Drainage Of Abdominal Abscesses Research Articles

Image-Guided Percutaneous Drainage of Abdominal Abscesses in Pediatric Patients.

Image-guided percutaneous abscess drainage (IPAD) is an effective, minimally invasive technique to manage infected abdominal fluid collections in children. It is the treatment of choice in cases where surgery is not immediately required due to another coexisting indication. The skills and equipment needed for this procedure are widely available. IPAD is typically guided by ultrasound, fluoroscopy, computed tomography, or a combination thereof. Abscesses in hard-to-reach locations can be drained by intercostal, transhepatic, transgluteal, transrectal, or transvaginal approaches. Pediatric IPAD has a success rate of over 80% and a low complication rate.

Effectiveness and safety of CT-guided drainage of abdominal abscesses with small and extra-small-bore drains: a single-centre observational study.

Computed tomography (CT)-guided percutaneous drainage is an established method for the treatment of abdominal abscesses. The purpose of this study is to evaluate the effectiveness and safety of drainage of abdominal abscesses with small-bore (6F and 9F) drains. The analysis of a prospectively maintained database included 135 consecutive patients from a single centre with abdominal or pelvic abscesses, who underwent CT-guided drainage. Procedures were performed using a one-step trocar technique with 6F (40 procedures) or 9F (95 procedures) catheters. Technical success was defined as insertion of the drain into the abscess cavity and aspiration of the fluid sample. Clinical success was defined as resolution of infection without surgical intervention or upsizing of the drain. The mean size of abscesses was 77.0 ± 28.8 mm (32-220 mm). Thick fluid was aspirated from 129 collections; 6 collections contained thin fluid. Technical success was achieved in 100% of procedures. Clinical success was achieved in 94.8% of patients. Surgical drainage was necessary in 3.7% of patients and upsizing in 1.5% of patients. Complications of Clavien-Dindo grade III were noted in 2.2% of patients without grade IV or V adverse events. The mean radiation dose in terms of Dose Length Product was 617 ± 467 mGy x cm. The mean procedure time was 28.0 ± 11.3 min. CT-guided drainage of abdominal abscesses with small- and very small-bore drains is usually sufficient to obtain clinical success with a low complication rate in the case of thick fluid collections.

Emergency Department Volume and Delayed Diagnosis of Pediatric Appendicitis: A Retrospective Cohort Study.

To determine the association of emergency department (ED) volume of children and delayed diagnosis of appendicitis. Delayed diagnosis of appendicitis is common in children. The association between ED volume and delayed diagnosis is uncertain, but diagnosis-specific experience might improve diagnostic timeliness. Using Healthcare Cost and Utilization Project 8-state data from 2014 to 2019, we studied all children with appendicitis <18 years old in all EDs. The main outcome was probable delayed diagnosis: >75% likelihood that a delay occurred based on a previously validated measure. Hierarchical models tested associations between ED volumes and delay, adjusting for age, sex, and chronic conditions. We compared complication rates by delayed diagnosis occurrence. Among 93,136 children with appendicitis, 3,293 (3.5%) had delayed diagnosis. Each 2-fold increase in ED volume was associated with a 6.9% (95% CI: 2.2, 11.3) decreased odds of delayed diagnosis. Each 2-fold increase in appendicitis volume was associated with a 24.1% (95% CI: 21.0, 27.0) decreased odds of delay. Those with delayed diagnosis were more likely to receive intensive care [odds ratio (OR): 1.81, 95% CI: 1.48, 2.21], have perforated appendicitis (OR: 2.81, 95% CI: 2.62, 3.02), undergo abdominal abscess drainage (OR: 2.49, 95% CI: 2.16, 2.88), have multiple abdominal surgeries (OR: 2.56, 95% CI: 2.13, 3.07), or develop sepsis (OR: 2.02, 95% CI: 1.61, 2.54). Higher ED volumes were associated with a lower risk of delayed diagnosis of pediatric appendicitis. Delay was associated with complications.

