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MM 12/23/08 The Curious Case of
G.W.Presented for discussion of recurrent
abdominal abscess and treatment

• Dorian Korz (JD) PGY-1

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Background

• G.W. healthy 20 yo AAM
• PMHx non contrib. PSHx none
• SHx MJ RX none NKDA
• 4/23/2004 MVC unrestrained backseat passenger,
  car vs tree and rollover, two other front seat
  passengers died on scene

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ED presentation

• Hemodynamically stable
• GCS 14 Bleeding from ears B
• LLQ Abd/pelvis tenderness
• L wrist tenderness
• Further W/U R mastoid fx w/ pneumocephalus R
  rib fx L pulm contusion L dist. Radial fx
  basilar skull fx w/ SDH

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ED Presentation

• Pt. had worsening abd pain and free air on abd CT
  in LLQ further w/u was halted for emergent ex
  lap

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Surgery

• Post-Op dx Multiple spleen lacerations
  perforated sigmoid colon central mesenteric
  hematoma with vasc compromise of Jejunum
• Procedure Splenectomy Resection of sigmoid
  colon, end colostomy w/distal Hartmann pouch
  resxn of sm bowel w/primary anastomosis
• 2 JP drains placed LUQLLQ

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Hospital course

• Pt. required NGT for bilious emesis
• 4/29/04- POD 6 Abd Ct showed no fluid
  collections but mod stranding throughout the L
  pericolic gutter ileus gas pattern w/o
  distention
• TPN started for extended NPO status due to ileus

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Hospital Course

• Persistent elevated WBC prompted a repeat Abd CT
  5/3/04 POD 10 showed LLQ fluid collection
  along edge of ant iliac spine
• IR drained 100cc fluid described as seroma and
  non-infected fluid red-tinged no puss
• Micro showed no growth, no anaerobes
• Pt.s WBC decreased from 30 to 19 remained
  afebrile after drainage, ileus resolved pt dced
  POD 17

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Since Initial Presentation

• 4/2005- One year later Colostomy takedown and
  reanastomosis
• Procedure described difficult with 2 hours of
  enterolysis, adherent omentum, sm bowel, abd
  wall hypertrophic scar
• Uneventful recovery with bowel function return
  POD 3
• Dced POD5

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Since Initial Presentation

• 12/2007 2 years later Pt. admitted for LLQ pain
  fevers/chills
• CT of abd showed 6cm LLQ collection fluid
  collection
• WBC 25, Tm38.8
• Place on Metronidazole and Pip/Tazo (Zosyn)
• IR drainage
• Repeat CT showed completely drained fluid
  collection

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Post Drainage
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Since Initial Presentation

• Micro of fluid Enterococcus Prevotella
  melaninogenica Bacteroides
• WBC mid 20s, afebrile pt clinically improved
• D/ced home HD 2 with Cipro and
  Amox-Clav(Augmentin)

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Since Initial Presentation

• F/u CT 2/11/08 showed sm. fluid collection around
  the drain drain exchanged 40cc yellowish oily
  fluid drained micro. negative
• 2/25/08 f/u CT showed 5x6cm fluid collection in
  LLQ
• Follow up CT 3/14/08 showed stable collection
  4x5cm with min. fluid from drain drain
  exchanged 2nd time drain removed 3/24 with
  stable fluid collection

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Since Initial Presentation

• 6/2008 3 months later pt. presented w/LLQ pain
  and fluid collection on CT WBC high 20s
• IR placed drain, pt. improves
• Micro showed Numerous white blood cells Gram
  Negative Bacilli
• Abx-Amox/Clav
• Gastrograffin enema negative for leak
• Pt. dced HD2 on Amox/Clav

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Since Initial Presentation

• 9/4/2008 CT abd showed no fluid accumulation with
  drain Drain removed
• Later that month 9/23/2008, 19 days later again
  LLQ pain, N, V WBC 19 CT- reaccumulation of
  fluid
• IR drainage of 200cc purulent material which grew
  E. coli, Prevotella melaninogenica, S. viridans
• Pip/Tazo (Zosyn) and Vanc started pt. improved
  clinically afebrile WBC trended down to 14
• Urology consult for possible ureter leak fluid
  neg for creatinine (0.5)
• Fistulogram neg for communication with bowel

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Post IR Drainage
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Since Initial Presentation

• Dced home with 10 day IV course Vanc and
  Pip/Tazo(Zosyn)
• Currently without drain and gt8wks without
  symptoms
• Future Directions/Considerations
• Exp. lap

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Successful Percutaneous Drainage

• Cinat et al.
• Percutaneous drainage of intra-abdominal abscess
  70 effective with 1 tx
• 82 effective with 2nd attempt
• Success rate of PCD decreases to 50 with
  additional drainage attempts

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Successful Percutaneous Drainage

• Gervias et al.
• Report approx. 5 recurrance rate after primary
  successful drainge
• Of those who had second attempt 77 avoided
  surgery
• Success is site and etiology where determinants
  of success
• Patients who had pancreatitis abscesses had only
  a 31 success rate

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Take Home

• 2-3 attempts are warranted for PCD of abdominal
  abscess
• Post-operative abscess had the highest rate of
  evacuation not requiring surgery

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References

• Cinat et al.. Arch Surg. 2002137(7)845-849
• Gervais DA et al.. Recurrent abdominaland pelvic
  abscesses incidence, resultsof repeated
  percutaneous drainage, and underlyingcauses in
  956 drainages. Am J Roentgenol 2004182463466.