Strategies in the management of pyogenic psoas abscesses.

The presentation and management of eight patients with pyogenic psoas abscesses treated at the National Naval Medical Center, Bethesda, Maryland, between January 1986 and July 1989 are presented. The psoas abscesses were secondary to underlying gastrointestinal disease in six patients and sacral osteomyelitis in one patient. In one patient, the etiology of the abscess could not be determined. The average duration of symptoms in these patients was 16 days. Computed tomography was useful in identifying the abscess, defining its complexity, and planning therapy in all eight patients. Seven patients had complex, multiloculated abscesses, and one patient had a simple abscess. Extraperitoneal drainage was used in all patients. The patients with multiloculated abscesses had open surgical drainage, while the patient with the simple abscess had percutaneous catheter drainage. Most patients with a gastrointestinal etiology for their abscess underwent staged resection 3 to 6 weeks after the drainage procedure. There were no deaths, recurrent abscesses, or fistulae in these patients. Two patients developed thromboembolic complications postoperatively. Extraperitoneal drainage with staged resection of underlying gastrointestinal pathology is a safe and effective way of treating patients with psoas abscesses.     

Management of liver abscess

Thirteen patients with amebic liver abscess and 26 with pyogenic abscess were identified during a 10 year period. All but one patient with an amebic abscess had emigrated or traveled to areas where amebiasis was endemic. Half of the patients in whom pyogenic abscesses developed had debilitating disease and anemia. Factors predisposing to multiple rather than solitary hepatic abscess were biliary tract disease before surgery, cancer, chemotherapy, steroid administration and alcoholism. Elevated levels of alkaline phosphatase and hypoalbuminemia were present in most patients. Three patients with amebic abscess died, two of whom has massive gastrointestinal hemorrhage from associated amebic colitis. No patient with a solitary pyogenic liver abscess died. Fifteen of 16 patients with multiple liver abscesses died. Failure to consider the diagnosis of liver abscess, confusion over interpretation of the scan, failure to operate or provide a timely operation and failure to adequately explore the abdomen or identify all abscesses were factors responsible for eight unnecessary deaths.     

Pyogenic liver abscess: Changing patterns in approach

AIM: To define optimum management of the pyogenic liver abscess and assess new trends in treatment.METHODS: One hundred and sixty nine patients with pyogenic liver abscess managed at Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir (India) from July 2001 to August 2006 were studied to evaluate and define the optimum treatment.RESULTS: Mortality in the surgically treated group of patients was 9.4% (12/119), while those treated non-surgically had a fatality rate of 16.66% (7/42). Multiple liver abscesses treated surgically had a surprisingly low mortality of 30%. The biliary tract (64.97%) was the most common cause of liver abscess. Multiple abscesses, mixed organisms and abscess complications are all associated with a significantly increased mortality. However, the lethality of the primary disease process was the most important factor in determining survival.CONCLUSION: Transperitoneal surgical drainage and antibiotics are the mainstay of treatment. Percutaneous drainage is recommended for high risk patients only.     

Treatment of pyogenic hepatic abscesses. Surgical vs percutaneous drainage

A retrospective review of 39 patients with pyogenic hepatic abscess treated from 1977 through 1984 included 23 patients who were surgically treated and 16 who underwent percutaneous drainage. The average age in each group was similar (about 55 years). The most common cause of abscesses in each group was biliary tract disease. Abscesses caused by portal seeding and local extension were more common in the surgical group, 14 of whom required additional surgical procedures at the time of surgical drainage. Of the 16 patients in the percutaneously drained group, seven were seen during the immediate postoperative period. Most of the abscesses occurred in the right lobe of the liver, but single abscesses in the left lobe (30%) and multiple abscesses (57%) were more common in the surgical group. Klebsiella enterobacter and group D streptococcus were most common in the surgically and percutaneously drained groups, respectively. All patients received antibiotics, with a mean length of treatment of 14 days. Mean time to defervescence was about four days in both groups, with a longer hospital stay for the percutaneously drained group (26 vs 46 days). Morbidity was high in both groups (surgical, 48%; percutaneous, 69%). Three of the percutaneously treated patients required surgical drainage because of highly viscous abscess contents. Mortality was 17% in the surgical group and 13% in the percutaneously drained group. Percutaneous drainage with computed tomography probably should be the initial drainage procedure in patients with pyogenic hepatic abscesses in whom no concomitant surgical procedure is planned. Regardless of treatment, the morbidity and mortality remain high.     