OUTCOMES OF MISSED DIAGNOSIS OF PEDIATRIC APPENDICITIS, NEW-ONSET DIABETIC KETOACIDOSIS, AND SEPSIS IN FIVE PEDIATRIC HOSPITALS

BackgroundMissed diagnosis can predispose to worse condition-specific outcomes. ObjectiveTo determine 90-day complication rates and hospital utilization after a missed diagnosis of pediatric appendicitis, new-onset diabetic ketoacidosis (DKA), and sepsis. MethodsWe evaluated patients under 21 years of age visiting five pediatric emergency departments (EDs) with a study condition. Case patients had a preceding ED visit within 7 days of diagnosis and underwent case review to confirm a missed diagnosis. Control patients had no preceding ED visit. We compared complication rates and utilization between case and control patients after adjusting for age, sex, and insurance. ResultsWe analyzed 29,398 children with appendicitis, 5366 with DKA, and 3622 with sepsis, of whom 429, 33, and 46, respectively, had a missed diagnosis. Patients with missed diagnosis of appendicitis or DKA had more hospital days and readmissions; there were no significant differences for those with sepsis. Those with missed appendicitis were more likely to have abdominal abscess drainage (adjusted odds ratio [aOR] 3.0, 95% confidence interval [CI] 2.4–3.6) or perforated appendicitis (aOR 3.1, 95% CI 2.5–3.8). Those with missed DKA were more likely to have cerebral edema (aOR 4.6, 95% CI 1.5–11.3), mechanical ventilation (aOR 13.4, 95% CI 3.8–37.1), or death (aOR 28.4, 95% CI 1.4–207.5). Those with missed sepsis were less likely to have mechanical ventilation (aOR 0.5, 95% CI 0.2–0.9). Other illness complications were not significantly different by missed diagnosis. ConclusionsChildren with delayed diagnosis of appendicitis or new-onset DKA had a higher risk of 90-day complications and hospital utilization than those with a timely diagnosis.

396 A Rare Encounter of “Forgotten Disease”

Abstract With the advent and prompt use of antibiotics after throat infections, the rare entity of Necrobacillosis has almost disappeared in clinical practice. Here we present a case of a fit and well 27-year-old lady who was brought into A&amp;E with septic shock, DIC and MODS after initial diagnosis of a sore throat 4 days ago which was treated by oral antibiotics. She was found to have bilateral patchy consolidations which later became necrotic cavities, empyema thoracis, peritonitis and abscess cavities in abdomen with evolving splenic abscess, prolonged QT and ectopics and type 2 respiratory failure. She was resuscitated, intubated, and transferred to the ICU. With an isolate of Fusobacterium necrophorum from blood culture Meropenem, clindamycin and metronidazole were started. However, over the next few days of treatment, lack of clinical response prompted antibiotics changing, and surgical drainage of abscesses in chest and abdomen. Eventually after a considerable period of abdominal abscess drainage and about 3 weeks of metronidazole and other antibiotics followed by Piperacillin and tazobactam for another 3 weeks the patient recovered from sepsis and was stepped down to ward. This case though rare is a good example of the benefits of surgical drainage and prolonged antibiotics for septic patients with collections. A rapid weaning only results in re-collection and clinical deterioration, or recurrent collection as happened to this patient. This is a rare case of Lemierre's syndrome which depicts the surgical difficulties faced due to recurrent abscess cavities formed in this condition.

EP-168 A rare encounter of “Forgotten disease”

Abstract With the advent and prompt use of antibiotics after throat infections, the rare entity of Necrobacillosis has almost disappeared in clinical practice. Here we present a case of a fit and well 27 year old lady who was brought into A&amp;E with septic shock, DIC and MODS after initial diagnosis of a sore throat 4 days ago which was treated by oral antibiotics. She was found to have bilateral patchy consolidations which later became necrotic cavities, empyema thoracis, peritonitis and abscess cavities in abdomen with evolving splenic abscess, prolonged QT and ectopics and type 2 respiratory failure. She was resuscitated, intubated and transferred to the ICU. With an isolate of Fusobacterium necrophorum from blood culture Meropenem, clindamycin and metronidazole were started. However, over the next few days of treatment, lack of clinical response prompted antibiotics changing, and surgical drainage of abscesses in chest and abdomen. Eventually after a considerable period of abdominal abscess drainage and about 3 weeks of metronidazole and other antibiotics followed by Piperacillin and tazobactam for another 3 weeks the patient recovered from sepsis and was stepped down to ward. This case though rare is a good example of the benefits of surgical drainage and prolonged antibiotics for septic patients with collections. A rapid weaning only results in re-collection and clinical deterioration or recurrent collection as happened to this patient. This is a rare case of Lemierre's syndrome which depicts the surgical difficulties faced due to recurrent abscess cavities formed in this condition.

