Predictive factors for recurrent acute appendicitis after conservative treatment.

INTRODUCTION: Conservative treatment of acute appendicitis is gaining popularity, and identifying patients with a higher risk of recurrence is becoming increasingly important. Previous studies have suggested that older age, male sex, diabetes, appendicolith and abscess formation may be contributing factors, however, results from the adult population are inconsistent. AIM: This study aims to identify predictive factors for recurrent appendicitis after conservative treatment. METHODS: This retrospective study included patients with conservatively treated acute appendicitis at Skåne University Hospital, Sweden during 2012-2019. Information on patient demographics at index admission and follow-up data were retrieved from medical charts and radiologic images. Uni -and multivariable logistic regression analysis were performed using Stata Statistical Software. RESULTS: In total, 379 patients with conservatively treated acute appendicitis were identified, of which 78 (20.6%) had recurrence. All patients were followed-up for a minimum of 41 months after the first diagnosis of acute appendicitis unless appendectomy after successful conservative treatment or death occurred during follow-up. The median time to recurrence was 6.5 (1-17.8) months. After multivariable logistic regression analysis, external appendix diameter >10 mm [OR 2.4 (CI 1.37-4.21), p = .002] and intra-abdominal abscess [OR 2.05 (CI 1.18-3.56), p = .011] on computed tomography were significant independent risk factors for recurrent appendicitis. Appendicolith was not associated with an increased risk of recurrence. CONCLUSION: This study suggests abscess formation and appendix distension of >10 mm to be potential risk factors for recurrent acute appendicitis after initial successful conservative treatment.

Long-term outcomes of intestinal penetrating Crohn's disease following successful nonoperative management.

There is a paucity of data on the surgical or medical treatment for abscess/fistula complicating Crohn's disease after successful nonsurgical management. We conducted a cohort study to investigate the long-term outcomes and the risk factors for the requirement of subsequent surgical intervention in Crohn's disease patients with complicating fistulas/abscess following successful nonsurgical management. Data were collected on penetrating Crohn's disease experiencing successful nonsurgical treatment between December 2012 and December 2021. Long-term outcomes and risk factors of surgery were assessed by univariate and multivariate analysis, and subgroup analysis was performed based on penetrating phenotype including abscess, fistula, and phlegmon. A total of 523 penetrating Crohn's disease patients; there were 390, 125, and 60 patients complicated with fistulas, abscess, and phlegmon, respectively. Long-term outcomes showed that BMI < 18.5 (kg/m 2 ), the recurrent abscess, and stricture were independent risk factors of surgery. Biologics and resolution of abscess were independent protective factors of surgery. Furthermore, in 399 patients undergoing early surgery, stricture and BMI < 18.5 (kg/m 2 ) were independent risk factors, and biologics and abscess resolution were protective of the early surgery. Subgroup analysis based on fistula, abscess, and phlegmon phenotype also demonstrated that concomitant stricture was an independent risk factor and the use of biologics was protective of surgical resection. Our data indicate that biologics can delay the requirement of surgery and may be given to patients with penetrating complicating Crohn's disease who have been successfully treated nonoperatively, but surgical resection should be considered in the setting of malnutrition and stenosis formation.

Towards a tailored approach for patients with acute diverticulitis and abscess formation. The DivAbsc2023 multicentre case-control study.

BACKGROUND: This multicentre case-control study aimed to identify risk factors associated with non-operative treatment failure for patients with CT scan Hinchey Ib-IIb and WSES Ib-IIa diverticular abscesses. METHODS: This study included a cohort of adult patients experiencing their first episode of CT-diagnosed diverticular abscess, all of whom underwent initial non-operative treatment comprising either antibiotics alone or in combination with percutaneous drainage. The cohort was stratified based on the outcome of non-operative treatment, specifically identifying those who required emergency surgical intervention as cases of treatment failure. Multivariable logistic regression analysis to identify independent risk factors associated with the failure of non-operative treatment was employed. RESULTS: Failure of conservative treatment occurred for 116 patients (27.04%). CT scan Hinchey classification IIb (aOR 2.54, 95%CI 1.61;4.01, P < 0.01), tobacco smoking (aOR 2.01, 95%CI 1.24;3.25, P < 0.01), and presence of air bubbles inside the abscess (aOR 1.59, 95%CI 1.00;2.52, P = 0.04) were independent predictors of failure. In the subgroup of patients with abscesses > 5 cm, percutaneous drainage was not associated with the risk of failure or success of the non-operative treatment (aOR 2.78, 95%CI - 0.66;3.70, P = 0.23). CONCLUSIONS: Non-operative treatment is generally effective for diverticular abscesses. Tobacco smoking's role as an independent risk factor for treatment failure underscores the need for targeted behavioural interventions in diverticular disease management. IIb Hinchey diverticulitis patients, particularly young smokers, require vigilant monitoring due to increased risks of treatment failure and septic progression. Further research into the efficacy of image-guided percutaneous drainage should involve randomized, multicentre studies focussing on homogeneous patient groups.

