Abdominal abscess is a limited abscess in the abdominal cavity enclosed in a pyogenic capsule. The features of the clinic depend on the localization and size of the purulent focus; common manifestations of abdominal abscess are pain and local tension of the abdominal muscles, fever, intestinal obstruction, nausea, etc. Diagnosis of an abscess includes an overview radiography of the abdominal organs, ultrasound and CT of the abdominal cavity. Treatment consists in opening, drainage and sanitation of the abscess; massive antibacterial therapy.
ICD 10
K65 Peritonitis
General information
In a broad sense, abdominal abscess in abdominal surgery include intraperitoneal (intraperitoneal), retroperitoneal (retroperitoneal) and intraorgan (intraorgan) abscesses. Intraperitoneal and retroperitoneal ulcers, as a rule, are located in the area of anatomical channels, pockets, bags of the abdominal cavity and cellular spaces of retroperitoneal fiber. Intra-organ abscesses of the abdominal cavity are more often formed in the parenchyma of the liver, pancreas or the walls of organs.
The plastic properties of the peritoneum, as well as the presence of adhesions between its parietal leaf, omentum and organs, contribute to the delineation of inflammation and the formation of a kind of pyogenic capsule that prevents the spread of the purulent process. Therefore, an abscess of the abdominal cavity is also called “delimited peritonitis”.
Causes of abdominal abscess
In 75% of cases, abscesses are located intra- or retroperitoneal; in 25% – intra-organically. The pyogenic flora of abscesses is more often polymicrobial, combining aerobic (E. coli, proteus, staphylococci, streptococci, etc.) and anaerobic (clostridia, bacteroids, fusobacteria) microbial associations. Causes of abscess:
- Peritonitis. In most cases, the formation of abdominal abscesses is associated with secondary peritonitis, which develops as a result of intestinal contents entering the free abdominal cavity with perforated appendicitis; blood, effusion and pus during drainage of hematomas, failure of anastomoses, postoperative pancreonecrosis, injuries, etc. Typical localization sites are the large omentum, mesentery, pelvis, lumbar region, subdiaphragmatic space, surface or thickness of tissues of parenchymal organs.
- Infectious processes in the pelvis. The cause of the abscess may be purulent inflammation of the female genitals – acute salpingitis, adnexitis, parametritis, piovar, piosalpinx, tubovarial abscess.
- Diseases of the gastrointestinal tract. There are abscesses of the abdominal cavity caused by pancreatitis: in this case, their development is connected with the action of pancreatic enzymes on the surrounding fiber, causing a pronounced inflammatory reaction. In some cases, abdominal abscess develops as a complication of acute cholecystitis or perforation of stomach ulcers and duodenal ulcer, Crohn’s disease.
- Infections of the retroperitoneal space. Psoas abscess may be a consequence of osteomyelitis of the spine, tuberculous spondylitis, paranephritis.
Classification
According to the leading etiofactor, microbial (bacterial), parasitic and necrotic (abacterial) abscesses of the abdominal cavity are distinguished.
In accordance with the pathogenetic mechanism, posttraumatic, postoperative, perforated and metastatic ulcers are isolated.
According to the location relative to the peritoneum, abscesses are divided into retroperitoneal, intraperitoneal and combined; according to the number of ulcers – single or multiple.
By localization, there are:
- subdiaphragmal,
- interstitial,
- appendicular,
- pelvic (Douglas space abscesses),
- parietal intra-organ abscesses (intra-mesenteric, pancreatic, liver, spleen abscesses).
Symptoms of abdominal abscess
At the beginning of the disease, with any type of abdominal abscess, general symptoms prevail: intoxication, intermittent fever with hectic temperature, chills, tachycardia. Nausea, impaired appetite, vomiting are often noted; paralytic intestinal obstruction develops, pronounced soreness in the area of the abscess, tension of the abdominal muscles is determined.
