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Percutaneous Drainage of the Abdominal Abscess
889
materials. CT correctly identified an abscess in 72 of 78 proven cases in one study and missed only one abscess requiring drainage in 32 apparently normal scans.8 Oral administration of water-soluble contrast material can help to show whether fluid is within the bowel; but even when the fluid is identified as extraintestinal, consideration of the clinical findings is still necessary to establish that it is indeed pus. Accurate diagnosis of an intra-abdominal abscess is not the only benefit of these new imaging methods; they can also help with treatment. The very accurate anatomical definition provided by CT and ultrasound, as well as the precise location of all the structures
contrast
surrounding the abscess, has made percutaneous puncture and drainage a safe procedure. Many abscesses abut onto the abdominal wall, and the larger the abscess the greater the displacement of surrounding structures-so the safer the percutaneous approach. In the series reported by GERZOF et al.,9 a safe Percutaneous Drainage of the Abdominal Abscess still troubleThey are always difficult to diagnose and, with the exception of a pelvic abscess, impossible to locate by clinical examination. Simple radiography pinpoints; only some of these abscesses2,3 and so the newer imaging techniques are usually needed. Radioactive gallium-67 concentrates within pus and can accurately identify an abscess in up to 8 out of 10 patients.4The’ false-positive rate, however, is high5 and the time that must elapse between injection of the gallium and scanning of the patient may be unacceptable. The newer technique whereby a patient’s own white cells are labelled with indium-111 is speedier and also more specific.6 Ultrasonography in experienced hands is also highly accurate7 as well as non-invasive and readily available. Fluid in the gallbladder or bowel must not be mistaken for an abscess, and the results must be interpreted in the context of the clinical picture.Abdominal wounds, colostomies, and bowel gas all make the investigation difficult but it can be repeated as often as necessary. Computed tomography (CT) is also repeatable and it too is highly accurate in the detection of an abscess. Pus has a different attenuation value from solid tissue and the rim of hyperaemia surrounding an abscess can often be enhanced with intravenous ABSCESSES within the abdomen
are
some. 1,2
.
s ;
:
1. Editorial. Pyogenic liver abscess-a continuing
problem of management. Lancet 1976; i: 1170-71. 2. Connell TR, Stephens DH, Carlson HC, Brown ML Upper abdominal abscess A continuing and deadly problem AJR 1980; 134: 759-65. 3. Altemeier WA, Culbertson WR, Fullen WD, Shook CD. Intra-abdominal abscess. Am J Surg 1973; 125: 70-79. 4. Forgacs P, Wahner HW, Keys TF, Van Scoy RE. Gallium scanning for the detection of abdominal abscesses. Am J Med 1978; 65: 949-54. 5 Ferrucci JT, Van Sonnenberg E. Intraabdominal abscess. Radiological diagnosis and JAMA 1981; 246: 2728-33. JQ, Koehler PR, Lee TG, Welch DM. Diagnosis of abdominal abscess with computed tomography, ultrasound and 111 In leukocyte scans. Radiology 1980; treatment.
6. Knochel
137: 425-32. 7. Taylor KJW, Sullivan
DC, Wasson JF, Rosenfield AT. Ultrasound and gallium for the diagnosis of abdominal and pelvic abscesses. Gastrointest Radiol 1978; 3: 281-86.
percutaneous route to the abscess could be found in all but one patient. Percutaneous drainage is not new. When an amoebic liver abscess needs to be drained, this is nearly always the method of choice10 and nearly thirty years ago MCFADZEAN successfully treated 14 pyogenic liver abscesses by aspiration and antibiotics. 11 CT, ultrasound, and fluoroscopy have only made the aspiration easier.12,14 Can we go a stage further and treat liver abscesses by antibiotics alone? Most will respond, like amoebic abscesses, to a long course of suitable antimicrobials, 15,16 and examination of pus may be unnecessary if the organism can be isolated from blood cultures. For abscesses at other sites within the abdomen, however, some type of drainage is still essential. With percutaneous drainage and antibiotics complete resolution was obtained in 40 out of 45 abscesses in one series. Operative drainage was avoided in 34 of the 40 patients.17 Two other groups have reported similar resultsl8,19 and even when the patients with intrahepatic abscesses in these three studies are excluded the success rate remains the same. A precise 8. Koehler PR, Moss AA. Diagnosis of intraabdominal and pelvic abscesses
computerised tomography. JAMA 1980; 244:
by
49-52.
