Abdominal Abscess

Updated: Jun 21, 2016

Author: Alan A Saber, MD, MS, FACS; Chief Editor: John Geibel,
MD, DSc, MSc, AGAF more...
Share

Feedback
Background
Intra-abdominal abscess continues to be an important and serious
problem in surgical practice. Appropriate treatment is often delayed
because of the obscure nature of many conditions resulting in abscess
formation, which can make diagnosis and localization difficult. Associated
pathophysiologic effects may become life threatening or lead to extended
periods of morbidity with prolonged hospitalization. Delayed diagnosis
and treatment can also lead to increased mortality; therefore, the
economic impact of delaying treatment is significant.
A better understanding of intra-abdominal abscess pathophysiology and a
high clinical index of suspicion should allow earlier recognition, definitive
treatment, and reduced morbidity and mortality. [1]
For patient education resources, see the Infections Center, as well
as Abscess and Antibiotics.

Anatomy
The eight functional compartments in the peritoneal cavity include the
following:
Pelvis
Right paracolic gutter
Left paracolic gutter
Right infradiaphragmatic space
Left infradiaphragmatic space
Lesser sac
Hepatorenal space (Morrison space)
 Interloop spaces between small intestine loops
The paracolic gutters slope into the subhepatic and subdiaphragmatic
spaces superiorly and over the pelvic brim inferiorly. In a supine patient,
the peritoneal fluid tends to collect under the diaphragm, under the liver,
and in the pelvis.
More localized abscesses tend to develop anatomically in relation to the
affected viscus. For example, abscesses in the lesser sac may develop
secondary to severe pancreatitis, or periappendiceal abscesses from a
perforated appendix may develop in the right lower quadrant. Small bowel
interloop abscesses may develop anywhere from the ligament of Treitz to
the ileum. An understanding of these anatomic considerations is
important for the recognition and drainage of these abscesses.

Pathophysiology
Intra-abdominal abscesses are localized collections of pus that are
confined in the peritoneal cavity by an inflammatory barrier. This barrier
may include the omentum, inflammatory adhesions, or contiguous
viscera. The abscesses usually contain a mixture of aerobic and
anaerobic bacteria from the gastrointestinal (GI) tract.
Bacteria in the peritoneal cavity, in particular those arising from the large
intestine, stimulate an influx of acute inflammatory cells. The omentum
and viscera tend to localize the site of infection, producing a phlegmon.
The resulting hypoxia in the area facilitates the growth of anaerobes and
impairs the bactericidal activity of granulocytes. The phagocytic activity of
these cells degrades cellular and bacterial debris, creating a hypertonic
milieu that expands and enlarges the abscess cavity in response to
osmotic forces.
If untreated, the process continues until bacteremia develops, which then
progresses to generalized sepsis with shock.

Etiology
Although multiple causes of intra-abdominal abscesses exist, the
following are the most common:

Perforation of viscus, which includes peptic ulcer perforation [2]

Perforated appendicitis and diverticulitis

Gangrenous cholecystitis

Mesenteric ischemia with bowel infarction

Pancreatitis or pancreatic necrosis progressing to pancreatic
abscess [3]
Other causes include untreated penetrating trauma to the abdominal
viscera and postoperative complications, such as anastomotic
leakage [1, 4] or missed gallstones during laparoscopic cholecystectomy.
Microbiology includes a mixture of aerobic and anaerobic organisms. The
most commonly isolated aerobic organism is Escherichia coli, and the
most commonly observed anaerobic organism is Bacteroides fragilis. [5] A
synergistic relationship exists between these organisms. In patients who
receive prolonged antibiotic therapy, yeast colonies (eg, candidal species)
or a variety of nosocomial pathogens may be recovered from abscess
fluids.
Skin flora may be responsible for abscesses after a penetrating
abdominal injury. Neisseria gonorrhoeae and chlamydial species are the
most common organisms involved in pelvic abscesses in females as part
of pelvic inflammatory disease. The type and density of aerobic and
anaerobic bacteria isolated from intra-abdominal abscesses depend upon
the nature of the microflora associated with the diseased or injured organ.
Microbial flora of the GI tract shifts from small numbers of aerobic
streptococci, including enterococci and facultative gram-negative bacilli in
the stomach and proximal small bowel, to larger numbers of these
species, with an excess of anaerobic gram-negative bacilli
(particularly Bacteroides species) and anaerobic gram-positive flora
(streptococci and clostridia) in the terminal ileum and colon.
Differences in microorganisms observed from the upper portion of the GI
tract to the lower portion partially account for differences in septic
complications associated with injuries or diseases to the upper and lower
gut. Sepsis occurring after upper GI perforations or leaks causes less
morbidity and mortality than sepsis after leaks from colonic insults.

