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Intra-abdominal abscess radiologic diagnosis and treatment
Abstracts
cystitis regardless of the localization of the site of the infection. [Mel D. Robinson, MD] Editor’s Note: All of these regimens required either two or four tablets. This should increase compliance significantly, since any of the regimens can be administered in the emergency department.
0 ANGIOGRAPHY AND PERITONEAL LAVAGE IN BLUNT ABDOMINAL TRAUMA. Ward RE, Miller P, Clark DC, Ben-Menachem Y. Duke J Trauma 1981; 21:848-853. This paper describes the findings of a retrospective review of the records of 123 patients who underwent abdominal angiography for blunt trauma. The purpose of the study was to determine the indications, risks, and accuracy of abdominal angiography in this setting. Twenty-four patients underwent angiography on the basis of physical examination and 29% of these patients required operative intervention as determined by angiography. Ninety-nine patients had abdominal angiography incidental to angiographic evaluation of the chest, pelvis, head, or extremities. Fourteen percent of these patients required operative intervention. Four patients had a peritoneal lavage which was interpreted as negative (less than 100,000 RBC’s/ mm) but had positive angiography that required intervention. These four patients all had RBC counts of 50,000-70,000 in the lavage fluid. Eleven patients had positive lavage and negative abdominal angiograms. Five of these patients avoided laparotomy on this basis. There were no complications related to the angiographic procedure in this series. The authors conclude that angiography is a safe, accurate procedure which should be used in conjunction with physical examination and peritoneal lavage in blunt trauma patients. They list the indications for abdominal angiography in blunt trauma as: (1) incidental to needed thoracic aortography; (2) incidental to angiograms for pelvic fractures; and (3) suspected intra-abdominal injuries when clinical and lavage results are inconclusive. [MDR] Editor’s Note: As MacKenzie suggests in the discussion of this paper, repeat peritoneal lavage might be quicker and easier in the patient with equivocal lavage. We have also utilized a lower count than 100,000, i.e., 5000 when diaphragmatic penetration is suspected, and have measured alkaline phosphatase to search for small bowel injury.
103
0 PHARYNGEAL GONORRHEA. Tice AW, Rodriguez VL. JAMA 1981; 246:27172719. This paper describes a retrospective study to determine the incidence of pharyngeal gonorrhea among service men and prostitutes in the area near Clark AFB in the Philippines. Positive pharyngeal cultures were obtained in 2.2% of women and 6% of men studied. Most cases were asymptomatic or presented with only mild sore throat. Approximately 35% of these infections were by penicillinase-producing Neisseria gonorrhea (PPNG). All cases of PPNG responded well to treatment with 2 Grams Spectinomytin IM. The authors conclude that pharyngeal gonorrhea is a small, but significant venereal disease problem in their patient population. They believe that all possible sites of infection should be cultured regardless of symptoms. [MDRI Editor’s Note: According to this article current CDC recommendations for therapy of pharyngeal gonorrhea are nine tablets of trimethoprim-sulfamethoxazole each day for five days.
0 INTRA-ABDOMINAL ABSCESS RADIOLOGIC DIAGNOSIS AND TREATMENT. Ferrucci JT, vansonnenberg E. JAMA 1981; 246:2728-2733. This article describes recent radiologic advances in the detection, localization, and treatment of intra-abdominal abscess. The authors point to the limitations of plain roentgenograms and barium studies. Ultrasound and body CT are fast, accurate and non-invasive. Ultrasound is 93.3% sensitive and 98.6% specific in the diagnosis of intraabdominal and pelvic abscess. Some of the specific diagnostic findings and technique problems are discussed. CT body scan may be even more sensitive and specific than ultrasound. Both modalities appear to be more accurate and much faster than radionuclide scanning. The authors therefore recommend ultrasound or body CT as the initial examinations in all patients critically ill or with localizing findings. The recent advent of nonsurgical catheter drainage of intra-abdominal abscess using US or CT is discussed. Success rates of up to 85% have been reported and the authors feel that this technique will have an increasing role in the high risk surgical patient. [MDRI
104
Editor’s Note: This is an encouraging article for the location of the elusive intra-abdominal abscess. Whether the suggested technique will prove superior to adequate drainage is still speculative.