9. Gerzof SG, Robbins AH, Birkett DH, Johnson WC, Pugatch RD, Vincent ME. Percutaneous catheter drainage of abdominal abscesses guided by ultrasound and
computed tomography AJR 1979; 133: 1-8. 10. Harries J. Amoebiasis: a review. J Roy Soc Med 1982; 75: 190-97. 11. McFadzean AJS, Chang KPS, Wong CC. Solitary pyogenic abscess of the liver treated by closed aspiration and antibiotics. Br J Surg 1953; 41: 141-52. 12. Dixon GD. Combined CT and fluoroscopic guidance for liver abscess drainage. AJR 1980; 135: 397-99. 13. Berger LA, Osborne DR. Treatment of pyogenic liver abscesses by percutaneous needle aspiration. Lancet 1982; i: 132-34. 14. Martin EC, Karlson KB, Fankuchen E, Cooperman A, Casarella WJ. Percutaneous drainage in the management of hepatic abscesses. Surg Clin North Am 1981; 61: 157-67. 15. Herbert DA, Fogel DA, Rothman J, Wilson S, Simmons F, Ruskin J. Pyogenic liver abscess. successful non-surgical therapy Lancet 1982; 1: 134-36. 16. De Cock KM, Bhatt KM, Bhatt SM, et al. Management of liver abscesses. Lancet 1982; i: 743 17. Van Sonnenberg E, Ferrucci JT, Mueller PR, Wittenberg J, Simone JF, Malt RA. Percutaneous radiographically guided catheter drainage of abdominal abscesses. JAMA 1982; 247: 190-92.. 18. Gerzof SG, Robbins AH, Johnson WC, Birkett DH, Nabseth DC. Percutaneous catheter drainage of abdominal abscesses. A five year experience. N Engl J Med 1981; 305: 653-57. 19. Karlson KB, Martin EC, Fankuchen EI, Schultz RW, Casarella WJ. Percutaneous abscess drainage. Surg Gynecol Obstet 1982, 154: 44-48
890
is obviously important but several golden rules of surgery can be ignored. The chosen drainage track does not have to be extraperitoneal, nor is dependent drainage essential, although both are desirable. IS For guidance of the needle to the abscess some operators favour ultrasound, 18 others CT,20 and yet others fluoroscopy.12 Once pus is identified by aspiration, a drainage catheter is inserted either over a guide wire or through a trocar. The second method is usually easier for the larger and more superficial abscesses.21 The thick pus which is aspirated immediately after insertion of the drain is followed by thin serosanguineous fluid that flows easily along small catheters, so large drains are unnecessary. On the other hand, drainage must be adequate. In one series 19 7 patients needed operations to complete the drainage of an abdominal abscess; in another, 6 abscesses recurred (although 4 were caused by a pre-existing intestinal fistula); 17 and in a third 3 patients died from inadequate drainage.16 Furthermore, it is possible to spread the infection to the pleura or peritoneum, 18 to create an intestinal fistula, 17,18or to damage blood vessels,17 so careful planning and accurate placement of the drain really is essential. Irrigation of the catheters’is probably unnecessary and some investigators prefer to monitor the resolution of the abscess with ultrasound or CT rather than with sinograms. Antibiotic treatment is essential during and after percutaneous drainage and, of course, tubes fall out and have to be replaced
technique
(whether they were inserted by surgeons or radiologists). Pancreatic abscesses are particularly troublesome. 18 On CT, pus
can be difficult to and even when pus is distinguish phlegmon,8 drained percutaneously the necrotic debris of a pancreatic abscess will often block the drains. Surgical drainage may therefore be wiser. Multiple abscesses and those caused by an intestinal fistula are also best treated by operation. Operative drainage of any intraabdominal extrahepatic abscess carries a substantial mortality 22 and in this respect percutaneous drainage offers a real advantage. However, the death rate associated with undrained pus approaches 100%; so, when the percutaneous approach is contraindicated or fails, surgical drainage is essential.