Ultrasound-guided Percutaneous Drainage of Intra-abdominal Collection and its Clinical Outcome: A Prospective Interventional Study

Introduction: Intra-abdominal collections are abscesses that occur within the peritoneal cavity, the pelvis or behind the peritoneum (retroperitoneum) or intra-parenchymal. They are common complications of colorectal disease, particularly inflammatory bowel disease, malignancy and trauma. Ultrasound is very useful in establishing the diagnosis, quantification and localisation of intraabdominal abscesses. Open Surgical Drainage (SD) used to be the traditional treatment protocol. Recently however, percutaneous drainage procedures are becoming an essential therapeutic strategy in the treatment of this condition. Aim: To study the therapeutic efficacy of ultrasound-guided drainage of abdominal abscess and to compare it with open SD. Materials and Methods: A prospective interventional study was conducted in 94 patients with intra-abdominal abscess at Gauhati Medical College and Hospital, Guwahati, Assam, India, in between July 2019 to June 2020 who were randomly allocated into two groups and underwent respective procedures. The first group was Percutaneous Catheter Drainage (PCD) and second group was open Surgical Drainage (SD) group. Patient demographics, symptoms, aetiologies and locations of the collections as well as duration of hospital stay, success rate, and complications were analysed. Results of radiological findings were tabulated, evaluated and collated between both the groups. Statistical Package for Social Sciences (SPSS) software 21.0 version was used for analysing data and p-value &lt;0.05 was considered significant. Results: For abdominal collections and abscesses, ultrasound guided percutaneous drainage was successful in 96.8% of the patients whereas it was successful in 80% cases in the SD group. Complications were more frequently encountered in patients who underwent open SD (16.70%) compared to percutaneous drainage (12.40%) which was significant (p-value 0.0136). The average duration of stay for the group undergoing percutaneous drainage was 9.13±1.62 days which was shorter than for the group undergoing SD was 11.10±1.75 days (p-value &lt;0.001). The overall rate of failed percutaneous drainage was 3.2% as compared to SD where it was 20%. Conclusion: This study concluded that image-guided percutaneous drainage has lesser complications and higher success rate for abdominal collections/abscesses as compared to SD. Due to lower mortality rates as well as shorter duration of hospitalisation than open SD it can replace the traditional open or laparoscopic approach of drainage in most cases.

CT-Guided Transhepatic Catheter Drainage of Deep Postoperative Collections: Initial Experience

Abstract Purpose This article assesses the safety and utility of transhepatic drainage of deep seated postoperative intra-abdominal collections under computed tomography (CT) guidance in a short series. Methods This retrospective study included five patients (mean age: 45.8 years; 3 males, 2 females) who underwent CT-guided transhepatic drainage of postoperative abdominal abscess in our department between April 2019 and December 2020. The clinical and surgical details and the details of the transhepatic drainage procedure were evaluated along with success rates and complications. Results The surgical procedures were Whipple's pancreaticoduodenectomy in four patients and gastrectomy in one patient. Four out of five abscesses were drained through the right lobe of liver, while one was through the left lobe with a technical success rate of 100%. The mean total time for catheter drainage procedure including patient positioning and preparation was 29.2 minutes. None of the patients had procedure-related complications. Mean duration of catheter drainage was 12 days. All patients had complete resolution of symptoms after drainage and the clinical success rate was 100%. Conclusion Transhepatic approach is safe and effective for the drainage of inaccessible postoperative abdominal collections or abscesses where a standard percutaneous approach is not possible.

A case of successful treatment of pylephlebitis in a patient with acute appendicitis

Pylephlebitis is a rare and potentially lethal complication of acute appendicitis. It leads to the development of liver abscesses and sepsis. Usually, this complication is the result of late diagnosis. Only rare cases of successful treatment of pylephlebitis in the context of acute appendicitis are published in special literature. The aim of the demonstration is to analyze of the diagnosis and medical tactic mistakes as a case of pylephlebitis in a patient with acute appendicitis; show the possibilities of modern methods of diagnosis and treatment, which made it possible to achieve a success. The case of successful treatment patient with pylephlebitis was shown in the article. Late diagnosis of acute appendicitis was associated with the patient’s refusal and with some diagnostic and tactic mistakes that were analyzed. The case presented by jaundice, liver failure and fever. Thrombosis of portal vein diagnosed by U/S, CT scan with intravenous contrast on day 11 of the illness. Appendectomy was performed. Intensive care with extracorporeal therapy, antibacterial and anticoagulant therapy were also provided. Septic thrombosis of portal vein was complicated by an abscess of the right lobe of the liver and sepsis. The case of successful treatment of patient with septic thrombosis of portal vein and superior mesenteric vein complicated by liver abscess and sepsis is considered in the article. Intensive therapy, extracorporeal detoxification and abdominal abscess drainage under the U/S control have resulted in a fully repatency of portal vein that was confirmed by CT scan data.