Laparoscopic Drainage of Pyogenic Liver Abscess

Background and Objectives:

Pyogenic liver abscesses are mainly treated by percutaneous aspiration or drainage under antibiotic cover. If interventional radiology fails, surgical drainage becomes necessary. Recently, we performed laparoscopic liver abscess drainage successfully, and we aimed to focus on the topic in light of a systematic review of the literature.

Methods:

A 22-year-old man was admitted with a 4.5-cm multiloculated abscess in the left lobe of the liver. The abscess did not resolve with antibiotic-alone therapy. Percutaneous aspiration was unsuccessful due to viscous and multiloculated contents. Percutaneous catheter placement was not amenable. Laparoscopic abscess drainage was preferred over open abscess drainage. We used 3 trocars, operation time was 40 minutes, and blood loss was minimal. In the mean time, we searched PubMed using the key words [(liver OR hepatic) abscess*] AND [laparoscop* OR (minimal* AND invasiv*)].

Results:

Postoperative recovery of the patient was uneventful, and the patient was asymptomatic after 3 months of follow-up. In the literature search, we found 53 liver abscesses (51 pyogenic and 2 amebic) that were treated by laparoscopy. Mean success rate was 90.5% (range, 85% to 100%) and conversion rate was zero.

Conclusion:

Treatment of liver abscess is mainly percutaneous drainage. Laparoscopic drainage should be selected as an alternative before open drainage when other modalities have failed.     

Percutaneous management of pyogenic hepatic abscesses

Twelve patients (9 men, 3 women) with a mean age of 65 (54-78) years, with pyogenic hepatic abscesses were managed by percutaneous drainage between 1979 and 1987. Biliary origin was most common (4 patients), followed by hepatic abscesses as a late postoperative complication (seen in 3 patients) and hepatic abscesses occurring in association with acute appendicitis (2 patients). The origin was unknown in 3 patients. Diagnosis was reached by computed tomography or ultrasonography with a diagnostic delay of in mean 11 days. Seventeen abscesses were found among the 12 patients. The median abscess size (maximal diameter) was 7 (1-12) cm. Nine patients were treated with percutaneous drainage with an indwelling catheter within the abscess cavity for up to 3 weeks, while 3 patients were managed with percutaneous puncture and aspiration alone. The most commonly isolated organism from the drained hepatic abscess was E. coli. The course following percutaneous treatment was uneventful, without mortality and recurrence of the hepatic abscess during follow-up. One patient required surgical drainage of an additional hepatic abscess. Percutaneous drainage of hepatic abscesses, independent of origin, thus seems as a safe and reliable method, which should be considered as the treatment of choice if facilities and knowledge of percutaneous management are provided.     

Multiple pyogenic brain abscesses

Summary Thirty eight patients with multiple pyogenic brain abscesses constituted 11% of all the brain abscesses treated during a 12 year period. Sixty per cent (23) of the patients were in the first two decades of life, including 9 (24%) infants.The clinical presentation was similar to brain abscess in general. 21 patients had altered sensorium at the time of admission. Otogenic brain abscesses were the commonest (26%), followed by those associated with congenital cyanotic heart disease (18%).The abscesses were invariably large in size.The pus was sterile on culture in 11 (29%) patients, while Staphylococcus aureus was the commonest organism grown in 9 (24%) patients.Aspiration of the pus was required as a life saving measure, to control raised intracranial pressure, in 29 (76%) patients. Twelve (32%) of these patients underwent secondary excision of the abscess capsule.The overall mortality was 32% with failure to control intracranial and systemic infection as the major causes of mortality. Level of consciousness at the time of admission was the most significant factor affecting the outcome.Surgery has a definite therapeutic and life saving role in the management of multiple pyogenic brain abscesses. A systematic treatment plan for multiple abscesses is proposed.     

