Institution: The Chicago Medical School at Rosalind Franklin University of Medicine and Science Program
Abstract Title: Intra-abdominal abscess...What to expect?
Abstract Text:
Case Presentation: A 58 year old male admitted with abdominal pain, acute onset, two days duration, 10/10, diffuse, sharp, non-radiating, no alleviating factors, associated nausea and an episode of vomiting. He had a similar but mild intensity pain in belly 2 weeks back which was symptomatically treated. He documented increased frequency of flatus and decreased appetite without any change in the bowel movement since 2 weeks. He denied weight loss, fever, chills, and recent use of drugs. His past history was significant for an episode of acute pancreatitis 20 years back, hepatitis C, sarcoidosis, alcohol abuse and cocaine dependence. On physical exam, he appeared calm without acute distress, T: 36.6 C, BP: 130/70 mm Hg, P: 86/min, RR: 16/min. Abdomen was soft, non-distended and tender with rebound tenderness. Bowel sounds were normal and rectal exam negative. Rest of the systemic examination was benign. Blood work revealed WBCs 4.4K/uL. Serum amylase, lipase, LFTs, urinalysis and UDS were negative. CT abdomen without IV contrast showed a mixed density lobular soft tissue mass about 3.0 x 2.2 cm at ileocecal junction with fat stranding consistent with loculated fluid/abscess or necrosis within the mass. As the mass was not accessible to percutaneous drainage, laparotomy with a partial colectomy was done on third day of admission. Post operative course was uneventful, and patient remained afebrile with normal WBCs all through his hospital stay. Pathology of the mass revealed an abscess cavity located 0.6 cm from the appendix and 0.5 cm from the terminal ileum, just deep to the colonic mucosa consistent with perforated cecal diverticulum with marked acute inflammation without any evidence of malignancy or an inflammatory bowel disease.
Discussion: Intra-abdominal abscess is a localized collections of pus that is confined by an inflammatory barrier i.e. omentum, inflammatory adhesions, or contiguous viscera, usually infected with both aerobic and anaerobic microbes. Its common etiologies are perforation of a diseased viscous, gangrenous cholecystitis, mesenteric ischemia with bowel infarction, pancreatitis or pancreatic necrosis progressing to pancreatic abscess, untreated penetrating trauma, and postoperative complications. Computed tomography is considered the best diagnostic imaging method with >95% accuracy. Treatment is with empirical antibiotics beginning prior to drainage. Percutaneous CT-guided catheter drainage has become the standard treatment of most intra-abdominal abscesses, which is effective in 90% of patients who have a single, unilocular abscess without any enteral communication. Surgical drainage becomes mandatory if residual fluid cannot be evacuated. Surgical approach may be either laparoscopic drainage or open (laparotomy) drainage.
Conclusion: Intra-abdominal abscess/abscesses are highly variable in presentation. Most of the patients have persistent abdominal pain, focal tenderness, spiking fever, prolonged ileus, leukocytosis, or intermittent polymicrobial bacteremia, but many of these classic features may be absent and merit constant vigilance.
DateTime: Fri Aug 20 15:00:22 2010
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