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Abdominal Abscess Workup

  • Author: Alan A Saber, MD, MS, FACS; Chief Editor: John Geibel, MD, DSc, MSc, MA  more...
 
Updated: Jun 21, 2016
 

Approach Considerations

Delayed diagnosis and treatment can lead to increased mortality and have a significant economic impact. Accordingly, an efficient and well-directed workup is important.

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Laboratory Studies

Appropriate hematologic studies should be done. Hematologic parameters suggestive of infection (eg, leukocytosis, anemia, abnormal platelet counts, and abnormal liver function) frequently are present, although patients who are debilitated or elderly often fail to mount reactive leukocytosis or fever.

Blood cultures indicating persistent polymicrobial bacteremia 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 bacteremia suggests intra-abdominal sepsis.

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Radiography

Plain abdominal radiographs, though rarely diagnostic, frequently indicate the need for further investigation.[8] 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.

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Ultrasonography

Ultrasonography is readily available, portable, and inexpensive. The findings can be quite specific when correlated with the clinical picture. In experienced hands, ultrasonography has an accuracy rate greater than 90% for diagnosing intra-abdominal abscesses. Bedside ultrasonography is particularly useful for immobile, critically ill intensive care unit (ICU) patients.

A drawback of ultrasonography 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 the efficacy of this modality in postoperative patients.

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Computed Tomography

Computed tomography (CT) has greater than 95% accuracy and is the best diagnostic imaging method for abdominal abscess. The presence of ileus, dressings, drains, or stomas does not interfere with reliability.

For good anatomic resolution, use oral and intravenous (IV) contrast (see the images below). Oral contrast may help to differentiate a fluid-filled extraluminal structure from a normal intestine. Extravasation of oral contrast indicates a fistula or an anastomotic leak. IV contrast may enhance the abscess by concentrating the contrast material within the abscess wall. The use of oral and IV contrast may be limited by ileus, allergy to contrast material, and renal insufficiency.

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

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 can document inflammatory edema in the adjacent fat (obliteration of fat plane) and hyperemia in the abscess wall (enhancement).

Drawbacks of CT 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 is not recommended for use in diagnosing such abscesses until approximately postoperative day 7, by which 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 is superior to graded-compression ultrasonography in the diagnosis of acute appendicitis, a potential cause of abdominal abscess.[9]

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Radioisotope Scanning

Scans using 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 a substantial false-positive rate resulting from nonpyogenic inflammatory conditions, bowel accumulation of tagged leukocytes, surgical drains, and incisions.

Typically, radioisotope scans provide no pertinent information that is not found with CT. The disadvantages of these scans limit their use to cases in which intra-abdominal abscesses are strongly suspected in a patient but ultrasonography or CT has failed to provide adequate diagnostic information.

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Contributor Information and Disclosures
Author

Alan A Saber, MD, MS, FACS FASMBS, Director of Bariatric and Metabolic Surgery, University Hospitals Case Medical Center; Surgical Director, Bariatric Surgery, Metabolic and Nutrition Center, University Hospitals Digestive Health Institute; Associate Professor of Surgery, Case Western Reserve University School of Medicine

Alan A Saber, MD, MS, FACS is a member of the following medical societies: American College of Surgeons, American Society for Metabolic and Bariatric Surgery, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Coauthor(s)

Raymond D LaRaja, MD, MD 

Raymond D LaRaja, MD, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, New York Academy of Medicine, New York County Medical Society

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow

John Geibel, MD, DSc, MSc, 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, Society for Surgery of the Alimentary Tract

Disclosure: Received royalty from AMGEN for consulting; Received ownership interest from Ardelyx for consulting.

Acknowledgements

H Scott Bjerke, MD, FACS Clinical Associate Professor, Department of Surgery, University of Missouri-Kansas City School of Medicine; Medical Director of Trauma Services, Research Medical Center; Clinical Professor, Department of Surgery, Kansas City University of Medicine and Biosciences

H Scott Bjerke, MD, FACS is a member of these 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.

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.

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Reference Salary Employment

References
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  2. Varcus F, Lazar F, Beuran M, Lica I, Turculet C, Nicolau E, et al. Laparoscopic treatment of perforated duodenal ulcer - a multicentric study. Chirurgia (Bucur). 2013 Mar-Apr. 108(2):172-6. [Medline].

  3. L V, Rao V D, Rao M S, Y M. "Toxic Pancreatitis with an Intra-Abdominal Abscess which was Caused by Organophosphate Poisoning (OP)". J Clin Diagn Res. 2013 Feb. 7(2):366-8. [Medline]. [Full Text].

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  6. Malangoni MA, Shumate CR, Thomas HA, Richardson JD. Factors influencing the treatment of intra-abdominal abscesses. Am J Surg. 1990 Jan. 159(1):167-71. [Medline].

  7. Greenberg J, Arnell TD. Diverticular abscess presenting as an incarcerated inguinal hernia. Am Surg. 2005 Mar. 71(3):208-9. [Medline].

  8. Pedrazzoli S, Liessi G, Pasquali C, Ragazzi R, Berselli M, Sperti C. Postoperative pancreatic fistulas: preventing severe complications and reducing reoperation and mortality rate. Ann Surg. 2009 Jan. 249(1):97-104. [Medline].

  9. van Randen A, Bipat S, Zwinderman AH, Ubbink DT, Stoker J, Boermeester MA. Acute appendicitis: meta-analysis of diagnostic performance of CT and graded compression US related to prevalence of disease. Radiology. 2008 Oct. 249(1):97-106. [Medline].

  10. Hemming A, Davis NL, Robins RE. Surgical versus percutaneous drainage of intra-abdominal abscesses. Am J Surg. 1991 May. 161(5):593-5. [Medline].

  11. Rypens F, Dubois J, Garel L, Deslandres C, Saint-Vil D. Percutaneous drainage of abdominal abscesses in pediatric Crohn's disease. AJR Am J Roentgenol. 2007 Feb. 188(2):579-85. [Medline].

  12. Laborda A, De Gregorio MA, Miguelena JM, Medrano J, Gómez-Arrue J, Serrano C, et al. Percutaneous treatment of intrabdominal abscess: urokinase versus saline serum in 100 cases using two surgical scoring systems in a randomized trial. Eur Radiol. 2009 Jul. 19(7):1772-9. [Medline].

  13. Kimura T, Shibata M, Ohhara M. Effective laparoscopic drainage for intra-abdominal abscess not amenable to percutaneous approach: report of two cases. Dis Colon Rectum. 2005 Feb. 48(2):397-9. [Medline].

 
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Percutaneous computed tomography (CT) scan–guided drainage of postoperative subhepatic collection.
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 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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