Hematogenous pyogenic spinal infections and their surgical management

STUDY DESIGN: Mainly a retrospective study of 101 cases of pyogenic spinal infection, excluding postoperative infections. Data were obtained through medical record review, imaging examination, and patient follow-up evaluation. SUMMARY OF BACKGROUND DATA: Hematogenous pyogenic spinal infection has been described variously as spondylodiscitis, discitis, vertebral osteomyelitis, and epidural abscess. Recommended treatment options have included conservative methods (antibiotics and bracing) and surgical intervention. However, a comprehensive classification that would aid in diagnosis, treatment planning, and prognosis has not yet been devised. OBJECTIVES: To analyze the bacteriology, pathologic entities, complications, and results of treatment options for pyogenic spinal infection. METHOD: All patients received plain radiographs, gadolinium-enhanced magnetic resonance imaging scans, and bone/gallium radionuclide studies. All patients had tissue biopsies. Bacteriology, hematology, and predisposing factors were analyzed. All patients received intravenous and oral antibiotics. A total of 58 patients underwent surgery. Patient outcomes were correlated with clinical status, with treatment method and, where applicable, with location and nature of epidural compression. Statistical analyses were performed. RESULTS: Spondylodiscitis occurred most commonly with primary epidural abscess, spondylitis, discitis, and pyogenic facet arthropathy, all occurring rarely. Staphylococcus aureus was the main organism. Infection elsewhere was the most common predisposing factor. Leukocyte counts were elevated in 42.6% of spondylodiscitis cases. The erythrocyte sedimentation rate was elevated in all cases of epidural abscess. There were 35 cases of epidural abscess (frank abscess, 29; granulation tissue, 6). Epidural abscess complicating spondylodiscitis occurred most often in the cervical spine, followed by thoracic and lumbar areas. The rate of paraplegia or paraparesis also was highest in cervical and thoracic regions. There were no cases of quadriplegia. All patients with either epidural granulation tissue or paraparesis recovered completely after surgical decompression. Only 18% of patients with frank epidural abscess and 23% of patients with paralysis recovered completely after surgical decompression. Patients with spondylodiscitis who were treated nonsurgically reported residual back pain more often (64%) than patients treated surgically (26.3%). CONCLUSIONS: Pyogenic spinal infection can be thought of as a spectrum of disease comprising spondylitis, discitis, spondylodiscitis, pyogenic facet arthropathy, and epidural abscess. Spondylodiscitis is more prone to develop epidural abscesses in the cervical spine (90%) than the thoracic (33.3%) or lumbar (23.6%) areas. Thecal sac neurocompression has a greater chance of causing neurologic deficit in the thoracic spine (81.8%). Treatment of neurologic deficit caused by epidural abscess is prompt surgical decompression, with or without fusion. Patients with frank abscess had less favorable outcomes than those with granulation tissue, and paraplegia responded to treatment more poorly than paraparesis. Surgery was preferable to nonsurgical treatment for improving back pain.     

Experience with liver abscess

One hundred ninety-two liver abscesses in 190 patients were treated: 109 by needle aspiration, and 83 by operation. Mortality and complication rates were lower in the aspiration group, and the average hospital stay was shorter. This was true for both pyogenic and sterile abscesses, the latter being presumed to be amebic, although trophozoites were recovered from liver pus in only two patients. Patients with pyogenic abscess were, on the average, considerably younger than patients with the condition in the United States for reasons that are not immediately apparent. The preponderance of amebic abscesses found in men is less than usual, again for reasons that are not clear. Both pyogenic and amebic abscesses were commonly associated with fever, chills, and tenderness and pain in the right upper abdomen and hepatomegaly on physical examination. We found metronidazole effective in the treatment of both pyogenic and amebic abscesses.     

