Multiple Intra-abdominal Abscesses Research Articles

Empyema associated with peritoneal dialysis peritonitis.

A 65-year-old woman on peritoneal dialysis (PD) was admitted due to abdominal pain with cloudy PD effluent. The white blood cell count in PD effluent was 5860/µL with 85% polymorphonuclear neutrophils. Therefore, she was clinically diagnosed with peritonitis. The cultures of PD effluent were negative. Initial abdominal computed tomography did not find suggest any intraabdominal pathology. The patient was treated with empirical intraperitoneal antibiotics. Because abdominal pain with cloudy PD effluent persisted, the PD catheter was removed eventually. The culture of the removed PD catheter grew Klebsiella pneumoniae. However, intermittent fever was noted over the following days and empyema developed approximately 2 weeks after PD catheter removal. The culture of pleural fluid also grew K. pneumoniae. Another computed tomography revealed multiple intraabdominal abscesses that was assumed to come from a complication of PD-associated peritonitis. We postulate that the empyema might be caused by transdiaphragmatic extension of the intraabdominal abscesses into the pleural space.

Case report of 58-year-old psychiatric male with neglected complicated acute appendicitis

Background: Studies revealed people with psychiatric conditions have a higher risk of complicated appendicitis. Patients with acute appendicitis classically present with acute pain in the right iliac fossa, fever, and vomiting. In complicated acute appendicitis, patients present with a palpable mass, appendix phlegm, or abscess. Commonly, appendicular abscesses are treated conservatively with ultrasound-guided percutaneous drainage and antibiotic therapy. Case Presentation: We demonstrate a case of a 58-year-old with neglected appendicitis in a psychiatric patient. The patient presents with multiple intraabdominal abscesses and septic shock, requiring open drainage and intensive care unit admission. Conclusion: To stop the progression of the disease and the emergence of complications, our study highlights the significance of careful assessment, early diagnosis, and treatment with attention to adherence for the psychiatric population.

S1783 Recurrent Metastatic Appendiceal Adenocarcinoma Presenting as Non-Specific Colitis – A Case Report

Introduction: Malignancies of the appendix are rare and there is a known association of appendicular carcinoid of the appendix and Crohn's disease. Appendicular carcinoid can be mixed with mucinous adenocarcinoma in both primary and metastatic lesions. We present an unusual case of a patient who presented with nonspecific colitis as a manifestation of recurrent metastatic appendiceal adenocarcinoma. Case Description/Methods: A 57-year-old male patient presented with 2 weeks of left lower quadrant pain, diarrhea, and hematochezia. Two years prior to this presentation, he had a perforated appendicitis due to poorly differential adenocarcinoma and goblet cell carcinoid. He was then found to have peritoneal metastasis treated with omentectomy, right hemicolectomy, multiple peritonectomy, and hyperthermic intraperitoneal chemotherapy. He also had multiple intra-abdominal abscesses requiring drainage and a Colo-cutaneous fistula requiring closure. A CT scan showed distal sigmoid colon and rectal thickening. Colonoscopy with biopsies of the terminal ileum showed mild acute inflammation, atypical submucosal glands suspicious for mucinous adenocarcinoma and acute colitis of the entire colon and rectum. After ruling out infectious etiologies, he was started on a prednisone taper with significant improvement in his symptoms. He was then referred to an outside institution for surgical considerations. However, he continued to have intermittent abdominal pain workup revealed a new peritoneal nodule consistent with his prior adenocarcinoma. He was given FOLFOX and bevacizumab for chemotherapy for metastatic disease as he was not a surgical candidate. Discussion: Appendicular carcinoid can be associated with Crohn’s colitis and this has been reported in the literature. This a unique case in which patient had a nonspecific inflammatory colitis which responded well to corticosteroid treatment and imaging identified recurrence of appendicular mucinous adenocarcinoma. If infectious etiologies for non-specific colitis have been excluded, thorough evaluation needs to be performed to rule out metastatic disease in patients with appendicular adenocarcinoma and/or carcinoid as treatment options can vary.

