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Mohamad Idham B Baharudin, group A2

Intraperitoneal abscess
Intraperitoneal abscesses are localized collections of pus that are confined in the peritoneal cavity by
an inflammatory barrier. This barrier may include the omentum, inflammatory adhesions, or
contiguous viscera. The abscesses usually contain a mixture of aerobic and anaerobic bacteria from
the gastrointestinal (GI) tract.
Anatomy
The 8 functional compartments in the peritoneal cavity include the (1) pelvis, (2) right paracolic
gutter, (3) left paracolic gutter, (4) right infradiaphragmatic space, (5) left infradiaphragmatic space,
(6) lesser sac, (7) hepatorenal space (Morrison space), and (8) interloop spaces between small
intestine loops.
Risk Factors
Risk factors for morbidity and mortality include multiple surgical procedures, age older than 50 years,
multiple organ failure, and complex, recurrent, or persistent abscesses.

Etiology
Perforation of viscus, which includes peptic ulcer perforation
Perforated appendicitis and diverticulitis
Gangrenous cholecystitis
Mesenteric ischemia with bowel infarction
Pancreatitis
Untreated penetrating trauma to the abdominal viscera
Postoperative complications, such as anastomotic leakage
Missed gallstones during laparoscopic cholecystectomy.
Bacteria most commonly isolated aerobic organism is Escherichia coli, and the most commonly
observed anaerobic organism is Bacteroides fragilis. Skin flora may be responsible for abscesses after
a penetrating abdominal injury while Neisseria gonorrhoeae and chlamydial species are the most
common organisms involved in pelvic abscesses in females as part of pelvic inflammatory disease.
Clinical Features
Intraperitoneal abscesses have variable presentation. The initial clues that suggest intraperitoneal
abscess is persistent fever, mild liver dysfunction, persistent gastrointestinal (GI) dysfunction, or
nonlocalizing debilitating illness. While, In patients with predisposing primary Intraperitoneal disease
or in individuals who have had abdominal surgery with persistent abdominal pain, focal tenderness,
spiking fever, persistent tachycardia, prolonged ileus, leukocytosis, or intermittent polymicrobial
bacteremia suggest an Intraperitoneal abscess. If it is a deeply seated abscess, many of these features
may be absent. The only
The diagnosis of an intraperitoneal abscess in the postoperative period is difficult, because
postoperative analgesics and incisional pain frequently mask abdominal findings. In addition,
antibiotic administration may mask abdominal tenderness, fever, and leukocytosis.
In patients with subphrenic abscesses may present with shoulder pain, hiccup, or unexplained
pulmonary manifestations, such as pleural effusion, basal atelectasis, or pneumonia, irritation of
contiguous structures. With pelvic abscesses, frequent urination, diarrhea, or tenesmus may occur. A
diverticular abscess may present as an incarcerated inguinal hernia.
Investigation