PYOGENIC LIVER ABSCESS: A REVIEW OF 10 YEARS’ EXPERIENCE IN MANAGEMENT

Background : Over the past 15 years, diagnostic and interventional radiology techniques have allowed accurate localization of liver abscesses and image-guided percutaneous drainage. This review examines whether these technical advances improve clinical results and discusses the selection of treatment for patients with liver abscesses. Methods : Ninety-eight patients were treated for pyogenic liver abscess (PLA) at the Royal Prince Alfred Hospital, Sydney, between January 1987 and June 1997. The hospital records were examined and clinical presentation, laboratory, radiological and microbiological findings were recorded. Associations between these findings and failure of initial non-operative management were determined using odds ratios with 95% confidence intervals. Independent predictors were then determined by logistic regression. This analysis was repeated to determine factors associated with mortality. Results : Cholelithiasis and previous hepatobiliary surgery were the most frequently identifiable causes of PLA, each responsible in 15 patients. All 98 patients were treated with intravenous antibiotics and in 13 patients this was the only therapy. Of the remaining 85 patients, six proceeded straight to laparotomy and 79 had percutaneous drainage, of whom 15 required subsequent laparotomy. Factors predicting failure of initial non-operative management were unresolving jaundice, renal impairment secondary to clinical deterioration, multiloculation of the abscess, rupture on presentation and biliary communication. The overall hospital mortality rate was 8%. Conclusion : Pyogenic liver abscess remains a disease with significant mortality. Image-guided percutaneous drainage is appropriate treatment for single unilocular PLA. Surgical drainage is more likely to be required in patients who have abscess rupture, incomplete percutaneous drainage or who have uncorrected primary pathology.     

CT-guided stereotactic surgery of brain abscess

Seven patients with brain abscess underwent CT-guided stereotactic aspiration using Iseki's stereotactic apparatus. Three of them were under the age of fifteen and four were older than thirty. The lesions were single and round in four cases, multilobular in two and multiple in one patient. Operations were performed after systemic administration of antibiotics for more than two weeks and after capsule formation was confirmed on CTs. Preoperative volume of the abscesses was estimated from CTs. The target point chosen was the center of the ring of the largest diameter in the enhanced lesion. Abscess was aspirated under monitoring with intraoperative CT scan. No continuous drainage was performed and no antibiotics were given directly into the abscess cavity. In all cases the center of the abscess was punctured with a single trial. Average volume of the preoperative brain abscesses was 18.8ml. Aspirated volume at the time of the operation averaged 16.9ml and all the abscesses decreased to unmeasurable size on CTs. In five of seven patients abscesses were cured after a single aspiration, and in one case after the second operation. One case required extirpation of the lesion. During the follow-up period of four months to five and a half years six patients showed no recurrence. One patient died of unrelated cause four and a half years after the operation. No operative complication was noted. There was no operative morbidity or mortality. Using a CT guided stereotactic method, brain abscess is punctured so accurately, regardless of its location and size, that damage to the surrounding brain during operation can be minimized. Therefore it is highly possible to aspirate abscesses completely.(ABSTRACT TRUNCATED AT 250 WORDS)     

Pyogenic liver abscess: a review of 10 years' experience in management

BACKGROUND: Over the past 15 years, diagnostic and interventional radiology techniques have allowed accurate localization of liver abscesses and image-guided percutaneous drainage. This review examines whether these technical advances improve clinical results and discusses the selection of treatment for patients with liver abscesses. METHODS: Ninety-eight patients were treated for pyogenic liver abscess (PLA) at the Royal Prince Alfred Hospital, Sydney, between January 1987 and June 1997. The hospital records were examined and clinical presentation, laboratory, radiological and microbiological findings were recorded. Associations between these findings and failure of initial non-operative management were determined using odds ratios with 95% confidence intervals. Independent predictors were then determined by logistic regression. This analysis was repeated to determine factors associated with mortality. RESULTS: Cholelithiasis and previous hepatobiliary surgery were the most frequently identifiable causes of PLA, each responsible in 15 patients. All 98 patients were treated with intravenous antibiotics and in 13 patients this was the only therapy. Of the remaining 85 patients, six proceeded straight to laparotomy and 79 had percutaneous drainage, of whom 15 required subsequent laparotomy. Factors predicting failure of initial non-operative management were unresolving jaundice, renal impairment secondary to clinical deterioration, multiloculation of the abscess, rupture on presentation and biliary communication. The overall hospital mortality rate was 8%. CONCLUSION: Pyogenic liver abscess remains a disease with significant mortality. Image-guided percutaneous drainage is appropriate treatment for single unilocular PLA. Surgical drainage is more likely to be required in patients who have abscess rupture, incomplete percutaneous drainage or who have uncorrected primary pathology.     