0 AN EPIDEMIOLOGIC STUDY OF INSECT ALLERGY IN CHILDREN. Schuberth KC, et al. JPeds 1982; 100:546-551. Anaphylactic reactions to an insect sting are common in the United States. Between one and two million people have a history of systemic reaction to an insect sting and a positive skin test. This study deals with the preliminary results of an ongoing prospective study of insect allergy in children. Of 235 children studied, all of whom had a history of allergic reactions to insect stings, 59 had severe life threatening systemic reactions, 123 had mild, non life threatening systemic reactions and 53 had local reactions. Allergic reactions are mediated by IgE antibodies directed against specific venom proteins. Immunotherapy using insect venoms has been shown to be a safe effective means of preventing future systemic allergic reactions. The ongoing prospective study done in this paper sets out to determine who indeed needs immunotherapy. Their data show that skin tests were not on an individual patient basis, indicative of the severity of previous reactions. In the particular group of children studied, the incidence of systemic reaction following re-sting in those patients who were not given immunotherapy is relatively low. The authors also point out that the cost of giving immunotherapy to all patients with an initial systemic reaction to insect stings is prohibitive. [Nancy Schlehner, MD] Editor’s Note: This series is small but appears to indicate that desensitization is not necessary. Probably a bee sting kit and instruction in its use will suffice and be much less expensive.
0 A CORRELATION BETWEEN CLINICAL PANCREATITIS AND ISOENZYME PA’ITERNS OF AMYLASE. Weaver DW, Bouwman DL, Walt AJ, Clink D, Resto A, Stephany J. Surgery 1982; 84:576-580. Isoamylase analysis was performed on 57 patients admitted with the diagnosis of acute pancreatitis trying to determine the source of their hyperamylasemia. The diagnosis of acute pan-
TheJournal of Emergency Medicine
creatitis was made when upper abdominal pain, nausea and vomiting, and hyperamylasemia occurred in the absence of intestinal perforation or obstruction. 39 of 57 (68%) had increased pancreatic amylase levels but 18 (32%) patients had normal pancreatic anylase levels. Of these 18,2 patients had macroamylasemia and 16 had amylase of nonpancreatic origin. Therefore 32% of patients admitted for acute pancreatitis had an incorrect diagnosis. The authors suggest that the abdominal pain associated with nonpancreatic amylase elevation was related to acute erosive gastritis, referred pain from pulmonary sources, or from drug withdrawal. They conclude that isoamylase profiles which can be done rapidly and inexpensively can save enormous amounts of time and money working up patients who do not have acute pancreatitis. [Larry A. Sokol, MD] Editor’s Note: We would argue against using a single laboratory finding as criterion of admission. Many alcoholics who do not have pancreatitis will still exhibit posthral vital signs, electrolyte and acid-base abnormalities which justify inpatient or observation unit therapy. Many of these patients are in an early phase of withdrawal, and aggressive fluid and tranquilization will prevent full-blown DTs.
0 NECROTIZING FASCIITIS: A PREVENTABLE DISASTER. Rouse TM, Malangoni MA, Schulte WJ. Surgery 1982; 84:765769. The authors examine 28 cases of necrotizing fasciitis (Nl?) in 27 patients from 1969 to 1981. NF was usually secondary to intra-abdominal operative procedures, cutaneous ulcers, and perineal disease. 77% of patients have associated chronic disease including atherosclerosis, diabetes mellitus, and obesity. Post-op NF developed when prophylactic antibiotics were omitted or not used properly during contaminated or clean bowel procedures and when primary skin closure was performed in the presence of intra-abdominal contamination. 20 of 27 (73%) patients died with death attributed to systemic septic complications in 9 patients, persistent wound sepsis in 9 patients, and 2 patients had myocardial infarctions. 85% of infections were polymicrobial with bacteroides, E. coli, enterococcus, and clostridia species predominating. 91% of patients with a 12 hour or greater delay
cystitis regardless of the localization of the site of the infection. [Mel D. Robinson, MD] Editor’s Note: All of these regimens required either two or four tablets. This should increase compliance significantly, since any of the regimens can be administered in the emergency department.
