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emptying is usually impaired for about 24 h or more. The colon is
often most affected and may remain inactive for 48 to 72 h or more.
Symptoms and Signs
Symptoms and signs include abdominal distention, vomiting, and
vague discomfort. Pain rarely has the classic colicky pattern present in
mechanical obstruction. There may be constipation or passage of slight
amounts of watery stool. Auscultation reveals a silent abdomen or
minimal peristalsis. The abdomen is not tender unless the underlying
cause is inflammatory.
Diagnosis
· Clinical evaluation
· Sometimes x-rays
The most essential task is to distinguish ileus from intestinal obstruction.
In both conditions, x-rays show gaseous distention of isolated segments
of intestine. In postoperative ileus, however, gas may accumulate
more in the colon than in the small bowel. Postoperative accumulation
of gas in the small bowel often implies development of a complication
(e.g., obstruction, peritonitis). In other types of ileus, x-ray findings are
similar to obstruction; differentiation can be difficult unless clinical
features clearly favor one or the other. Water-soluble contrast
(gastrografin) studies may help differentiate.
Treatment
· NGT
· IV fluids
Treatment involves continuous nasogastric suction, npo status, IV
fluids and electrolytes, a minimal amount of sedatives, and avoidance
of opioids and anticholinergic drugs. Maintaining an adequate serum
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K level (> 4 m Eq/L [> 4 mmol/L]) is especially important. Ileus
persisting > 1 wk probably has a mechanical obstructive cause, and
laparotomy should be considered. Sometimes colonic ileus can be
relieved by colonoscopic decompression; rarely, cecostomy is required.
Colonoscopic decompression is helpful in treating pseudo-obstruction
(Ogilvie's syndrome), which consists of apparent obstruction at the
splenic flexure, although no cause can be found by contrast enema or
colonoscopy for the failure of gas and feces to pass this point. Some
clinicians use IV neostigmine (requires cardiac monitoring) to treat
Ogilvie's syndrome.
Ischemic Colitis
Ischemic colitis is a transient reduction in blood flow to the colon.
Necrosis may occur but is usually limited to the mucosa and submucosa,
only occasionally causing full-thickness necrosis necessitating surgery.
It occurs mainly in older people (> 60) and is thought to be caused by
small-vessel atherosclerosis.
Ischemic colitis.
241
Symptoms are milder and of slower onset than those of acute
mesenteric ischemia and consist of left lower quadrant pain followed
by rectal bleeding. Diagnosis is made by colonoscopy; angiography or
magnetic resonance angiography is not indicated. Treatment is
supportive with IV fluids, bowel rest, and antibiotics. Surgery is rarely
required. About 5% of patients have a recurrence. Occasionally,
strictures develop at the site of the ischemia several weeks later,
necessitating surgical resection.
Upright abdominal X-ray of a patient
with a large bowel obstruction
showing multiple air fluid levels and
dilated loops of bowel.
Upright abdominal X-ray
demonstrating a small bowel
obstruction. Multiple air fluid levels.
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Intra-Abdominal Abscesses
Abscesses can occur anywhere in the intra-abdominal cavity and
retroperitoneum. They mainly follow operation, trauma, or conditions
involving abdominal infection and inflammation, particularly when
peritonitis or perforation occurs. Symptoms are malaise, fever, and
abdominal pain and ileus.
Diagnosis is by ultrasonography and abdominal CT.
Treatment is with drainage, either surgical or percutaneous.
Antibiotics are ancillary.
Etiology
Intra-abdominal abscesses are classified as intraperitoneal, retroperitoneal,
or visceral. Many intra-abdominal abscesses develop after perforation
of a hollow viscus or colonic cancer. Others develop by extension of
infection or inflammation resulting from conditions such as appendicitis,
diverticulitis, Crohn's disease, pancreatitis, pelvic inflammatory disease,
or indeed any condition causing generalized peritonitis. Abdominal
surgery particularly that involving the digestive or biliary tract is
another significant risk factor: The peritoneum may be contaminated
during or after surgery from such events as anastomotic leaks. Traumatic
abdominal injuries - particularly lacerations and hematomas of the liver,
pancreas, spleen, and intestines - may develop abscesses, whether treated
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operatively or not. Pus may accumulate in the abdomen after successful
local treatment of the cause of diffuse peritonitis, after non-operative
treatment of an emergency situation, or as a complication of either
elective or emergency surgery in which the bowel, or one of its
appendages, is opened.
The infecting organisms typically reflect normal bowel flora and are a
complex mixture of anaerobic and aerobic bacteria. Most frequent
isolates are aerobic gram-negative bacilli (e.g., Escherichia coli and
Klebsiella) and anaerobes (especially Bacteroides fragilis).
Undrained abscesses may extend to contiguous structures, erode into
adjacent vessels (causing hemorrhage or thrombosis), rupture into the
peritoneum or bowel, or form a cutaneous fistula. Subdiaphragmatic
abscesses may extend into the thoracic cavity, causing an empyema,
lung abscess, or pneumonia. An abscess in the lower abdomen may
track down into the thigh or perirectal fossa. Splenic abscess is a rare
cause of sustained bacteremia in endocarditis that persists despite
appropriate antimicrobial therapy.