Liver abscess: a clinicopathological analysis of 82 cases

Liver abscesses are a common pathology in India, but a strategy for effective treatment has not been established. Eighty-two patients with liver abscess were studied over a 4-year period. Clinical features, ultrasound findings, laboratory studies, and outcome of therapy were evaluated. Treatment options were antibiotics alone, needle aspiration, catheter drainage, or open surgical drainage; 51.2% of all abscesses were amebic, 23.2% were pyogenic, and 25.6% had unknown causes. A total of 75.6% of the abscesses were solitary, with 62.2% confined to the right lobe. Pyogenic abscesses were more likely to have anemia, leukocytosis, and deranged liver function. Amebic abscesses tended to have a larger volume. Patients undergoing catheter drainage showed a more rapid reduction in initial abscess volume, whereas resolution of the abscess cavity took longer with antibiotic therapy alone. Ultrasound-guided needle aspiration and catheter drainage are safe and effective in the management of liver abscess. Drug therapy alone may be useful only in select cases.     

Pyogenic liver abscess complicating biliary stricture due to chronic pancreatitis

BACKGROUND: Chronic pancreatitis uncommonly causes common bile duct stricture, and common bile duct stricture rarely leads to pyogenic liver abscess. METHODS: We describe a 51-year-old man who developed a pyogenic liver abscess after the development of a common bile duct stricture due to chronic pancreatitis. RESULTS: The patient required open drainage of the liver abscess and decompressive choledochoduodenostomy. His infection was persistent and he required percutaneous and subsequent open drainage of a second hepatic abscess. The patient died of refractory sepsis and multi-organ failure. CONCLUSIONS: The relevant English literature concerning pyogenic liver abscesses, specifically in the setting of common bile duct stricture due to chronic pancreatitis, is reviewed and discussed.     

The initial approach to anorectal abscesses: fistulotomy is safe and reduces the chance of recurrences

BACKGROUND/AIMS: Anorectal abscesses are most frequently based on a coexistent fistula in ano. Whether these should be searched for and excised initially or not remains controversial. Our aim was to determine which approach has less recurrences and carries a lower risk of continence disorders. METHODS: 158 patients with an anorectal abscess or anal fistula were identified in our institution over a period of 75 consecutive months. The records and follow-up questionnaires of 131 patients were evaluable. The mean follow-up period was 40 (range 3-78) months. RESULTS: When fistulotomy was performed at the time of draining the abscess, the recurrence rate could be reduced, in comparison to incision and drainage alone, from 34 to 4% (p = 0.007). In the group of patients undergoing surgery for a recurrence, the recurrence rate could even be reduced from 67 to 0% (p = 0.03) by simultaneous fistulotomy. A total of 4 of the 131 patients (3%) developed incontinence of liquid stool and flatus, but no incontinence of solid stool occurred. Incontinence did only occur after recurrent disease. CONCLUSIONS: The number of recurrences requiring surgery can be significantly reduced by initial fistulotomy. The risk to develop incontinence increases with recurrent anorectal disease, not with careful fistulotomy.     

