eMedicine Specialties > General Surgery > Abdomen

Abdominal Abscess: Workup

Author: Alan A Saber, MD, MS, FACS, Chief, Minimally Invasive Surgery and Bariatric Surgery, Associate Professor, Department of Surgery, Michigan State University
Coauthor(s): Raymond D LaRaja, MD, Chairman, Program Director, Clinical Professor, Department of Surgery, Cabrini Medical Center, Mount Sinai School of Medicine
Contributor Information and Disclosures

Updated: May 1, 2009

Workup

Laboratory Studies

  • Hematologic parameters suggesting infection (eg, leukocytosis, anemia, abnormal platelet counts, abnormal liver function) frequently are present, although patients who are debilitated and/or elderly often fail to mount reactive leukocytosis or fever.
  • Blood cultures indicating persistent polymicrobial bacteremias strongly implicate the presence of an intra-abdominal abscess. Because more than 90% of intra-abdominal abscesses contain anaerobic organisms, particularly B fragilis, postoperative Bacteroides species bacteremia suggests intra-abdominal sepsis.

Imaging Studies

  • Plain abdominal radiographs, though rarely diagnostic, frequently indicate the need for further investigation.5
    • Abnormalities on plain abdominal films may include a localized ileus, extraluminal gas, air-fluid levels, mottled soft-tissue masses, absence of psoas outlines, or displacement of viscera.
    • In subphrenic or even subhepatic abscesses, the chest radiograph may show pleural effusion, elevated hemidiaphragm, basilar infiltrates, or atelectasis.
  • In experienced hands, ultrasonography has an accuracy rate greater than 90% for diagnosing intra-abdominal abscesses.
    • Ultrasonography is readily available, portable, and inexpensive. The findings can be quite specific when correlated with the clinical picture.
    • A drawback is that marked obesity, bowel gas, intervening viscera, surgical dressings, open wounds, and stomas can create problems with definition.
    • In addition, the quality of the procedure is operator-dependent.
    • These disadvantages may limit efficacy in postoperative patients.
  • Computed tomography (CT) scanning has greater than 95% accuracy and is the best diagnostic imaging method.
    • The presence of ileus, dressings, drains, or stomas does not interfere with reliability.
    • For good anatomical resolution, use oral and intravenous contrast. (See images below and Images 2-3.) Oral contrast may help to differentiate a fluid-filled extraluminal structure and a normal intestine. Extravasation of oral contrast indicates a fistula or an anastomotic leak. Intravenous contrast may enhance the abscess by concentrating the contrast material within the abscess wall. The use of oral and intravenous contrast may be limited by the ileus, allergy to contrast material, and renal insufficiency.


Contrast-enhanced computed tomography (CT) scan o...

Contrast-enhanced computed tomography (CT) scan of infected pancreatic pseudocyst (which can develop from acute necrotizing pancreatitis and give rise to an abscess).

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Contrast-enhanced computed tomography (CT) scan o...

Contrast-enhanced computed tomography (CT) scan of infected pancreatic pseudocyst (which can develop from acute necrotizing pancreatitis and give rise to an abscess).


A 35-year-old man with a history of Crohn disease...

A 35-year-old man with a history of Crohn disease presented with pain and swelling in the right abdomen. Figure A shows a thickened loop of terminal ileum adherent to the right anterior abdominal wall. In figure B, the right anterior abdominal wall, adjacent to the inflamed terminal ileum, is markedly thickened and edematous. Figure C shows a right lower quadrant abdominal wall abscess and enteric fistula (confirmed by the presence of enteral contrast in the abdominal wall).

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A 35-year-old man with a history of Crohn disease...

A 35-year-old man with a history of Crohn disease presented with pain and swelling in the right abdomen. Figure A shows a thickened loop of terminal ileum adherent to the right anterior abdominal wall. In figure B, the right anterior abdominal wall, adjacent to the inflamed terminal ileum, is markedly thickened and edematous. Figure C shows a right lower quadrant abdominal wall abscess and enteric fistula (confirmed by the presence of enteral contrast in the abdominal wall).