from
a
myocardial involvement are indications for treatment with corticosteroids. Although the cause of sarcoidosis remains an enigma, it is now clear that T lymphocytes are concerned in pathogenesis of the pulmonary lesions.This opens the possibility that some measure of inflammatory activity, such as lymphocyte counts in fluid obtained by bronchoalveolar lavage, or gallium-67 scanning of the lungs, might help in identification of patients requiring treatment.2For this purpose some clinicians measure serum angiotensinconverting enzyme (ACE),3 but its value is questionable. It
ACE does not accurately reflect activity of the pulmonary component of the disease as assessed by the bronchoalveolar lavage lymphocyte count. 2,4 The place of gallium-67 scanning has yet to be defined. It may be of use in distinguishing active granulomatous pulmonary disease from burntout fibrosis, or in the assessment of response to treatment.5 On existing evidence, however, this expensive investigation, with its small but distinct radiation hazard, should not be used routinely in the investigation of sarcoidosis. There is a rough correlation between gallium scanning and serum ACE, but not between gallium scanning and lymphocyte counts in bronchoalveolar lavage fluid.Much has yet to be learned about the usefulness of these investigations in assessment and staging of the individual patient, but it is already clear that serum ACE measurements by themselves are of limited value; so most clinicians will continue to use the crude guidelines which have evolved from decades of clinical experience.
WHEN
of
Pulmonary Sarcoidosis
sarcoidosis be left untreated? Most chest physicians will say, when the patient has hilar adenopathy without symptoms or biochemical disturbance; whereas hypercalcaemia, rapidly progressive pulmonary disease, and evidence of ocular, brain, or can
Alfidi RJ, Weinstem A. Percutaneous catheter drainage of abdominal abscesses N Engl Med 1982; 306: 106-07. J 21 Haaga JR, George C, Weinstein AJ, Cooperman AM. New interventional techniques in the diagnosis and management of inflammatory disease within the abdomen. Radiol Clin North Am 1979; 17: 485-513 22 Bonfils-Roberts EA, Barone JE, Nealon TF Treatment of subphrenic abscess. Surg Clin North Am 1975; 55;. 1361-66 20.
Haaga JR,
emerges that
serum
The existing treatment policies are not wholly without rational foundation, and a review from Denmark’ now provides reassuring data. 243 patients were followed for up to 10 years and in 8707o the chest X-ray abnormalities spontaneously improved within 2 years. A clear X-ray for 2 years can be regarded as a permanent remission. This review also confirmed that hilar glandular sarcoidosis (stage I) carries the most favourable prognosis, 58% of patients in this group improving within 12 months and only 9% progressing to pulmonary sarcoidosis. Patients presenting with pulmonary infiltration and hilar adenopathy (stage II)
Roberts WC, Hunninghake GW, et al. Pulmonary sarcoidosis a disease characterised and perpetuated by activated lung T-lymphocytes. Ann Intern Med 1981, 94: 73-94 2. Schoenberger CI, Line BR, Keogh BA, et al. Lung inflammation m sarcoidosis comparison of serum angiotensin-converting enzyme levels with bronchoalveolar lavage and gallium-67 scanning assessment of the T-lymphocyte alveolitis Thorax 1982, 37: 19-25. 3. Leiberman J. Elevation of serum angiotensin-converting enzyme (ACE) level in sarcoidosis. Am J Med 1975; 59: 365-72 4. Rossman MD, Dauber JH, Cardillo ME, Daniele RP Pulmonary sarcoidosis: correlation of serum angiotensin-converting enzyme with blood and bronchoalveolar lymphocytes. Am Rev Resp Dis 1982; 125: 366-69. 5. Turton CWG, Grundy E, Firth G, et al Value of measuring serum angiotensinconverting enzyme and serum lysozyme in the management of sarcoidosis Thorax 1979, 34: 57-62. 6 Beaumont D, Herry JY, Sapene M, et al. Gallium-67 in the evaluation of sarcoidosis correlations with serum angiotensin-converting enzyme and bronchoalveolar lavage Thorax 1982, 37: 11-18 7 Romer FK. Presentation of sarcoidosis and outcome of pulmonary changes Dan Med Bull 1982; 29: 27-32 1.
