Download - Intra abdominal abscess
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Presenter: Dr. A R Shaan Moderator: Dr. S B Choudhary
Intra Abdominal
Abscess
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Michael DeBakey & Alton Oschner
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Abdominal Abscess
“ well-defined collections of infected purulent material that are walled off from the rest of the peritoneal cavity by inflammatory adhesions, loops of intestines and their mesentry, the greater omentum or other abdominal viscera”
-Maingot’s 12th ed.
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Types of Intra abdominal abscess
Intraperitoneal( Extravisceral)
Visceral
Retroperitoneal
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Intraperitoneal spaces
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Perihepatic Spaces
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Extravisceral Abscess
2 situations:
Resolution of diffuse peritonitis loculated infection
Perforation of a viscous or Anastomotic Breakdown
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Retroperitoneal spaces
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Pathophysiology
3 major defense mechanisms of peritoneal cavity
Mechanical clearance via Diaphragmatic Lymphatics
Phagocytosis and destruction of adherent bacteria
Sequestration and walling off of bacteria, with delayed clearance
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Bacterial Contamination
HyperemiaExudative fluidMacrophages
Neutrophilic Exudate
2-4 hr
Innate Immunity
TNF-αIL-1IL-6IL-10
RESOLUTION of peritonitis
Mast cells Mesothelial lining Cells
Cytokinesprocagulants
FibrinCOMPARTMENTALIZATION of peritonitis
ABSCESS
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Factors favouring abscess
LOCAL FACTORS MICROBIAL FACTORS
Local fibrin deposition
Low pH
Particulate stool
Hypoxia
Polymicrobial Flora
Bacteroides fragilis
Capsular polysaccharide
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Clinical Features
High spiking fevers Chills Tachycardia Tachypnoea Leukocytosis Localised abdominal pain Anorexia Delay in return of bowel function
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Special Features
Subphrenic Abscess
Paracolic abscess
Pelvic abscess
Retroperitoneal Abscess
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Diagnostic testsXray
CT Scan
USG Scan
MRI
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Abdominal Xrays Air fluid levels
Extraluminal gas
Soft tissue mass displacing the bowel
Elevated diaphragm
Collapse/consolidation at lung base
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Diagnostic features in CT scan
Low CT attenuation
Mass effect displacing normal structures
“lucent centre with rim enhancement”
Gas in fluid collection
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CT Scan vs USGAdvantages of CT Disadvantages of CT
Not impaired in ileus
Wound dressings and stomas
Open abdomen
Retroperitoneal and pancreatic region
Absence of rim enhancement/ gas/ visible septations
High leucocyte and protein content
Loculated Abscess
Subphrenic and pulmonic fluid
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MRIDelineate the extent of an abscess
Pregnancy
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Management
Adequate resuscitation and support
Antimicrobial therapy
Source control/ abscess drainage
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Resuscitation & Support
ABC
Oral/enteric nutritional/ TPN
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Antimicrobial Therapy
3 Categories:
community- acquired infections of mild to moderate severity
High risk/ severe community- acquired infections
Health care associated infections
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Community acquired infectionsMild-moderate severity(perforated/ abscessed appendicitis and other infections of mild-moderate severity)
High Risk or Severe(severe physiological disturbance, advanced age, immunocompromised state)
Cefoxitin
Ertapenem
Moxifloxacin
Ticaricillin-clavulanic acid
Imipenem-cilastin
Meropenem
Doripenem
Piperacillin-tazobactum
CefazolinCefuroximeCeftriaxoneCefotaxime + Metronidazole
CiprofloxacinLevofloxacin
CefepimeCeftazidime + MetronidazoleCiprofolacinLevofloxacin
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Health care associated infectionsOrganism Carbepenem Piperacillin-
tazobactumCeftazidime/cefepime + metronidazole
Aminoglycoside
Vancomycin
<20% Res. PseudomonasESBL Enterobacteracea, acenetobacter, MDR-GNB
√ √ √
ESBL-Enterobacteraceae
√ √ √
P. Aeruginosa>20% res ceftazidime
√ √ √
MRSA √
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Pyogenic liver abscesses< 3cm
Single/multiple
Antibiotic therapy
PCD if not responding
> 3 cm
unilocular
antibiotics
PCD by needle aspiration or catheter
Surgical therapy if not responding
multilocular
antibiotics
Percutaneous drainage
Surgical therapy by resection / drainage if not responsive
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Amoebic Liver abscess Metronidazole 750mg TID for 14 days
Chloroquine
Dihydromentine
Drainage ---- needle aspirations Percutaneous catheter drainage
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Source Control
Percutaneous Drainage
Surgery
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Prerequisites for percutaneous drainage
Anatomically safe route
Well defined unilocular abscess cavity
Surgical & radiological evaluation
Surgical backup for technical failure
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Post-requisites for percutaneous drainage Gram’s stain and culture
8-12f catheter
Closed drainage system
Irrigation of catheter once daily
Repeat CT
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Complications with percutaneous drainage Enterocutaneous fistula
Bacteremia
Sepsis
Vascular injury
Enteric puncture
Transpleural catheter placement
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Criteria for removal of a Drain
Clinical resolution of septic parameters
Minimal drainage from the catheter
CT evidence of resolution
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Comparing outcome in different scenarios…. Single well defined bacterial abscess with no enteric communication
Abscess with enteric communication
Interloop abscess/ difficult to access abscess
Early post operative diffuse peritonitis
Infected tumour massFungal abscessInfected hematomaPancreatic necrosis
Small abscess (<4cm diameter)
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Surgical Drainage Failure of percutaneous drainage
Diffuse infection
Content of abscess is too thick
Access is impossible
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Surgical approach
Transperitoneal approach
Extraperitoneal approach
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Posterior Extraserous Approach
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Anterior incisions
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Thank You…..
Every operation in surgery is an experiment in bacteriology
-Berkeley Moynihan