Photoclinic: Postoperative Intra-abdominal Abscess
During a laparotomy for perforated sigmoid colon diverticulitis, a 75-year-old woman was found to have extensive peritonitis. She underwent sigmoid colon resection and colostomy. Postoperatively, she recovered slowly. The peritoneal fluid grew Escherichia coli, and she was given broad-spectrum intravenous antibiotic therapy.
Five days after surgery, high-grade fever and abdominal pain on the left side developed. The patient’s white blood cell count rose to 20,000/μL. There were signs of septicemia.
Virendra Parikh, MD, of Fort Wayne, Ind, reports that a CT scan of the abdomen showed a well-localized abscess in the left paracolic gutters (arrows). Percutaneous drainage of the abscess with CT guidance removed 30 mL of purulent material, which grew E coli and Klebsiella. The antibiotic regimen was changed based on the sensitivity of the organisms. The patient recovered completely.
Persistent, spiking fever accompanied by dull pain, anorexia, and weight loss are the clinical hallmarks of an intra-abdominal abscess.1 Abdominal CT imaging is the most efficient means of diagnosis. Exact localization of the abscess is important for management, which may involve needle aspiration and catheter drainage using CT or ultrasonography.
Indications for open surgical drainage are failure of percutaneous drainage, inability to safely drain percutaneously, an association with a bowel fistula, and the presence of multiloculated interloop abscesses.
1. Wittman DH, Walker AP, Condon RE. Peritonitis and intra-abdominal infections. In: Schwartz SI, Shires GT, Spencer FC, eds. Principles of Surgery. 6th ed. New York: McGraw-Hill; 1994:1449-1483.