Antibiotic treatment after appendectomy for acute complicated appendicitis to prevent intrabdominal abscess and wound infections.

INTRODUCTION: The purpose of this analysis was to investigate the most appropriate duration of postoperative antibiotic treatment to minimize the incidence of intraabdominal abscesses and wound infections in patients with complicated appendicitis. MATERIALS AND METHODS: In this retrospective study, which included 396 adult patients who underwent appendectomy for complicated appendicitis between January 2010 and December 2020 at the University Hospital Erlangen, patients were classified into two groups based on the duration of their postoperative antibiotic intake: ≤ 3 postoperative days (group 1) vs. ≥ 4 postoperative days (group 2). The incidence of postoperative intraabdominal abscesses and wound infections were compared between the groups. Additionally, multivariate risk factor analysis for the occurrence of intraabdominal abscesses and wound infections was performed. RESULTS: The two groups contained 226 and 170 patients, respectively. The incidence of postoperative intraabdominal abscesses (2% vs. 3%, p = 0.507) and wound infections (3% vs. 6%, p = 0.080) did not differ significantly between the groups. Multivariate analysis revealed that an additional cecum resection (OR 5.5 (95% CI 1.4-21.5), p = 0.014) was an independent risk factor for intraabdominal abscesses. A higher BMI (OR 5.9 (95% CI 1.2-29.2), p = 0.030) and conversion to an open procedure (OR 5.2 (95% CI 1.4-20.0), p = 0.016) were identified as independent risk factors for wound infections. CONCLUSION: The duration of postoperative antibiotic therapy does not appear to influence the incidence of postoperative intraabdominal abscesses and wound infections. Therefore, short-term postoperative antibiotic treatment should be preferred.

Minimally invasive step-up approach for the management of postoperative intraabdominal abscess after laparoscopic appendectomy.

BACKGROUND: Postoperative intraabdominal abscess (IAA) is the most feared complication after laparoscopic appendectomy (LA). We aimed to evaluate the management of this complication in a large cohort of patients undergoing LA in order to design a treatment algorithm. METHODS: We included a consecutive series of patients undergoing LA for acute appendicitis from January 2008 to December 2018. The cohort of patients with postoperative IAA was divided into three groups based on the implemented treatments: G1: antibiotics only, G2: CT-guided drainage, and G3: laparoscopic lavage. Characteristics of the fluid collections and outcomes were analyzed in the three groups. RESULTS: A total of 1668 LA were performed; the rate of IAA was 2.2% (36 patients). There were 12 (33%) patients who received antibiotics only (G1), 8 (22%) underwent CT-guided percutaneous drainage (G2), and 16 (45%) underwent laparoscopic lavage (G3). The median size of the abscesses was 2.7 (1.2-4) cm in G1, 6.2 (4.5-8) cm in G2, and 9.6 (8-11.4) cm in G3 (p < 0.04). Patients with two or more fluid collections underwent a laparoscopic lavage in all cases. Treatment failure occurred in 16% (2/12), 12.5% (1/8) and 12.5% (2/16) of the patients in G1, G2, and G3, respectively. None of the patients in the entire cohort required open surgery to resolve the postoperative IAA. CONCLUSIONS: A minimally invasive step-up approach based on the size and number of fluid collections is associated with excellent outcomes. A treatment algorithm for post-appendectomy IAA is proposed.

Usefulness of intraoperative culture swabs in laparoscopic appendectomy for complicated appendicitis.

PURPOSE: Intraabdominal abscess (IAA) is a feared complication after laparoscopic appendectomy (LA) for complicated appendicitis. Benefits of obtaining intraoperative culture swabs (ICS) still remain controversial. We aimed to determine whether ICS modify the rate and management of IAA after LA for complicated appendicitis. METHODS: A consecutive series of patients who underwent LA for complicated appendicitis from 2008 to 2018 were included. The cohort was divided into two groups: group 1 (G1), with ICS, and group 2 (G2), without ICS. Demographics, operative variables, pathogen isolation, antibiotic sensitivity, and postoperative outcomes were analyzed. RESULTS: A total of 1639 LA were performed in the study period. Of these, 270 (16.5%) were complicated appendicitis; 90 (33%) belonged to G1 and 180 (67%) to G2. In G1, a higher proportion of patients had generalized peritonitis (G1, 63.3%; G2, 35%; p < 0.01). Seventy-two (80%) patients had positive cultures in G1. The most frequently isolated bacteria were E. coli (66.7%), Bacteroides spp. (34.7%), and Streptococcus spp. (19.4%). In 26 (36%) patients, the initial empiric antibiotic course was modified due to bacterial resistance. The rate of IAA was higher in patients with ICS (G1, 21.1%; G2, 9.4%; p = 0.01). IAA was treated similarly in both groups. A different type of bacteria was isolated in 7 (53.8%) patients with new culture swabs. CONCLUSIONS: Obtaining ICS in LA for complicated appendicitis with further antibiotic adjustment to the initial pathogen did not lower the incidence of postoperative IAA and did not modify the treatment needed for this complication.