Povidone-iodine intra-abdominal irrigation versus no irrigation in pediatric perforated appendicitis: A secondary economic analysis of a Bayesian randomized controlled trial.

BACKGROUND: A pilot randomized controlled trial (RCT) conducted in children (2-17 â€‹y) with perforated appendicitis demonstrated an 89% probability of reduced intra-abdominal abscess (IAA) rate with povidone-iodine (PVI) irrigation, compared with no irrigation (NI). We hypothesized that PVI also reduced 30-day hospital costs. METHODS: We conducted a retrospective economic analysis of a pilot RCT. Hospital costs, inflated to 2019 U.S. dollars, were obtained for index admissions and 30-day emergency visits and readmissions. Cost differences between groups were assessed using frequentist and Bayesian generalized linear models. RESULTS: We observed a 95% Bayesian probability that PVI reduced 30-day mean total hospital costs ($16,555 [PVI] versus $18,509 [NI]; Bayesian cost ratio: 0.90, 95% CrI, 0.78-1.03). The mean absolute difference per patient was $1,954 less with PVI (95% CI, -$4,288 to $379). CONCLUSIONS: PVI likely reduced the IAA rate and 30-day hospital costs, suggesting the intervention is both clinically superior and cost saving.

[Diagnostics and treatment of splenic abscesses]. / Diagnostik und Therapie des Milzabszesses.

A splenic abscess is a rare disease found in less than 1% of all autopsy studies. Several different diseases are associated as a predisposing factor, such as septic bacteremia due to endocarditis or diverticulitis, previous splenic trauma, immunosuppressive medication or diseases. The reported mortality in the literature is up to 24.5% in correctly diagnosed and treated cases. The diagnostic work-up primarily comprises sonography and computed tomography as well as a percutaneous puncture for determination of the pathogen. In most cases, a percutaneous interventional drainage treatment is sufficient and a splenectomy is necessary only in refractory cases.

Splenic abscess due to non-operative management of splenic injury: a case report.

BACKGROUND: Splenic abscess is a rare disease, with incidence of 0.2-0.7% in previous studies. It often appears with left upper quadrant abdominal pain, fever, chills. Splenic abscess often happens because of hematogenous spreading of infections, endocarditis, angioembolization and some other rare reasons. Treatment relies on one of these two methods: percutaneous drainage or surgery. CASE PRESENTATION: A 68-year-old diabetic Asian female (Asian woman) presented with generalized abdominal pain, low blood pressure, tachycardia, fever, lethargy and elevated level of blood sugar. She had history of conservative therapy in intensive care unit due to blunt abdominal trauma and splenic injury. She had a huge splenic abscess in ultrasonography and computed tomography scan so she went under splenectomy. Our patient had a splenic abscess without performing any intervention like angioembolization. CONCLUSION: Immune compromised patients who are selected for nonoperative management after splenic injury need close follow up and evaluating about abscess formation for at least 2 weeks. Early diagnosis and treatment with two methods including percutaneous drainage or splenectomy should be considered and it depends on patient's risk factors, vital signs, general conditions and presence or absence of sepsis.

Diverticulitis with abscess formation: Outcomes of non-operative management and nomogram for predicting emergency surgery: The Diplicab Study Collaborative Group.

BACKGROUND: To assess short- and long-term outcomes from non-surgical management of diverticulitis with abscess formation and to develop a nomogram to predict emergency surgery. METHODS: This nationwide retrospective cohort study was performed in 29 Spanish referral centers, including patients with a first episode of a diverticular abscess (modified Hinchey Ib-II) from 2015 to 2019. Emergency surgery, complications, and recurrent episodes were analyzed. Regression analysis was used to assess risk factors, and a nomogram for emergency surgery was designed. RESULTS: Overall, 1,395 patients were included (1,078 Hinchey Ib and 317 Hinchey II). Most (1,184, 84.9%) patients were treated with antibiotics without percutaneous drainage, and 194 (13.90%) patients required emergency surgery during admission. Percutaneous drainage (208 patients) was associated with a lower risk of emergency surgery in patients with abscesses of ≥5 cm (19.9% vs 29.3%, P = .035; odds ratio 0.59 [0.37-0.96]). The multivariate analysis showed that immunosuppression treatment, C-reactive protein (odds ratio: 1.003; 1.001-1.005), free pneumoperitoneum (odds ratio: 3.01; 2.04-4.44), Hinchey II (odds ratio: 2.15; 1.42-3.26), abscess size 3 to 4.9 cm (odds ratio: 1.87; 1.06-3.29), abscess size ≥5 cm (odds ratio: 3.62; 2.08-6.32), and use of morphine (odds ratio: 3.68; 2.29-5.92) were associated with emergency surgery. A nomogram was developed with an area under the receiver operating characteristic curve of 0.81 (95% confidence interval: 0.77-0.85). CONCLUSION: Percutaneous drainage must be considered in abscesses ≥5 cm to reduce emergency surgery rates; however, there are insufficient data to recommend it in smaller abscesses. The use of the nomogram could help the surgeon develop a targeted approach.

