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.

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.

Intra-abdominal abscess caused by Streptococcus constellatus in an immunocompetent patient.

Streptococcus constellatus is a Gram-positive commensal bacterium of the oropharyngeal, gastrointestinal and urogenital flora. It can cause abscesses in different parts of the body, especially in immunocompromised patients. We present the clinical case of a 33-year-old female patient with a previous history of one anastomosis gastric bypass, among others. The patient was hospitalized two years after surgery for peritonitis secondary to a perforation in the biliopancreatic loop, underwent laparoscopic surgery and was hospitalised for two weeks. Fifteen days after being discharged from the hospital, she went to the emergency service for abdominal pain and fever. An abdominal and pelvic computerized tomography (CT) scan showed a multiloculated pelvic collection with thickened and hypercapillary walls.

CT-guided percutaneous drainage of abdominopelvic collections: a pictorial essay.

CT-guided percutaneous drainage is a safe and effective procedure that allows minimally invasive treatment of abdominopelvic abscesses and fluid collections. This technique has become an alternative for surgery with lower morbility and mortality rates. In this pictorial essay, we aim at providing an overview of the technical approaches, the main clinical indications and complications of CT-guided percutaneous drainage, in order to provide a practical guide for interventional radiologists, with a review of the recent literature. The focus will be the CT-guidance, preferred when the interposition of viscera, vascular and skeletal structures, counteracts the ultrasound guidance.

Use of Tissue Plasminogen Activator in Abdominal Abscesses in Children-A Single-Center Randomized Control Trial.

PURPOSE: To establish the efficacy of once-per-day intracavitary tissue plasminogen activator (tPA) in the treatment of pediatric intra-abdominal abscesses. METHODS: A single-center prospective, double-blinded, randomized controlled trial of the use of intracavitary tPA in abdominal abscesses in children. Patients were randomized to either tPA-treatment or saline-treatment groups. Primary outcome was drainage catheter dwell (hours). Secondary outcomes were length of hospital stay, times to discharge, clinical and sonographic resolution, and adverse events (AEs). RESULTS: Twenty-eight children were randomized to either group (n = 14 each). Demographics between groups were not significantly different (age P = .28; weight P = .40; gender P = .44). There were significantly more abscesses in the tPA-treated group (P = .03). Abscesses were secondary to perforated appendicitis (n = 25) or postappendectomy (n = 3). Thirty-four abscesses were drained, 4 aspirated, 3 neither drained/aspirated. There was no significant difference in number of drains (P = .14), drain size (P = .19), primary outcome (P = .077), or secondary outcomes found. No procedural or intervention drug-related AEs occurred. No patient in the saline-treated group required to be switched/treated with tPA. CONCLUSION: No significant difference in the length of catheter dwell time, procedure time to discharge, or time to resolution was found. Intracavitary tPA was not associated with morbidity or mortality. The results neither support nor negate routine use of tPA in the drainage of intra-abdominal abscess in children. It is possible that a multicentre study with a larger number of patients may answer this question more definitively.

CT-Guided Percutaneous Drainage Catheter Placement in the Abdomen and Pelvis: Predictors of Outcome and Protocol for Follow-up.

PURPOSE: To determine predictors of outcomes for patients who undergo computed tomography (CT)-guided percutaneous abdominal or pelvic drainage catheter placement and to identify which patients benefit from fluoroscopic drainage catheter interrogation (abscessogram). MATERIALS AND METHODS: A retrospective review of 383 patients (mean, 52 years old; range 8-89 years old; 158 males: 225 females) who underwent 442 CT-guided procedures and 489 catheter placements for fluid collections in the abdomen or pelvis from January 1, 2015, to December 31, 2016 was performed. Variables including underlying disease, fluid location, number of collections drained, number of catheter exchanges and follow-up abscessograms performed, catheter size, and fistula detection were analyzed to determine factors associated with fistula formation and increased catheter dwell time. RESULTS: A single abscessogram followed by catheter removal was performed for 217 catheters (44%). An increased number of abscessograms was significantly associated with drainage catheter size (P < .001) and presence of a fistula (P < .001). Fistulae were detected in 95 cases (19%) and were significantly associated with an increased number of drain exchanges (P < .001) and an underlying diagnosis of Crohn's disease (P = .02). Based on these data, a clinical algorithm for drain management is presented. CONCLUSIONS: Abscessograms performed after CT-guided percutaneous drainage catheter placement are useful to detect catheter malposition, occluded catheters, and fistulae but are not necessary for all patients. If performed selectively, particularly in patients with an underlying diagnosis of Crohn's disease or those at high risk for developing fistulae, unnecessary examinations can be avoided, reducing cost, extra hospital visits, and radiation dose.