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.

Laparoscopic versus open appendectomy in pediatric patients with complicated appendicitis: a meta-analysis.

BACKGROUND: Acute appendicitis is a common condition in the pediatric population. In patients with uncomplicated appendicitis, laparoscopic appendectomy (LA) is preferred as compared to open appendectomy (OA). However, in patients with complicated appendicitis (CA), as defined as suppurative, gangrenous or perforated appendicitis, or appendicitis with periappendicular abscess formation, the decision to perform OA or LA remains unclear. METHODS: The PRISMA guidelines were adhered to. An electronic database search from 1997 to 2017 was performed using the Cochrane, Medline, PubMed, Scopus, Ovid, Embase, and Web of Knowledge databases. Data analysis, including subgroup analysis of randomized-control trials, was performed using RevMan 5.3. Assessment of methodological and statistical heterogeneity, as well as publication bias of the included studies, was performed. RESULTS: Six randomized-control trials (296 LA versus 373 OA) and 33 case-control trials (3106 LA versus 4149 OA) were analyzed. Compared to OA, LA has a shorter length of stay (WMD = - 0.96, 95% CI - 1.47 to - 0.45) and a lower rate of surgical site infection (OR 0.37, 95% CI 0.25-0.54), although the rates of intraabdominal abscess formation were similar (OR 1.01, 95% CI 0.71-1.43). LA was also shown to have lower readmission rates, lower incidences of postoperative ileus or intestinal obstruction, lower incidence of reoperation, as well as a shorter time taken to oral intake. Operative time for OA was shorter than LA (WMD = 12.44, 95% CI 2.00-22.87). CONCLUSION: While studies in the past have associated LA with higher rates of intraabdominal abscess in patients with CA, our meta-analysis has shown that they were similar. Considering this, together with other improved postoperative outcomes, LA should be the procedure of choice in pediatric patients presenting with CA.

Are Preoperative CT Findings Useful for Predicting Postoperative Intraabdominal Abscess in the Patients with Acute Appendicitis?

Background and objective: In patients with acute appendicitis (AA), preoperative computed tomography (CT) findings suggesting development of intraabdominal abscess (IAA) had not been widely used. The aim of this study was to investigate the preoperative clinical and radiological factors that predict the development of a postoperative IAA in patients with AA who were treated by laparoscopic appendectomy (LA). Methods: Two hundred and sixteen patients with pathologically proven AA underwent LA between January 2013 and March 2018 in our department. Medical records and preoperative CT images of these 216 patients were retrospectively reviewed and the predictive factors of postoperative IAA were investigated. In addition, patients were divided into complicated appendicitis (CA) and simple appendicitis (SA) and perioperative factors of two groups were compared. Results: One hundred and forty-seven patients were diagnosed with CA, while the other 69 patients were diagnosed with SA. Sixteen patients developed postoperative IAA in the CA group, while no patients in the SA group did. The univariate analysis revealed that time from onset to surgery more than 3 days (p = 0.011), the preoperative CT finding of periappendiceal fluid (p = 0.003), abscess (p < 0.001), and free air (p < 0.001), operation time more than 120 min (p = 0.023) and placement of a drainage tube (p < 0.001) were significantly associated with the development of IAA. Multivariate analysis revealed that the preoperative CT finding of free air was independently associated with the development of IAA (p = 0.007, odds ratio = 5.427, 95% CI: 1.586⁻18.57). Conclusions: IAA developed predominantly in patients with CA. Preoperative CT findings of free air was found to be an independent predictor for the development of IAA. Surgeons should be meticulous in managing the postoperative course of patients with this finding.

