosis as a result of vasculopathology [see Figure limited to patients with symptomatic pelvic masses, ruptured 14a] or volvulus, missed traumatic injury, and IBD [see Figure 14b]. Except for IBD, the standard therapy is excision of the affected seg- ment and reanastomosis, with or without a covering stoma. For patients with numerous comorbidities, a high degree of feculent Table 5—CDC Guidelines for Diagnosis of contamination, or very severe illness necessitating an extremely abbreviated operating time, a Hartmann procedure with a mucous Pelvic Inflammatory Disease230 fistula or an oversewn distal segment is the primary treatment. Minimal symptoms Because perforation associated with IBD is typically a self-limited Uterine/adnexal tenderness disease, treatment is directed at the underlying pathophysiology Cervical motion tenderness and excision of the diseased segment is not always indicated.229 Additional supportive criteria (enhance specificity of minimal symptoms) Oral temperature >101° F (> 38.3° C) Abnormal cervical or vaginal mucopurulent discharge Other Abdominal Infections Presence of white blood cells on saline microscopy of vaginal secretions PELVIC INFLAMMATORY DISEASE Elevated erythrocyte sedimentation rate Elevated C-reactive protein Because of the diverse clinical presentations of pelvic inflam- Laboratory documentation of cervical infection with Neisseria gonorrhoeae matory disease (PID) and the significant sequelae associated with or Chlamydia trachomatis delayed diagnosis, women with this condition can pose a major Most specific criteria diagnostic dilemma in the ED. In 2002, the Centers for Disease Endometrial biopsy with histopathologic evidence of endometritis Control and Prevention (CDC) updated their established diag- Transvaginal sonography or magnetic resonance imaging techniques nostic guidelines for initiating therapy in patients with suspected showing thickened, fluid-filled tubes with or without free pelvic fluid or PID.230 According to these guidelines, empirical treatment should tubo-ovarian complex Laparoscopic abnormalities consistent with PID be started if a young sexually active woman or any woman at risk for sexually transmitted diseases presents with minimal symptoms
- 22. © 2004 WebMDInc. All rights reserved. ACS Surgery: Principles and Practice 8 CRITICAL CARE 18 Intra-Abdominal Infection — 22 Table 6—CDC Guidelines for Antibiotic outpatient treatment with trimethoprim-sulfamethoxazole or a fluoroquinolone usually suffices.232 Complicated pyelonephritis, Treatment of PID230 however, often is caused by microbes other than E. coli, including Parenteral Regimens Pseudomonas species and enterococci. Hospitalization is required, and treatment usually involves parenteral administration of ceftri- Cefotetan, 2 g I.V. q. 12 hr axone and gentamicin233 or piperacillin-tazobactam234; vanco- or mycin is indicated if the patient is allergic to penicillin. More ag- A Cefoxitin, 2 g I.V. q. 6 hr gressive therapies, including percutaneous nephrostomy or ab- plus scess drainage, may be considered on a case-by-case basis. Doxycycline, 100 mg p.o. or I.V. q. 12 hr SPONTANEOUS BACTERIAL PERITONITIS Clindamycin, 900 mg I.V. q. 8 hr plus In adult patients, primary peritonitis usually accompanies cir- B Gentamicin, loading dose I.V. or I.M. (2 mg/kg body weight) rhosis and ascites235; however, the presentation can be highly vari- followed by maintenance dose (1.5 mg/kg) q. 8 hr; single able.To diagnose spontaneous bacterial peritonitis, paracentesis is daily dosing may be substituted performed and the fluid sent for Gram stain and culture; pH Ofloxacin, 400 mg I.V. q. 12 hr determination; measurement of glucose, protein, lactate, and lac- or tic dehydrogenase levels; and a cell count with differential. Accord- Levofloxacin, 500 mg I.V. s.i.d. ing to a consensus statement from the International Ascites Club, with or without diagnostic paracentesis is recommended for every cirrhotic patient Alternative Metronidazole, 500 mg I.V. q. 8 hr or with ascites upon admission to the hospital.236 Empirical therapy Ampicillin-sulbactam, 3 g I.V. q. 6 hr is started if the neutrophil count is higher than 250/mm3, the pH plus is lower than 7.35, and the lactate concentration is greater than 32 Doxycycline, 100 mg p.o. or I.V. q. 12 hr ng/ml. If the results of other studies suggest peritonitis, radi- ographic evaluation is indicated to rule out potential causes of sec- Enteral Regimens ondary peritonitis. Ofloxacin, 400 mg p.o., b.i.d., for 14 days Treatment consists of cefotaxime at a minimum dosage of 2 g or every 12 hours for 5 days, with follow-up paracentesis scheduled A Levofloxacin, 500 mg p.o., s.i.d., for 14 days for 48 hours after the start of treatment.237,238 If the neutrophil with or without count does not decrease significantly (to < 25% of the pretreat- Metronidazole, 500 mg p.o., b.i.d., for 14 days ment value), treatment may be assumed to have failed. Surgical Ceftriaxone, 250 mg I.M. in single dose intervention is undertaken if the patient is refractory to medical or management, the ascitic fluid grows mixed aerobes and anaer- Cefoxitin, 