0 ANGIOGRAPHY AND PERITONEAL LAVAGE IN BLUNT ABDOMINAL TRAUMA. Ward RE, Miller P, Clark DC, Ben-Menachem Y. Duke J Trauma 1981; 21:848-853. This paper describes the findings of a retrospective review of the records of 123 patients who underwent abdominal angiography for blunt trauma. The purpose of the study was to determine the indications, risks, and accuracy of abdominal angiography in this setting. Twenty-four patients underwent angiography on the basis of physical examination and 29% of these patients required operative intervention as determined by angiography. Ninety-nine patients had abdominal angiography incidental to angiographic evaluation of the chest, pelvis, head, or extremities. Fourteen percent of these patients required operative intervention. Four patients had a peritoneal lavage which was interpreted as negative (less than 100,000 RBC’s/ mm) but had positive angiography that required intervention. These four patients all had RBC counts of 50,000-70,000 in the lavage fluid. Eleven patients had positive lavage and negative abdominal angiograms. Five of these patients avoided laparotomy on this basis. There were no complications related to the angiographic procedure in this series. The authors conclude that angiography is a safe, accurate procedure which should be used in conjunction with physical examination and peritoneal lavage in blunt trauma patients. They list the indications for abdominal angiography in blunt trauma as: (1) incidental to needed thoracic aortography; (2) incidental to angiograms for pelvic fractures; and (3) suspected intra-abdominal injuries when clinical and lavage results are inconclusive. [MDR] Editor’s Note: As MacKenzie suggests in the discussion of this paper, repeat peritoneal lavage might be quicker and easier in the patient with equivocal lavage. We have also utilized a lower count than 100,000, i.e., 5000 when diaphragmatic penetration is suspected, and have measured alkaline phosphatase to search for small bowel injury.
103
0 PHARYNGEAL GONORRHEA. Tice AW, Rodriguez VL. JAMA 1981; 246:27172719. This paper describes a retrospective study to determine the incidence of pharyngeal gonorrhea among service men and prostitutes in the area near Clark AFB in the Philippines. Positive pharyngeal cultures were obtained in 2.2% of women and 6% of men studied. Most cases were asymptomatic or presented with only mild sore throat. Approximately 35% of these infections were by penicillinase-producing Neisseria gonorrhea (PPNG). All cases of PPNG responded well to treatment with 2 Grams Spectinomytin IM. The authors conclude that pharyngeal gonorrhea is a small, but significant venereal disease problem in their patient population. They believe that all possible sites of infection should be cultured regardless of symptoms. [MDRI Editor’s Note: According to this article current CDC recommendations for therapy of pharyngeal gonorrhea are nine tablets of trimethoprim-sulfamethoxazole each day for five days.
0 INTRA-ABDOMINAL ABSCESS RADIOLOGIC DIAGNOSIS AND TREATMENT. Ferrucci JT, vansonnenberg E. JAMA 1981; 246:2728-2733. This article describes recent radiologic advances in the detection, localization, and treatment of intra-abdominal abscess. The authors point to the limitations of plain roentgenograms and barium studies. Ultrasound and body CT are fast, accurate and non-invasive. Ultrasound is 93.3% sensitive and 98.6% specific in the diagnosis of intraabdominal and pelvic abscess. Some of the specific diagnostic findings and technique problems are discussed. CT body scan may be even more sensitive and specific than ultrasound. Both modalities appear to be more accurate and much faster than radionuclide scanning. The authors therefore recommend ultrasound or body CT as the initial examinations in all patients critically ill or with localizing findings. The recent advent of nonsurgical catheter drainage of intra-abdominal abscess using US or CT is discussed. Success rates of up to 85% have been reported and the authors feel that this technique will have an increasing role in the high risk surgical patient. [MDRI
104
Editor’s Note: This is an encouraging article for the location of the elusive intra-abdominal abscess. Whether the suggested technique will prove superior to adequate drainage is still speculative.
