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Chapter-10 Intra-abdominal Infections

BOOK TITLE: Common Surgical Emergencies

Author
1. Kochar SK
ISBN
9788184486537
DOI
10.5005/jp/books/10158_10
Edition
2/e
Publishing Year
2009
Pages
16
Author Affiliations
1. Royal Hospital, Greenock, Scotland, UK, Army Base Hospital, New Delhi, India, Fortis Heart Institute and Multispeciality Hospital, Mohali, Punjab, India
Chapter keywords

Abstract

The significance of aerobic and anaerobic organisms in the pathogenesis of intra-abdominal infection was first demons­trated in animal model. These findings were corroborated in a clinical study of patients with penetrating abdominal trauma when those treated with an antimicrobial agent active only against aerobes developed significantly more infectious complications than those treated with a combination of antimicrobial active against both aerobes and anaerobes. Despite improved diagnostic methods, surgical techniques and clinical management, mortality associated with severe intra-abdominal infections may range from 10–54 percent depending on the site of perforation and adverse patient risk factors. Adhesions, postoperative abscesses, septic shock and respiratory failure can complicate the course of this disease. High spiking fevers, mild localized abdominal pain, and anorexia and weight loss composes the classic presentation of an intra­peritoneal abscess. The sign symptoms of intra-abdominal infection vary according to the underlying cause and the length of time between onset of symptoms and presentation. Patient in the earlier stages typically report vague, generalized pain that may be localized or diffuse. In more advance stage, the pain may be described as constant and severe, and may worsen with movement and respiration. Plane X-ray abdomen lying and standing including dome of the diaphragm should be done in all cases. Findings indicative of intra-abdominal abscess are: 1. an air fluid in the upright or decubitus film, 2. the presence of extra-luminal gas, and 3. a soft tissue mass displacing adjacent bowel or other organs. Chest radiographs may demonstrate lower lobe atelactasis or a pleural effusion, if a sub-phrenic abscess is present. It is an excellent modality to evaluate a patient with intra-abdominal abscess. Advantages include, portability, noninvasive, rapid, inexpensive no ionizing radiation’s, and pregnancy no contraindication. It seems to be most accurate modality available for assessment of intra-abdominal abscess. In unselected patients, the diagnostic accuracy rates of upto 95 percent have been reported. The CT appearance of an abscess is variable and depends on its stage of evolution and location. In its early stage, an abscess may appear as a mass of soft tissue attenuation. As liquefactive necrosis occurs, the center or entire lesion attains water like attenuation, with most abscesses having attenuation between 15 and 35 HU. Early diagnosis, prompt surgical intervention and appropriate antimicrobial therapy are essential to the successful outcome of intra-abdominal infections. The surgical procedure often includes debridement of necrotic tissue, removal of any foreign bodies, repair of any perforation and drainage of all localized purulent material. Treatments with systemic antibiotics are initiated at diagnosis and before surgery to prevent bacterimia, limit peritoneal contamination and facilitate healing process. Ideally, the selection of an antibiotics regimen should be made on the basis of in vitro susceptibility of the pathogens, bacterial resistance patterns, and demonstrated efficacy in clinical trials, patient risk factors for renal or hepatic toxicity, possible adverse effects and cost effectiveness. Availability of ultrasonography and CT scan not only to diagnose but also to map out the intra-abdominal abscess has encouraged surgeons to drain it percutaneously. Where facility exists one can even use CT/ultrasound guided needle aspiration. Percuta­neously drainage may be attempted in following situations: (i) unilocular abscess, (ii) multiloculated or multiple abscesses, (iii) abscess with enteric communication, and (iv) the need to traverse normal peritoneum or solid viscera to reach the abscess. In developing countries non-availability of CT scan and ultra­sono­graphy/non-availability of expertise it becomes the indication for surgical drainage. Other indications are: (i) the abscess is poorly defined or difficult to localize by imaging techniques, (ii) thick, tenacious or necrotic material, where needle aspira­tion may not be successful or fails, (iii) if associated with malignancy, (iv) the approach entails perforation of a hollow viscus, and (v) as and when attempted percutaneous needle aspiration fails.

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