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Drainage of superficial and deep abscesses

  • An abscess is collection of pus within soft tissues
  • Occurs when hosts response to infection is inadequate
  • Predisposing factors include foreign bodies, haematoma formation and poor blood supply

Pathology

  • An abscess contains bacteria, acute inflammatory cells, protein exudate and necrotic tissue
  • It is surrounded by granulation tissue (the 'pyogenic membrane')
  • The organisms usually involved are:
    • In superficial abscesses - Staph. aureus, Strep. pyogenes
    • In deep abscesses - Gram negative species (e.g. E. coli) and anaerobes (e.g. Bacteroides)

Clinical features

  • Superficial abscesses include infected sebaceous cysts, breast and pilonidal abscesses
  • Show cardinal features of inflammation - calor, rubor, dolor, tumor
    • Heat
    • Redness
    • Pain
    • Swelling
  • After a few days superficial abscess usually 'point' and are fluctuant
  • Deep abscesses include diverticular, subphrenic and anastomotic leaks
  • Patients shows signs of inflammation - swinging pyrexia, tachycardia, tachypnoea
  • Physical signs are otherwise difficult to demonstrate
  • Site of abscess may not be clinically apparent
  • Radiological imaging often required to make the diagnosis

Treatment

  • All abscesses require adequate drainage
  • Should be performed under general anaesthesia
  • Antibiotics have little to offer as tissue penetration is usually poor
  • Prolonged antibiotic treatment can result in a chronic inflammatory mass (an 'antibioma')
  • Superficial abscesses are usually suitable for open drainage
  • For deep abscesses closed drainage may be attempted

Open technique

  • Superficial abscesses can usually be drained through a cruciate incision
  • Position of incision may allow depended drainage
  • Pus should be sent for microbiology
  • Loculi should be broken down and necrotic tissue excised
  • A dressing should be inserted into the wound
  • Packing is not required - it is painful

Closed techniques

  • Deep abscess can be treated by ultrasound or CT guided aspiration
  • Success can not always be guaranteed
  • Multiloculated abscesses may not drain adequately
  • Percutaneous access my be difficult because of the position of adjacent organs

CT appearance of an appendix abscess

Bibliography

Abraham N,  Doudle M,  Carson P.  Open versus closed treatment of abscesses. a controlled clinical trial.  Aust NZ J Surg 1997;  67:  173-176.

 

 
 

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