Prognosis
The introduction of computed tomography (CT) for the diagnosis and
drainage of intra-abdominal abscesses has led to a dramatic reduction in
mortality. (See Workup, Computed Tomography.) Sequential, multiple
organ failure is the main cause of death. Incidence of death is correlated
to the severity of the underlying cause, a delayed diagnosis, inadequate
drainage, and unsuspected foci of infection in the peritoneal cavity or
elsewhere.
Risk factors for morbidity and mortality include the following [1, 6] :
Multiple surgical procedures
Age older than 50 years
Multiple organ failure
Complex, recurrent, or persistent abscesses
History and Physical Examination
Intra-abdominal abscesses are highly variable in presentation. Persistent
abdominal pain, focal tenderness, spiking fever, persistent tachycardia,
prolonged ileus, leukocytosis, or intermittent polymicrobial bacteremia
suggest an intra-abdominal abscess in patients with predisposing primary
intra-abdominal disease or in individuals who have had abdominal
surgery. If a deeply seated abscess is present, many of these classic
features may be absent. The only initial clues may be persistent fever,
mild liver dysfunction, persistent gastrointestinal (GI) dysfunction, or
nonlocalizing debilitating illness.
The diagnosis of an intra-abdominal abscess in the postoperative period
may be difficult, because postoperative analgesics and incisional pain
frequently mask abdominal findings. In addition, antibiotic administration
may mask abdominal tenderness, fever, and leukocytosis.
In patients with subphrenic abscesses, irritation of contiguous structures
may produce shoulder pain, hiccup, or unexplained pulmonary
manifestations, such as pleural effusion, basal atelectasis, or pneumonia.
With pelvic abscesses, frequent urination, diarrhea, or tenesmus may
occur. A diverticular abscess may present as an incarcerated inguinal
hernia. [7]
Many patients have a significant septic response, suffer volume depletion,
and develop a catabolic state. This syndrome may include high cardiac
output, tachycardia, low urine output, and low peripheral oxygen
extraction. Initially, respiratory alkalosis due to hyperventilation may occur.
If left untreated, this progresses to metabolic acidosis. Sequential multiple
organ failure is highly suggestive of intra-abdominal sepsis.

Differential Diagnoses
Inflammatory Bowel Disease
Persistent tachycardia
Prolonged ileus
Unexplained postoperative fever

