Endoscopic ultrasound-guided drainage of pelvic abscess: A case series of 8 patients

AIM: To show the safety and effectiveness of endo-scopic ultrasound(EUS)-guided drainage of pelvic ab-scess that were inaccessible for percutaneous drainage. METHODS: Eight consecutive patients with pelvic abscess that were not amenable to drainage under computed tomography(CT) guidance were referred for EUS-guided drainage. The underlying cause of the abscesses included diverticulitis in 4, postsurgical surgi-cal complications in 2, iatrogenic after enema in 1, and Crohn's disease in 1 patient. Abscesses were all drained under EUS guidance via a transrectal or transsigmoidal approach. RESULTS: EUS-guided placement of one or two 7 Fr pigtail stents was technically successful and uneventful in all 8 patients(100%). The abscess was perisigmoidal in 2 and was multilocular in 4 patients. All procedures were performed under conscious sedation and without fluoroscopic monitoring. Fluid samples were success-fully retrieved for microbiological studies in all cases and antibiotic policy was adjusted according to cultureresults in 5 patients. Follow-up CT showed complete re-covery and disappearance of abscess. The stents were retrieved by sigmoidoscopy in only two patients and had spontaneously migrated to outside in six patients. All drainage procedures resulted in a favourable clinical outcome. All patients became afebrile within 24 h after drainage and the mean duration of the postprocedure hospital stay was 8 d(range 4-14). Within a median follow up period of 38 mo(range 12-52) no recurrence was reported. CONCLUSION: We conclude that EUS-guided drain-age of pelvic abscesses without fluoroscopic monitoring is a minimally invasive, safe and effective approach that should be considered in selected patients.     

Pyogenic liver abscess: a 7-year experience in a large community hospital

This is a retrospective study of 27 consecutive patients with a diagnosis of pyogenic liver abscess (PLA) seen over a period of 7 years. There were 10 males and 17 females whose ages ranged from 5 to 86 years (mean 56). Fever, abdominal pain and vomiting were the commonest symptoms, and abdominal tenderness was the commonest physical finding. An elevated alkaline phosphatase was seen in 78% of all patients and was the commonest biochemical abnormality. Biliary disease accounted for a third of all cases, and in 22% of the patients the abscesses were considered to be idiopathic. Ultrasonography and/or CT scanning was employed in the diagnosis and follow-up of all patients. Percutaneous needle aspiration (PNA) and percutaneous drainage (PCD) under ultrasound or CT guidance was employed as the primary therapy in 24 patients. The procedure failed in 5 patients (18.5%), there was 1 complication (3.7%) and no deaths were seen as a result of these procedures. Three patients (11%) ultimately died of their abscesses. This study emphasizes the important role of percutaneous drainage as a complementary form of therapy to surgical drainage in the management of pyogenic liver abscesses.     

Endoscopic ultrasound‐guided drainage of pelvic abscess without fluoroscopy guidance

Background and Aims: Few case series are reported on endoscopic ultrasound (EUS)‐guided drainage of pelvic abscesses under fluoroscopy guidance. We hypothesized that EUS‐guided drainage of pelvic abscesses without fluoroscopy is an effective alternative to surgery in patients whose abscesses are not amenable to percutaneous drainage techniques. The aim of this study is to evaluate the clinical efficacy of EUS‐guided trans‐rectal/transcolonic drainage of pelvic abscess without fluoroscopy. Methods: Fourteen consecutive patients with pelvic abscesses not amenable to percutaneous drainage underwent EUS‐guided drainage over a period of 22 months. Main outcome measures were the resolution of the pelvic abscess on repeat imaging and improved clinical symptoms. Results: Fourteen consecutive patients were enrolled. EUS‐guided aspiration was performed in three patients. In two patients, dilatation and aspiration was performed, while trans‐rectal stent was placed in nine patients. All patients became afebrile within 72 h. Stent was removed in all patients, after confirming the resolution of the abscess on repeat computed tomography after 7 days. One patient in whom only aspiration was done had recurrence of fever and abscess on the seventh day and was treated by surgical drainage. A follow‐up EUS done in 13 of the patients after 3 months revealed no recurrence, and all patients were asymptomatic at 6 months. The procedure was uneventful in all patients. Conclusion: Endoscopic ultrasound‐guided drainage without fluoroscopy is a safe and effective modality of treatment for pelvic abscesses not amenable to radiologically guided drainage, thus reducing the need for surgical intervention.     

