Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Abscesses and Other Infections Treated by Surgery
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Liver Abscesses
Liver abscesses may be bacterial, fungal, or parasitic (usually amebic). Diagnosis
is not easy without computerized tomography or ultrasound. Where these technologies
are not available, exploratory laparotomy is effective for diagnosis and treatment.
When a liver abscess is encountered, insert a moderately large-bore needle
into the abscess and aspirate using a 20cc to 50cc syringe. If the material is creamy
pus, open the abscess and place a large drain. If the fluid is dark reddish-brown, it is
probably an amebic abscess. In this case, aspirate as much as you can by needle
without opening the abscess and begin treatment with Flagyl. If the patient has a
history of dysentery and a palpable upper abdominal mass that moves with respiration,
careful percutaneous needle aspiration may be performed to avoid laparotomy
for amebic liver abscess.
Subphrenic Abscesses
Subphrenic abscesses are difficult to diagnose and harder to find without exploration.
Many interesting and sometimes helpful techniques have been devised to
detect the site of subphrenic abscesses and to drain them without exploration. Usually,
however, it is best to perform an exploratory laparotomy and to drain the abscess
with a sump drain (see figure 23, below).
Retroperitoneal Abscesses
Retroperitoneal abscesses may be caused by tuberculosis, especially of the spine
or kidneys. Other causes include pyelonephritis or perforation of a part of the gastrointestinal
tract such as the appendix, cecum, duodenum, or colon. Necrotizing
pancreatitis is a serious but less common cause. Retroperitoneal abscesses are uncommon
but dangerous because they are difficult to diagnose and treat and the
infection spreads readily in the retroperitoneum. Symptoms are those of severe bacterial
infection with high spiking fever and malaise. Tuberculous abscesses may produce
less severe symptoms. There may be a palpable mass in the abdomen and localized
tenderness in the abdomen or costo-vertebral angle. Plain X-ray of the abdomen
may show loss of the psoas shadow on the affected side. Leukocytosis is present and
pyuria occurs when the kidney is responsible. Ultrasonography is helpful in making
the diagnosis. Psoas abscess is a characteristic variant of retroperitoneal abscess. The
patient will have pain on attempting to fully extend the leg at the hip and will tend
to hold the leg in partial flexion at the hip. Sometimes a mass or sinus may eventually
appear just below the groin as the psoas abscess “points” to the skin surface.
Treatment of retroperitoneal abscesses is surgical drainage. The causative infection
must be found and the source treated. To drain a retroperitoneal abscess use a flank
incision, taking care to avoid entering the peritoneal cavity. Insertion of one or more
large sump drain(s) (see figure 23, below) is necessary to eradicate the abscess. After
culture of the pus, appropriate antibiotics may be used if the fever does not subside.
If tuberculosis is the cause, complete anti-tuberculous treatment must be provided.
Sinuses and Fistulae
A sinus is an abnormal tract which opens onto an epithelial surface, usually the
skin. Most sinuses are due to chronic infection in a deeper structure. Some sinuses
are congenital, such as the thyroglossal duct sinus. Tuberculosis is a common under-
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