Approach Considerations
Delayed diagnosis and treatment can lead to increased mortality and
have a significant economic impact. Accordingly, an efficient and well-
directed workup is important.
Laboratory Studies
Appropriate hematologic studies should be done. Hematologic
parameters suggestive of infection (eg, leukocytosis, anemia, abnormal
platelet counts, and abnormal liver function) frequently are present,
although patients who are debilitated or elderly often fail to mount reactive
leukocytosis or fever.
Blood cultures indicating persistent polymicrobial bacteremia strongly
implicate the presence of an intra-abdominal abscess. Because more
than 90% of intra-abdominal abscesses contain anaerobic organisms,
particularly B fragilis, postoperative Bacteroides bacteremia suggests
intra-abdominal sepsis.
Radiography
Plain abdominal radiographs, though rarely diagnostic, frequently indicate
the need for further investigation. [8] Abnormalities on plain abdominal films
may include a localized ileus, extraluminal gas, air-fluid levels, mottled
soft-tissue masses, absence of psoas outlines, or displacement of
viscera.
In subphrenic or even subhepatic abscesses, the chest radiograph may
show pleural effusion, elevated hemidiaphragm, basilar infiltrates, or
atelectasis.
Ultrasonography
Ultrasonography is readily available, portable, and inexpensive. The
findings can be quite specific when correlated with the clinical picture. In
experienced hands, ultrasonography has an accuracy rate greater than
90% for diagnosing intra-abdominal abscesses. Bedside ultrasonography
is particularly useful for immobile, critically ill intensive care unit (ICU)
patients.
A drawback of ultrasonography is that marked obesity, bowel gas,
intervening viscera, surgical dressings, open wounds, and stomas can
create problems with definition. In addition, the quality of the procedure is
operator-dependent. These disadvantages may limit the efficacy of this
modality in postoperative patients.
Computed Tomography
Computed tomography (CT) has greater than 95% accuracy and is the
best diagnostic imaging method for abdominal abscess. The presence of
ileus, dressings, drains, or stomas does not interfere with reliability.
For good anatomic resolution, use oral and intravenous (IV) contrast (see
the images below). Oral contrast may help to differentiate a fluid-filled
extraluminal structure from a normal intestine. Extravasation of oral
contrast indicates a fistula or an anastomotic leak. IV contrast may
enhance the abscess by concentrating the contrast material within the
abscess wall. The use of oral and IV contrast may be limited by ileus,
allergy to contrast material, and renal insufficiency.
 Contrast-
enhanced computed tomography (CT) scan of infected pancreatic
pseudocyst (which can develop from acute necrotizing pancreatitis and
give rise to an abscess).
View Media Gallery
 A 35-year-old man with a history of Crohn
disease presented with pain and swelling in the right abdomen. Figure A
shows a thickened loop of terminal ileum adherent to the right anterior
abdominal wall. In figure B, the right anterior abdominal wall, adjacent to
the inflamed terminal ileum, is markedly thickened and edematous. Figure
C shows a right lower quadrant abdominal wall abscess and enteric
fistula (confirmed by the presence of enteral contrast in the abdominal
wall).
View Media Gallery
Identify any occult abscesses using serial images obtained from the
diaphragm to the pelvis. The appearance of an air bubble within a fluid
collection or a low-attenuation extraluminal mass is diagnostic of an intra-
abdominal collection. CT can document inflammatory edema in the
adjacent fat (obliteration of fat plane) and hyperemia in the abscess wall
(enhancement).
Drawbacks of CT include nonportability, relative difficulty in diagnosing
intraloop abscesses, and, possibly, poor patient cooperation.
Recent intra-abdominal surgery also may pose a diagnostic problem in
patients in whom intra-abdominal abscesses are suspected. CT is not
recommended for use in diagnosing such abscesses until approximately
postoperative day 7, by which time postoperative tissue edema is
reduced and nonsuppurative fluids (eg, hematoma, seroma,
intraoperative irrigation fluid) should be reabsorbed. In most postoperative
patients, signs of intra-abdominal abscesses do not develop within the
first 4-5 days.
A literature review from the Netherlands indicated that CT is superior to
graded-compression ultrasonography in the diagnosis of acute
appendicitis, a potential cause of abdominal abscess. [9]
Radioisotope Scanning
Scans using radioactive agents, such as leukocytes labeled or tagged
with gallium-67 or indium-111, may localize the area of inflammation.
Such scans are time consuming, and they have a substantial false-
positive rate resulting from nonpyogenic inflammatory conditions, bowel
accumulation of tagged leukocytes, surgical drains, and incisions.
Typically, radioisotope scans provide no pertinent information that is not
found with CT. The disadvantages of these scans limit their use to cases
in which intra-abdominal abscesses are strongly suspected in a patient
but ultrasonography or CT has failed to provide adequate diagnostic
information.

Approach Considerations
Contraindications for surgical correction of abdominal abscesses are
based on the patients comorbidities and on the individuals ability to
tolerate surgery.
Pharmacologic Therapy
Pharmacologic therapy involves the empiric administration of parenteral
empiric antibiotics. This should be initiated before abscess drainage and
concluded when all systemic signs of sepsis have resolved. Because
abscess fluid usually contains a mixture of aerobic and anaerobic
organisms, initial empiric therapy must be directed against both types of
microbes. This may be accomplished with antibiotic combination therapy
or with broad-spectrum single-agent therapy. Specific therapy is then
guided by the results of cultures retrieved from the abscess. [5]
In patients who are immunosuppressed, candidal species may play an
important pathogenic role, and treatment with amphotericin B may be
indicated.
Percutaneous Abscess Drainage
Drainage of pus is mandatory and is the first line of defense against
progressive sepsis. Percutaneous computed tomography (CT)-guided
catheter drainage has become the standard treatment of most intra-
abdominal abscesses (see the image below). It avoids anesthesia and
possibly difficult laparotomy, prevents the possibility of wound
complications from open surgery, and may reduce the length of
hospitalization. It also obviates the possibility of contaminating other
areas within the peritoneal cavity.