Gastric submucosal abscess caused by Edwardsiella tarda infection: a case report.

BACKGROUND: Edwardsiella tarda is a motile, facultatively anaerobic gram-negative bacillus that is isolated from a wide spectrum of animals in aquatic environments but rarely causes infection in humans. Here, we describe the case of a gastric submucosal abscess caused by E. tarda infection. CASE PRESENTATION: The patient was a 74-year-old man with a history of hypertension and chronic alcohol consumption who was admitted to our hospital for abdominal pain, appetite loss and vomiting. Contrast-enhanced computed tomography (CT) revealed choledocholithiasis in the common bile duct, a gastric wall abscess and an intra-abdominal abscess. Endoscopic ultrasound (EUS)-guided drainage with antibiotics successfully cured the patient. CONCLUSION: The combination of CT, endoscopy and EUS-guided drainage with antibiotic therapy might be effective for diagnosis and treatment of a gastric submucosal abscess caused by E. tarda infection.

Non-toxigenic Corynebacterium diphtheriae infective endocarditis with embolic events: a case report.

BACKGROUND: Corynebacterium diphtheriae (C. diphtheriae) infections, usually related to upper airways involvement, could be highly invasive. Especially in developing countries, non-toxigenic C. diphtheriae strains are now emerging as cause of invasive disease like endocarditis. The present case stands out for reinforcing the high virulence of this pathogen, demonstrated by the multiple systemic embolism and severe valve deterioration. It also emphasizes the importance of a coordinated interdisciplinary work to address all these challenges related to infectious endocarditis. CASE PRESENTATION: A 21-year-old male cocaine drug abuser presented to the emergency department with a 1-week history of fever, asthenia and dyspnea. His physical examination revealed a mitral systolic murmur, signs of acute arterial occlusion of the left lower limb, severe arterial hypotension and acute respiratory failure, with need of vasoactive drugs, orotracheal intubation/mechanical ventilation, empiric antimicrobial therapy and emergent endovascular treatment. The clinical suspicion of acute infective endocarditis was confirmed by transesophageal echocardiography, demonstrating a large vegetation on the mitral valve associated with severe valvular regurgitation. Abdominal ultrasound was normal with no hepatic, renal, or spleen abscess. Serial blood cultures and thrombus culture, obtained in the vascular procedure, identified non-toxigenic C. diphtheriae, with antibiotic therapy adjustment to monotherapy with ampicillin. Since the patient had a severe septic shock with sustained fever, despite antimicrobial therapy, urgent cardiac surgical intervention was planned. Anatomical findings were compatible with an aggressive endocarditis, requiring mitral valve replacement for a biological prosthesis. During the postoperative period, despite an initial clinical recovery and successfully weaning from mechanical ventilation, the patient presented with a recrudescent daily fever. Computed tomography of the abdomen revealed a hypoattenuating and extensive splenic lesion suggestive of abscess. After sonographically guided bridging percutaneous catheter drainage, surgical splenectomy was performed. Despite left limb revascularization, a forefoot amputation was required due to gangrene. The patient had a good clinical recovery, fulfilling 4-weeks of antimicrobial treatment. CONCLUSION: Despite the effectiveness of toxoid-based vaccines, recent global outbreaks of invasive C. diphtheriae infectious related to non-toxigenic strains have been described. These infectious could be highly invasive as demonstrated in this case. Interdisciplinary work with an institutional "endocarditis team" is essential to achieve favorable clinical outcomes in such defiant scenarios.

Non-tuberculosis cold abscess.

An 85-year-old cachectic man was found unconscious in his home. He had no specific medical history. On arrival, he was in a deep coma and hypothermic state. He had a soft mass the size of his fist in the right lower abdomen without redness or heat. Truncal computed tomography revealed subcutaneous fluid collection with gas formation. A test puncture for right lower abdominal subcutaneous fluid collection revealed pus, so an open incision was performed, with the administration of broad-spectrum antibiotics. Unfortunately, the patient died of sepsis-induced multiple organ failure. The results of abscess culture later revealed Proteus mirabilis, Escherichia coli, and Prevotella melaninogenica. This is the first report of a cold abscess induced by mixed bacteria.

Gossypiboma with perforation of the umbilicus mimicking a complicated urachal cyst: a case report.

