My MediNotes

Ronald C Merrell, M.D. and Rifat Latifi, M.D.

Department of Surgery, Virginia Commonwealth University, Richmond, U.S.A.

Anatomy of intra-abdominal sepsis

The abdomen may be implicated as the primary occult, secondary dependent or secondary independent source of sepsis.

In septic patients the abdomen may be implicated as the primary but

in-apparent source of the problem (primary occult); secondary dependent,

when the initial process began in the abdomen (post-operative

infection, perforation, anastomic leak et cetera); and secondary

independent, when intra-abdominal organ sustain an insult from

splanchnic hypoperfusion (table I).

Suspicion of abdomen as source of sepsis in critically ill patients.

When there is no clear cause of clinical deterioration in septic patient, or

in a patient with other multiple medical problems (pneumonia, cardiac

disease, diabetes, et cetera), the abdomen becomes a natural target of

suspicion, investigation, and reason for surgical consultation.

Anatomically and biologically, the abdomen is regarded as one unit. Embryologically

intra-abdominal organs develop from foregut (stomach, liver and biliary

tree, spleen, pancreas and duodenum); midgut (small bowel, appendix, and

right colon); and hindgut (left colon and rectum). The peritoneum

represent and organ, and can be involved with infectious or inflammatory

processes. Retroperitoneal solid organs and structures are often a

source of sepsis, which require prompt identification and treatment, if

significant morbidity and mortality is to be avoided. Consequently, the

septic patient should be approached in a stepwise fashion, in order to

identify the septic source. Depending on the patient's age, and other

concomitant risk factors, heart disease, arrhythmia, pneumonia, urinary

tract infections, vascular disease, and medication history, each system

and organ should be considered carefully.

Gastrointestinal tract including liver, gall bladder, biliary tree, and pancreas are common

sources of sepsis. Urinary system with kidney, bladder and prostate, and

gynecologic pathology are also possible causes of septic sources in

patient that is rendered septic. Systematic approach, accompanied with

biochemical, hematological and radiographic examination, will identify

or eliminate each organ from these systems as a source of sepsis.

Diagnostic approach to patient with expected abdominal sepsis

Expeditious diagnosis and therapeutic response by clearly defined algorithm may

reduce mortality of patients with suspected sepsis. Truly occult sepsis

(negative cultures, and no site identified) may in fact represent a

failure to identify an intra-abdominal source of bacterial or fungal

infection.

In critically ill and septic patient with unknown source, meningitis, purulent sinusitis, septic superficial or deep thrombophlebitis, wound infections and decubiti, perirectal abscesses,

and ischemic or infarcted limbs should be excluded. One should seek

opportunities for astute diagnosis of simple conditions.

Before proceeding, with expensive and complex investigations of the

intra-abdominal organs as a source of sepsis in critically ill patients,

after urinary and respiratory tract have been rule out, a few

infections that are more common should be excluded. These include

meningitis, purulent sinusitis, septic superficial or deep

thrombophlebitis, wound infections and decubiti, perirectal abscesses or

ischemic and infarcted limbs. If, on the other hand, patient continues

to have evidence of SIRS or full blown sepsis, but no obvious source of

infections, than the abdomen becomes a suspect, and one need to proceed

with the appropriate investigations (table II).

Diagnostic approach to critically ill with unknown source of sepsis.

Patient with primary occult abdominal pathology: Treat and search

Patient with primary occult pathology may have acute calculous or acalculous

cholecystitis, cholangitis, pancreatitis, appendicitis, diverticulitis,

subphrenic abscess, retroperitoneal abscess (perinephric, psoas or

pancreatic), sealed perforation of stomach, duodenum, gallbladder or

colon, and or bowel ischemia.

Patients, who manifest full-blown SIRS or even sepsis, may not demonstrate a source of infection readily. In these patients, the search for cause of abdominal manifestations can

be very difficult. These patients are treated and supported

concomitantly and empirically for respiratory and cardiac compromise.

The evaluation should be expeditious, well focused and the end points

resuscitation followed closely. Response to life-threatening

manifestations of infection such as shock, respiratory failure, renal

failure or cardiovascular collapse should be critically evaluated on a

minute to minute basis. This is treat and search mode (table II).

Physiologic support

The clinical and diagnostic concert of physiologic support and treatment:

define and follow the physiologic endpoints of resuscitation.