Ultrasound guided percutaneous treatment for splenic abscesses： The significance in treatment of critically ill patients

INTRODUCTION Splenic abscess is an uncommon entity with a reported frequency in autopsy series between 0.14% and 0.7%, and with high mortality rates because of delayed detection and treatment[1-3]. It often presents with either vague or nonspecific signs,…     

老年人糖尿病合并细菌性肝脓肿的超声介入治疗

目的 评价超声引导下穿刺抽脓及置管引流治疗老年人糖尿病合并细菌性肝脓肿的临床应用价值。方法 对46例老年糖尿病合并细菌性肝脓肿的患者进行经超声引导下脓汁抽吸、置管引流治疗。结果 46例患者穿刺抽脓及置管引流全部成功，治愈率93．5％（43／46），所有患者均未出现穿刺并发症。随后30、60、180d经门诊随访未见复发。结论 超声引导下介入治疗老年人糖尿病合并细菌性肝脓肿安全、有效，可以明显缩短疗程，可作为首选的治疗方法。     

Tuberculous liver abscess: a case report and review of literature

Tuberculous liver abscess is rare worldwide. We report a 45-year-old man who presented with abdominal pain, fever and weight loss. Ultrasound and computed tomography of the abdomen showed multiple cystic lesions in the liver. Ultrasound guided needle aspiration revealed yellowish brownish aspirate, which was flooded with acid-fast bacilli. The abscess was drained under ultrasound guidance. Subsequent abdominal ultrasound a few days later showed resolution of the abscess cavity. He was concomitantly started on systemic antituberculous therapy. A tuberculous liver abscess has to be thought of in the differential diagnosis of liver abscesses and to consider the role of percutaneous drainage along with systemic antituberculous chemotherapy as an alternative to surgery in the management. A greater awareness of this clinical entity is required for successful treatment.     

Non-operative management of pyogenic liver abscess

BackgroundLiver abscess is a serious disease traditionally managed by open drainage. The advances in interventional radiology over the last two decades have allowed a change in approach to this condition. We have reviewed our experience in managing liver abscess over the last 7 years.MethodsDetails of all patients admitted with liver abscess between 1995 and 2002 were prospectively entered onto our database. A review was performed to document the use of imaging and drainage techniques. Aetiology, morbidity, mortality and duration of hospital stay were recorded.ResultsForty-two patients (median age 53 [22–85] years; M:F 18:24) were admitted with liver abscess (multiple abscess 20); 19 cases were of portal tract origin, 16 cases were of biliary tract origin and 7 cases were spontaneous. Forty-one patients were managed non-operatively, all received antibiotics (cephalo-sporins 76%, metronidazole 88%, quinolones 33%). Diagnosis was made on ultrasound scan (22) or CT (20). Five patients were managed with antibiotics alone. Fifteen patients were managed initially with percutaneous aspiration and five subsequently required percutaneous drainage. Twenty-one patients had primary percutaneous drainage, nine requiring a further procedure (aspiration 3, drainage 6). One patient underwent hepatic resection. Median hospital stay was 16 (6–35) days. There was one death, but no procedure-related morbidity.DiscussionNon-operative management of solitary and multiple liver abscesses is safe and effective.     