An unexpected pathogen causing multiple intra-abdominal abscesses in an immunocompetent patient

Streptococcus constellatus is a member of the group now called Streptococcus anginosus. This microorganism is part of the normal oropharyngeal, gastrointestinal and genitourinary microbiota. However, it may cause serious infections such as pharyngitis, bacteremia and invasive pyogenic infections in immunocompromised patients. We report the first case in Colombia of an adult male with no relevant medical history and with an unusual presentation of infection by S. constellatus and whose laboratory results showed an important systemic inflammatory response and radiographic evidence of abdominal involvement with poor response to medical and surgical management. Since there are few reports in international medical journals about intra-abdominal infection by S. constellatus and taking into consideration the need of a multidisciplinary intervention, this report may be of interest for both clinical and surgical practitioners.

Colonic perforation due to inadvertent intraperitoneal LVAD driveline placement

BackgroundLeft ventricular assist devices (LVAD) are placed for patients with advanced heart failure or cardiogenic shock as destination therapy or as a bridge to cardiac transplantation. Significant complications associated with LVAD placement include bleeding, infection, pump thrombosis, right heart failure, device malfunction and stroke. The case below illustrates inadvertent intraperitoneal driveline placement causing colonic perforation and the subsequent management.Case presentationA 54 year old male with a history of Wolff-Parkinson-White syndrome resulting in multiple readmissions for heart failure, ultimately required placement of a left ventricular assist device (LVAD). Several weeks later, he was found to have stool draining from the driveline site. The patient was taken to the operating room for limited exploration by the Cardiothoracic Surgery team and a bowel injury was identified and repaired. Three days after this repair, stool was once again leaking from the driveline site, requiring re-exploration by the Acute Care Surgery team. Intraoperatively, the prior repair was found to be leaking and multiple intra-abdominal abscesses were discovered. The transverse colon was resected and left in discontinuity. On a planned second look operation, the LVAD driveline was relocated to be extra-peritoneal and a colostomy was formed.Discussion and conclusionThis case demonstrates the importance of early recognition and involvement of an Acute Care Surgeon in the management of this complex problem. Appropriate treatment involves a complete exploration, source control, driveline relocation and possible fecal diversion. Although the incidence of this complication is low, it must be considered in the differential in a septic LVAD patient.

Bouncing Off the Balloon: A New Trick for Selective Cystic Duct Cannulation

Introduction: Management of acute cholecystitis in non-surgical or high-risk candidates includes endoscopic (transpapillary or transmural stenting) or percutaneous drainage of the gallbladder (GB). Endoscopic cannulation of the cystic duct (CD) for transpapillary GB drainage in such cases can be technically challenging and difficult, given narrowing of cystic duct orifice from edema, stones and valves in the cystic duct, and angulation of the cystic duct takeoff. Here we describe a novel technique, using no special equipment that can be utilized in cases of angulated CD takeoff. Case Description: A 47-year-old woman was admitted with acute cholecystitis and choledocholithiasis. Her vitals were stable with no signs of sepsis. Her WBC was 7.7 X 103/dl, AST 78 unit/L, ALT 267 unit/L, ALP 207 unit/L, total bilirubin was 1.2 mg/dl. Given her morbid obesity (BMI 53) and multiple comorbidities (history of recent uterine infection with perforation, multiple intra-abdominal abscesses, and a diversion colostomy) she was deemed not a surgical candidate for cholecystectomy. Subsequently, she underwent an endoscopic retrograde cholangiography (ERC) with successful mechanical lithotripsy and balloon extraction of multiple common bile duct (CBD) stones. Selective CD cannulation was then attempted; however, was unsuccessful despite multiple attempts using different guidewires and catheters given the downward angulation (Image 1) of the CD takeoff that made it technically challenging. A 15 mm extraction balloon was inflated in the distal common hepatic duct (1 cm proximal to the CD orifice) and a 0.035-inch guidewire was inserted into the CBD alongside the extraction balloon catheter. The guidewire was further advanced into the bile duct allowing the guidewire to recoil (bounce) off the balloon, and was carefully manipulated into the angulated CD takeoff (Image 2). Contrast injection showed filling defect in the neck of the gallbladder. Pus was seen draining from the major ampulla after CD cannulation. A transpapillary 7 Fr x 22 cm double-pigtail plastic stent was successfully placed across the CD with the internal pigtail in the gallbladder lumen (Image 3).1323_A.tif Figure 1: No Caption available.1323_B.tif Figure 2: No Caption available.1323_C.tif Figure 3: No Caption available.Discussion: There is a paucity of techniques describing CD cannulation. These include using intraductal ultrasound or cholangioscopy for guidance, however, such devices may not be readily available. We believe our novel and simple method can be utilized for selective CD cannulation in such difficult cases.