2 g I.M. in single dose, and probenecid, 1 g p.o. obes, or radiographic studies suggest bowel perforation. administered concurrently in a single dose or PERITONEAL DIALYSIS CATHETER–RELATED INFECTIONS B Other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime) Peritonitis is a major cause of failure of peritoneal dialysis in plus long-term studies.239 Peritonitis is especially difficult to diagnose Doxycycline, 100 mg p.o., b.i.d., for 14 days in dialysis patients because the presentation is usually vague. with or without Accordingly, it is critical to maintain a low threshold for testing. Metronidazole, 500 mg p.o., b.i.d., for 14 days The definition of peritonitis in this population includes satisfac- tion of two of the following three criteria: (1) a Gram stain demon- strating microorganisms or a positive culture of the dialysis efflu- ent, (2) a dialysate white blood cell count higher than 100/mm3, tubo-ovarian abscesses, or draining abscesses that do not respond with at least 50% neutrophils, and (3) peritoneal signs or symp- to antibiotic therapy. Aspiration has also been considered as a toms.240 The microbes most commonly identified are S. epider- treatment modality; it may limit morbidity and preserve fertility.231 midis and S. aureus (~ 60% of isolates), followed by gram-negative bacteria (~30% of isolates); the remaining isolates are largely PYELONEPHRITIS accounted for by fungi, anaerobes, and mycobacteria. Pyelonephritis is a complication of urinary tract infection; conse- Treatment usually includes cefazolin and an aminoglycoside, quently, it affects women more often than men.The diagnosis is typ- with or without vancomycin (depending on local S. aureus resis- ically made on the basis of systemic symptoms in the setting of a tance patterns). Antibiotics are administered via the catheter and known, bacteriologically confirmed urinary tract infection. Pyelo- allowed to dwell intraperitoneally. When treatment is complete, nephritis may be classified as either complicated or uncomplicated, the antibiotic effluent is drained via the catheter. If infection con- depending on patient factors (e.g., previous transplantation or an tinues despite antibiotic treatment, a recurrent infection with the anatomic abnormality) and infectious characteristics (e.g., sepsis). same microbe is likely. If fecal contamination occurs, the catheter The typical pathogen in uncomplicated disease is E. coli, and must be removed.
- 23. © 2004 WebMDInc. All rights reserved. ACS Surgery: Principles and Practice 8 CRITICAL CARE 18 Intra-Abdominal Infection — 23 Discussion Controversies and Special Cases greater than 250 mm Hg, bacteria may pass directly from the bile The controversies surrounding the management of intra- ductules through the spaces of Mall and Disse and into the hepat- abdominal infections are numerous and ongoing, in large part ic sinusoids via cholangiovenous reflux.242 One study confirmed because of the relative lack of well-organized, unbiased clinical evi- the clinical significance of increasing ductal pressure by demon- dence. There are several reasons for this information deficit. strating a higher ductal pressure and a higher incidence of bac- First, although in the aggregate, peritonitis is a common prob- teremia in patients with proximal ductal obstruction, compared lem seen by general surgeons, any given practitioner sees most of with those with distal malignant biliary obstruction.243 However, the life-threatening forms of the disease (e.g., free perforation from no correlation exists between the degree of suppuration in the colon cancer) infrequently. Second, advances in nonsurgical med- duct and the clinical or pathologic severity of obstructive cholan- icine and technology (e.g., laparoscopy) have made new forms of gitis.82 Therefore, the terms acute nonsuppurative cholangitis and treatment available and have improved outcomes from older tech- acute suppurative cholangitis are purely descriptive and do not niques. As a result, conclusions drawn from older data may no imply differing degrees of severity. longer be accurate. Third, many forms of intra-abdominal infec- The source of bacteria in acute cholangitis is most often the tion routinely present in such a complex and ill patient population duodenum. The ease with which organisms reflux from the duo- (e.g., elderly patients with multiple comorbidities) that random- denum depends on the degree of obstruction. Thus, in patients ized studies with multiple exclusion criteria can rarely capture a with malignant biliary obstruction, in whom obstruction is usual- high percentage of what is a highly heterogeneous group. Fourth, ly complete, bile culture is positive in only 10% to 15% of patients presenting with common causes of intra-abdominal infec- patients244; acute cholangitis is seldom spontaneous in this setting tion that occur in relatively healthy and homogeneous populations but often follows radiologic intervention.245 By comparison, in (e.g., acute appendicitis and cholecystitis) tend to do well no mat- patients with ductal stones or benign strictures, in whom biliary ter what