Spontaneous rupture of pyonephrosis presenting as anterior abdominal wall abscess: a rare case report

BackgroundA pyonephrosis caused by an obstructing calculus is typically accompanied by fever, loin pain, and other signs of urinary tract infection. Occasionally, severe thinning of the renal parenchyma in pyonephrosis allows direct forniceal rupture into the retroperitoneum and very rarely into the anterior abdominal wall, misconstruing it as an isolated abdominal wall abscess.Case presentationDiabetes-related 55-year-old diabetic male presented with abscess in his periumbilical region extending into right lumbar region. He did not exhibit any urinary symptoms, and contrast enhanced computed tomography [CECT] abdominal and pelvic examinations revealed right pelvic calculus with pyonephrosis. There is a 7.5 mm defect in the lower pole of the right kidney with 171 cc of collection adjacent to the kidney communicating with 150 cc of superficial abdominal wall collection through a 15 mm defect. Incision and drainage of abdominal and retroperitoneal abscesses were done at first. Right DJ stenting was performed. Right lateral decubitus was placed for dependent drainage. Resolution of residual collections was confirmed by subsequent ultrasonography KUB, and drain was then removed. Right DJ stenting done, and patient was discharged. Two months later, DTPA scan done and revealed GFR of 30 ml/min of right kidney. Patient underwent right percutaneous nephrolithotomy.ConclusionThe sudden rupture of pyonephrosis is a rare event. Even rarer is the presentation of pyonephrosis as an abscess on the anterior abdominal wall. The correct diagnosis and search for the source of the abscess must be undertaken before intervention. An aggressive and prompt management is needed to prevent further complications from occurring. This case is being presented to add to the literature with regard to abnormal presentations of ruptured pyonephrosis and its management.

Perivesicular Abscess Drainage with Lumen-Apposing SelfExpanding Metal Stents

Abdominal and pelvic abscesses can occur due to a number of reasons, the most common being surgery. They are associated with significant morbidity and mortality. The treatment approach for these types of collections is often the initiation of broad-spectrum antibiotics, accompanied by drainage. Multiple diagnostic and therapeutic modalities have been described, including; percutaneous, transvaginal, endoscopic, and surgicaldrainage. Due to the complexity of pelvic anatomy, minimally invasive approaches such as percutaneous drainage are usually difficult. Pelvic abscesses have been historically drained through surgery. Endoscopic ultrasound (EUS)-guided interventions have emerged as an alternative for the management of difficult abdominal and pelvic abscesses. Endoscopic interventions have classically included diagnostic and therapeutic aspiration, utilizing drainage catheters with or without placement of plastic stents. More recently, the use of lumen apposing self-expanding metal stents has become a treatment option for deep pelvic abscesses. Lumen opposing metal stents (LAMS) have a saddle-shaped design with two large-diameter flanges on both ends of the stent to anchor the stent edges within the respective lumens as well asa central waist that allows for communication between the two lumens. LAMS were originally designed for transmural pancreatic fluid collection drainage; however,they have been successfully implemented for numerous other off-label uses, including the drainage of pelvic and abdominal abscesses. We present the case of a 34-year-old womanwho presented with a septated abscess located between the urinary bladder and the rectum, which was successfully and definitively drained with LAMS.