Do Cultures From Percutaneously Drained Intra-abdominal Abscesses Change Treatment? A Retrospective Review.

BACKGROUND: Routinely obtaining intraoperative cultures for abdominal infections is not a currently recommended evidence-based practice. Yet, cultures are frequently sent from these infections when they are managed by image-guided percutaneous drains. OBJECTIVE: This study aimed to determine the utility of cultures from percutaneously drained intra-abdominal abscesses. DESIGN: Retrospective medical record review. SETTING: Single university-affiliated institution. PATIENTS: Inpatients with an intra-abdominal abscess secondary to diverticulitis or appendicitis between 2013 and 2021 managed with image-guided percutaneous drain, excluding those with active chemotherapy, HIV, or solid organ transplant, were included in the study. MAIN OUTCOME MEASURES: Frequency culture data from percutaneous drains changed antimicrobial therapy. RESULTS: There were 221 patients who met the inclusion criteria. Of these, 56% were admitted for diverticulitis and 44% for appendicitis. Patients were 54% female and had a median age of 62 years (range, 18-93), and 14% were active smokers. The median length of hospitalization was 8 days (range, 1-78) and the median antibiotics course was 8 days (range, 1-22). Culture data from percutaneous drains altered antimicrobial therapy in 8% of patients (16/211). A culture was obtained from 95% of drains, with 78% of cultures with growth. Cultures grew multiple bacteria in 66% and mixed variety without speciation in 13%. The most common pathogen was the Bacteroides family at 33% of all bacteria. The most common empiric antibiotic regimens were ceftriaxone used in 33% of patients and metronidazole used in 40% of patients. Female sex ( p = 0.027) and presence of bacteria with any antibiotic resistance ( p < 0.01) were associated with higher likelihood of cultures influencing antimicrobial therapy. LIMITATIONS: Retrospective and single institution's microbiome. CONCLUSIONS: Microbiology data from image-guided percutaneous drains of abdominal abscesses altered antimicrobial therapy in 8% of patients, which is lower than reported in previously published literature on cultures obtained surgically. Given this low rate, similar to the recommendation regarding cultures obtained intraoperatively, routinely culturing material from drains placed in abdominal abscesses is not recommended. See Video Abstract at http://links.lww.com/DCR/C64 . LOS CULTIVOS DE ABSCESOS INTRA ABDOMINALES DRENADOS PERCUTNEAMENTE CAMBIAN EL TRATAMIENTO UNA REVISIN RETROSPECTIVA: ANTECEDENTES:La obtención rutinaria de cultivos intra-operatorios para infecciones abdominales no es una práctica basada en evidencia actualmente recomendada. Sin embargo, con frecuencia se envían cultivos de estas infecciones cuando se manejan con drenajes percutáneos guiados por imágenes.OBJETIVO:Determinar la utilidad de los cultivos de abscesos intra-abdominales drenados percutáneamente.DISEÑO:Revisión retrospectiva de gráficos.ESCENARIO:Institución única afiliada a la universidad.PACIENTES:Pacientes hospitalizados con absceso intra-abdominal secundario a diverticulitis o apendicitis entre 2013 y 2021 manejados con drenaje percutáneo guiado por imagen, excluyendo aquellos con quimioterapia activa, VIH o trasplante de órgano sólido.PRINCIPALES MEDIDAS DE RESULTADO:Los datos de cultivo de frecuencia de los drenajes percutáneos cambiaron la terapia antimicrobiana.RESULTADOS:Hubo 221 pacientes que cumplieron con los criterios de inclusión. De estos, el 56% ingresaron por diverticulitis y el 44% por apendicitis. El 54% de los pacientes eran mujeres, tenían una edad media de 62 años (18-93) y el 14% eran fumadores activos. La duración de hospitalización media fue de 8 días (rango, 1-78) y la mediana del curso de antibióticos fue de 8 días (rango, 1-22). Los datos de cultivo de drenajes percutáneos alteraron la terapia antimicrobiana en el 7% (16/221) de los pacientes. Se obtuvo cultivo del 95% de los drenajes, con un 79% de cultivos con crecimiento. Los cultivos produjeron múltiples bacterias en el 63% y variedad mixta sin especiación en el 13%. El patógeno más común fue la familia Bacteroides con un 33% de todas las bacterias. El régimen de antibiótico empírico más común fue ceftriaxona y metronidazol, utilizados en el 33% y el 40% de los pacientes, respectivamente. El sexo femenino ( p = 0,027) y la presencia de bacterias con alguna resistencia a los antibióticos ( p < 0,01) se asociaron con una mayor probabilidad de que los cultivos influyeran en la terapia antimicrobiana.LIMITACIONES:Microbioma retrospectivo y de una sola institución.CONCLUSIONES:Los datos microbiológicos de los drenajes percutáneos guiados por imágenes de los abscesos abdominales alteraron la terapia antimicrobiana en el 7% de los pacientes, que es inferior a la literatura publicada previamente sobre cultivos obtenidos quirúrgicamente. Dada esta baja tasa, similar a la recomendación sobre cultivos obtenidos intraoperatoriamente, no se recomienda el cultivo rutinario de material de drenajes colocados en abscesos abdominales. Consulte Video Resumen en http://links.lww.com/DCR/C64 . (Traducción-Dr. Mauricio Santamaria.