reasonable therapy is applied. Consequently, it is fre- obstruction is often incomplete, bile cultures obtained on ERCP quently difficult to detect any significant differences between ther- are positive in 64% to 87% of cases; in these patients, acute apeutic modalities. For example, despite multiple randomized tri- cholangitis occurs frequently, both spontaneously and after ductal als, it is still unclear whether a laparoscopic approach has any long- manipulation.246 term superiority over an open approach in patients with right An alternative source of organisms in acute bacterial cholan- lower quadrant pain and suspected appendicitis: outcomes are gitis is portal venous blood. In patients who have recurrent pyo- excellent with either method. Finally, for almost any given argu- genic cholangitis, which occurs frequently in the Far East, a ment, sufficient supporting data, whether in the form of random- 40% incidence of positive portal blood culture has been report- ized trials or—equally valuable—of large observational studies ed.247 In studies of rats with ligated bile ducts, bacteria were performed with statistical rigor, simply do not exist at present. shown to be effectively transmitted to the bile ducts and the liver Even simple questions, such as the optimum duration of antibiot- through portal blood.248 Finally, in nonobstructive cholangitis ic treatment for a patient with a single well-drained liver abscess, and acute cholecystitis, as well as in the early stages of obstruc- lack good answers. tive cholangitis, infection ascends to the liver through the lym- In the end, most controversies in this area are not so much a phatic system. matter of precisely determining the right or the wrong interven- CHANGING BACTERIOLOGY OF ACUTE BILIARY INFECTION tion for a disease as they are a matter of making a judgment about which of many possible interventions is likely to result in Most biliary infections are polymicrobial. The organisms most the lowest morbidity and mortality. For example, the decision to frequently cultured are E. coli, Klebsiella species, Enterobacter species, perform a primary colon reanastomosis in a patient with a per- and enterococci. Anaerobic bacteria are infrequently implicated in forated colon cancer cannot be considered either universally cor- biliary infections. Peptostreptococci and clostridia are found occa- rect or universally incorrect; rather, it is subject to the surgeon’s sionally; clostridia are especially common in patients with emphy- opinion about the specific patient involved. In what follows, we sematous cholecystitis.47 Gram-negative anaerobic bacilli are rarely focus on several controversial decision points and discuss impor- present in patients with biliary infection. In one study, only two of tant factors that ought to be considered in attempting to opti- 28 patients with acute cholangitis had anaerobic bacteria in the mize patient care. bile; another investigator found anaerobic bacteria in 3% to 4% of cultures in similar patients.83 However, a higher incidence of anaer- NEW CONCEPTS IN PATHOPHYSIOLOGY OF ACUTE BACTERIAL obic bacteria has been reported in patients who have acute cholan- CHOLANGITIS gitis and acute cholecystitis than in patients who have chronic Longmire’s widely accepted classification of acute bacterial cholecystitis and cholelithiasis.249 cholangitis consists of five categories: acute nonobstructive, acute One investigator noted an increased incidence of anaerobic bac- nonsuppurative, acute suppurative, acute obstructive suppurative, teria in biliary infection and suggested that B. fragilis may play a and acute suppurative with intrahepatic abscess. It implies that the more important role in the polymicrobial flora of biliary tract infec- severity of disease parallels the degree of obstruction of biliary tion than was previously appreciated.250 These findings remain con- ducts.241 This suggestion is well founded. In acute nonobstructive troversial. Bacteroides species are generally considered to be of lim- cholangitis associated with acute cholecystitis, infection ascends ited importance in biliary tract infections, except in selected groups along the intrahepatic and extrahepatic lymphatics. In obstructive of patients.These groups include diabetics, the elderly,251 and those cholangitis, the bile duct contains bacteria under pressure. When with acute cholangitis who have previously undergone biliary oper- the pressure is at or above the normal secretion pressure (i.e., 200 ation252,253; in particular, malfunctioning biliary-intestinal anasto- mm Hg), bacteria pass into the lymphatic system. At a pressure moses increase the risk of Bacteroides infection.254