    • Identify any occult abscesses using serial images obtained from the diaphragm to the pelvis.
    • The appearance of an air bubble within a fluid collection or a low-attenuation extraluminal mass is diagnostic of an intra-abdominal collection.
    • CT scans can document inflammatory edema in the adjacent fat (obliteration of fat plane) and hyperemia in the abscess wall (enhancement).
    • Drawbacks include nonportability, relative difficulty in diagnosing intraloop abscesses, and, possibly, poor patient cooperation.
    • Recent intra-abdominal surgery also may pose a diagnostic problem in patients in whom intra-abdominal abscesses are suspected. CT scanning is not recommended for use in the diagnosis of such abscesses until approximately the eighth postoperative day. By that time, postoperative tissue edema is reduced, and nonsuppurative fluids (eg, hematoma, seroma, intraoperative irrigation fluid) should be reabsorbed. In most postoperative patients, signs of intra-abdominal abscesses do not develop within the first 4-5 days.
    • A literature review from the Netherlands indicated that CT scanning is superior to graded-compression ultrasonography in the diagnosis of acute appendicitis, a potential cause of abdominal abscess.6
  • Radioactive agents, such as leukocytes labeled or tagged with gallium-67 or indium-111, may localize the area of inflammation.
    • Such scans are time consuming, and they have many false-positive errors as a result of nonpyogenic inflammatory conditions, bowel accumulation of tagged leucocytes, surgical drains, and incisions.
    • Disadvantages limit such techniques for use in cases in which intra-abdominal abscesses are strongly suspected in a patient, but ultrasonography or CT scanning has failed to provide adequate diagnostic information.
    • These scans typically provide no pertinent information that is not found using a CT scan.

More on Abdominal Abscess

Overview: Abdominal Abscess
Workup: Abdominal Abscess
Treatment: Abdominal Abscess
Follow-up: Abdominal Abscess
Multimedia: Abdominal Abscess
References
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References

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Further Reading

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Keywords

abdominal abscess, abscess, fistula, pancreatitis, diverticulitis, appendicitis, abscesses, abscess treatment, ruptured appendix, drainage abscess, abscess surgery, abscess drain, abscess fistula, percutaneous drainage, colon abscess, surgical drainage, Escherichia coli, E coli, Bacteroides fragilis, B fragilis, intra-abdominal abscess, intra-abdominal suppuration

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Contributor Information and Disclosures

Author

Alan A Saber, MD, MS, FACS, Chief, Minimally Invasive Surgery and Bariatric Surgery, Associate Professor, Department of Surgery, Michigan State University
Alan A Saber, MD, MS, FACS is a member of the following medical societies: American College of Surgeons, American Society for Gastrointestinal Endoscopy, and American Society for Metabolic and Bariatric Surgery
Disclosure: Nothing to disclose.

Coauthor(s)

Raymond D LaRaja, MD, Chairman, Program Director, Clinical Professor, Department of Surgery, Cabrini Medical Center, Mount Sinai School of Medicine
Raymond D LaRaja, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, New York Academy of Medicine, and New York County Medical Society
Disclosure: Nothing to disclose.

Medical Editor

H Scott Bjerke, MD, FACS, Clinical Associate Professor, Department of Surgery, Indiana University School of Medicine, Medical Director of Trauma Services, Methodist Hospital, Clarian Health Partners, Inc
H Scott Bjerke, MD, FACS is a member of the following medical societies: American Association for the History of Medicine, American Association for the Surgery of Trauma, American College of Surgeons, Association for Academic Surgery, Eastern Association for the Surgery of Trauma, Midwest Surgical Association, National Association of EMS Physicians, Pan-Pacific Surgical Association, Royal Society of Medicine, Southwestern Surgical Congress, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Michael A Grosso, MD, Consulting Staff, Department of Cardiothoracic Surgery, St Francis Hospital
Michael A Grosso, MD is a member of the following medical societies: American College of Surgeons, Society of Thoracic Surgeons, and Society of University Surgeons
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA, Vice Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital
John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract
Disclosure: AMGEN Royalty Other

 
 
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