The symptom of abdominal muscle tension is most pronounced in abscesses localized in the mesogastrium; ulcers of subdiaphragmatic localization, as a rule, occur with erased local symptoms. With subdiaphragmatic abscesses, pain in the hypochondrium on inspiration with irradiation into the shoulder and shoulder blade, cough, shortness of breath may bother.
Symptoms of pelvic abscesses include abdominal pain, increased urination, diarrhea and tenesmus due to reflex irritation of the bladder and intestines. Retroperitoneal abscesses are characterized by localization of pain in the lower back; at the same time, the intensity of pain increases with flexion of the lower limb in the hip joint. The severity of symptoms is associated with the size and localization of the abscess, as well as with the intensity of antimicrobial therapy.
Diagnostics
Usually, during the initial examination, the abdominal surgeon pays attention to the forced position of the patient, which he takes to relieve his condition: lying on his side or back, half-sitting, bending, etc. To confirm the diagnosis, the following diagnostic procedures are performed:
- Objective examination. The tongue is dry, overlaid with a grayish coating, the abdomen is slightly swollen. Palpation of the abdomen reveals soreness in the departments corresponding to the localization of purulent formation (in the hypochondrium, pelvic depth, etc.). The presence of a subdiaphragmatic abscess is characterized by asymmetry of the chest, the intercostal and lower ribs protrude.
- X-ray examinations. An overview radiography of the abdominal cavity allows you to identify an additional formation with a fluid level. With contrast examination of the gastrointestinal tract (radiography of the esophagus and stomach, irrigoscopy, fistulography), the displacement of the stomach or intestinal loops by infiltration is determined. In case of failure of postoperative sutures, the contrast agent enters from the intestine into the cavity of the abscess.
- Other visualization techniques. Ultrasound of the abdominal cavity is most informative for abscess of its upper parts. With the difficulties of differential diagnosis, CT and diagnostic laparoscopy are indicated.
- Laboratory tests. In the blood test, leukocytosis, neutrophilosis, acceleration of ESR are detected.
Treatment of abdominal abscess
Surgical treatment is carried out under the guise of antibacterial therapy (aminoglycosides, cephalosporins, fluoroquinolones, imidazole derivatives) to suppress aerobic and anaerobic microflora. The principles of surgical treatment of all types of abscesses are autopsy and drainage, adequate sanitation. Access is determined by the localization of the abscess: subdiaphragmatic abscesses are opened extraperitoneal or transperitoneal; abscesses of the Douglas space – transrectally or transvaginally; psoas abscesses – from lumbotomic access, etc.
In the presence of multiple abscesses, a wide opening of the abdominal cavity is performed. After the operation, drainage is left for active aspiration and washing. Small single subdiaphragmatic abscesses can be drained percutaneously under ultrasound guidance. However, with incomplete evacuation of pus, there is a high probability of recurrence of the abscess or its development elsewhere in the subdiaphragmatic space.
Prognosis and prevention
With a single abscess, the prognosis is more often favorable. Complications of an abscess may be a breakthrough of pus into the free pleural or abdominal cavity, peritonitis, sepsis. Prevention requires timely elimination of acute surgical pathology, gastroenterological diseases, inflammatory processes on the part of the female genital area, adequate management of the postoperative period after interventions on the abdominal organs.
Literature
- Roehler R., RnochelJ. Computed Tomography in the Evaluation of Abdominal Abscesses // Amer. J. Surg. 1980.Vol. 140. № 5. P. 675 -678. link
- Timoshin A.D., Shestakov A.L., Jurasov A.V. Maloinvazivnye vmeshatel’stva v ab-dominal’noj hirurgii. M.: Triada H, 2003. 216 s.
- Benoist S.,Panis Y., PannegeonV.Can failure of percutaneous drainage of postoperative abscesses be predict?// American journal of surgery. 2002. № 2. P. 3439. link
- Bufalari A, Giustozzi G., Moggi L. Postopera_tive intraabdominal abscesses: percutaneous