- 24. © 2004 WebMDInc. All rights reserved. ACS Surgery: Principles and Practice 8 CRITICAL CARE 18 Intra-Abdominal Infection — 24 NECESSITY OF DIVERSION AFTER EMERGENCY COLONIC MANAGEMENT OF ANASTOMOTIC LEAKS PROCEDURES Dehiscence of a gastrointestinal anastomosis is a common and The goal of safely repairing or resecting the colon in an emer- too frequently fatal complication of modern GI surgery. Again, gency setting without leaving a patient with a temporary or per- there is little debate regarding which therapeutic options are avail- manent stoma for diversion has been pursued for decades. able to surgeons managing this problem. The options include the Through much of the 20th century, largely on the basis of following: supporting the patient with medical care only, in the wartime experience, diversion was routinely performed. Today, case of a tiny radiographically evident but clinically insignificant however, it is apparent that this approach is not always necessary leak seen on fluoroscopic study; reoperating and performing pri- either for trauma or for intrinsic colon disease. Thus, the ques- mary repair and drainage, in the case of a small early leak from an tion is no longer whether primary repair or reanastomosis can be enteroenterostomy with minimal soilage; performing percuta- achieved safely but, rather, in which individual patient a given neous drainage, in the case of a moderately symptomatic leak pre- treatment is prudent. senting in a delayed manner with an abscess; and reexploring and Traditionally, clinical studies have attempted to define patient performing a diverting procedure, in the case of complete disrup- characteristics associated with complications after attempted pri- tion of an anastomosis with widespread fecal contamination. The mary repair or reanastomosis. Not surprisingly, hypotension, blood only controversy has to do with which course (or combination of loss, delay before treatment, and extensive contamination have all courses) to take in an individual patient. been associated with postoperative complications after primary Some general guidelines for the management of anastomotic repair; however, these risk factors are associated with complica- dehiscence may be recommended, with the caveat that they have tions after diversion as well.The nature of the colon injury is clear- not yet been rigorously tested. Leaks diagnosed in the immediate ly an important consideration: multiple studies now support a postoperative period are easily approached because the relevant one-step approach to traumatic colon injury in all except the most tissue planes have been dissected free. After 1 to 2 weeks, howev- ill patients, but primary resection and reanastomosis for other er, early adhesion formation makes reoperation more difficult, causes of perforation (e.g., diverticulosis and cancer) remain con- especially if the initial operation was for an infectious or inflam- troversial. Many nonrandomized studies have demonstrated that matory process, and increases the risk of complications, particu- for nontraumatic causes of perforation, on-table lavage and pri- larly inadvertent enterotomy and enterocutaneous fistula forma- mary resection yield outcomes equivalent to those of the tion. Small, contained leaks, if accessible, frequently respond to Hartmann procedure, which suggests that both approaches are percutaneous drainage and antibiotics alone, with the small fistu- safe and that surgeons are capable of identifying the patients best la resolving spontaneously. Medical management in such cases suited to each one. generally includes TPN, though enteral nutrition is occasionally Perhaps more important than determining how likely a patient feasible if it is shown to have no effect on drain output. Larger is to experience a complication after a given operation, however, is leaks, on the other hand, are more likely to call for direct operative assessing how well the patient is likely to tolerate that complication repair, resection and reanastomosis, or diversion. Once it is decid- in the early postoperative period. Thus, elderly patients with mul- ed that surgical treatment is warranted and is not precluded by the tiple comorbidities might be better off undergoing diversion and state of the abdomen, definitive management should not be thus avoiding the potential significant physiologic stress posed by delayed. Exactly which operation is to be performed depends on an anastomotic leak in the early postoperative period, even though the health of the bowel, the severity of abdominal contamination, they will face the additional risk associated with reoperation if they and the level of overall physiologic dysfunction. subsequently choose to have a stoma reversed. MANAGEMENT OF ENDOSCOPIC BOWEL PERFORATION ROLE OF LAPAROSCOPY IN MANAGEMENT OF PERITONITIS Large rents in a peritoneal portion of the bowel generally call for Laparoscopy has altered the surgical landscape by offering a operative repair (most commonly to the colon), though it should minimally invasive approach that reduces the morbidity associat- be noted that simple repair or resection without diversion is almost ed with a large incision, generally decreasing convalescence time always all that is required. Extraperitoneal or retroperitoneal per- and hastening return to normal activity. Nonetheless, laparoscop- forations, however, can be managed nonoperatively with antibi- ic management of intra-abdominal infection is still hindered otics and I.V. fluids if the patient is stable. This situation occurs somewhat