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SURGERY Medical

The document discusses intraperitoneal abscesses, which can form in four main spaces within the abdomen: 1) the left subphrenic space, 2) the left subhepatic/lesser sac space, 3) the right subphrenic space, and 4) the right subhepatic space. Common causes include appendicitis, cholecystitis, and perforations from ulcers or surgery. Symptoms include abdominal pain, fever, and localized tenderness. Diagnosis involves blood tests, imaging like CT scans, and physical exams. Treatment requires incisions over areas of maximum tenderness to drain pus and insert drainage tubes, along with antibiotics. Pelvic abscesses most commonly result from appendic

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175 views15 pages

SURGERY Medical

The document discusses intraperitoneal abscesses, which can form in four main spaces within the abdomen: 1) the left subphrenic space, 2) the left subhepatic/lesser sac space, 3) the right subphrenic space, and 4) the right subhepatic space. Common causes include appendicitis, cholecystitis, and perforations from ulcers or surgery. Symptoms include abdominal pain, fever, and localized tenderness. Diagnosis involves blood tests, imaging like CT scans, and physical exams. Treatment requires incisions over areas of maximum tenderness to drain pus and insert drainage tubes, along with antibiotics. Pelvic abscesses most commonly result from appendic

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Intraperitoneal abscess

NAME – PALAK MITTAL


ROLL NO. – 60
BATCH - 2018
MODERATOR – DR. NAVIN KUMAR
Intraperitoneal abscess

Abdominal
abscess

Pelvic abscess
Abdominal abscess
 The complicated arrangement of the peritoneum results in the
formation of four intraperitoneal spaces in which pus may commonly
collect -
1. The left subphrenic space- The common cause of an abscess here is
an operation on the stomach, the tail of the pancreas, the spleen or
the splenic flexure of the colon
2. Left subhepatic space/lesser sac- a perforated gastric ulcer rarely
cause a collection here because the potential space is
obliterated by adhesions
3. Right subphrenic space - perforating cholecystitis, a perforated
duodenal ulcer and a duodenal cap ‘blow-out’ following
gastrectomy and appendicitis.
4. Right subhepatic space- most common site of a subphrenic
abscess, which usually arises from appendicitis, cholecystitis, a
perforated duodenal ulcer or following upper abdominal surgery
Clinical features
Symptoms
 Malaise, lethargy
 Anorexia and weight loss
 Sweats ± rigors
 Abdominal/pelvic pain
 Symptoms from local irritation, e.g. shoulder tip/hiccoughs (subphrenic),
diarrhoea and mucus (pelvic), nausea and vomiting (any upper abdominal)
Signs
 Increased temperature and pulse ± swinging pyrexia
 Localised abdominal tenderness ± mass
Diagnosis
 Blood tests-  Blood may be drawn to look
for signs of infection . Radiolabelled white
blood cell scanning
 Imaging tests- plain chest radiograph, CT
scan, ultrasound
 Physical exam- check for temperature and
tenderness in the abdomen. Sometimes, the
abscess can be felt as a mass on palpation.
Treatment

 An incision is made over the site of maximum tenderness or over any


area where oedema or redness is discovered.
 Cautious blunt finger exploration can then be used to avoid
dissemination of pus into the peritoneal or pleural cavities and minimise
the risk of an intestinal fistula.
 When the cavity is reached, all of the fibrinous loculi must be broken
down with the finger and one or two drainage tubes fully inserted.
 These drains are withdrawn gradually over the next 10 days, and the
closure of the cavity can be checked by sinograms or scan.
 Appropriate antibiotics are also given.
Pelvic abscess
 Most common site of abscess formation- vermiform appendix is
often pelvic in position and the fallopian tubes are also frequent
sites of infection

Clinical features
.

 Pelvic pain
 Diarrhoea and the passage of mucus in the stools.
 Bulging of the anterior rectal wall, which, when the
abscess is ripe, becomes softly cystic
Investigation and management
 The presence of pus should be confirmed by
ultrasonography or CT scanning
 In women, vaginal drainage through the posterior
fornix is often chosen.
 When the abscess is definitely pointing into the
rectum, rectal drainage is employed.
 Increasingly common to insert drainage tubes
percutaneously, e.g. via the buttock or via the
vagina or rectum under CT guidance
Q1. A 50-year-old patient underwent a laparoscopic closure
of a perforated duodenal ulcer. On the fourth postoperative
day, he developed pyrexia, looked toxic, complained of pain
in his right shoulder tip and was tender and rigid over his
right upper quadrant. What is the most probable diagnosis ?

a) Pelvic abscess
b) Subphrenic abscess
c) Postoperative peritonitis
d) Bile peritonitis
e) Basal pneumonia
Q1. A 50-year-old patient underwent a laparoscopic closure
of a perforated duodenal ulcer. On the fourth postoperative
day, he developed pyrexia, looked toxic, complained of pain
in his right shoulder tip and was tender and rigid over his
right upper quadrant. What is the most probable diagnosis ?

a) Pelvic abscess
b) Subphrenic abscess
c) Postoperative peritonitis
d) Bile peritonitis
e) Basal pneumonia
Q2. Following emergency appendicectomy for acute perforated
appendicitis, a 30-year-old female patient progressed well for
about 6 days. After that she felt unwell, was pyrexial and
complained of tenesmus and foul-smelling vaginal discharge.
What is the most probable diagnosis ?

a) Pelvic abscess
b) Subphrenic abscess
c) Postoperative peritonitis
d) Bile peritonitis
e) Basal pneumonia
Q2. Following emergency appendicectomy for acute perforated
appendicitis, a 30-year-old female patient progressed well for
about 6 days. After that she felt unwell, was pyrexial and
complained of tenesmus and foul-smelling vaginal discharge.
What is the most probable diagnosis ?

a) Pelvic abscess
b) Subphrenic abscess
c) Postoperative peritonitis
d) Bile peritonitis
e) Basal pneumonia
References
 Bailey HH, Love RJ Williams N, O’Connel R. McCaskie AW.
Bailey & Love’s short practice of surgery. 27th ed. Roca Raton:
CRC Press, 2017
Thank you

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