[Predictive factors of gangrenous post-appendectomy intra-abdominal abscess. A case-control study]. / Factores predictivos de absceso intraabdominal post-apendicectomía gangrenada. Un estudio caso-control.

BACKGROUND: Acute appendicitis is the most frequent surgical urgency in children. Frequently, it can be complicated with an intraabdominal abscess that will require a longer and expensive treatment. Our aim is to know if it is possible to predict this complication before its beginning. MATERIAL AND METHODS: Retrospective case-control study with patients treated between 2011 and 2016, paired according to their own characteristics (age, sex and weight), clinical aspects (symptoms, time of their onset, physical examination) and type of appendicitis (gangrenous). The main variable was the appearance of an intraabdominal abscess in the postoperative period (cases). Univariate and multivariate analysis were performed, with a statistical significance level of p < 0.05. RESULTS: We included 54 cases and 108 controls. The occurrence of intraabdominal abscess was significantly associated with preoperative hyponatremia (p < 0.001), elevated CRP (p < 0.05), appendix perforation (p < 0.001) and wound infection (p < 0.001). The multivariate analysis dismissed the value of the CRP as an abscess predictor but showed association in the other three variables cited before. There was no association with the presence of generalized peritonitis at the intervention or the type of surgical approach. CONCLUSIONS: Appendix perforation, infection of the surgical wound and hyponatremia at diagnosis are predictive factors for the appearance of a postoperative intraabdominal abscess after acute gangrene appendicitis. We believe that early identification would favor the secondary prevention of this complication and the decrease of its morbidity.

OBJETIVOS: La apendicitis aguda es la urgencia quirúrgica más frecuente en niños. En numerosas ocasiones el postoperatorio puede complicarse con un absceso intraabdominal que requerirá un tratamiento más largo y costoso. Nuestro objetivo es conocer si es posible predecir dicha complicación antes de producirse. MATERIAL Y METODOS: Estudio retrospectivo de casos y controles tratados entre 2011 y 2016 y pareados según características del paciente (edad, sexo y peso), cuadro clínico (síntomas, tiempo de evolución, exploración física) y tipo de apendicitis (gangrenada). La variable de agrupación fue la aparición de un absceso intraabdominal en el postoperatorio (casos). Se realizó análisis uni y multivariante, con un nivel de significación estadística p < 0,05. RESULTADOS: Se incluyeron 54 casos y 108 controles. La aparición de absceso intraabdominal se asoció significativamente con la hiponatremia preoperatoria (p < 0,001), la PCR elevada (p < 0,05), la perforación del apéndice (p < 0,001) y la infección de la herida quirúrgica (p < 0,001). El análisis multivariante descartó el valor de la PCR como predictor de absceso pero demostró asociación en las otras tres variables citadas. No se encontró asociación con la presencia de peritonitis generalizada en la intervención o el tipo de abordaje quirúrgico. CONCLUSION: La perforación del apéndice, la infección de la herida quirúrgica y la hiponatremia al diagnóstico son factores predictores de la aparición de un absceso intraabdominal postoperatorio después de una apendicitis aguda gangrenada. Creemos que la identificación precoz favorecería la prevención secundaria de esta complicación y la disminución de su morbilidad.

Comparison of clinical outcome of laparoscopic versus open appendectomy for complicated appendicitis.

BACKGROUND: Laparoscopic appendectomy is now the treatment of choice in uncomplicated appendicitis. To date its importance in the treatment of complicated appendicitis is not clearly defined. METHODS: From January 2005 to June 2013 a total of 1762 patients underwent appendectomy for the suspected diagnosis of appendicitis at our institution. Of these patients 1516 suffered from complicated appendicitis and were enrolled. In total 926 (61 %) underwent open appendectomy (OA) and 590 (39 %) underwent laparoscopic appendectomy (LA). The following parameters were retrospectively analyzed: age, sex, operative times, histology, length of hospital stay, 30-day morbidity focusing on occurrence of surgical site infections, intraabdominal abscess formation, postoperative ileus and appendiceal stump insufficiency, conversion rate, use of endoloops and endostapler. RESULTS: A statistically significant difference in operative time was observed between the laparoscopic and the open group (64.5 vs. 60 min; p = 0.002). Median length of hospitalization was significantly shorter in the laparoscopic group (p < 0.000). Surgical site infections occurred exclusively after OA (38 vs. 0 patients). Intraabdominal abscess formation occurred statistically significantly more often after LA (2 vs. 10 patients; p = 0.002). There were no statistical significances concerning the occurrence of postoperative ileus (p = 0.261) or appendiceal stump insufficiencies (p = 0.076). CONCLUSIONS: The laparoscopic approach for complicated appendicitis is a safe and feasible procedure. Surgeons should be aware of a potentially higher incidence of intraabdominal abscess formation following LA. Use of endobags , inversion of the appendiceal stump and carefully conducted local irrigation of the abdomen in a supine position may reduce the incidence of abscess formation.