BACKGROUND: A retained surgical sponge, also known as a gossypiboma, is a rare cause of serious postoperative complications. Diverse retained surgical materials including instruments such as clamps and sutures have been reported, but surgical sponges are the most common material. We report an unusual case of a gossypiboma mimicking a complicated urachal cyst that led to perforation of the umbilicus. CASE PRESENTATION: A 38-year-old female patient presented in our facility with a palpable periumbilical mass and discharge of pus from the umbilicus for 7 months after an open appendectomy. Since the onset of symptoms, the patient had been treated conservatively in a peripheral hospital where she had been operated on. As no improvement was seen, an ultrasound scan was performed that suggested an intraperitoneal abscess adjacent to the umbilicus. Consequently, the patient was referred to our specialist outpatient department for surgical intervention. Suspecting a complicated urachal cyst, an exploratory laparotomy was performed but revealed a retained surgical sponge as the underlying cause. The gossypiboma was resected, and the postoperative period was unremarkable. CONCLUSION: This case demonstrates that gossypibomas, even though rare, continue to occur. They may clinically and radiologically mimic other pathologies, especially abscesses and tumors. Preventive measures as well as the inclusion of gossypibomas in the differential diagnosis of intraabdominal masses or fistulation detected in patients with a history of surgery are of utmost importance to minimize morbidity, mortality, and potential medicolegal implications.

Retrospective cohort study comparing endoscopic ultrasound-guided and percutaneous drainage of upper abdominal abscesses.

BACKGROUND AND AIM: Endoscopic ultrasonography (EUS)-guided drainage (EUS-D) has become the standard treatment for peripancreatic fluid collections. Its use in other intra-abdominal abscesses has been reported, although there is limited evidence. METHODS: We carried out a single-center retrospective cohort study comparing percutaneous drainage (PCD) and EUS-D of upper abdominal abscesses between January 2012 and June 2017. Pancreatic fluid collections and liver transplant recipients were excluded. Primary endpoints were technical and clinical success rates. RESULTS: We included 18 EUS-D (nine hepatic and nine intraperitoneal abscesses) and 62 PCD. There were no differences regarding age, gender and etiology. Size was larger in the PCD group (80 vs 65.5 mm, P = 0.04) and perivesicular location was more frequent in the PCD group (24.2% vs 11.1%, P = 0.003). In the EUS-D group, metal stents were deployed in 16 (88.9%) subjects (eight lumen-apposing metal stents and eight self-expandable metal stents), coaxial double-pigtail plastic stents in six (33.3%) and lavage/debridement was carried out in five (27.8%). There were no significant differences in technical success (EUS-D: 88.9%, PCD: 96.8%, P = 0.22) or clinical success (EUS-D: 88.9%, PCD: 82.3%, P = 0.50), with no relapses in the EUS-D group and 10 (16.1%) in the PCD group (P = 0.11). There were four (22.2%) adverse events in the EUS-D group, none of them severe, and 13 (21%) in the PCD group (P = 0.91). CONCLUSIONS: EUS-D is an alternative to PCD in the treatment of upper abdominal abscesses, reaching similar success, relapse and adverse events rates.

[Ultrasound in the diagnosis and treatment of abdominal abscesses]. / Ul'trazvukovoe issledovanie v diagnostike i lechenii abstsessov briushnoi polosti.

OBJECTIVE: To improve the results of surgical treatment of abdominal abscesses using ultrasound-assisted drainage. MATERIAL AND METHODS: There were 103 cases of percutaneous ultrasound-assisted drainage of intraperitoneal abscesses for the period from 2012 to 2017. Patients who underwent drainage of intraorganic and retroperitoneal abscesses associated with pancreatic necrosis were excluded from the study. RESULTS: Complete recovery was observed in 101 (98%) out of 103 patients within 10-73 days. CONCLUSION: Ultrasound-assisted drainage is an effective procedure for abscesses. This method has demonstrated high efficiency, availability and safety without need for open approach. This method may be a reliable alternative to open surgery, for example in emergency surgical hospitals.

Does Imaging Before Percutaneous Drain Removal Affect Rates of Intra-abdominal Abscess Recurrence?