Brain abscess associated with congenital heart disease

Between 1952 and 1985, 25 cases of brain abscess with congenital heart disease were treated at the Department of Neurosurgery, Tianjin Medical College Hospital. Patients' ages ranged from 5 to 38 years. The most common form of congenital heart disease was tetralogy of Fallot, occurring in 13 cases. The abscesses were located in the parietal, frontal, and temporal lobes. The pus from the abscesses was sterile in 13 of 19 cases. In the rest, Streptococcus was the predominant organism. Twenty-three cases were treated by aspiration of the abscess through a burr hole. In two cases, initial aspiration was followed by excision of the abscess. The mortality rate of the whole group was 32%. The etiology of brain abscess in patients with congenital heart disease is discussed.     

Pyogenic liver abscess complicated by endogenous endophthalmitis

Background: Endogenous endophthalmitis is an inflammation of ocular tissues that can lead to deterioration of and loss of vision. Rarely, this can complicate the course of a patient with pyogenic liver abscess. Methods: Over an 18‐month period, 68 patients were treated for pyogenic liver abscesses. Three patients, all of whom were male and with diabetes, were diagnosed with a Klebsiella pneumoniae liver abscess complicated by endogenous endophthalmitis. Open surgical or percutaneous drainage of the liver abscess was undertaken and the symptomology and outcome of the endophthalmitis reviewed. Results: There was no mortality in our series. Two patients presented with simultaneous abdominal and ocular symptoms and one patient had ocular symptoms 3 days after surgical drainage of the liver abscess. Despite aggressive treatment, all patients had permanent deterioration of visual function with one patient becoming blind and requiring evisceration of the infected eye. Conclusion: Ocular symptoms in patients treated for pyogenic abscesses must be dealt with urgently with an ophthalmologic consultation. Increased awareness of this complication and a high index of suspicion are paramount for salvage of visual function.     

单发及多发细菌性肝脓肿临床资料的对比分析

摘要：目的:探讨单发及多发肝脓肿的临床特点及诊治方法。方法:回顾性分析近25年间收治的148例细菌性肝脓肿患者的临床资料，按单发及多发性肝脓肿分组，比较两组临床特征、治疗方法及预后。结果:胆源性在多发性肝脓肿组的比例明显高于单发组（P=0.018），平均年龄、就诊时间及住院天数多发性肝脓肿组也明显高于单发组(P=0.023,0.043，0.015)。多发性肝脓肿患者的碱性磷酸酶水平较高（P=0.021）， 血清白（清）蛋白水平较低（P=0.039）。单发肝脓肿最常见部位在肝右叶(P=0.002)，而多发性肝脓肿更易累及左右两叶(P<0.001)。大肠杆菌是两种肝脓肿最常见的致病菌。单纯抗生素治疗多用于多发脓肿的患者（P=0.022），经皮穿刺置管引流则多用于单发性肝脓肿（P=0.021）。多发性肝脓肿患者发生急性呼吸窘迫综合征（ARDS）的比例较高（P=0.03）。肝脓肿相关的病死率在多发性肝脓肿患者中明显为高（P=0.025）。结论:与单发性肝脓肿相比，多发性肝脓肿病例具有年龄较大、症状持续时间较长、常合并胆道疾病、脓肿多侵及肝脏两叶、容易发生ARDS和病死率较高的特点，治疗多采用手术和/或单纯抗生素治疗。     

Liver abscess. The need for complete gastrointestinal evaluation

The cause of liver abscess is frequently obscure at initial presentation. We reviewed the medical records of 20 patients with pyogenic liver abscess over a 6-year period from 1981 to 1987. Liver abscess was suspected in only 3 patients on admission; the most common initial diagnosis was fever of unknown origin. Subsequently, the origin of the abscess was found to be intestinal in 7 patients, pancreatobiliary in 11 patients, and cryptogenic in 2 patients. Eleven patients underwent percutaneous transhepatic drainage of the abscess as the initial treatment, while open operation was the initial treatment in 9 patients. Percutaneous transhepatic drainage was ultimately successful in only 4 patients (36%). In the absence of an obvious pathologic condition of the biliary tract, all patients should undergo full gastrointestinal evaluation.