Surgical drainage of primary iliopsoas abscess--safe and cost-effective treatment

The report evaluates surgical drainage (SD) as a primary treatment of primary iliopsoas abscess (PIA). Seventy-two patients, who underwent SD for PIA at B P Koirala Institute of Health Sciences, Dharan, Nepal were studied. SD was performed through a lower abdominal, extra peritoneel, muscle splitting incision. Ultrasonography was used to diagnose the abscess in 53/54 patients (98%). Staphylococcus aureus was the most frequent organism grown in 45/65 patients (69%).The mean duration of drainage was 3.2 +/- 1.4 days (range, 1-7 days). The treatment was successful in resolving the abscesses in all patients.The mean hospital stay was 9.0 +/- 5.4 days (range, 3-40 days). Two patients (2.8%) developed a recurrence, 10 months and 1 year after the operation, respectively. Another patient developed an incisional hernia. There were no deaths. The average cost of treatment to the patient was approximately Nepali rupees 2800 (US$ 40). Surgical drainage appears to be a cost-effective and safe treatment for PIA.     

Percutaneous drainage under real-time computed tomography-fluoroscopy guidance

BACKGROUND/AIMS: The goal of our study was to assess the use of real-time computed tomography-fluoroscopy guidance for percutaneous drainage of abnormal thoracic, abdominal, and pelvic fluid collections. METHODOLOGY: The subjects were 32 patients who underwent 36 percutaneous computed tomography-fluoroscopy guided thoracic, abdominal, and pelvic drainage procedures to drain abscess (n=29), fluid collection after pancreatitis (n=3), lymphocyst after gynecological surgery (n=3), and the gallbladder transhepatically (n=1) between September 1997 and August 2003. The patient population was 28-86 years old and consisted of 19 men and 13 women. The drainage methods included a Seldinger's technique with a guidewire and serial dilators in every case. The procedures were guided by using a helical computed tomography scanner that provided real-time fluoroscopy reconstruction. RESULTS: Percutaneous drainage under real-time computed tomography-fluoroscopy guidance was successfully performed in every procedure. Real-time computed tomography-fluoroscopy allowed rapid assessment of needle, guidewire, dilator, and catheter placement. The only drainage-induced complication encountered was a subcutaneous hematoma after one procedure (2.8%). No patients had serious complications. The average procedure time was 32 minutes. CONCLUSIONS: Computed tomography-fluoroscopy is a useful method for guiding the accurate and safe drainage of abnormal thoracic, abdominal, and pelvic fluid collections.     

Effective Laparoscopic Drainage for Intra-Abdominal Abscess Not Amenable to Percutaneous Approach: Report of Two Cases

PURPOSE The usefulness of the laparoscopic approach for massive intra-abdominal abscesses is controversial. We report two patients who underwent laparoscopic abscess drainage for massive intra-abdominal abscesses not amenable to the percutaneous approach that were suspected to be caused by acute appendicitis.METHODS In both patients, four ports were placed at their abdominal walls under general anesthesia. Intra-abdominal abscess cavities were punched out, and the purulent exudates that spilled out from the cavities were aspirated completely. Copious irrigation was performed under direct vision. These procedures were completed laparoscopically.RESULTS The postoperative clinical courses of the patients were uneventful. The intra-abdominal abscesses did not recur, and no wound complications were recognized. The patients were discharged from our hospital in excellent condition within two weeks.CONCLUSIONS Laparoscopic drainage for massive intra-abdominal abscess is a minimally invasive and useful procedure compared with the open method or the percutaneous approach. It offers the advantage of being able to explore of the abdominal cavity without an unnecessary wide incision, and aspiration of a purulent exudate is possible under direct vision.     