Percutane
ous computed tomography (CT) scanguided drainage of postoperative
subhepatic collection.
View Media Gallery
CT-guided drainage delineates the abscess cavity and may provide safe
access for percutaneous drainage. When performed by experienced
physicians, it also prevents the possibility of injury to adjacent viscera or
blood vessels. [10, 11]
A diagnostic needle aspiration initially is performed to confirm the
presence of pus, which makes Gram staining and culture possible. A
large-bore drainage catheter is then placed in the most dependent
position.
In patients who are critically ill, initial percutaneous drainage can control
sepsis and improve hemodynamics before definitive surgical treatment (if
this becomes necessary). Initial catheter drainage also may drain a
peridiverticular abscess enough to make a single-stage resection and
bowel anastomosis possible, thus avoiding multiple-stage procedures. A
visualized collection may be sterile (eg, bile, hematoma) or infected, and
CT-guided aspiration is most helpful in distinguishing between these
states. [12]
After drainage, clinical improvement should occur within 48-72 hours.
Lack of improvement within this time frame mandates repeat CT to check
for additional abscesses. Surgical drainage becomes mandatory if
residual fluid cannot be evacuated with catheter irrigation, manipulation,
or additional drain placement.
Criteria for removal of percutaneous catheters include resolution of sepsis
signs, minimal drainage from the catheter, and resolution of the abscess
cavity as demonstrated by ultrasonography or CT. Persistent drainage
usually reflects the presence of an enteric fistula, and CT with contrast
should be performed. Frequently, this fistula can be documented by
sinography.
Complications of percutaneous drainage include bleeding or inadvertent
puncture of the gastrointestinal (GI) tract.
Percutaneous drainage is effective in 90% of patients who have a single
unilocular abscess with no enteral communication. Complex abscesses
that include multiple loculations or interloop abscesses or those
associated with an enteric fistula may necessitate surgery. Surgical
intervention also may be indicated for abscesses with tenacious contents,
such as infected hematoma, infected pancreatic necrosis, or fungal
abscesses.
Laparoscopic or Open Abscess Drainage
If percutaneous drainage fails or if collections are not amenable to
catheter drainage, surgical drainage is an option. The surgical approach
may be either laparoscopic or open (laparotomic).
Laparoscopic drainage for a massive intra-abdominal abscess is
minimally invasive, permitting exploration of the abdominal cavity without
the use of a wide incision; purulent exudate can be aspirated under direct
vision. [13]
With accurate preoperative localization, direct open surgical drainage
may be possible through an extraperitoneal open approach. This
technique reduces the risk of bowel injury, contamination spread, and
bleeding. It also allows for a faster return of bowel function.
The transperitoneal open approach is made safer by the judicious use of
preoperative antibiotics. Although contamination of otherwise uninfected
sites remains a major concern, this complication is particularly reduced if
the organisms involved are sensitive to the chosen drugs.
Transabdominal exploration of the entire peritoneal cavity allows fibrin
debridement. It also permits complete bowel mobilization to locate and
drain all synchronous abscesses, which occur in as many as 23% of
patients.
Transperitoneal exploration is indicated for multiple abscesses not
amenable to CT-guided drainage, such as interloop collections or an
enteric fistula feeding the abscess. In the latter situation, draining the
abscesses with an enteric communication may be possible for several
days before a laparotomy is performed to control the fistula. This may
allow some resolution of the inflammatory process, thus making surgery
less difficult.
Pelvic abscesses often are palpable as tender, fluctuant masses
impinging on the vagina or rectum. Draining these abscesses
transvaginally or transrectally is best to avoid the transabdominal
approach.
During the course of a laparotomy, the surgeon must use digital or direct
exploration to be certain that all loculations are broken down and that all
debris (eg, hematoma, necrotic tissue) is evacuated. Irrigation must be
complete, and a Penrose or sump drain should be placed to allow
continued evacuation and collapse of the abscess cavity postoperatively.
Improved clinical findings within 3 days after treatment indicate successful
drainage. Failure to improve may indicate inadequate drainage or another
source of sepsis. If left untreated, the septic state inevitably produces
multiple organ failure.
The transabdominal open approach to intra-abdominal abscesses can be
exceedingly difficult. Matted bowel, adhesions, and loss of anatomic
integrity can pose severe problems. This is especially true when
susceptible viscera, such as a loop of small bowel, intermittently adhere
to the abscess wall or cavity. Therefore, whenever possible, CT-guided
drainage is a valuable initial step.