Management
now
Crystal RG,
materials. CT correctly identified an abscess in 72 of 78 proven cases in one study and missed only one abscess requiring drainage in 32 apparently normal scans.8 Oral administration of water-soluble contrast material can help to show whether fluid is within the bowel; but even when the fluid is identified as extraintestinal, consideration of the clinical findings is still necessary to establish that it is indeed pus. Accurate diagnosis of an intra-abdominal abscess is not the only benefit of these new imaging methods; they can also help with treatment. The very accurate anatomical definition provided by CT and ultrasound, as well as the precise location of all the structures
contrast
surrounding the abscess, has made percutaneous puncture and drainage a safe procedure. Many abscesses abut onto the abdominal wall, and the larger the abscess the greater the displacement of surrounding structures-so the safer the percutaneous approach. In the series reported by GERZOF et al.,9 a safe Percutaneous Drainage of the Abdominal Abscess still troubleThey are always difficult to diagnose and, with the exception of a pelvic abscess, impossible to locate by clinical examination. Simple radiography pinpoints; only some of these abscesses2,3 and so the newer imaging techniques are usually needed. Radioactive gallium-67 concentrates within pus and can accurately identify an abscess in up to 8 out of 10 patients.4The’ false-positive rate, however, is high5 and the time that must elapse between injection of the gallium and scanning of the patient may be unacceptable. The newer technique whereby a patient’s own white cells are labelled with indium-111 is speedier and also more specific.6 Ultrasonography in experienced hands is also highly accurate7 as well as non-invasive and readily available. Fluid in the gallbladder or bowel must not be mistaken for an abscess, and the results must be interpreted in the context of the clinical picture.Abdominal wounds, colostomies, and bowel gas all make the investigation difficult but it can be repeated as often as necessary. Computed tomography (CT) is also repeatable and it too is highly accurate in the detection of an abscess. Pus has a different attenuation value from solid tissue and the rim of hyperaemia surrounding an abscess can often be enhanced with intravenous ABSCESSES within the abdomen
are
some. 1,2
.
s ;
:
1. Editorial. Pyogenic liver abscess-a continuing
problem of management. Lancet 1976; i: 1170-71. 2. Connell TR, Stephens DH, Carlson HC, Brown ML Upper abdominal abscess A continuing and deadly problem AJR 1980; 134: 759-65. 3. Altemeier WA, Culbertson WR, Fullen WD, Shook CD. Intra-abdominal abscess. Am J Surg 1973; 125: 70-79. 4. Forgacs P, Wahner HW, Keys TF, Van Scoy RE. Gallium scanning for the detection of abdominal abscesses. Am J Med 1978; 65: 949-54. 5 Ferrucci JT, Van Sonnenberg E. Intraabdominal abscess. Radiological diagnosis and JAMA 1981; 246: 2728-33. JQ, Koehler PR, Lee TG, Welch DM. Diagnosis of abdominal abscess with computed tomography, ultrasound and 111 In leukocyte scans. Radiology 1980; treatment.
6. Knochel
137: 425-32. 7. Taylor KJW, Sullivan
DC, Wasson JF, Rosenfield AT. Ultrasound and gallium for the diagnosis of abdominal and pelvic abscesses. Gastrointest Radiol 1978; 3: 281-86.
percutaneous route to the abscess could be found in all but one patient. Percutaneous drainage is not new. When an amoebic liver abscess needs to be drained, this is nearly always the method of choice10 and nearly thirty years ago MCFADZEAN successfully treated 14 pyogenic liver abscesses by aspiration and antibiotics. 11 CT, ultrasound, and fluoroscopy have only made the aspiration easier.12,14 Can we go a stage further and treat liver abscesses by antibiotics alone? Most will respond, like amoebic abscesses, to a long course of suitable antimicrobials, 15,16 and examination of pus may be unnecessary if the organism can be isolated from blood cultures. For abscesses at other sites within the abdomen, however, some type of drainage is still essential. With percutaneous drainage and antibiotics complete resolution was obtained in 40 out of 45 abscesses in one series. Operative drainage was avoided in 34 of the 40 patients.17 Two other groups have reported similar resultsl8,19 and even when the patients with intrahepatic abscesses in these three studies are excluded the success rate remains the same. A precise 8. Koehler PR, Moss AA. Diagnosis of intraabdominal and pelvic abscesses
computerised tomography. JAMA 1980; 244:
by
49-52.