Perforated Appendicitis Preoperatively complicated by Multiple Intra-Abdominal Abscesses

Perforated Appendicitis Preoperatively complicated by Multiple Intra-Abdominal Abscesses

Recurrent echinocandin-resistant Candida glabrata candidemia following prolonged micafungin treatment of multiple intra-abdominal abscesses

Candida glabrata is the second leading cause of candidemia in North America and reports of treatment failure attributed to echinocandin-resistant C. glabrata are increasing. This report describes a case of clinical failure of C. glabrata treatment associated with de novo resistance to micafungin (MICA) after prolonged MICA therapy in a patient with multiple intra-abdominal abscesses. The decreased susceptibility to MICA was associated with acquired mutations in Fks1p and Fks2p subunits of the 1,3-β-D-glucan synthase complex.

Unorthodox Presentation of Colorectal Cancer With Multiple Fistulas and Multiple Abscesses

Colorectal cancer is the third most lethal cancer in the United States and is the third most common type of cancer. In 2016, 134,490 cases of colorectal cancer were diagnosed in the United States. The diagnosis is usually made with screening colonoscopy on asymptomatic patients, while other patients are diagnosed after presenting symptoms such as hematochezia, iron deficiency anemia, changes in bowel movements, and abdominal pain. Also on emergency surgical procedures, a tumor may be found. We present a case of a 50-year-old Hispanic woman, G3P3AO, with a past medical history of hypertension, major depressive disorder and hysterectomy in 2003 without any toxic habits or family history of colon cancer or inflammatory bowel disease. Patient arrived with left lower quadrant pain, fever, and loss of appetite and was treated with IV antibiotics for an acute diverticulitis. Patient had multiple visits to urgency room for fecal material that discharged from the vaginal area and multiple intraabdominal abscesses in addition to obstruction. On imaging studies, patient had rectovaginal fistula and multiple abscesses. The patient’s clinical condition became more complicated with enterocutaneous fistula and enterocolonic fistula 4 months later, suggesting inflammatory bowel disease. Sigmoid adenocarcinoma was diagnosed on the second colonoscopy. The clinical presentations of this patient with multiple abscesses and fistulas are commonly found on inflammatory bowel disease and can also be found in complicated intraabdominal infections. Rectovaginal fistulas which were the first fistula more commonly are caused by obstetric complications. Other common causes associated include surgery, inflammatory bowel disease, radiation therapy, and malignancy. These findings can mask the diagnosis of colorectal cancer and make the diagnosis challenging. J Med Cases. 2018;9(1):29-33 doi: https://doi.org/10.14740/jmc2959w

Successful treatment of an invasive Aspergillus flavus infection in a premature infant with liposomal amphotericin B and caspofungin

Aspergillosis is an uncommon diagnosis in neonates, especially if caused by Aspergillus flavus. Although amphotericin B remains the drug of choice for treatment of invasive aspergillosis, Aspergillus flavus has been reported as being resistant to amphotericin B. We present here a case of a 24-week gestational age preterm infant who developed skin and invasive intestinal Aspergillus flavus infection after laparotomy for necrotizing enterocolitis. Aspergillus flavus was first isolated from the smear of the umbilical stump at the third postoperative day. The initial response to antimycotic treatment with amphotericin B and caspofungin was not sufficient. Because of continued disseminated infection and multiple intra-abdominal abscesses with necrotic areas of the liver, a second surgical intervention was performed on the 24th day of life. Antimycotic therapy was continued for approximately 43 days so as to ensure clinical remission. No adverse events were observed. This case supports the importance of the combination of surgery and newer antimycotic drugs for the outcome of premature infants with invasive aspergillosis.

Ultra-high C-reactive protein levels in hospitalized inflammatory bowel disease (IBD) patients predicts serious complications

