Intra-abdominal Abscess

last authored: Feb 2010, David LaPierre
last reviewed:

 

Introduction

Intra-abdominal abscess can be a serious complication of gastrointestinal conditions or surgery. Their formation is often indolent, making diagnosis at times difficult, but most patients are febrile.

 

Abscess may form from an intraabdominal organ following spread from blood, lymph, or gut. They may also develop as extravisceral abscess in the peritoneal or retroperitoneal spaces, usually following peritonitis or lumenal rupture.

 

 

 

The Case of...

 

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Causes and Risk Factors

Liver abscess

Liver abscess usually occurs among patients with other conditions, including

  • biliary tract disease
  • appendicitis
  • diverticulitis
  • liver transplantation
  • trauma

Causative organisms can include:

 

Splenic abscess

Splenic abscesses generally result from hematogenous spread:

  • endocarditis
  • sickle cell disease (in children)
  • trauma

Causative organisms can include:

  • Staphylococci
  • streptococci
  • gram-negative bacilli

 

Pancreatic abscess

Pancreatitis can uncommonly result in pancreatic abscess, leading to persistent or recurrent fever.

Causative organisms can include:

  • enterobaceteriacae
  • anaerobes
  • streptococci

 

Extravisceral abscess

Extravisceral abscess can follow:

  • peritonitis
  • intra-abdominal surgery
  • gut perforation, often following peptic ulcer
  • perforated appendicitis
  • perforated diverticulitis
  • gangrenous cholecystitis
  • mesenteric ischemia and infarction
  • post-operative complications
  • penetrating trauma

Causative organisms can include:

  • enterobaceteriacae
  • anaerobes
  • streptococci
  • E coli
  • Bacteroides fragilis
  • Staph and Strep following trauma/surgery

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Pathophysiology

Abscesses represent local collections of pus walled off by inflammation, omentum, or viscera.

Extraperitoneal abscess can occur in the subphrenic, pelvic, or retroperitoneal space.

 

Intermittent bacteremia can result in recurrent fevers and rigors.

Liver seeding can occur through the hepatic portal veins. Abscesses can be single or multiple.

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Signs and Symptoms

  • history
  • physical exam

History

Presenting symptoms are diverse and include:

  • abdominal pain, often poorly localized
  • nausea, vomiting
  • paralytic ileus

Subphrenic abscesses can cause:

  • shoulder pain (referred diaphragmatic pain, C3,4)
  • hiccup
  • pulmonary manefestations

Splenic abscess can cause:

  • left upper quadrant abdominal pain, potentially pleuritic

Pelvic abscesses can cause:

  • polyuria
  • diarrhea
  • tenesmus

History of abdominal surgery

 

Physical Exam

Physical exam can reveal

  • focal tenderness
  • ileus

Pyogenic hepatic abscess can cause

  • right-sided pain
  • hepatomegaly
  • jaundice in less than 25% of patients

Splenic abscess can cause:

  • pleural rub or effusion

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Investigations

  • lab investigations
  • diagnostic imaging

Lab Investigations

elevated WBC is often present

Needle aspiration can be used to perform gram stain and culture and assist with therapy.

 

Liver abscess can lead to

  • elevation of alkaline phosphatase
  • modest elevation of bilirubin

 

Entamoeba histolytica titres can assess for a possible cause of liver abscess

Diagnostic Imaging

Abdominal X-ray can reveal:

  • extravisceral gas
  • air-fluid levels

Chest X-ray can show:

  • elevated right diaphragm, atalectasis, or effusion with liver abscess

Abdominal ultrasound can reveal fluid collection, especially in the pelvis.

 

CT, and MRI can be very helpful.

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Differential Diagnosis

Liver tumour...

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Treatments

 

Drainage

Percutaneous drainage is the first line treatment, guided by CT. Surgical intervention is indicated if drainage fails.

 

Antibiotics

IV antibiotics should be given at the same time, emperically and then according to culture results.

Antibiotics are rarely sufficient, save with amebic abscess or multiple microabscesses of the liver.

Confounding issues include

broad-spectrum antibiotics

 

Surgery

Biliary tract obstruction should be relieved surgically if present.

Splenectomy is usually the treatment for splenic abscess.

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Consequences and Course

 

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Resources and References

 

Open-Access

 

Non-Open-Access

Marshall JC, Innes M. 2003. Intensive care unit management of intra-abdominal infection. Crit Care Med. 31(8):2228-37.

 

 

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