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  • • Fever and chills

    • Tachycardia

    • Leukocytosis

    • Focal abdominal tenderness

    • Predisposing condition

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Epidemiology

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  • • Most common causes are

    • -GI perforations

      -Postoperative complications

      -Penetrating trauma

      -Genitourinary infections

    • Abscess forms as sequelae of generalized peritonitis in 33% of cases

    • Intra-abdominal abscess forms adjacent to diseased viscus (eg, perforated appendicitis) or as a result of external contamination (subphrenic abscess)

    • Broadly classified based on anatomic location:

    • -Subdiaphramatic

      -Subhepatic

      -Pericolic

      -Pelvic

      -Interloop abscesses

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Symptoms and Signs

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  • • Fever and chills

    • Tachycardia

    • Focal abdominal tenderness

    • Prolonged ileus or sluggish postoperative recovery

    • Mass seldom appreciated

    • Irritation of contiguous structures manifesting symptoms such as:

    • -Lower chest pain

      -Dyspnea

      -Referred shoulder pain or hiccup

      -Basilar atelectasis or effusion

      -Diarrhea

      -Urinary frequency

    • Severe peritoneal sepsis with multiple organ failure may develop in patients with advanced cases

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Laboratory Findings

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  • • Leukocytosis

    • Bacteremia

    • Abnormal liver profile, renal function tests, or ABG measurements

    • Elevated ESR and C-reactive protein levels

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Imaging Findings

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  • Abdominal x-ray: Suggest abscess in up to 50% of cases via nonspecific findings, such as

    • -Ileus pattern

      -Air-fluid levels

      -Soft-tissue mass

      -Free or mottled gas pockets

      -Effacement of preperitoneal or psoas outlines

      -Displacement of viscera

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    • -Diagnose intra-abdominal abscesses in up to 80% of cases

      -Most useful when an abscess is suspected in the right upper quadrant

      -Bowel gas, stomas, and incisions interfere with the study

    • Water-soluble contrast study sensitive in detecting a perforated viscus

    • Abdominal pelvic CT scan with IV and PO contrast is the best diagnostic study with > 95% sensitivity, particularly in postoperative patients

    • -Percutaneous drainage procedures can often be performed at the same setting

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  • • Sterile fluid collection

    • Hematoma

    • Biloma

    • Urinoma

    • Neoplasm

    • Other common infectious/inflammatory sources that manifest with fever, leukocytosis, and abdominal pain:

    • -Pancreatitis

      -Pyelonephritis

      -Lower lobe pneumonia

      -Deep wound infection

    • Bacteremia/line sepsis

    • Evaluate for source of abscess:

    • -GI anastomotic leak

      -Perforated appendicitis

      -Perforated diverticulitis

      -Crohns enterocolitis

      -Perforated peptic ulcer

      -Pelvic inflammatory disease/tubo-ovarian abscess

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  • • CBC

    • Basic chemistries

    • Amylase and lipase

    • UA

    • Blood cultures

    • Sputum culture and Gram stain

    • Chest film

    • Abdominal x-ray

    • Abdominal pelvic CT scan with IV and PO contrast

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When to Admit

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  • • All patients with an intra-abdominal abscess should be admitted (if not already) for drainage and initiation of IV antibiotics

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When to Refer

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  • • Most patients with intra-abdominal abscesses should be managed by a general surgeon

    • Postoperative abscesses ideally should be addressed by the operative surgeon

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  • • IV antibiotic therapy may initially be attempted for small abscesses < 1-2 cm if the patient is clinically stable

    • Treatment of most abscesses consists of prompt and complete drainage, control of the primary cause, and adjunctive use of antibiotics

    • Percutaneous drainage is the preferred ...

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