PUNCTURE FROM A TOOTHPICK: AN ATYPICAL PRESENTATION OF PYLEPHLEBITIS

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Septic thrombophlebitis comprises of a spectrum of venous thrombi arising as a sequelae of inflammation in the setting of bacteremia. Pylephlebitis describes a septic thrombophlebitis involving the portal vein. We report a unique case of pylephlebitis resulting from endovascular foreign body perforation of the gastric wall. CASE PRESENTATION: A 69 year old female presented to our Emergency Department with 1 week of progressive abdominal pain, bloating and anorexia complaining of dark stools. She was noted to have sepsis and was started on broad spectrum antibiotics. Workup for sepsis revealed gastric antral thickening (Figure 1). Subsequent esophagogastroduodenoscopy (EGD) showed a toothpick perforating the gastric antral wall (Figure 2). Despite of removal, she continued to have abdominal pain and fever, prompting repeat CT abdomen. It showed infected portal venous, superior mesenteric venous (SMV) thrombus and portal venous gas (Figure 3). Blood cultures grew Streptococcus anginosus and Rothia mucilaginosa. Despite appropriate antibiotics, she developed septic shock and DIC, prompting another CT abdomen revealing a 1.4 cm abscess adjacent to the left anterolateral aspect of the SMV, thrombosis of the left portal vein with extensive portal venous air in the left lobe consistent with septic thrombophlebitis of the superior mesenteric vein and portal venous system (Figure 4). She was taken to OR for exploratory laparotomy, repair of gastric perforation, abdominal abscess drainage, portal vein thrombolysis. She was started on anticoagulation and was given extended course of antibiotic therapy at discharge. DISCUSSION: Pylephlebitis describes a septic thrombophlebitis involving the portal vein. The etiology of pylephlebitis is the pathophysiologic development of localized pockets of inflammation as an humoral immune response to an infection. Thrombophlebitis in small veins either embolize or extend into larger downstream veins, coalescing into the apogee of a portal vein thrombosis. While most cases involve thrombosis involving the SMV (42%), involvement of intrahepatic branches of the portal vein (39%) and the splenic vein (12%) is common. Pylephlebitis may arise from intra-abdominal or pelvic infection through direct downstream sequelae caught in the portal system. While of cases of pylephlebitis occur more commonly in the setting of diverticulitis, pylephlebitis remains a rare complication. Due to the paucity of data regarding pylephlebitis, it is difficult to assert that there is any greater association with extragastric complications when compared to other abdominal disease states. Gastric perforation from tooth pick with secondary pylephlebitis is a very unique clinical presentation. On review of available literature, only one case similar case was found. CONCLUSIONS: Physicians should have a high index of suspicion in cases of intra-abdominal pathology who remain unstable. Reference #1: Kanellopoulou T, Alexopoulou A, Theodossiades G, et al. Pylephlebitis: an overview of non-cirrhotic cases and factors related to outcome. Scand J Infect Dis 2010; 42:804. Reference #2: Plemmons RM, Dooley DP, Longfield RN. Septic thrombophlebitis of the portal vein (pylephlebitis): diagnosis and management in the modern era. Clin Infect Dis 1995; 21:1114. Reference #3: Peters, Thomas G., et al. “Suppurative Pylephlebitis Caused by Toothpick Perforation.” Southern Medical Journal 1988; 81:414-415. https://doi.org/10.1097/00007611-198803000-00034. DISCLOSURES: No relevant relationships by Krishna Akella, source=Web Response No relevant relationships by Brian Boden, source=Web Response No relevant relationships by Rajeev Fernando, source=Admin input No relevant relationships by Steve Georgopoulos, source=Admin input No relevant relationships by Kashif Hussain, source=Web Response No relevant relationships by Najia Hussain, source=Web Response No relevant relationships by Samer Ibrahim, source=Web Response No relevant relationships by ahsan khan, source=Web Response No relevant relationships by Paul Poidomani, source=Web Response No relevant relationships by Richard Ricca, source=Web Response No relevant relationships by Howard Sklarek, source=Web Response No relevant relationships by Amanda Stashin, source=Web Response

Detection of bacterial DNA from central venous catheter removed from patients by next generation sequencing: a preliminary clinical study

BackgroundCatheter-related infection (CRI) is one of the serious challenges in clinical practice. This preliminary clinical study aimed to examine whether next-generation sequencing (NGS) targeting 16S rDNA, which was PCR-amplified directly from the tip of a central venous catheter (CVC), can be used to identify causative pathogens in CRI, compared to the culture method.MethodsHospitalized patients, from whom a CVC had just been removed, were prospectively enrolled and divided into the CRI-suspected and routine removal groups. DNA was extracted from the sonication fluid of CVC specimens derived from patients. For analysis of bacterial composition by NGS, the V3–V4 fragments of bacterial 16S rDNA were PCR-amplified, followed by index PCR and paired-end sequencing on an Illumina MiSeq device. Conventional culture methods were also performed in the CRI-suspected group.ResultsOf CVCs collected from the 156 enrolled patients (114 men; mean age 65.6 years), a total of 14 specimens [nine out of 31 patients suspected with CRI and five out of 125 patients without infection symptoms (routine removal group)] were PCR-positive. In five patients with definite CRI, Staphylococcus was the most frequently detected genus by NGS (4/5 specimens), although no pathogens were detected by NGS in the one remaining specimen. The genera identified by NGS were consistent with those from conventional culture tests. There was high agreement between NGS and the culture method in the CRI-suspected group, with sensitivity and specificity values of 80.0% and 76.9%, respectively; meanwhile, the false-positive rate of NGS was as low as 4.0% in the routine removal group. Moreover, several genera, besides the genus identified by culture test, were detected in each patient with definite CRI and surgical site infection (SSI). Additionally, in one patient with SSI, Enterococcaceae were detected not only by NGS but also by abdominal abscess drainage culture.ConclusionsNGS targeting 16S rDNA was able to analyze the bacterial composition of CVC specimens and detect causative pathogens in patients with CRI and was therefore suggested as a promising diagnostic tool for CRI.