The sites of intra-abdominal abscesses are:
1. Where the original operation was performed.
2. In the leaves of the mesentery.
3. Under either dome of the diaphragm.
4. Beneath the lobes of the liver.
5. The pelvis.
6. The paracolic gutters.
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Intra-Abdominal Abscesses
Location Etiology Organisms
Intraperitoneal
Subphrenic
Right or left lower
quadrant
Interloop
Paracolic
Pelvic
Retroperitoneal
Pancreatic Trauma; pancreatitis
Perinephric
Visceral
Hepatic
Postoperative;
perforation of hollow
viscus, appendicitis,
diverticulitis, or tumor;
Crohn's disease; pelvic
inflammatory disease;
generalized peritonitis
of any etiology
Spread of renal
parenchymal abscess
(complication of
pyelonephritis or
rarely hematogenous
from remote source)
Trauma, ascending
cholangitis, portal
bacteremia
Bowel flora, often
polymicrobial
Bowel flora, often
polymicrobial
Aerobic gram-negative
bacilli
Aerobic gram-negative
bacilli if biliary origin;
polymicrobial bowel flora, if
portal bacteremia; amebic
infection may occur (see
Intestinal Protozoa:
Amebiasis)
Splenic
Trauma,
hematogenous,
infarction (as in sickle
cell disease and
malaria)
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Staphylococci, streptococci,
anaerobes, aerobic gramnegative bacilli including
Salmonella, Candida in
immunocompromised
patients
Pelvic abscess:
The commonest site of intraperitonial collection because of the position
of the appendix and the Fallopian tubes. It can be as a part of diffuse
peritonitis,or as a sequel of anastomotic leakage in large bowel and
rectal surgery
Symptomes:
Characteristically diarrhoea and passage of mucus in the stool, urinary
symptoms. P/R pulging of the anterior rectal wall.
Diagnosis: confirmed by the ultrasonography or CT scan.
Treatment:
· Incision and drainage through rectal wall or the posterior fornex of
the vagina.
· Drainage tubes inserted under radiological guide
· Laparotomy is almost unnecessary
Subphrenic abscess:
Anatomically there are 4 intraperitoneal and 3 extraperitoneal abscesses.
4 Intraperitoneal abscesses:
1. Left superior intraperitoneal (subphrenic) space collection after
operations on: stomach, tail of pancreas, spleen, splenic flexure of
the colon
2. Left inferior intraperitoneal (subhepatic) space (lesser sac) infected
after acute pancreatitis, rarely perforation of GU
3. Right superior intraperitoneal (subphrenic) space following perforating
cholecystitis, perforated DU, appendicitis, blow out of duodenal cap
4. Right inferior intraperitoneal (subhepatic) space the deepest and
the commonest site of subphrenic collection following appendicitis,
cholecystitis, perforated DU, upper abdominal surgery
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3 Extraperitoneal abscesses:
a. Right and left extraperitoneal, perinephric abscesses.
b. Midline extraperitoneal: bare area of the liver, amoebic abscess the
commonest or pyogenic liver abscess.
Symptoms and Signs
Abscesses may form within 1 week of perforation or significant peritonitis,
whereas postoperative abscesses may not occur until 2 to 3 weeks after
operation and, rarely, not for several months. Although manifestations
vary, most abscesses cause fever and abdominal discomfort ranging
from minimal to severe (usually near the abscess). Paralytic ileus, either
generalized or localized, may develop. Nausea, anorexia, and weight
loss are common.
Abscesses in Douglas' cul-de-sac, adjacent to the colon, may cause
diarrhea. Contiguity to the bladder may result in urinary urgency and
frequency and, if caused by diverticulitis, may create a colovesical
fistula.
Subphrenic abscesses may cause chest symptoms such as nonproductive
cough, chest pain, dyspnea, and shoulder pain. Rales, rhonchi, or a friction
rub may be audible. Dullness to percussion and decreased breath sounds are
typical when basilar atelectasis, pneumonia, or pleural effusion occurs.
Generally, there is tenderness over the location of the abscess. Large
abscesses may be palpable as a mass.
Diagnosis
1. Ultrasonography of abdomen.
2. Abdominal CT
3. Rarely, radionuclide scanning
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CT of the abdomen and pelvis with oral contrast is the preferred
diagnostic modality for suspected abscess. Other imaging studies, if
done, may show abnormalities; plain abdominal x-rays may reveal
extraintestinal gas in the abscess, displacement of adjacent organs, a
soft-tissue density representing the abscess, or loss of the psoas
muscle shadow. Abscesses near the diaphragm may result in chest xray abnormalities such as ipsilateral pleural effusion, elevated or
immobile hemidiaphragm, lower lobe infiltrates, and atelectasis.
CBC and blood cultures should be done. Leukocytosis occurs in most
patients, and anemia is common.
Occasionally, radionuclide scanning with indium
111
-labeled
leukocytes may be helpful in identifying intraabdominal abscesses.
Prognosis
Intra-abdominal abscesses have a mortality rate of 10 to 40%. Outcome
depends mainly on the patient's primary illness or injury and general
medical condition rather than on the specific nature and location of the
abscess.
Treatment
IV antibiotics and fluids.
Drainage: percutaneous or surgical
All intra-abdominal abscesses require drainage, either by percutaneous
catheters or surgery. Drainage through catheters (placed with CT or
ultrasound guidance) may be appropriate given the following
conditions: Few abscess cavities are present; the drainage route does
not traverse bowel or uncontaminated organs, pleura, or peritoneum;
the source of contamination is controlled; and the pus is thin enough
to pass through the catheter.
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Antibiotics are not curative but may limit hematogenous spread and
should be given before and after intervention.
Therapy requires drugs active against bowel flora, such as a
combination of an aminoglycoside (e.g., gentamicin 1.5 mg/kg q 8 h)
and metronidazole 500 mg q 8 h. Single-agent therapy with cefotetan
2 g q 12 h is also reasonable. Patients previously given antibiotics or
those who have hospital-acquired infections should receive drugs active
against resistant aerobic gram-negative bacilli (e.g., Pseudomonas)
and anaerobes. Nutritional support is important, with the enteral route
preferred. Parenteral nutrition should begin early if the enteral route is
not feasible.
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