by the difficulty of inspecting the entire bowel, the most frequently after ERCP or with low rectal perforations. decreased tactile sensation, and the significantly greater expertise Typically, CT scanning demonstrates retroperitoneal air with min- required for laparoscopic resection and reanastomosis of the bowel. imal free peritoneal air. In these circumstances, patients can be These obstacles notwithstanding, almost every intra-abdominal safely observed as long as their condition does not deteriorate; oral procedure used to treat infection has been performed laparo- intake can be restarted after 5 to 7 days. Endoscopic perforations scopically with acceptable results. of a normal distal esophagus can also be managed nonoperative- The single most important factor in the decision whether to ly, though a perforation proximal to a tumor or stricture is unlike- take a laparoscopic approach is the skill and experience of the ly to heal and almost always must be treated operatively. surgeon. From a theoretical point of view, it is almost always pos- NONOPERATIVE MANAGEMENT OF INFECTED FLUID sible to treat a patient with peritonitis laparoscopically; the real COLLECTIONS question is whether the attending surgeon can perform the pro- cedure most safely and efficiently via an open or a minimally It is axiomatic that abscesses are best treated with drainage invasive approach.The answer to this question will rely to a large rather than with antibiotics, but there are certain circumstances in extent on preoperative imaging studies. In addition, even if the which drainage may not be possible. Pyogenic liver abscesses may surgeon does not plan to complete the operation laparoscopical- not be amenable to either percutaneous or open drainage if they ly, initial placement of the scope may aid in planning the most are multiple and involve both lobes. In such circumstances, aspi- appropriate open incision and procedure by localizing the lesion ration or drainage of the largest abscess, followed by a long course of interest. of antibiotics, is generally successful. It has been argued that this
- 25. © 2004 WebMDInc. All rights reserved. ACS Surgery: Principles and Practice 8 CRITICAL CARE 18 Intra-Abdominal Infection — 25 approach works because of the liver’s luxurious dual blood supply. response to the original insult. Such deaths are still attributed to On the other hand, multiple peritoneal fluid collections (with- overwhelming sepsis, to multiple organ dysfunction syndrome, or out a natural blood supply) are not infrequently seen even after to any number of other terms used to describe an irreversible successful management of diffuse or fecal peritonitis yet can occa- sequence of organ failure and death [see 8:13 Multiple Organ sionally be managed without drainage. Even if these collections Dysfunction Syndrome]. are subsequently proved to be infected, they may be too numer- Multiple attempts over the years to alter this downward trajec- ous to approach percutaneously, and ongoing inflammation of the tory by using novel therapies to target this generalized inflamma- bowel may render an operative approach unsafe. Again, drainage tory response proved unsuccessful. In the past few years, however, of the largest accessible collection to establish a diagnosis and both recombinant human activated protein C and corticosteroid guide antibiotic management, followed by long-term antibiotic replacement therapy (for those with sepsis-associated adrenal therapy, is the most feasible course. In this case, sampling is imper- insufficiency) were shown to improve survival in randomized, ative because a hospital-acquired intra-abdominal infection is placebo-controlled trials involving mixed populations of patients more likely to involve less common but more resistant pathogens, with sepsis. Although the number of patients with intra-abdomi- including fungi. Regardless of the situation, though, the optimal nal infection was relatively small in each study, there was no indi- duration of antibiotic therapy for small undrained abscesses cation that these agents would not be similarly effective in this spe- remains to be established. cific subgroup. The overall benefit of each of these treatments appears to be small, but the results of these trials are highly ADJUNCTIVE MEDICAL THERAPIES encouraging in that they suggest that related agents might be able Until recently, it could be said that advances in surgical therapy to achieve further decreases in mortality.These possibilities, com- for intra-abdominal infection were outpacing other aspects of bined with significant improvements in general critical care, por- patient management. Too often, operations were technically suc- tend a future in which significant reductions in mortality may be cessful, yet patients died afterward as a result of their systemic realized even in the most severely infected patients. References 1. Schofield PF, Hulton NR, Baildam AD: Is it 14. Windsor AC, Kanwar S, Li AG, et al: Compared 25. Fan ST, Lai EC, Mok FP, et al: Early treatment acute cholecystitis? 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