Percutaneous postoperative intra-abdominal abscess drainage after elective colorectal surgery

Intra-abdominal abscesses are a frequent source of morbidity and mortality following both elective and emergent surgery of the alimentary tract. CT-guided percutaneous drainage of intra-abdominal abscess is an alternative to immediate surgical intervention. We studied the clinical characteristics and outcomes of patients undergoing percutaneous drainage of intra-abdominal abscesses arising after elective colorectal procedures. We retrospectively identified 40 patients with postoperative intraabdominal abscess following elective colorectal surgery who underwent CT-guided percutaneous drainage with a Von Sonnenberg sump drain between 1990 and 1998. The most common presenting symptoms were pyrexia in 39 (97%), abdominal tenderness in 32 (80%), guarding in 1 (2.5%) and abdominal mass in 3 (7.5%); no patient had generalized peritonitis. The most common index procedure was proctocolectomy with ileoanal anastomosis and ileal Jpouch in 12 (30%) patients. Drainage was performed using an anterior approach in 32 (80%) and a transgluteal window in 8 (20%) patients. Thirty-five (87.5%) patients had a single collection, while 2 (5.0%) patients had 2 collections and 3 (7.5%) patients had 3 collections. Thirteen (32.5%) patients had perioperative steroids, 30 (75%) had preoperative antibiotics, and 40 (100%) had postoperative antibiotics. Follow-up at a mean of 35.8 days revealed complete resolution of abscess in 26 (65%) patients; 14 (35%) patients had residual or recurrent abscess successfully treated by repeat drainage in 8 patients and requiring laparotomy in 6. Percutaneous CT-guided abscess drainage is an effective method for treating intra-abdominal abscess following elective colorectal surgery. The primary success was 65% after the first and 85% after a second drainage. In conclusion, this technique should be considered as the treatment of choice in patients with localized intra-abdominal abscess without signs of generalized peritonitis. Received: 20 July 2002 / Accepted: 4 November 2002     

The role of percutaneous transhepatic abscess drainage for liver abscess

To evaluate the efficacy of percutaneous transhepatic abscess drainage (PTAD) as an initial choice of treatment for liver abscess, the medical records of 28 patients with liver abscess were retrospectively analyzed. The patients were predominantly men (23 of 28) with a mean age of 59 years (range, 19—86 years). Their chief complaints were fever (86%), right hypochondralgia (32%), and jaundice (11%). Fifteen of the 28 patients (54%) had hepatobiliary and pancreatic carcinoma, and 31% had postoperative liver abscess. PTAD was performed in 23 patients and surgical drainage in 5. The overall success rate for PTAD was 83%. The success rate for PTAD for patients with multiple abscesses was 83% (5 of 6), compared with a success rate of 82% (14 of 17) for patients with solitary abscess. The prognostic factors for survival were cancer and sepsis and the mortality rate for patients with cancer was 40% (6 of 15) while the mortality rate for patients with sepsis was 56% (5 of 9). As a complication of drainage, 1 patient (4%) in the PTAD group had pleural abscess due to the transpleural puncture. Our findings support the use of PTAD as the primary treatment for liver abscess, as it is safe and effective irrespective of the number of abscesses and the patient's condition.     

Outcome of surgical versus percutaneous drainage of abdominal and pelvic abscesses in Crohn's disease

OBJECTIVE: Abdominal and pelvic abscesses are a common complication of Crohn's disease. We studied the effect of the initial choice of therapy on time to resolution of abdominal and pelvic abscesses. METHODS: We recorded clinical, laboratory, and radiographic data on all adult patients with Crohn's disease and abdominal or pelvic abscesses treated at our institution from 1991 to 2001 and followed > or = 1 yr. Univariate analysis identified variables associated with initial choice of drainage modality. These variables were included in a Cox regression model to identify factors independently associated with time to resolution. RESULTS: Of 66 episodes identified, surgery was the initial modality in 29 and percutaneous drainage in 37. Median time to resolution was not different between surgical drainage (25.0 days, range 0-240) and percutaneous drainage (21.5 days, range 0-182) (p = 0.084). Older age, longer duration of symptoms prior to drainage, no fistula identified radiographically, immune modulator use, no rebound tenderness, and admission to the medical service were factors associated with percutaneous drainage as initial modality. These factors, when incorporated in a Cox regression model, did not significantly affect the time to resolution. Days from onset of symptoms to radiographic diagnosis or drainage were independently associated with time to resolution of the abscess. CONCLUSION: Time to resolution of abdominal or pelvic abscesses in Crohn's disease is similar with percutaneous drainage and surgery. One-third of patients treated with percutaneous drainage required surgery within 1 yr. Earlier intervention for abdominal and pelvic abscesses is associated with shorter time to resolution.     