Cooperative Study of the Spanish Pancreas Transplant Group (GETP): Surgical Complications.

UNLABELLED: Technical failure in pancreas transplant has been the main cause of the loss of grafts. In the last few years, the number of complications has reduced, and therefore the proportion of this problem. OBJECTIVES: The Spanish Pancreas Transplant Group wanted to analyze the current situation with regard to surgical complications and their severity. MATERIAL AND METHODS: A retrospective and multicenter study was performed. 10 centers participated, with a total of 410 pancreas transplant recipients between January and December 2013. RESULTS: A total of 316 transplants were simultaneous with kidney, 66 after kidney, pancreas-only 10, 7 multivisceral and 11 retrasplants. Surgical complication rates were 39% (n=161). A total of 7% vascular thrombosis, 13% bleeding, 6% the graft pancreatitis, 12% surgical infections and others to a lesser extent. Relaparotomy rate was 25%. The severity of complications were of type IIIb (13%), type II (12%) and type IVa (8.5%). Graft loss was 8%. Early mortality was 0.5%. The percentage of operations for late complications was 17%. CONCLUSIONS: The number of surgical complications after transplantation is not negligible, affecting one in 3 patients. They are severe in one out of 5 and, in one of every 10 patients graft loss occurs. Therefore, there is still a significant percentage of surgical complications in this type of activity, as shown in our country.

Intraoperative bacterial cultures fail to reliably predict the bacterial spectrum encountered during infectious complications after appendicitis.

Acute appendicitis is a common surgical emergency. Complicated appendicitis usually warrants perioperative antibiotic treatment in order to prevent infectious complications. Whether routine microbiological testing benefits the individual patient is a topic of debate. The goal of our study was to assess perioperative antibiotic prescriptions as well as the benefit of microbiological testing during the appendectomy as a predictor for bacteria encountered in infectious complications. This is a retrospective analysis of 1218 consecutive patients that underwent appendectomy at a tertiary referral center between 2014 and 2021. The patient charts were systematically analyzed regarding intraoperative outcome, microbiologic results, and postoperative infectious complications. 1218 patients were included in this study of which 768 were uncomplicated appendicitis (UA) and 450 were complicated appendicitis (CA). Microbiological testing was performed in 39.2% of UA cases (33.6% of which grew bacteria) compared to 74.9% of CA cases (78.6% positive cultures). The strongest individual predictors for SSI were gangrenous and perforated appendicitis. A total of 58 surgical-site infections developed, of which 49 were intra-abdominal fluid collections or abscesses. Thirty-two patients had revision surgery or CT-guided drainage for SSI. In the cases where microbiological testing was done both during the appendectomy and the SSI, 13/18 showed different bacteria on culture testing. The infectious outcome was favorable in 98.3%. While microbiological testing offers insights into resistance patterns, it is of little benefit for the individual patient, given the low predictive value for bacteria found during SSI. Achieving source control combined with empiric antibiotic coverage leads to favorable outcomes independent of culture results.

Impact of Concomitant Traumatic Pancreatic and Colon Injuries on Outcomes.