Restoration and maintenance of optimal organ perfusion is key factor in both

minimizing the initial ischemia-induced injury as well as decreasing the

late consequences of the stress response. Early and late physiologic

end points should be clearly defined. During early stress response or

early sepsis, cardiac index > 4, wedge 12–16 mmHg, O2 delivery and

consumption 1.5 times normal should be maintained, as well as the anion

gap should be normalized. Yet, since there is no conclusive evidence

that tissue oxygenation dept exist in patient with sepsis, and there is

no evidence that supranormal levels of oxygenation are more effective in

reducing morbidity and mortality (grade C recommendation), the

resuscitation should be aimed at hemodynamic stabilization and tissue

perfusion improvement. General perfusion, based on blood pressure and

urine output, may appear adequate, but impairment of splanchnic

perfusion may exist. Gastric tonometry measurements appears to be a

useful marker of splanchnic perfusion. Persistent splanchnic

hypoperfusion, as expressed by low gastric mucosal pH (pHι) and

inability to correct gastric pHi, has been associated with

increased mortality and development of MOF, although large scale

randomized clinical trials with high levels of evidence is lacking. Use

of gastric pHi as a tool for resuscitation currently cannot be

recommended (grade C). Maintaining arterial O2 saturation, volume

expansion with fluid or blood and blood products, and judicious use of

inotropes, are methods to maintain perfusion, while the search for

intra-abdominal septic focus is underway. Identification and correction

of basic cellular dearrangements is the priority in these patients.

A difficult patient

The search for septic source may be very difficult in a patient, who is on a

respirator, sedated, obtunded, or paralyzed with medication.

There may be few details from the history, from the family or friends, and

often these patients do not have well documented medical history in the

chart. Worse, patients is found in 2–3 powerful vasopressors to maintain

blood pressure, with severely compromised liver or kidney function, and

now present with a distended abdomen, and a picture of possible

intra-abdominal catastrophe. The most senior member of the consulting

team should perform a thorough physical examination, including rectal

exam.

Review of chest x-rays, urine, blood, sputum, and other

cultures, as well as review of the hemograms, and all biochemical

indices available, should be the first phase of the evaluation, and will

identify a likely source in greater than 85% of patients. When faced

with a patient who has developed SIRS with respiratory failure and a

picture of adult respiratory distress syndrome (ARDS), and who has

findings of positive blood culture for a putative enteric organism, then

the abdomen becomes certainly a logical suspect harboring the septic

focus. Often times though, this scenario is complicated in the patient

who in addition to positive blood cultures, has positive sputum cultures

and radiographic evidence of pneumonia, yet the clinical conglomerate

is complicated with lactic acidosis, leukocytosis, failing kidneys and

worsening abdominal exam.

Diagnostic studies (table II)

In a case of patient with a septic picture but with no clear evidence of

intra-abdominal infection, one should start with the routine-3-way

abdominal film, bearing in mind very low yield of this diagnostic test.

In a series of 143 patients with surgically proven abdominal abscess,

abdominal films were of value in only 15% of patients. Due to low level

of associated clinical confidence, this study, unless it demonstrates

free air or intestinal obstruction, rarely is the sole basis upon which a

clinical decision for operation is made. While some authors have

reported up to 50% level of diagnostic value for this study, the

availability of other techniques makes this study less favorable (grade

C).

If this study is of no diagnostic value, than one should

proceed with ultrasound (US) to exam liver, gall bladder, biliary tree,

pancreas, pelvis, and pelvic organs. US have high sensitivity for liver

and pelvic pathology. The use of US in diagnosing intra-abdominal

abscesses may have an accuracy exceeding 90% in experienced hands (grade

A, B). It is portable, can be performed at bed site, it is reproducible

and can be repeated easily. Major drawbacks are ileus, obesity and

inexperience of the operator. Depending on the suspected pathology, a CT

scan of the abdomen with oral and intra-venous contrast, may be the

next step in the diagnostic work up, if ultrasound negative or

non-diagnostic.

Cholangitis may present with Charcot's triad (right upper quadrant pain, fever, and jaundice), or Reynolds's pentad (Charcot's triad plus shock and mental status changes).

If acute cholecystitis is expected, but US is not diagnostic, one should obtain a

morphine injected HIDA scan as the most definitive study to diagnose

cystic duct occlusion (grade A, B).

In a patient with pain out of

proportion to physical findings, metabolic acidosis, leukocytosis,

lactate dehydrogenase elevation, ischemia of the bowel should be very

high on the list. Intestinal vascular catastrophes (arterial or venous)

will have grave consequences if not identified early and treated

effectively. Because, even a small area of necrosis may prove fatal

because of prolonged observation, a patient with correctable pathology

may die for a lack of well-timed and well-executed laparotomy.

In these patients a CT scan may, or may not be of diagnostic value (grade

C). As a rule, a CT scan will demonstrate an ileus pattern of the small

bowel, and a bowel wall edema (fig. 1). When pneumatosis intestinally is present, this is a late sign of infarcted bowel (fig. 2).

When ischemia of the intestines is expected, in the face of normal or

non-diagnostic CT scan, three-vessel abdominal angiogram should be

performed.

Figure 1

A CT scan of a 33-year-old-female who sustained a myocardial infarction, for

which she underwent angiplasty and coronary stent placement. Five days

after the procedure, she was complaining of right flank pain associated

with abdominal distention, and increased (more...)

