Diagnostic Imaging Pathways - Abscess (Intra-Abdominal)
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This pathway provides guidance for imaging adult patients with suspected intra-abdominal abscess, including those with and without a recent surgical operation.
Date reviewed: January 2012
Date of next review: January 2015
Published: January 2012
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Image 1 (Computed Tomography): Sigmoid diverticulitis complicated by abscess formation (arrow).
- Ultrasound or Computed Tomography (CT) may be useful in the investigation of suspected intra-abdominal abscess. There have been relatively few studies that have looked at the diagnostic accuracy of both tests in the same cohort of patients. However, both CT and US have a high diagnostic yield for the detection of abdominal abscess
- Ultrasound is recommended in patients who have not undergone recent surgery
- CT is recommended in patients who have undergone recent surgery
- Percutaneous drainage is indicated in the following circumstances
- All simple abscesses with a safe drainage route
- Most complex abscesses with a safe drainage route
- Pyogenic liver abscesses (single or few in number)
- Infected pancreatic pseudocysts
- Amoebic abscesses
Image Guided Aspiration / Drainage
- If an abscess is detected, CT- or US- guided percutaneous drainage, may
be performed in the following ,
- All simple abscesses with safe drainage route
- Most complex abscesses with safe drainage route
- Pyogenic liver abscesses (single or few in number.
- Infected pancreatic pseudocysts ,,
- Amoebic abscess (although usually not necessary, can be drained. Most amoebic abscesses resolve on medical treatment and do not require percutaneous drainage unless causing symptoms related to large size)
- Abscesses not suitable for percutaneous drainage include ,
- Hydatid liver abscesses (usually secondarily infected hydatid cyst)
- Multiple small liver abscesses
- Hepatic or other deeply situated abscesses in the presence of coagulopathy and/or ascites
- Uncertain role of percutaneous drainage in
- Pancreatic and splenic abscesses
- Infected necrotic tumours
- There are no prospective randomised controlled trials to support above recommendations. These recommendations are mainly based on retrospective studies (level III evidence)
Computed Tomography (CT)
- "Gold standard" for the diagnosis of intra-abdominal abscess (superior diagnostic accuracy compared to ultrasound and nuclear medicine scan) ,,,
- Initial imaging study of choice in the post-operative patient ,
- Water-soluble contrast may be given orally or rectally to determine whether there is an ongoing leak at the anastomosis in patients who have undergone a bowel anastomosis
- In non-operative patients, CT is indicated if ultrasound is negative or inconclusive and there is a high clinical suspicion of abscess
- Advantages: provides high anatomical resolution, allows visualisation of retroperitoneal structures and intraluminal fluid collections
Nuclear Medicine Scan
- Useful in detection of intra-abdominal abscess when there are no localised signs and in cases of occult sepsis or fever of unknown origin ,
- Gallium or white cell labelled scan may be performed, when a satisfactory CT and/or US scan have yielded negative results but early infection cannot be excluded ,,,
- Advantages - allows detection of sites of infection beyond the abdominal region and can help distinguish normal post-operative inflammation from infection
- Disadvantages - long waiting period to allow appropriate concentration of isotope
- Initial imaging investigation of choice in certain circumstances, including suspected liver abscess post cholecystectomy ,,
- 85-95% diagnostic accuracy for detection and localisation of intra-abdominal abscess ,,
- Advantages - rapid, non-invasive, readily available and portable (preferred initial method in ICU patients).
- Limitations: Not suitable in obese patients and post-operative patients with surgical dressings, large wounds and/or ileus
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Kochel JQ, Koehler PR, Lee TG, et al. Diagnosis of abdominal abscesses with computed tomography, ultrasound, and 111-In leuckocyte scans. Radiology. 1980;137:425-32. (Level II/III evidence)
- Carter CR, McKillop JH, Gray HW, et al. Indium-111 leucocyte scintigraphy and ultrasound in the detection of intra-abdominal abscesses in patients without localizing signs. J R Coll Surg Edinb. 1995;40:380-2. (Level II/III evidence)
- Weldon MJ, Joseph AE, French A, et al. Comparison of 99m-technetium hexamethylpropylene-amine oxime labelled leucocyte with 111-indium tropolonate labelled granulocyte scanning and ultrasound in the diagnosis of intra-abdominal abscess. Gut. 1995;37:557-64. (Level III evidence)
- Taylor KJW, Wasson JF, De Graff C, et al. Accuracy of grey scale ultrasound diagnosis of abdominal and pelvic abscesses in 220 patients. Lancet. 1978;1:83-4. (Level II/III evidence)
- Korobkin M, Callen PW, Filly RA, et al. Comparison of computed tomography, ultrasonography, and gallium-67- scanning in the evaluation of suspected abdominal abscess. Radiology. 1978;129:89-93. (Level III evidence)
- Dobrin PB, Gully PH, Greenlee HB, etal. Radiologic diagnosis of an intra-abdominal abscess. Do multiple tests help? Arch Surg. 1986;10:111-4. (Level III evidence)
- Lundstedt C, Hederstrom E, Brismar J, et al. Prospective investigation of radiologic methods in the diagnosis of intra-abdominal abscesses. Acta Radiol Diagn. 1986;27:49-54. (Level II/III evidence)
- Roche J. Effectiveness of computed tomography in the diagnosis of intra-abdominal abscess: a review of 111 patients. Med J Aust. 1981;2:85-8. (Level II/III evidence)
- Gazelle GS, Mueller PR. Abdominal abscess: imaging and intervention. Radiol Clin North Am. 1994;32(5):913-32. (Review article)
- Bearcroft PW, Miles KA. Leucocyte scintigraphy or computed tomography for the febrile post-operative patients? Eur J Radiol. 1996;23:126-9. (Level II/III evidence). View the reference
- Paling MR, Gouse JC. Efficacy of abdominal computed tomography in evaluation of possible abdominal abscess. J Comput Tomogr. 1986;10:111-4. (Level III evidence)
- Baldwin JE, Wraight EP. Indium labelled leucocyte scintigraphy in occult infection: comparison with ultrasound and computed tomography. Clin Radiol. 1990;42:199-202. (Level III evidence)
- Tsai SC, Chai TH, Lin WY, et al. Abdominal abscesses in patients having surgery: an application of Ga-67 scintigraphic and computed tomographic scanning. Clin Nucl Med. 2001;26(9):761-4. (Level III evidence)
- Goldman M, Ambrose NS, Drolc Z, et al. Indium-111-labelled leucocytes in the diagnosis of abdominal abscess. Br J Surg. 1987;74:184-6. (Level II evidence). View the reference
- VanSonnenberg E, Wittich GR, Goodcare BW, et al. Percutaneous abscess drainage: update. World J Surg. 2001;25:362-72. (Review article)
- ACR appropriateness criteria. Percutaneous catheter drainage of infected intra-abdominal fluid collections. American College of Radiology, Reston, 1996. (Guidance statement)
- Mithofer K, Mueller PK, Warshaw Al. Interventional and surgical treatment of pancreatic abscess. World J Surg. 1997;21:162. (Level III evidence)
- VanSonnenberg E, Wittich GR, Casola G, et al. Percutaneous drainage of infected and non infected pancreatic pseudocysts: experience in 101 cases. Radiology. 1989;170:757-61. (Level III evidence)
- VanSonnenberg E, Wittich GR, Chon KS, et al. Percutaneous radiologic drainage of pancreatic abscesses. AJR Am J Roentgenol. 1997;168:979-84. (Level III evidence)
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