BACKGROUND: Colon and pancreatic injuries have both long been independently associated with intraabdominal infectious complications in trauma patients. The goal of this study was to evaluate the impact of concomitant pancreatic injury on outcomes in patients with traumatic colon injuries. METHODS: Consecutive patients over a 3-year period who underwent operative management of colon injuries were identified. Patient characteristics, severity of injury and shock, presence and grade of pancreatic injury, and intraoperative packed red blood cell (PRBC) transfusions were recorded. Outcomes including intraabdominal abscess formation and suture line failure were collected and compared. Multivariable logistic regression analysis was then performed to determine the impact of concomitant pancreatic injury on intraabdominal abscess formation. RESULTS: 243 patients with traumatic colon injuries were identified. 17 of these also had pancreatic injuries. Patients with combined colon and pancreatic injuries were clinically similar to those with isolated colon injuries with respect to age, gender, penetrating mechanism of injury, admission lactate, ISS, suture line failure, and admission systolic blood pressure. Both intraabdominal abscess rates (88.2% vs 29.6%, P < .001) and intraoperative PRBC transfusions (8 vs 1 units, P = .004) were higher in the combined pancreatic and colon injury group. Multivariable logistic regression identified both intraoperative PRBC transfusions (odds ratio, 1.09; 95% confidence interval, 1.04-1.15; P < .001) and concomitant pancreatic injury (odds ratio, 14.8; 95% confidence interval, 3.92-96.87; P < .001) as independent predictors of intraabdominal abscess formation. DISCUSSION: Both intraoperative PRBC transfusions and presence of concomitant pancreatic injury are independent predictors of intraabdominal abscess formation in patients with traumatic colon injuries.

Graham Patch Repair of a Prepyloric Ulcer Complicated by Recurrent Abdominal Abscesses and Leukocytosis: A Case Report.

This case report describes the clinical course of a 51-year-old Caucasian woman with a history of anemia who presented to the emergency department with worsening diffuse abdominal pain and weakness two days after dental surgery. The patient's condition rapidly deteriorated, manifesting as tachycardia, diaphoresis, and a peritonitic abdomen. A CT scan revealed a perforated gastric ulcer, prompting emergent laparoscopy, Graham patch repair, and abdominal washout. Postoperatively, the patient developed leukocytosis, and imaging indicated the formation of an abscess. Despite initial attempts at percutaneous drainage, a subsequent exploratory laparotomy was performed. The patient's leukocytosis eventually resolved, and she was discharged after 21 days with outpatient follow-up. The discussion delves into the declining incidence of peptic ulcer disease but a constant rate of complications, emphasizing the role of factors such as nonsteroidal anti-inflammatory drug use. The diagnostic approach using CT scans in suspected perforated peptic ulcers is highlighted. The study also explores risk stratification scoring systems, with a preference for operative management. The laparoscopic omental patch repair (Graham patch) is discussed, citing its safety and efficacy. The case presented an uncommon occurrence of failed primary percutaneous abscess drainage, leading to subsequent surgical drainage. The discussion concludes by noting variables that may contribute to drainage failure and emphasizes the need for further research to understand such complications.

Initial management of intraabdominal abscesses and preventive strategies for abscess recurrence in penetrating Crohn's disease: a national multicenter study based on ENEIDA registry.

INTRODUCTION: Intra-abdominal abscesses complicating Crohn's disease (CD) are a challenging situation. Their management, during the hospitalization and after resolution, is still unclear. METHODS: Adult patients with CD complicated with intraabdominal abscess who required hospitalization were included from the prospectively maintained ENEIDA registry from GETECCU. Initial strategy effectiveness and safety to resolve abscess was assessed. Survival analysis was performed to evaluate recurrence risk. Predictive factors associated with resolution were evaluated by multivariate regression and predictive factors associated with recurrence were assessed by Cox regression. RESULTS: 520 patients from 37 Spanish hospitals were included; 322 (63%) were initially treated with antibiotics alone, 128 (26%) with percutaneous drainage, and 54 (17%) with surgical drainage. The size of the abscess was critical to the effectiveness of each treatment. In abscesses < 30mm, the antibiotic was as effective as percutaneous or surgical drainage. However, in larger abscesses, percutaneous or surgical drainage was superior. In abscesses > 50mm, surgery was superior to percutaneous drainage, although it was associated with a higher complication rate. After abscess resolution, luminal resection was associated with a lower 1-year abscess recurrence risk (HR 0.43, 95% CI 0.24-0.76). However, those patients who initiated anti-TNF therapy had a similar recurrence risk whether luminal resection had been performed. CONCLUSIONS: Small abscesses (<30mm) can be managed with antibiotics alone, while larger ones require drainage. Percutaneous drainage will be effective and safer than surgery in many cases. After discharge, anti-TNF therapy reduces abscess recurrence risk in a similar way to bowel resection.