Most important investigation to order is to visualize the abscess. This can be done by ultrasound or
CT scan which are more accurate to visualize the abscess. Ultrasound in the hand of an expert has an
accuracy rate greater than 90% for diagnosing abscess but marked obesity, bowel gas, intervening
viscera, surgical dressing, open wounds and stomas can create problems in diagnosing abscess using
ultrasound. Ultrasound are useful in hospital that doesnt have CT scan and in immobile, critically ill
patients. Leukocytosis, anemia, abnormal platelet counts, abnormal liver function, elevated CRP and
ESR which suggestive of infection can be found in patient with intraperitoneal abscess. Blood
cultures indicating persistent polymicrobial bacteremia strongly suggesting the presence of an intraabdominal abscess. Because more than 90% of intra-abdominal abscesses contain anaerobic
organisms, particularly B fragilis,postoperative Bacteroides bacteremia suggests intra-abdominal
sepsis.
Treatment
Antibiotic Therapy
Antibiotic therapy involves the administration of parenteral empirical antibiotics. It should be initiated
before abscess drainage. Because abscess fluid usually contains a mixture of aerobic and anaerobic
organisms, initial empiric therapy must be directed against both types of microbes. This may be
accomplished with antibiotic combination therapy or with broad-spectrum, single-agent therapy.
Specific therapy is then guided by the results of cultures retrieved from the abscess.
Percutaneous Abscess Drainage
Complex abscesses that include multiple loculations or interloop abscesses or those associated with an
enteric fistula may necessitate surgery. Drainage of pus is mandatory and is the first line of defense
against progressive sepsis. Percutaneous computed tomography (CT)-guided catheter drainage has
become the standard treatment of most intra-abdominal abscesses. It avoids anaesthesia and possibly
difficult laparotomy, prevents the possibility of wound complications from open surgery, and may
reduce the length of hospitalization. It also obviates the possibility of contaminating other areas
within the peritoneal cavity. mA diagnostic needle aspiration initially is performed to confirm the
presence of pus, which makes performing Gram stain and culture possible. A large-bore drainage
catheter is then placed in the most dependent position.
In patients who are critically ill, initial percutaneous drainage can control sepsis and improve
hemodynamics before definitive surgical treatment (if this becomes necessary). After drainage,
clinical improvement should occur within 48-72 hours. Surgical drainage becomes mandatory if
residual fluid cannot be evacuated with catheter irrigation, manipulation, or additional drain
placement. Criteria for removal of percutaneous catheters include resolution of sepsis signs, minimal
drainage from the catheter, and resolution of the abscess cavity as demonstrated by an ultrasonogram
or a CT scan. Complications of percutaneous drainage include bleeding or inadvertent puncture of the
gastrointestinal (GI) tract.
Laparoscopic or Open Abscess Drainage
If percutaneous drainage fails or if collections are not amenable to catheter drainage, surgical drainage
is an option. The surgical approach may be either laparoscopic or open. Laparoscopic drainage for a
massive intra-abdominal abscess is minimally invasive, permitting exploration of the abdominal
cavity without the use of a wide incision; purulent exudate can be aspirated under direct vision.
Pelvic abscesses often are palpable as tender, fluctuant masses impinging on the vagina or rectum.
Draining these abscesses transvaginally or transrectally is best to avoid the transabdominal approach.
Improved clinical findings within 3 days after treatment indicate successful drainage. Failure to
improve may indicate inadequate drainage or another source of sepsis. If left untreated, the septic state
inevitably produces multiple organ failure.

Mohamad Idham b Baharudin


A2, 111303239, SDL assignment
Mesenteric cyst
A mesenteric cyst is defined as any cyst located in the mesentery; it may or may not extend into the
retroperitoneum, which has a recognizable lining of endothelium or mesothelial cell. Mesenteric cyst
can occur anywhere in the mesentery of gastrointestinal tract from duodenum to rectum. Mesenteric
cysts are rare benign intra-abdominal tumours with an incidence of 1 case per 250,000 hospital
admission.Because of variable and non-specific clinical symptoms and signs, they are discovered
either accidentally during an abdominal radiological examination for other reason or during
laparotomy for the management of one of the complications. Mesenteric cysts can be simple or
multiple, unilocular or multilocular, and they may contain hemorrhagic, serous, chylous, or infected
fluid. They can range in size from a few millimetres to few cm in diameter, however, at times may be
so large that it may mimic tubercular ascites
Aetiology and clinical features
The aetiology of such cysts remains unknown. Some suggest that failure of the lymph nodes to
communicate with the lymphatic or venous systems or blockage of the lymphatics as a result of
trauma, infection, and neoplasm are said to be contributing factors. Mesenteric cyst may occur in
patients of any age.
The cyst may present either as non-specific abdominal feature, as an incidental finding, or as an acute
abdomen. They are often asymptomatic and found incidentally while patients are undergoing work-up
or receiving treatment for other conditions, such as appendicitis, smallbowel obstruction, or
diverticulitis, although patients may present with lower abdominal pain and symptoms that are
frequently associated with other abdominal conditions. The symptoms are variable and non-specific
and include pain (82%), nausea and vomiting (45%), constipation (27%), and diarrhoea (6%). An
abdominal mass may be palpable in up to 61% of patients.
Investigation
Mesenteric cyst should be evaluated with complete history, clinical examination, blood investigations
and radiological investigations (X-ray abdomen erect, ultrasound abdomen (USG) and computed
tomography (CT) scan in selected cases) to reach a provisional diagnosis. The cyst are proven on
laparotomy and has to be histologically confirmed.
Treatment and Complication
The treatment of choice is complete excision to avoid recurrence and possible malignant
transformation. Bowel resection may be necessary in cases where cysts are close to bowel structures
or involve blood vessels that supply the bowel. Once removed, mesenteric cysts rarely recur, and have
a excellent prognosis. Total cystectomy is the therapeutic method of choice. Laparoscopic surgery has
allowed resection of these cysts to be achieved without full laparotomy. Laparoscopic exploration is
done using four ports after insufflation with Veress needle and excision of cyst is done using cautery
scissors and blunt dissection. Endobags are then used to retrieve the cyst.