BACKGROUND: Intra-abdominal abscesses account for a large proportion of surgical complications and carry high mortality if not promptly controlled. Image-guided percutaneous drainage is standard of care. The objective of the study was to identify factors that predict abscess recurrence after percutaneous drain (PD) removal and determine if imaging before drain removal effects recurrence. METHODS: A consecutive multicenter retrospective cohort analysis of all patients who underwent PD insertion for abscesses between January 1, 2015, and December 31, 2015, was performed. Patient characteristics, PD details, and abscess recurrence were assessed. RESULTS: One hundred eighty-eight patients underwent PD insertion for spontaneous or postoperative abscesses, and overall abscess recurrence was 21%. Drains remained in situ for a median of 21.5 d (interquartile range: 9-42 d) with antibiotics used in 91% of cases. Forty-seven patients (25%) had a sinogram before PD removal, while 22% had computed tomography (CT) scans and 11% had ultrasounds. Hierarchical multivariable regression analysis showed that imaging before PD removal was associated with a 66% reduction in the odds of abscess recurrence (OR 0.34; 95% confidence interval [CI] 0.13-0.70; P = 0.006). Sinogram use was associated with an 86% reduction in the odds of recurrence (OR 0.14; 95% CI 0.02-0.39; P = 0.002) and ultrasound use was associated with a 78% reduction in the odds of recurrence (OR 0.22; 95% CI 0.02-0.76; P = 0.044) while CT use was not associated with a significant reduction in recurrence. CONCLUSIONS: Imaging before PD removal is associated with a reduction in the rates of abscess recurrence and requirement for additional drainage procedures or surgery. In addition, CT is not superior to ultrasound or sinograms as an imaging modality.

A Spectrum of Entities That May Mimic Abdominopelvic Abscesses Requiring Image-guided Drainage.

A variety of entities may mimic drainable abscesses. This can lead to misdiagnosis of these entities, unnecessary percutaneous placement of a pigtail drainage catheter, other complications, and delay in appropriate treatment of the patient. Types of entities that may mimic drainable abscesses include neoplasms (lymphoma, gallbladder cancer, gastrointestinal stromal tumor, ovarian cancer, mesenteric fibromatosis, ruptured mature cystic teratoma, recurrent malignancy in a surgical bed), ischemia/infarction (liquefactive infarction of the spleen, infarcted splenule), diverticula (calyceal, Meckel, and giant colonic diverticula), and congenital variants (obstructed duplicated collecting system). Postoperative changes, including expected anatomy after urinary diversion or Roux-en-Y gastric bypass and small bowel resection, may also pose a diagnostic challenge. Nonpyogenic infections (Mycobacterium tuberculosis, Mycobacterium avium complex, echinococcal cysts) and inflammatory conditions such as xanthogranulomatous pyelonephritis and gossypiboma could also be misinterpreted as drainable fluid collections. Appropriate recognition of these entities is essential for optimal patient care. This article exposes radiologists to a variety of entities for which percutaneous drainage may be requested, but is not indicated, and highlights important imaging findings associated with these entities to facilitate greater diagnostic accuracy and treatment in their practice. ©RSNA, 2018.

Retroperitoneal abscess with subcutaneous extension: case report of a rare complication of percutaneous renal biopsy.

BACKGROUND: Infective complications following percutaneous renal biopsy are rare, even among immunocompromised. However it is important to be vigilant about such complications, to detect them early and prevent morbidity and mortality. We report a case of retroperitoneal abscess with extension to subcutaneous plane after a renal biopsy. CASE PRESENTATION: A 42-year-old female with long standing cutaneous lupus underwent renal biopsy for evaluation of nephrotic range proteinuria. She was on high dose prednisolone complicated with steroid induced hyperglycaemia. Eight weeks after the biopsy she presented with left flank pain, malaise and fever. There was a tender subcutaneous induration over the biopsy site. Contrast CT abdomen showed a retroperitoneal abscess with subcutaneous extension along the path of the biopsy needle. This was successfully treated with surgical drainage and broad-spectrum antibiotics. CONCLUSIONS: Infections and abscess formation are rare but serious complications of renal biopsy. Immunocompromised state is a potential risk factor. Possible mechanisms and measures for prevention and early detection of this rare complication are discussed.

Case Report of a Tubo-ovarian Abscess Caused by Candida kefyr.

BACKGROUND: Candida species are harmless commensals of hosts, including humans, but they can cause infection when the immune system is compromised. Infections with non-albicans species can occur, ranging from urinary tract infections to sepsis, especially among patients in intensive care units. CASE: The patient, a 37-year-old woman, presented with severe abdominal pain, fever, and vomiting. The patient's symptoms and fever continued in spite of treatment with antibiotics, and she underwent exploratory laparotomy. Cyst content culture results showed that Candida kefyr was present in the cyst. CONCLUSION: To the best of our knowledge, this is the first case report of a tubo-ovarian abscess caused by C. kefyr. Rare pathogens can be found in patients with a tubo-ovarian abscess, so culture of the abscess material is important for determining subsequent treatment, particularly in women who require an operation for tubo-ovarian abscess.