Dear Editor: C-reactive protein (CRP), erythrocyte sedimentation rate, fecal lactoferrin, and fecal calprotectin have been evaluated as markers of disease activity and predictors of disease course in inflammatory bowel disease (IBD). Studies on the predictive value of CRP elevations in IBD patients are difficult to interpret or generalize because of different laboratory cutoff values. Fourteen hospitalized IBD patients with ultra-high Creactive protein (UH-CRP), defined as CRP more than ten times the upper limit of normal (ULN), were identified and followed for 6 months. Eight patients had ulcerative colitis, ages ranged between 20 and 69 years, with a mean of 37.36±17.248 (SD) years. CRP levels ranged from 14.3 to 41 times ULN, with a mean elevation of 25.66 times the ULN±8.67 (SD). Ten out of 14 patients (71.43 %) had IBD-related complications, with 50 % requiring surgery either during admission or within 6 months. Three out of five patients who were admitted with typical symptoms of abdominal pain and bloody diarrhea had severe complications, two had a perforated viscus and one had multiple intraabdominal abscesses. One in five had a bowel obstruction, and two (14.3 %) had a newly diagnosed fistula. Finally, three patients (21.4 %) had an acute severe infection; two with clostridium difficile associated colitis, and the third with enterococcus bacteremia. Compared to previously reported data, there was a non-statistically significant trend towards longer hospital stay in patients with UH-CRP elevations. AUH-CRP level in hospitalized IBD patients is associated with significant complications and should not be solely attributed to disease flare. Describing CRP elevations as multiples of the upper limit of normal from various laboratories provides an alternative way of comparing results, and may help predict serious complications. Additional prospective studies are needed.

Multiple intraabdominal abscesses after endoluminal bariatric surgery: Case report and literature review

Current management options for obese patients include lifestyle changes, pharmacologic and behavioral therapies, and bariatric surgery. Although surgery is the only treatment that can provide a dramatic, lasting weight loss in these patients, it is associated with a significant morbidity. The obesity epidemic mostly concerns relatively less obese patients (i.e., body mass index [BMI] 30–35 kg/m2), with or without co-morbidity, who do not meet the current weight criteria for surgical therapy. Because of this, there has been a drive toward less invasive, endoscopic, potentially ambulatory procedures that mimic current mainstream bariatric procedures but with limited associated morbidity.

Tuberculous Iliopsoas Muscle Abscess Associated with Multiple Intraabdominal and Thoracic Abscesses in 9-year-old Boy

Tuberculous Iliopsoas Muscle Abscess Associated with Multiple Intraabdominal and Thoracic Abscesses in 9-year-old Boy

Early experience with diagnosis and management of eroded gastric bands

PurposeBand erosion is a well-known complication of laparoscopic adjustable gastric band placement. We gained experience with laparoscopic removal of an eroded gastric band.MethodsWe retrospectively reviewed the operative log of our obesity surgery unit to identify all operations performed for band erosion from March 2009 to May 2011.ResultsDuring the study period, a total of six of 96 patients (6.3%), five females and one male, were diagnosed with band erosion and underwent surgical removal of the band system. The median time interval from the initial gastric band placement to the diagnosis of band erosion was 8.5 months (range, 7 to 22 months), with most band erosion occurring within the first year (5/6, 83%). The median body mass index at band removal was 28.4 kg/m2. Upper abdominal pain was the most common symptom (5/6, 83%), and other signs and symptoms were port site infection (3/6, 50%) and loss of restriction and weight regain (1/6, 17%). All eroded bands were removed using laparoscopy. Further complications after laparoscopic removal of the band system were observed in three cases. One patient showed multiple intra-abdominal abscesses requiring insertion of a pigtail catheter for drainage. The other two patients experienced sepsis with localized peritonitis, eventually requiring laparoscopic washout and drainage.ConclusionGastric band erosion requires the removal of the gastric band. Laparoscopic removal is technically achievable in the majority of patients with eroded gastric band. The method can be challenging, has potential postoperative complications (fistula, abscess), and should be attempted only by experienced surgeons.

Emergence of New Delhi Metallo-β-Lactamase, Austria

Emergence of New Delhi Metallo-β-Lactamase, Austria

Laparoscopic Appendectomy: An Efficacious Alternative for Complicated Appendicitis in Children

Laparoscopic appendectomy is now well accepted for the treatment of uncomplicated appendicitis in children. Nevertheless, the effectiveness and safety of laparoscopy in cases with complicated appendicitis is still controversially discussed. This study evaluates outcomes of laparoscopic appendectomies in children presenting with complicated appendicitis. Over a 5-year period (2002-2007), all children presenting to the authors with complicated appendicitis were approached laparoscopically using a standardized protocol and their intra-operative findings and postoperative outcomes were recorded. Seventy-two consecutive laparoscopic appendectomies for complicated appendicitis were performed with no conversions. The average patient age was 8.5 years. The mean operating time was 45 min. There were no peri-operative complications. The overall rate of postoperative infectious complications was 8.3% (One child developed a large pelvic abscess required ultrasound-guided percutaneous drainage. Two children had multiple intra-abdominal abscesses that resolved with antibiotic treatment. Umbilical port-site infections were encountered in 3 patients). The average length of hospital stay was 5.7 days. Laparoscopic appendectomy can be performed safely in children who present with complicated appendicitis. The procedure is efficacious and the complication rate is low.