Efficacy and Safety of Prothrombin Complex Concentrate (PCC) for Direct Oral Anticoagulant Reversal: A Single Institutional Experience

BackgroundAn increasing number of patients (pts) requiring anticoagulation are treated with oral factor Xa inhibitors (DOAC) as an alternative to vitamin K antagonists. Prior to the recent approval of coagulation factor Xa (recombinant), inactivated-zhzo in May 2018, four factor prothrombin complex concentrates (4PCC) have been used to reverse the effects of DOACs. We retrospectively analyzed our institutional experience with 4 PCC for reversal of apixaban and rivaroxaban to determine the indications for 4PCC use and outcomes.MethodsAfter IRB approval, pts receiving 4PCC, from Feb 2016 to January 2018 were identified from our pharmacy database and pts receiving PCC for reversal of apixiban and rivaroxaban were selected. Consenting pts medical records (MR) were reviewed for demographics and indications for DOAC and 4PCC as well as outcomes of 4PCC use. Pts were excluded if they had discontinued DOAC greater than 7 days before receiving 4PCC or if they were started on alternative forms of anticoagulation at a therapeutic dose prior to receiving PCC.Primary endpoint was clinical efficacy (clinical improvement or stability) or ability to undergo required procedure) and secondary endpoint was safety (thromboembolism and death) up to 35 days post-infusion of 4PCC. Stability for intracranial hemorrhages (ICH) was determined by clinical improvement and if head imaging performed, no change in head CT or MRI scan, whereas stability for other bleeds was determined by hemoglobin stability and opinions of providers in the MR. Primary efficacy outcome for pts undergoing surgery was based on MR comments by the performing surgeon and use of other hemostatic agents and red blood cell transfusions.Results49 (32 male) pts, median age of 74 (31-95) years, met our study criteria and received 4PCC for reversal of apixaban (n=29) and rivaroxaban (n=20). Indications for anticoagulation were atrial fibrillation (n=35) and thrombosis (n=14). Of the 14 pts with thrombosis, 11 had deep vein thrombosis while 3 had thrombosis at other sites (arterial graft thrombus, aortic thrombus, and portal vein thrombosis). 4PCC was administered in the emergency department (n=36), intensive care unit (n=10), or the general medical wards (n=3). Indications for 4PCC included bleeding (n=40), procedure/surgery (n=6), and hemodynamic instability with clinical suspicion for bleeding (n=3). Bleeding location is reported in table 1. All procedure/surgery performed for clinical symptoms not related to hemorrhage were non-elective procedures and included exploratory laparotomy (n=4), laparoscopic cholecystectomy (n=1), and incision and drainage of abdominal wall abscess (n=1). Median PCC dose was 42 (10.3-63.3) IU/kg.Outcomes32/40 (80%) pts had stability or an improvement in bleeding, while 5 pts had bleeding that did not improve. 3 pts, all with ICH, had a bleed that worsened 8 (6-8) hours after PCC but then spontaneously stabilized 24 (8-24) hours later. Of those presenting with clinical bleeding, 3 pts received FFP within 3 hours prior to treatment with 4PCC, 2 pts received FFP within 12 hours after 4PCC, and 2 pts received FFP within 3 hours before and 12 hours after 4PCC. Of 40 pts receiving PCC for bleeding, 14 also had a procedure to help achieve hemostasis (Table 2).All 6 pts were able to undergo procedure/surgery. 5/6 patients achieved adequate hemostasis. One pt had no mention of unanticipated bleeding in the MR but received 8 units of FFP intraoperatively after 4PCC.6/49 (12%) pts had a thrombotic complication within 35 days of receiving PCC (median 4 days; (range 1-31) including arterial graft thrombus (n=1), superficial venous thrombus (n=1), bilateral soleal vein thrombosis (n=1), internal jugular vein and innominate vein thrombosis (n=1) stroke (n=1), and progression of preexisting portal vein thrombosis (n=1). All-cause mortality was 20%. 3/10 deaths were in pts who never achieved neurologic recovery after ICH and one pt had stroke-like symptoms leading to death 30 days after 4PCC (administered for ICH).ConclusionIn this cohort, 80% of pts demonstrated clinical stability/improvement of hemorrhage. All pts were able to undergo surgical procedures; however 17% required additional FFP to achieve hemostasis. Thromboembolism occurred in 12% of patients. No deaths could definitely be attributed to 4PCC; however, 30% of deaths could be attributable to the underlying hemorrhagic episode. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Rectal Adenocarcinoma in Crohnʼs Disease: A Case Report