Outcome of hepatic amebic abscesses managed with three different therapeutic strategies

Three different approaches to hepatic abscesses due toEntamoeba histolytica were compared in 51 patients. The three modes of therapy utilized were: medical therapy with nitroimidazoles(N=11 patients), open surgical drainage (N=9 patients), and percutaneous drainage using ultrasound guidance followed by intralesional nitroimidazole administration (N=31 patients). The results with each form of therapy were assessed clinically and by abdominal ultrasound. Patients receiving combined US-guided drainage and intralesional chemotherapy experienced a faster and overall better clinical response, which was confirmed also by sonographic follow-up of the hepatic lesions. This better response was associated with faster resolution, fewer relapses, and less residual hepatic scarring than either with medical therapy alone or open surgical drainage combined with medical therapy.     

Splenic abscess: sonographic diagnosis and percutaneous drainage or aspiration.

During a recent 5-year period, 12 patients with splenic abscesses were evaluated by abdominal ultrasound (US) examination. Multifocal abscesses were noted in seven patients, three of them were secondary to infectious endocarditis, three were in immunosuppressed state, and one was caused by tuberculosis. The latter four patients had developed splenic microabscesses with a diameter of less than 1.5 cm. The larger abscesses showed an irregular wall, weak or no internal echoes, ovoid or round in shape, and accompanied by mild to moderate distal acoustic enhancement. Wedge-shaped abscesses were typically noted in patients with infectious endocarditis and septic embolism. US-guided percutaneous drainage was done in five patients (abscesses greater than 4 cm). Simple aspiration in conjunction with antibiotic administration was done for seven smaller abscesses (diameter less than 3.5 cm) in five patients. A second drainage, either for a dislodged catheter or a recurrent abscess, was performed in two cases. All patients had uneventful clinical course following this therapeutic approach.     

Percutaneous treatment of an intrahepatic abscess caused by a penetrating duodenal ulcer

We present a well-documented case of duodenal ulcer that penetrated into the quadrate lobe of the liver with subsequent abscess and fistula formation. An accurate diagnosis depended on the use of ultrasound to identify the presence of an abnormal gas pattern in the liver which had been mistaken for bowel on computed tomography. Successful percutaneous drainage under ultrasound guidance was then accomplished. This is the first recorded case we can find in which percutaneous drainage combined with antibiotic and H2 blocker therapy was able to supplant the surgical treatment of liver abscess with an enteric fistula. The diagnosis and management of this condition are discussed. Special reference is made to the use of ultrasound to overcome a major pitfall in the use of computed tomography for diagnosing liver abscesses with fistula formation.     