9. Gerzof SG, Robbins AH, Birkett DH, Johnson WC, Pugatch RD, Vincent ME. Percutaneous catheter drainage of abdominal abscesses guided by ultrasound and
computed tomography AJR 1979; 133: 1-8. 10. Harries J. Amoebiasis: a review. J Roy Soc Med 1982; 75: 190-97. 11. McFadzean AJS, Chang KPS, Wong CC. Solitary pyogenic abscess of the liver treated by closed aspiration and antibiotics. Br J Surg 1953; 41: 141-52. 12. Dixon GD. Combined CT and fluoroscopic guidance for liver abscess drainage. AJR 1980; 135: 397-99. 13. Berger LA, Osborne DR. Treatment of pyogenic liver abscesses by percutaneous needle aspiration. Lancet 1982; i: 132-34. 14. Martin EC, Karlson KB, Fankuchen E, Cooperman A, Casarella WJ. Percutaneous drainage in the management of hepatic abscesses. Surg Clin North Am 1981; 61: 157-67. 15. Herbert DA, Fogel DA, Rothman J, Wilson S, Simmons F, Ruskin J. Pyogenic liver abscess. successful non-surgical therapy Lancet 1982; 1: 134-36. 16. De Cock KM, Bhatt KM, Bhatt SM, et al. Management of liver abscesses. Lancet 1982; i: 743 17. Van Sonnenberg E, Ferrucci JT, Mueller PR, Wittenberg J, Simone JF, Malt RA. Percutaneous radiographically guided catheter drainage of abdominal abscesses. JAMA 1982; 247: 190-92.. 18. Gerzof SG, Robbins AH, Johnson WC, Birkett DH, Nabseth DC. Percutaneous catheter drainage of abdominal abscesses. A five year experience. N Engl J Med 1981; 305: 653-57. 19. Karlson KB, Martin EC, Fankuchen EI, Schultz RW, Casarella WJ. Percutaneous abscess drainage. Surg Gynecol Obstet 1982, 154: 44-48
890
is obviously important but several golden rules of surgery can be ignored. The chosen drainage track does not have to be extraperitoneal, nor is dependent drainage essential, although both are desirable. IS For guidance of the needle to the abscess some operators favour ultrasound, 18 others CT,20 and yet others fluoroscopy.12 Once pus is identified by aspiration, a drainage catheter is inserted either over a guide wire or through a trocar. The second method is usually easier for the larger and more superficial abscesses.21 The thick pus which is aspirated immediately after insertion of the drain is followed by thin serosanguineous fluid that flows easily along small catheters, so large drains are unnecessary. On the other hand, drainage must be adequate. In one series 19 7 patients needed operations to complete the drainage of an abdominal abscess; in another, 6 abscesses recurred (although 4 were caused by a pre-existing intestinal fistula); 17 and in a third 3 patients died from inadequate drainage.16 Furthermore, it is possible to spread the infection to the pleura or peritoneum, 18 to create an intestinal fistula, 17,18or to damage blood vessels,17 so careful planning and accurate placement of the drain really is essential. Irrigation of the catheters’is probably unnecessary and some investigators prefer to monitor the resolution of the abscess with ultrasound or CT rather than with sinograms. Antibiotic treatment is essential during and after percutaneous drainage and, of course, tubes fall out and have to be replaced
technique
(whether they were inserted by surgeons or radiologists). Pancreatic abscesses are particularly troublesome. 18 On CT, pus
can be difficult to and even when pus is distinguish phlegmon,8 drained percutaneously the necrotic debris of a pancreatic abscess will often block the drains. Surgical drainage may therefore be wiser. Multiple abscesses and those caused by an intestinal fistula are also best treated by operation. Operative drainage of any intraabdominal extrahepatic abscess carries a substantial mortality 22 and in this respect percutaneous drainage offers a real advantage. However, the death rate associated with undrained pus approaches 100%; so, when the percutaneous approach is contraindicated or fails, surgical drainage is essential.