This is a case of a 21 year old male patient who underwent total colectomy and a colostomy for a long standing and extensive Crohns disease who developed rectal adenocarcinoma and eventually expired. In Crohn's disease, cancer risk data is limited. If colorectal cancer does develop, however, the prognosis is recognized to be poor with reduced survival.This 21 year old male presented to our clinic in 2007 at age 13 who was diagnosed with Crohn disease at age 7.His medical history is remarkable with 4 to 5 blood transfusions for anemia, growth hormone deficiency, hypogonadism, vitamin D deficiency and a stable pituitary microadenoma. He was managed with numerous courses of steroids, antimetabolites such as infliximab, certolizumab and 5ASA.His Colonoscopy in 2008 revealed complete loss of vascularity and large pseudo polyps, biopsy was consistent with markedly active chronic colitis with crypt distortion in the colon, marked acute ileitis and acute chronic inflammation in the stomach supporting the diagnosis of Crohn disease .Despite aggressive medical management, his symptoms continued to progress and was hesitant to have an ileostomy over the years .In august 2014 he has failed all medications and was placed on Entyvio.He was having flare ups and recurrent pelvic and abdominal abscess with partial bowel obstruction, perforation of the ileum likely contributed to the abscess and impending fistula. His routine colonoscopy procedure was not successful as there was a large rectal mass which was consistent with malignancy and the biopsy of the rectal mass showed a poorly differentiated infiltrating adenocarcinoma .So, he had diagnostic laparoscopy converted to exploratory laparotomy, extensive lysis of abdomen and pelvic adhesions, drainage of pelvic and abdominal abscesses, ileocectomy and colostomy, eventually deteriorated and expired with rectal adenocarcinoma.Colorectal cancer represents the major cause for excess morbidity and mortality by malignant disease in ulcerative colitis as well as in Crohn's disease. Younger patients with long-standing Crohn's disease should be considered for colonic surveillance to permit earlier diagnosis and treatment of potential colorectal carcinoma. Cancer risk begins to be significant 8 years after the onset of pancolitis (involvement of entire large intestine), or 12-15 years after the onset of left-sided colitis. Colonoscopy every 1 to 2 years with biopsies for dysplasia.3062_A Figure 1. a large rectal mass3062_B Figure 2. Showing large pseudopolyps

A New CT-Guided Modified Trocar Technique for Drainage of Difficult Locations Abscesses.

Computed tomography (CT) is commonly used to guide drainage of deep-seated abdominal fluid collections. However, in some cases, these collections seem to be inaccessible due to surrounding organs or their being in difficult locations. The aim of this study is to describe a modified Trocar technique to drain collections in difficult locations, especially those in the subphrenic space, without passing through intervening organs. This retrospective case series study describes seven inpatients who underwent CT-guided drainage using a modified Trocar technique for abscesses that are difficult to access percutaneously. All patients provided written informed consent prior to the procedure. After placement of a 12-14F catheter inside the peritoneum, the Trocar stylet was removed so that the tip of the catheter became blunt and flexible to avoid injury to organs and structures in the catheter route, and the catheter was slowly advanced towards the collection using CT guidance and tactile sensation. After reaching the target, the stylet was reintroduced to enter the abscess wall. All procedures were performed using an anterior abdominal wall access with adequate catheter positioning and resulted in clinical status improvement in the days after the drainage. No complications related to the procedure were identified in any of the patients. The modified Trocar technique for percutaneous CT-guided drainage of abdominal abscesses may be feasible for lesions that are difficult to access with conventional methods.

CT fluoroscopy-guided percutaneous drainage: comparison of the one step and the Seldinger techniques

Objective: To evaluate the one step technique compared with the Seldinger technique in computed tomography (CT) fluoroscopy-guided percutaneous drainage of abdominal and pelvic abscess.Material and methods: Seventy-six consecutive patients (49 men, 27 women; mean age 63.5 years, range 19–87 years) with abdominal and pelvic abscess were included in this study. Drainages were performed with the one step (n = 46) and with the Seldinger (n = 48) technique between September 2012 and June 2014.Results: The technical success and clinical success rates were 95.8% and 93.5%, respectively, for the one step group, and 97.8% and 95.7%, respectively, for the Seldinger group. The mean procedure time was significantly shorter with the one step than with the Seldinger method (15.0 ± 4.3 min, range 10–29 min vs. 21.0 ± 9.5 min, range 13–54 min, p < .01). The mean abscess size and depth were 73.4 ± 44.0 mm and 42.5 ± 19.3 mm, respectively, in the one step group, and 61.0 ± 22.8 mm and 35.0 ± 20.7 mm in the Seldinger group.Conclusion: The one step technique was easier and faster than the Seldinger technique. The effectiveness of both techniques was similar for the CT fluoroscopy-guided percutaneous drainage of abdominal and pelvic abscess.