Using Artificial Neural Networks to Predict Intra-Abdominal Abscess Risk Post-Appendectomy.

Objective: To determine if artificial neural networks (ANN) could predict the risk of intra-abdominal abscess (IAA) development post-appendectomy. Background: IAA formation occurs in 13.6% to 14.6% of appendicitis cases with "complicated" appendicitis as the most common cause of IAA. There remains inconsistency in describing the severity of appendicitis with variation in treatment with respect to perforated appendicitis. Methods: Two "reproducible" ANN with different architectures were developed on demographic, clinical, and surgical information from a retrospective surgical dataset of 1574 patients less than 19 years old classified as either negative (n = 1,328) or positive (n = 246) for IAA post-appendectomy for appendicitis. Of 34 independent variables initially, 12 variables with the highest influence on the outcome selected for the final dataset for ANN model training and testing. Results: A total of 1574 patients were used for training and test sets (80%/20% split). Model 1 achieved accuracy of 89.84%, sensitivity of 70%, and specificity of 93.61% on the test set. Model 2 achieved accuracy of 84.13%, sensitivity of 81.63%, and specificity of 84.6%. Conclusions: ANN applied to selected variables can accurately predict patients who will have IAA post-appendectomy. Our reproducible and explainable ANNs potentially represent a state-of-the-art method for optimizing post-appendectomy care.

Microbial Spectrum and Antibiotic Resistance in Patients Suffering from Penetrating Crohn's Disease.

Intraabdominal abscess formation occurs in up to 30% of patients suffering from Crohn´s disease (CD). While international guidelines recommend a step-up approach with a combination of empiric antibiotic therapy and percutaneous drainage to delay or even avoid surgery, evidence about microbial spectrum in penetrating ileitis is sparse. We retrospectively assessed outcomes of 46 patients with terminal penetrating Ileitis where microbial diagnostics have been performed and compared microbial spectrum and antibiotic resistance profile of CD patients with patients suffering from diverticulitis with intraabdominal abscess formation. In both groups, the most frequently isolated pathogen was the gram-negative bacterium E.coli belonging to the family of Enterobacterales. However, overall Enterobacterales were significantly more often verifiable in the control group than in CD patients. Furthermore, microbial analysis showed significant differences regarding isolation of anaerobic pathogens with decreased frequency in patients with CD. Subgroup analysis of CD patients to evaluate a potential influence of immunosuppressive therapy on microbial spectrum only revealed that Enterobacterales was less frequently detected in patients treated with steroids. Immunosuppressive therapy did not show any impact on all other groups of pathogens and did not change antibiotic resistance profile of CD patients. In conclusion, we were able to demonstrate that the microbial spectrum of CD patients does differ only for some pathogen species without increased rate of antibiotic resistance. However, the empiric antibiotic therapy for CD-associated intra-abdominal abscess remains challenging since different points such as local epidemiological and microbiological data, individual patient risk factors, severity of infection, and therapy algorithm including non-surgical and surgical therapy options should be considered before therapeutical decisions are made.

Small Bowel Perforation Secondary to Portal Vein Thrombosis.

Portal vein thrombosis (PVT) is a heterogeneous entity often described as either an acute or chronic occlusion of the portal vein or its tributaries. The clinical presentation is highly variable, and it often mimics other more common causes of abdominal pain. In most patients, imaging studies such as doppler ultrasound, computed tomography, or magnetic resonance imaging are adequate for diagnosis. Occasionally imaging studies may be inadequate, and the diagnosis may not be made until complications such as bowel necrosis and perforation have occurred. We present a case of a morbidly obese 45-year-old female who was initially treated for suspected small bowel enteritis and discharged home on several occasions after nonspecific findings on abdominal imaging were seen and interval improvement in symptoms occurred with intravenous fluids and antibiotics. She then presented with worsening symptoms and was found on abdominal imaging to have a large fluid collection in the peritoneal cavity requiring exploratory laparotomy with peritoneal washout and partial small bowel resection due to perforation. She was diagnosed with PVT with mesenteric extension after samples of the resected mesentery were evaluated in the pathology laboratory. Her treatment included a prolonged course of antibiotics, total parenteral nutrition, and anticoagulation.