from
a
myocardial involvement are indications for treatment with corticosteroids. Although the cause of sarcoidosis remains an enigma, it is now clear that T lymphocytes are concerned in pathogenesis of the pulmonary lesions.This opens the possibility that some measure of inflammatory activity, such as lymphocyte counts in fluid obtained by bronchoalveolar lavage, or gallium-67 scanning of the lungs, might help in identification of patients requiring treatment.2For this purpose some clinicians measure serum angiotensinconverting enzyme (ACE),3 but its value is questionable. It
ACE does not accurately reflect activity of the pulmonary component of the disease as assessed by the bronchoalveolar lavage lymphocyte count. 2,4 The place of gallium-67 scanning has yet to be defined. It may be of use in distinguishing active granulomatous pulmonary disease from burntout fibrosis, or in the assessment of response to treatment.5 On existing evidence, however, this expensive investigation, with its small but distinct radiation hazard, should not be used routinely in the investigation of sarcoidosis. There is a rough correlation between gallium scanning and serum ACE, but not between gallium scanning and lymphocyte counts in bronchoalveolar lavage fluid.Much has yet to be learned about the usefulness of these investigations in assessment and staging of the individual patient, but it is already clear that serum ACE measurements by themselves are of limited value; so most clinicians will continue to use the crude guidelines which have evolved from decades of clinical experience.
WHEN
of
Pulmonary Sarcoidosis
sarcoidosis be left untreated? Most chest physicians will say, when the patient has hilar adenopathy without symptoms or biochemical disturbance; whereas hypercalcaemia, rapidly progressive pulmonary disease, and evidence of ocular, brain, or can
Alfidi RJ, Weinstem A. Percutaneous catheter drainage of abdominal abscesses N Engl Med 1982; 306: 106-07. J 21 Haaga JR, George C, Weinstein AJ, Cooperman AM. New interventional techniques in the diagnosis and management of inflammatory disease within the abdomen. Radiol Clin North Am 1979; 17: 485-513 22 Bonfils-Roberts EA, Barone JE, Nealon TF Treatment of subphrenic abscess. Surg Clin North Am 1975; 55;. 1361-66 20.
Haaga JR,
emerges that
serum
The existing treatment policies are not wholly without rational foundation, and a review from Denmark’ now provides reassuring data. 243 patients were followed for up to 10 years and in 8707o the chest X-ray abnormalities spontaneously improved within 2 years. A clear X-ray for 2 years can be regarded as a permanent remission. This review also confirmed that hilar glandular sarcoidosis (stage I) carries the most favourable prognosis, 58% of patients in this group improving within 12 months and only 9% progressing to pulmonary sarcoidosis. Patients presenting with pulmonary infiltration and hilar adenopathy (stage II)
Roberts WC, Hunninghake GW, et al. Pulmonary sarcoidosis a disease characterised and perpetuated by activated lung T-lymphocytes. Ann Intern Med 1981, 94: 73-94 2. Schoenberger CI, Line BR, Keogh BA, et al. Lung inflammation m sarcoidosis comparison of serum angiotensin-converting enzyme levels with bronchoalveolar lavage and gallium-67 scanning assessment of the T-lymphocyte alveolitis Thorax 1982, 37: 19-25. 3. Leiberman J. Elevation of serum angiotensin-converting enzyme (ACE) level in sarcoidosis. Am J Med 1975; 59: 365-72 4. Rossman MD, Dauber JH, Cardillo ME, Daniele RP Pulmonary sarcoidosis: correlation of serum angiotensin-converting enzyme with blood and bronchoalveolar lymphocytes. Am Rev Resp Dis 1982; 125: 366-69. 5. Turton CWG, Grundy E, Firth G, et al Value of measuring serum angiotensinconverting enzyme and serum lysozyme in the management of sarcoidosis Thorax 1979, 34: 57-62. 6 Beaumont D, Herry JY, Sapene M, et al. Gallium-67 in the evaluation of sarcoidosis correlations with serum angiotensin-converting enzyme and bronchoalveolar lavage Thorax 1982, 37: 11-18 7 Romer FK. Presentation of sarcoidosis and outcome of pulmonary changes Dan Med Bull 1982; 29: 27-32 1.
Management
now
Crystal RG,