Trends in Use of Percutaneous Versus Open Surgical Drainage of Abdominal Abscesses

PurposeTo compare recent trends in the use of percutaneous and surgical approaches to treating abdominal abscesses in a large population. MethodsThe nationwide Medicare Physician/Supplier Procedure Summary Master Files for 2001 through 2013 were searched. Current Procedural Terminology-4 codes were selected for the four types of abdominal abscesses that had distinct codes for both open surgical and percutaneous drainage—appendiceal, peritoneal, subphrenic, and liver. Medicare specialty codes were used to determine if the procedures were performed by radiologists or other nonradiologist physicians. Trends in use of the two approaches were compared. ResultsIn 2001, a total of 14,068 abdominal abscesses were drained percutaneously. This volume increased progressively every year thereafter, reaching 28,486 in 2013 (+102%). Open surgical drainage volume was 8,146 in 2001, decreasing progressively to 6,397 in 2013 (–21%). In 2001, 63% of all abdominal abscesses had been drained percutaneously; by 2013, this figure had risen to 82%. In 2001, radiologists had performed 90% of all percutaneous abdominal abscess drainages; this percentage share increased to 97% in 2013. Of all abdominal abscesses treated in 2013 in Medicare patients, 79% were treated by radiologists. ConclusionsUse of percutaneous drainage of abdominal abscesses has steadily increased, whereas use of open surgical drainage has declined. The vast majority of these abscesses are now treated percutaneously. Radiologists are a strong majority of those performing the procedures. Although this database does not provide information on outcomes, percutaneous drainage is another good example of radiology-related value.

Laparoscopic Management of a Cholecystocutaneous Fistula: A Case Report

Introduction: A cholecystocutaneous fistula an abnormal epithelial tract that allows communication between the gallbladder and the skin, manifests as a rare complication of gall stones.The treatment of choice is definitive surgical excision of both the gallbladder and the tract, usually by an open operation. However, a laparoscopic approach is another option, especially if the patient is elderly and has other co morbidities. We report a case of a laparoscopically managed cholecystocutaneous fistula. Case Presentation: A 55-year-old male with comorbidities presented with a discharging sinus at the right upper quadrant area after an abdominal wall abscess drainage. A Computerized tomography scan showed a biliary fistula. Laparoscopic cholecystectomy was carried out successfully. Conclusions: Laparoscopic cholecystectomy is a safe and feasible technique to manage cholecystocutaneous fistulas.

Intracavitary contrast-enhanced ultrasound in abscess drainage – feasibility and clinical value

Objective. To evaluate the usefulness of intracavitary-applied contrast-enhanced ultrasound (ICCEUS) with BR1 in ultrasound-guided puncture and drainage of abdominal and pelvic abscesses. Material and methods. A total of 71 consecutive patients received ICCEUS after placement of a drainage catheter or a needle in abdominal or pelvic abscesses. Portions of 0.1 ml of BR1 and 20 ml of saline were injected through the drainage catheter or needle. Ultrasound recordings were evaluated to answer the following questions: correct placement of the catheter by showing enhancement in the cavity and the drain – ICCEUS findings suggesting incomplete enhancement in all abscess cavities – enhancement in non-abscess structures. Results. About 52% of patients had liver, 14% of patients had intraperitoneal, 11% had subphrenic, 14% had retroperitoneal, 6% had splenic, and 4% had pelvic abscesses. The majority of the patients received drain placement with 10-F using trocar technique. Enhancement in the drain or needle was seen in all patients. In 2% of patients, during the initial approach, a dislodgment of the catheter from the abscess cavity was diagnosed. Due to non-enhancing abscess compartments, in 36% of the patients more than one drainage treatment was necessary at the time of the first approach. In 14% of the patients communication with surrounding structures was diagnosed. Additional treatment resulted in 4% of cases. Conclusion. ICCEUS was helpful in all patients to confirm correct placement of drain or puncture needle. In 40% of patients, as a consequence of ICCEUS, additional therapy was scheduled, either additional drainage or abscess puncture, endoscopic retrograde drainage of the biliary or pancreatic duct or thoracic intervention.