Persistent Left Superior Vena Cava Diagnosed by Bedside Echocardiography

Persistent left superior vena cava (PLSVC) is a congenital anomaly with an estimated incidence of 0.3-0.5% in the normal population. Its usual discovery is often made by an abnormally positioned catheter inserted in the left subclavian or left jugular vein. In this situation, an easy bedside approach to confirm an anatomic variation in the central venous system is helpful. In the majority of cases, the PLSVC drains to the coronary sinus. To describe the contribution of bedside echocardiography in diagnosing the unstable patient in whom there is suspicion of a PLSVC. A 29-year-old man underwent an emergent laparotomy for multiple intra-abdominal abscesses. Postoperatively, after insertion of a central line catheter through the left subclavian vein, a chest X-ray study showed the tip of the catheter in a left paramediastinal position instead of crossing the midline to the superior vena cava. A PLSVC was suspected. The patient was hemodynamically unstable; therefore, a bedside non-invasive confirmation of the diagnosis of PLSVC was preferred. A transthoracic echocardiography study was performed after injection of agitated saline (creating air-filled microbubbles by shaking saline solution in a syringe), which showed that the coronary sinus was opacified, confirming the diagnosis of a PLSVC. In this brief report, we describe the contribution of echocardiography to the diagnosis of a PLSVC. Echocardiography is a reliable and easy diagnostic tool that allows a bedside approach in a patient in whom there is suspicion of a PLSVC, without administration of radiographic contrast.

Image-guided drainage of multiple intraabdominal abscesses in children with perforated appendicitis: an alternative to laparotomy

Image-guided drainage of multiple intraabdominal abscesses in children with perforated appendicitis: an alternative to laparotomy

Gossypibom

A 48-year-old woman with a history of five previous laparotomies had symptoms of nonspecific abdominal pain and recurrent postoperative paralytic ileus six months after her last operation. Because of her as yet undiagnosed abdominal pain admission to a psychosomatic hospital was suggested. MRI was performed because of increasing abdominal pain. It revealed an intraabdominal large surgical towel retained in the abdomen (gossypiboma: gossypium [Latin]:cotton; boma [Swahili]: place of concealment). The surgical towel, accidentally left behind at one of the previous intraabdominal operation) was removed through a previous appendectomy scar. An abscess was additionally found at the operation. Three days later, a second laparotomy became necessary because of multiple intraabdominal interenteric abscesses. A segmental resection had to be performed for a chronic small-bowel stricture. Postoperatively, a subcutaneous wound infection developed. The patient was discharged home on 12th postoperative day. Retained surgical towel (gossypiboma) is a rare but well known complication of surgery. It presents a diagnostic problem if there are no symptoms for a long time. To make the correct diagnosis it is important to simply to consider the possibility of gossypiboma after a complicated or unsatisfactory postoperative course.

Image-guided drainage of multiple intraabdominal abscesses in children with perforated appendicitis: an alternative to laparotomy

Appendicitis is the most common cause of an acute abdomen in children. With perforation, multiple intraperitoneal collections can be seen at presentation. In this situation, surgical treatment alone is rarely effective. To determine the role of image-guided drainage in treating patients with acute appendicitis complicated by multiple intraabdominal collections. A retrospective review of patient charts and interventional radiology records was performed to identify all patients with acute complicated appendicitis treated by multiple image-guided drainage procedures. Data reviewed included the number of drainages and aspirations performed, drain dwell time, the clinical course and temperature profile, and the length of inpatient hospital stay and any complications experienced. The study population comprised 42 children with a mean age of 107.6 months. A total of 100 drainage catheters were inserted and 56 aspirations were performed. Of the 42 children, 24 were successfully treated at a single sitting, while 18 returned for further intervention. The mean drain dwell time was 8.18 days. The mean inpatient stay was 15.02 days. Treatment of the acute presentation with image-guided intervention was successful in 92.3% of children. Successful management of acute perforated appendicitis with multiple intraabdominal abscesses can be achieved with multiple minimally invasive image-guided drainage procedures.