Intra-abdominal abscesses in CD - When to treat with biologics?

Management of intra-abdominal abscesses complicating Crohn's disease (CD) is challenging. After initial drainage and antibiotherapy treatment, surgery with delayed intestinal resection is often recommended but new data suggests efficacy of biotherapies in this context. This review aims to summarize new data regarding efficacy and safety of anti-TNF in the management of intra-abdominal abscesses complicating CD. We performed a review of the literature on medical management of intra-abdominal abscesses complicating CD. After effective drainage of abscess, treatment with anti-TNF can allow resolving of abscess. In some patients and at a specific timing, the use of biotherapies could avoid delayed surgery and long-term abscess recurrence.

Post-Bariatric Splenic Complications; Diagnosis and Treatment. A Systematic Review.

This systematic review intends to evaluate incidence and symptoms of post-bariatric splenic complications as well as best available modalities establishing the diagnosis and management protocols. A systematic literature search was performed in electronic database until March 2022. A total of 41 articles were included on the subject of splenic complications following bariatric/metabolic surgery (BMS). Splenic abscess was the most common splenic complications (44.2%) after BMS and leak was the most common reported etiology of the splenic abscess. Fever and abdominal pain were the most common presenting symptom in all splenic complications and CT scan was the most common diagnostic modality. Splenic complications after BMS are relatively rare but may lead to dangerous consequences. Prompt diagnosis and treatment can prevent potentially life-threatening outcomes.

Uterine abscess as an appendicitis complication: a case report.

INTRODUCTION: Acute appendicitis is a frequent cause of abdominal pain that requires surgical intervention. Rarely complications such as appendico-vesical, appendico-cutaneous, or appendico-uterine fistula formation may occur. CASE AND OUTCOMES: We present a case of an 83-year-old woman who suffered from a very rare complication of acute appendicitis. Multimodal radiologic examination including ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI) revealed complicated appendicitis with an abscess formation involving the right adnexal region and uterine cavity. The patient was treated conservatively with percutaneous drainage of the abscess and IV antibiotics. DISCUSSION: Acute appendicitis is one of the common causes of emergency surgery. It is important to differentiate simple and complicated appendicitis to determine the best treatment option, thus, the diagnostic accuracy of certain US and CT findings in making this differentiation has been the subject of investigation. Even though some imaging findings suggest appendiceal perforation, deciding a conservative treatment plan based solely on imaging findings is still inaccurate. MRI is complementary to CT and US as a problem solving modality in certain situations. CONCLUSION: This case report reminds us that physicians and radiologists should be aware of rare complications of acute appendicitis such as fistula formation to visceral organs. MRI is superior in order to differentiate complex fluid collections such as abscess formations.

Intra-abdominal and Anorectal Abscesses.

Intra-abdominal and anorectal abscesses are common pathologies seen in both inpatient and outpatient settings. To decrease morbidity and mortality, early diagnosis and treatment are essential. After adequate drainage via a percutaneous or incisional approach, patients need to be monitored for worsening symptoms or recurrence and evaluated for the underlying condition that may have contributed to abscess formation.