0 AN EPIDEMIOLOGIC STUDY OF INSECT ALLERGY IN CHILDREN. Schuberth KC, et al. JPeds 1982; 100:546-551. Anaphylactic reactions to an insect sting are common in the United States. Between one and two million people have a history of systemic reaction to an insect sting and a positive skin test. This study deals with the preliminary results of an ongoing prospective study of insect allergy in children. Of 235 children studied, all of whom had a history of allergic reactions to insect stings, 59 had severe life threatening systemic reactions, 123 had mild, non life threatening systemic reactions and 53 had local reactions. Allergic reactions are mediated by IgE antibodies directed against specific venom proteins. Immunotherapy using insect venoms has been shown to be a safe effective means of preventing future systemic allergic reactions. The ongoing prospective study done in this paper sets out to determine who indeed needs immunotherapy. Their data show that skin tests were not on an individual patient basis, indicative of the severity of previous reactions. In the particular group of children studied, the incidence of systemic reaction following re-sting in those patients who were not given immunotherapy is relatively low. The authors also point out that the cost of giving immunotherapy to all patients with an initial systemic reaction to insect stings is prohibitive. [Nancy Schlehner, MD] Editor’s Note: This series is small but appears to indicate that desensitization is not necessary. Probably a bee sting kit and instruction in its use will suffice and be much less expensive.
0 A CORRELATION BETWEEN CLINICAL PANCREATITIS AND ISOENZYME PA’ITERNS OF AMYLASE. Weaver DW, Bouwman DL, Walt AJ, Clink D, Resto A, Stephany J. Surgery 1982; 84:576-580. Isoamylase analysis was performed on 57 patients admitted with the diagnosis of acute pancreatitis trying to determine the source of their hyperamylasemia. The diagnosis of acute pan-
TheJournal of Emergency Medicine
creatitis was made when upper abdominal pain, nausea and vomiting, and hyperamylasemia occurred in the absence of intestinal perforation or obstruction. 39 of 57 (68%) had increased pancreatic amylase levels but 18 (32%) patients had normal pancreatic anylase levels. Of these 18,2 patients had macroamylasemia and 16 had amylase of nonpancreatic origin. Therefore 32% of patients admitted for acute pancreatitis had an incorrect diagnosis. The authors suggest that the abdominal pain associated with nonpancreatic amylase elevation was related to acute erosive gastritis, referred pain from pulmonary sources, or from drug withdrawal. They conclude that isoamylase profiles which can be done rapidly and inexpensively can save enormous amounts of time and money working up patients who do not have acute pancreatitis. [Larry A. Sokol, MD] Editor’s Note: We would argue against using a single laboratory finding as criterion of admission. Many alcoholics who do not have pancreatitis will still exhibit posthral vital signs, electrolyte and acid-base abnormalities which justify inpatient or observation unit therapy. Many of these patients are in an early phase of withdrawal, and aggressive fluid and tranquilization will prevent full-blown DTs.
0 NECROTIZING FASCIITIS: A PREVENTABLE DISASTER. Rouse TM, Malangoni MA, Schulte WJ. Surgery 1982; 84:765769. The authors examine 28 cases of necrotizing fasciitis (Nl?) in 27 patients from 1969 to 1981. NF was usually secondary to intra-abdominal operative procedures, cutaneous ulcers, and perineal disease. 77% of patients have associated chronic disease including atherosclerosis, diabetes mellitus, and obesity. Post-op NF developed when prophylactic antibiotics were omitted or not used properly during contaminated or clean bowel procedures and when primary skin closure was performed in the presence of intra-abdominal contamination. 20 of 27 (73%) patients died with death attributed to systemic septic complications in 9 patients, persistent wound sepsis in 9 patients, and 2 patients had myocardial infarctions. 85% of infections were polymicrobial with bacteroides, E. coli, enterococcus, and clostridia species predominating. 91% of patients with a 12 hour or greater delay