Medication Summary
The goals of pharmacotherapy in patients with abdominal abscess are to
reduce morbidity and prevent complications. Empiric antimicrobial therapy
must be comprehensive and should cover all likely pathogens in the
context of the clinical setting.
Antifungal Agents
Class Summary
Antifungal agents may alter cell membrane permeability in susceptible
fungi, causing subsequent death.
Amphotericin B
Amphotericin B is produced from a strain of Streptomyces nodosus. The
antifungal activity of amphotericin B results from its ability to insert itself
into fungal cytoplasmic membrane at sites containing ergosterol or other
sterols. Aggregates of amphotericin B accumulate at sterol sites, resulting
in an increase in cytoplasmic membrane permeability to monovalent ions
(eg, potassium, sodium). At low concentrations, the main effect is
increased intracellular loss of potassium, resulting in reversible fungistatic
activity; however, at higher concentrations, pores of 40-105 nm are
produced in the cytoplasmic membrane, leading to large losses of ions
and other molecules. A second effect of amphotericin B is its ability to
cause auto-oxidation of the cytoplasmic membrane and release of lethal
free radicals. The main fungicidal activity of amphotericin B may reside in
its ability to cause auto-oxidation of cell membranes.

1. Eberhardt JM, Kiran RP, Lavery IC. The impact of anastomotic leak
and intra-abdominal abscess on cancer-related outcomes after
resection for colorectal cancer: a case control study. Dis Colon
Rectum. 2009 Mar. 52(3):380-6. [Medline].
2. Varcus F, Lazar F, Beuran M, Lica I, Turculet C, Nicolau E, et al.
Laparoscopic treatment of perforated duodenal ulcer - a multicentric
study. Chirurgia (Bucur). 2013 Mar-Apr. 108(2):172-6. [Medline].

3. L V, Rao V D, Rao M S, Y M. "Toxic Pancreatitis with an Intra-

Abdominal Abscess which was Caused by Organophosphate
Poisoning (OP)". J Clin Diagn Res. 2013 Feb. 7(2):366-
8. [Medline]. [Full Text].

4. Yang YM, Tian XD, Zhuang Y, Wang WM, Wan YL, Huang YT. Risk
factors of pancreatic leakage after
pancreaticoduodenectomy. World J Gastroenterol. 2005 Apr 28.
11(16):2456-61. [Medline].

5. Hasper D, Schefold JC, Baumgart DC. Management of severe

abdominal infections. Recent Pat Antiinfect Drug Discov. 2009 Jan.
4(1):57-65. [Medline].

6. Malangoni MA, Shumate CR, Thomas HA, Richardson JD. Factors

influencing the treatment of intra-abdominal abscesses. Am J Surg.
1990 Jan. 159(1):167-71. [Medline].
7. Greenberg J, Arnell TD. Diverticular abscess presenting as an
incarcerated inguinal hernia. Am Surg. 2005 Mar. 71(3):208-
9. [Medline].

8. Pedrazzoli S, Liessi G, Pasquali C, Ragazzi R, Berselli M, Sperti C.

Postoperative pancreatic fistulas: preventing severe complications
and reducing reoperation and mortality rate. Ann Surg. 2009 Jan.
249(1):97-104. [Medline].

9. van Randen A, Bipat S, Zwinderman AH, Ubbink DT, Stoker J,

Boermeester MA. Acute appendicitis: meta-analysis of diagnostic
performance of CT and graded compression US related to
prevalence of disease. Radiology. 2008 Oct. 249(1):97-
106. [Medline].

10. Hemming A, Davis NL, Robins RE. Surgical versus

percutaneous drainage of intra-abdominal abscesses. Am J Surg.
1991 May. 161(5):593-5. [Medline].

11.Rypens F, Dubois J, Garel L, Deslandres C, Saint-Vil D.

Percutaneous drainage of abdominal abscesses in pediatric
Crohn's disease. AJR Am J Roentgenol. 2007 Feb. 188(2):579-
85. [Medline].

12. Laborda A, De Gregorio MA, Miguelena JM, Medrano J,

Gmez-Arrue J, Serrano C, et al. Percutaneous treatment of
intrabdominal abscess: urokinase versus saline serum in 100 cases
using two surgical scoring systems in a randomized trial. Eur
Radiol. 2009 Jul. 19(7):1772-9. [Medline].

13. Kimura T, Shibata M, Ohhara M. Effective laparoscopic

drainage for intra-abdominal abscess not amenable to
percutaneous approach: report of two cases. Dis Colon Rectum.
2005 Feb. 48(2):397-9. [Medline].

What to Read Next on Medscape