An encapsulated bulky abdominal abscess due to amoeba.

We report a rare case of amebiasis associated with an intraabdominal abscess without colitis, an intestinal perforation, or other extraintestinal amebiasis. A patient was admitted with cirrhosis and a history of spontaneous bacterial peritonitis (SBP) and was found to have a high C-reactive protein (CRP) level. Dynamic CT and ultrasound echo findings showed an intraabdominal abscess. No intestinal lesions or extraintestinal lesions other than the intraabdominal abscess were observed. Blood cultures and puncture fluid cultures were negative for bacteria. However, microscopic examination of the puncture fluid showed a cystic form of amoeba, leading to a diagnosis of an amoeba abscess. The abscess disappeared after 10 days of oral treatment with metronidazole. When an abdominal abscess is seen in an immunocompromised patient such as a cirrhotic patient, amoeba infection should be considered as a possible diagnosis.

An Unusual Case of Intraabdominal Abscess After a Colonoscopy With Polypectomy.

The use of colonoscopies in the screening of colorectal cancers has helped in the early detection and treatment of these cancers. Less than 0.5% of patients develop colonoscopy complications, mostly bleeding, and less frequently, perforations. There have been very few reported cases of micro-perforations following colonoscopies. We present a case of a 66-year-old female smoker who had undergone a screening colonoscopy for colorectal cancer with two polyps removed 3 weeks prior, who was brought to the hospital because of altered mental status and hypotension. A computed tomography (CT) scan of the abdomen and pelvis with contrast demonstrated intraabdominal abscess which was drained by interventional radiology. A culture of the pus grew Streptococcus constellatus, a pus-forming bacterium. She was treated with ceftriaxone and metronidazole for a total of 6 weeks, and a repeat CT of abdomen and pelvis demonstrated complete resolution. The only contributing factor to the formation of the intraabdominal abscess was a screening colonoscopy with polypectomy, which might have caused micro-perforations in the colon with the seeding of Streptococcus constellatus. The occurrence of intraabdominal abscess following a colonoscopy is very rare, and requires a high index of suspicion in patients who present with sepsis following colonoscopies.

Point-of-Care Ultrasound Diagnosis of a Crohn's Disease-Related Intraabdominal Abscess in the Emergency Department.

The emergency department (ED) diagnosis of Crohn's disease (CD)-associated complications is typically established with abdominopelvic computed tomography imaging. Ultrasonography has been suggested as an effective alternative modality for diagnosing several CD complications, including intraabdominal abscesses. We report the identification of a CD-related intraabdominal abscess by emergency physician (EP)-performed point-of-care ultrasound (POCUS). This case highlights the feasibility of EPs integrating POCUS into the clinical decision-making for patients with inflammatory bowel disease in the ED.

Prophylactic intraabdominal drains do not confer benefit in pediatric perforated appendicitis: Results from a quality improvement initiative.

BACKGROUND/PURPOSE: Prophylactic, intraabdominal drains have been used to prevent intraabdominal abscess (IAA) after perforated appendicitis. We hypothesized that routine drain placement would reduce the IAA rate in pediatric perforated appendicitis. METHODS: A 27-month quality improvement (QI) initiative was conducted: closed-suction, intraabdominal drains were placed intraoperatively in pediatric (age < 18) perforated appendicitis patients. QI patients were compared to controls admitted during the preceding 8 months and following 4 months. The primary outcome was 30-day IAA rate. Univariate and multivariate analyses were performed. RESULTS: Two hundred seventy QI patients were compared to 109 controls. There was 100% compliance during 21 of 27 months of the QI initiative; only 7 QI patients did not receive drains. IAA occurred in 20.0% of QI patients and 22.9% of control (p = 0.52). After adjustment, the QI initiative was not associated with reduced odds of IAA (OR 0.83, 95% CI 0.48-1.44). Median length of stay was longer in QI patients during the index admission (p = 0.03) and over 30 postoperative days (p = 0.03), but these relationships did not persist after adjustment. CONCLUSIONS: A QI initiative investigating prophylactic, intraabdominal drain placement in perforated appendicitis did not reduce the IAA rate. We recommend against routine drain placement in pediatric perforated appendicitis. LEVEL OF EVIDENCE: Level III.