Abscess Definition

An abscess is a localised collection of pus contained within a cavity. Pus is a mixture of dead
and dying inflammatory cells called neutrophils, combined with special protein fluids secreted by
cells to try and kill of bugs. Abscessescontain dead tissue in the centre and are surrounded by a
fibrous capsule or case. This capsule ensures that the infection cannot spread to other parts of
the body. However, it can be difficult to treat abscesses because antibiotics also have trouble
crossing this fibrous layer. Abscesses can occur virtually anywhere within the body but only
those occurring within the abdomen are discussed in this article. These often contain a mixture
of bacteria which means they can be harder to treat. The most common organism involved is
the bacteria called Bacteroides fragilis which makes up a small percentage of the normal bowel
flora. Intra-abdominal abscesses often develop secondary to peritonitis an infection of the serous
membranes lining the abdominal organs and walls.
The different types of abscesses are listed below:

Sub-phrenic abscess
This is a collection of pus below the diaphragm (the muscular organ separating the abdominal
cavity from the chest cavity). It is often caused by rupture of thegallbladder that causes fluid to
build up under the diaphragm. Abscesses at this location are close to the lungs so can cause
basal lung infections. In addition, shoulder tip pain is a common feature of these abscesses. The
image below shows two large abscesses (arrows) situated below the right side of the
diaphragm. (CT image shows a cross-section through the abdomen, looking from below). The
abscesses have well-defined margins of connective tissue with semi-dense pus in the cavity.
These abscesses are most likely secondary to gall bladder perforation.



Intra-peritoneal abscess
This is an abscess within the peritoneal cavity due to an infection of free fluid, bile or blood. Often
these abscesses are the result of bowel perforation or a complication of bowel surgery. Spillage
of feacal material from an inflamedappendix frequently causes this type of abscess.

Visceral abscess
Abscesses are also found on the surface or within gastrointestinal organs. Liver abscesses are
the most common and account for approximately half of all visceral abscesses. These may
cause pain in the right upper part of the abdomen. Pancreatic abscesses occur as a late
complication of acute pancreatitis. Pancreatitis causes severe central abdominal pain that spreads
to the back. Early recognition and treatment of this disorder will prevent abscesses forming.
Abscesses of the spleen are rare but can occur if this organ is damaged or if there is an
infection in the blood. Patients with immune disorders or the sickle cell trait are at greater risk.
Abscesses in or near the kidneys are quite rare but can occur due to the spread of infection up
theurinary tract from a urinary tract infection. The CT image below demonstrates a large abscess
within the liver.


Pelvic abscess
Pelvic abscesses car occur secondary to the same conditions that cause intra-peritoneal
abscesses if the pus and fluid tracks downwards into the pelvis. In
addition, gynaecologicalinfections can cause pelvic abscesses. The image below shows CT
findings of a pelvic abscess causes by appendicitis. Pelvic abscesses can cause symptoms
of frequent urination, diarrhoea or tenesmus (a sensation of incomplete bowel emptying). If
symptoms are mild, pelvic abscesses do not require treatment as they often self resolve on their
own by draining out the rectum.


Psoas abscess
The psoas muscle is a large muscle running alongside the spine which crosses the pelvis. It
helps bend the hip so your doctor may do tests to see if hip flexion is painful to make this
diagnosis. Clinical signs of back pain or pain during flexion of the hip can help doctors make the
diagnosis early by triggering them to perform imaging such as CT (as displayed below) or MRI.
Abscesses occur in the psoas muscle when infections spread in the blood or from local organs
of the abdomen or pelvis. In addition, infections in the bones of the spine (osteomyelitis) can
cause psoas abscesses.


Anorectal abscess
The anus and rectum (which form the back passage) are other common sites of abscess
formation worth separate mention. Anorectal abscesses are more common in men and often
develop from anorectal fistulas or sexually transmitted infections. They present as painful, tender
swellings and are easily accessible for surgical treatment. The image below shows a magnified
view of a perianal abscess on the skin surrounding the anal opening. This should be picked up
by your doctor on careful examination of the anus and rectum.



Causes of abscesses
As previously mentioned, abdominal abscesses are caused by various infectious organisms
within the abdomen. They develop as the bodys immune system attempts to treat the infection
and prevent it from spreading. Intra-abdominal infection (peritonitis) quite commonly is the
source of an abscess but infections can also seed from organs or via the bloodstream.

Some common causes of abdominal abscesses are listed below:
Bowel perforation- often due to an underlying disease process or weakness. This includes peptic
ulcer perforation. Diverticular disease, colonic tumoursand inflammatory bowel disease can also
predispose to infection and ruptures.
Ruptured appendix or gallbladder due to inflammation or infection within these organs. Infection of
virtually any abdominal or pelvic organ may lead to local abscess formation.
Abdominal trauma or injury.
Bowel surgery- Faecal contamination of operation sites or leakage of bowel contents post-operatively
due to poor re-anastomosis (connection of segments) often lead to abscess formation.

Signs and symptoms
The clinical presentation of abdominal abscesses is highly variable. If you have an abscess it is
likely you will have constant abdominal pain and a spikingfever. You will have cycles of feeling hot
and cold which is an important sign doctors look for to diagnose this condition. Blood tests will
show that you have lots of white blood cells which increase to try to fight the infection. You may
also have changes in bowel function such as diarrhoea or obstruction. If your abscess is deep
within an organ, the classic signs may not be present. It can also be difficult for doctors to
diagnose abscesses instead of other disorders such as pancreatitis. Your doctor will feel your
abdomen to detect any areas of tenderness or masses. Generally the site of pain corresponds
well with the location of the abscess. If you have an associated peritonitis your abdomen will be
markedly tender and may stiffen up like a board. Your doctor may also like to perform a rectal
examination. For this they insert a gloved finger gently into the back passage to see if they can
feel any hot and tender masses. You will also be examined in general to make sure you are not
too sick or dehydrated. If you develop an abscess following an operation it can be very hard to
diagnose because the pain killers and antibiotics you would be taking can mask some of the
symptoms. Doctors must have a high index of suspicion for this disorder to make sure it doesnt
get missed. Sometimes the doctor will need to perform investigations to confirm the site and
size of an abdominal abscess. These may include:
Abdominal ultrasound- Reasonably reliable and safe test.
CT- A very accurate test that will find most abscesses.
Radioisotope scanning using white blood cells labelled with special radioactive substances that
localise in the abscess. These are however very time consuming so will only be used if other
investigations are negative but it is still thought there is an abscess.
Plain abdominal x-rays have little diagnostic value and often highlight the need for further
investigation.

Management
The underlying principal for management of abscesses involves incision and drainage, which is
cutting them open to allow the pus to drain. In many cases this can be performed as a
procedure through the skin. Ultrasounds or CT scans can be used by the treating doctor to
guide the needle into the right spot. Occasionally the abdomen will need to be cut open
(laparotomy) to allow the abscess to be drained. Some types of abscesses in the pelvis, below
the diaphragm or associated with diverticuli may resolve on there own without any surgical
treatment. In general, if surgery is performed it is expected that your symptoms will resolve
within three days. Failure to do so may indicate incomplete drainage or alternative sources of
infection. In addition to surgery you are likely to receive antibiotic therapy that covers a broad
range of bugs. Once the abscess is drained the pus can be examined under a microscope and
cultured so the specific bug(s) involved can be identified. At this stage your doctor may need to
change your antibiotics to make sure they will kill the bug involved. In most cases your
symptoms will improve rapidly and you will have no long term consequences from the abscess.
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