Percutaneous drainage of liver and splenic abscess

42 patients with solitary (n = 34) and multiple (n = 8) abscesses of the liver (n = 36) and the spleen (n = 6) were treated with ultrasound guided percutaneous interventions. 38 patients (90%) underwent a total of 97 closed abscess aspirations using needles of 0.9 and 1.3 mm in diameter. In 4 cases (10%) percutaneous catheter drainage was performed. Intravenous antibiotics were used in all cases. Those patients with closed abscess aspiration additionally received local injection of aminoglycosides into the cavity. 40 out of the 42 patients could be treated successfully by percutaneous methods for a cure rate of 95.2%. Percutaneous drainage failure occurred in 2.4%. One patient with multiple liver abscesses and catheter drainage died from myocardial infarction (hospital mortality 2.4%). Complications of ultrasound-guided interventions included two minor bleedings, requiring no therapy, and one pleural empyema (complication rate 7.1%). There were no treatment related lethal complications. These results indicate that abscesses of the liver and the spleen up to 10 cm in diameter can be effectively treated by closed (repetitive) needle aspiration and antibiotic therapy with a relatively low rate of complications. About half of our patients with abscesses of more than 10 cm received percutaneous catheter drainage. On the basis of our experience surgical drainage of liver abscesses and splenectomy in splenic abscesses should be restricted to those cases with percutaneous drainage failure.     

Hepatic abscesses in immunocompromised patients: ultrasonically guided percutaneous drainage.

Ultrasonically guided percutaneous drainage (US-PD) is considered first-line therapy for hepatic abscesses, but no data are available on its efficacy in severely immunocompromised patients. Therefore, we examined 15 such patients in whom one or more hepatic abscesses of different etiology were treated with US-PD. Eleven patients underwent needle aspiration and four had catheter drainage under US guidance. In 12 cases we achieved complete healing of the abscesses. In one case, clinical improvement was obtained but surgery was required for cure. In another case (fungal abscess in AIDS), we had no improvement and the patient died. No procedural complications were observed. Seven patients died during the follow-up periods of up to 49 months from their underlying disease. We conclude that US-PD must be considered the therapy of choice for hepatic abscess (except the fungal lesions) in severely immunocompromised patients.     

Abscesses in Crohn's disease: outcome of medical versus surgical treatment

GOALS: To compare the long-term outcome of medical, percutaneous, and surgical treatment of abdominal and pelvic abscesses complicating Crohn's disease. STUDY: All patients with Crohn's disease and an abdominal abscess treated at one institution during a 10-year period were retrospectively identified. We reviewed hospital and outpatient records and contacted patients for telephone interviews. Outcome measures included abscess recurrence, subsequent surgery for Crohn's disease, and medications used at the time of most recent follow-up. RESULTS: Fifty-one subjects were identified, with a mean follow-up of 3.75 years. Fewer patients developed recurrent abscesses after initial surgical drainage and bowel resection (12%) than patients treated with medical therapy only or percutaneous drainage (56%) (p = 0.016). One half of the patients treated nonoperatively ultimately required surgery, whereas only 12% of those treated with initial surgery required reoperation during the follow-up period (p = 0.010). Most failures of nonoperative therapy occurred within 3 months. Medication use was similar between the treatment groups at the time of most recent follow-up. CONCLUSIONS: In this series, surgical management of abscesses in Crohn's disease was more effective than medical treatment or percutaneous drainage for prevention of abscess recurrence. However, nonoperative therapy prevented subsequent surgery in half of the patients and may be a reasonable treatment option for some patients.     

Obturator internus muscle abscess in children: report of seven cases and review.

Obturator internus muscle (OIM) abscess is an uncommon entity often mistaken for septic arthritis of the hip. We describe seven children with OIM abscess and review seven previously reported cases. The most common presenting symptoms were hip or thigh pain (14 patients), fever (13), and limp (13). The hip was flexed, abducted, and externally rotated in 11 patients. Magnetic resonance imaging and computed tomography (CT) were diagnostic for OIM abscess in the 14 patients. Associated abscesses were located in the obturator externus muscle (5 patients), psoas muscle (2), and iliac muscle (1). The etiologic agents were Staphylococcus aureus (8 patients), Streptococcus pyogenes (2), Neisseria gonorrhoeae (2), and Enterococcus faecalis (1). Three patients underwent CT-guided percutaneous drainage, and three had surgical drainage. Three patients had ischial osteomyelitis in addition to OIM abscess. The 11 children with uncomplicated OIM abscess were treated for a median of 28 days. All patients had an uneventful recovery.