Figure 2

Same patient, two days later, now in multiple organ system failure. A repeat

CT scan demonstrates diffuse air fluid levels of small and large bowel,

without wall thickening, findings consistent with an ileus. On surgical

exploration, two hours after this (more...)

Increase

of pancreatic enzymes in the right clinical setting will add to

suspicious and diagnosis of pancreatitis, which can be confirmed by a CT

scan or US. Increasingly, a spiral CT is becoming the preferred

technique for evaluating the pancreas. Certainly a CT scan is the

preferred diagnostic method for diverticulitis, perinephric abscesses,

or liver abscesses.

In septic patients who are immunocompromised

(high-risk trauma, severe burns, transplant patients, cancer patients

undergoing chemotherapy, AIDS patients, and those with diabetes),

diagnostic and therapeutic approaches may not be straightforward. Their

presentation may be atypical.

In very critically ill patients, the choice of diagnostic study is very difficult. Transferring the patient

away from the ICU for a CT scan may be a dangerous undertaken. In these

situation one can utilize other studies such as abdominal paracentesis

or diagnostic peritoneal lavage. A negative or positive DPL is helpful. A

return from DPL will differentiate blood from the ascites and from an

inflammatory or infectious exudate. The lavage will also differentiate

primary from the secondary peritonitis. Aspiration of fecal material,

bile, or bloody fluid will warrant surgical exploration. Isolation of

anaerobic flora, may also be an indication for laparotomy.

The usefulness of endoscopy in critically ill septic patients depends on the

suspected organ. An ERCP may be diagnostic and therapeutic for biliary

and pancreatic diseases, while sigmoidoscopy or colonoscopy may diagnose

ischemic colitis, and should be used in appropriate clinical settings.

Most nuclear studies have limited role in critically ill patients, as their are cumbersome, inconclusive and expensive.

Other than HIDA scan that is a diagnostic test of choice for acute

cholecystitis (grade A, B) and VQ scan for pulmonary embolus, most

nuclear studies have limited role in critically ill patients, as their

are for the most part cumbersome, inconclusive and add to more expenses.

Gallium-67 citrate is concentrated in areas of inflammation; thus, it

is thought that this isotope scan may have potential value in diagnosing

even small abscesses. However, due to concentration of gallium in the

areas of inflammation as well as the uptake of the isotope in the

postoperative area, false positive scans are common and difficult to

interpret. Additionally it takes 48 hours for the isotope to

concentrate, and requires mechanical bowel preparation to eliminate the

intraluminal background, thus making it less desirable and practical.

The indium-111-labeled leukocyte scan although has greater specificity and

image re-solution than gallium scan, and is relatively simple to

perform, it is also not suggested to be used in post operative patient

due to leukocyte aggregation in other areas of inflammation (grade C).

In cases when “standard” clinical, biochemical and radiological diagnostic

studies are exosted, and the abdomen is still suspect by exclusion, it

is justifiable to explore the abdomen as a diagnostic endeavor of

desperation. Laparoscopic diagnostic exploration in the setting of ICU

may be a method of choice, shorter of open traditional abdominal

exploration, although the evidence is still lacking (grade C). Few

non-randomized, case series reports with mixed group of patients with

peritonitis, minimally invasive diagnostic and therapeutic technique

have reported favorable results, while the experience with open approach

has mixed reports (grade C).

Patient with secondary dependent pathology

Patients with secondary, dependent pathology is in postoperative state, treated

in ICU, or return to ICU because of comorbid diseases or for unexpected

clinical or aprupt decline and worsen SIRS.

This may follow surgery upon a hollow viscus, in which the possibility of anastomotic

leak or abscess should be considered. In of such patients, non-abdominal

sources of sepsis such as pneumonia, urinary tract infections, blood

stream line infections, evaluation should be done as outlined on tables II and III.

Precipitous re-operation in the abdomen might not be appropriate, but

should not be delayed either, in proper clinical setting. If the abdomen

is still the leading candidate after excluding other possibilities, the

imaging sequence is invoked.

Diagnostic approach to postoperative patient with SIRS.

Water soluble contrast studies should be used for accessible anastomosis of

the esophagus, stomach and rectum and lower colon, while use of barium

is not advised. Endoscopy, on other hand is not advocated in assessment

of fresh anastomosis. Wound infection may be easily missed if patient is

not examined carefully. A triple contrast CT scan or delayed re-scans

are useful techniques in diagnosing low colon anastomic leak.

In patient who is post cholecystectomy or other biliary or liver surgery,

the presentation of SIRS mandates exclusion of biliary tree leak or

obstruction, which can be done with US, HIDA scan, ERCP or percutaneous

transhepatic cholangiography (PTC). The advantages of latter modalities

are in the ability to provide therapeutic options.

Intestinal ischemia may rapidly progress to full-thickness infarction, and dramatic

clinical deterioration. This may happen due to obstruction or during

low flow state in a compromised elderly patient, due to arterial or

venous occlusion. Small bowel ischemia or necrosis should be suspected

in a patients who present with rapid clinical deterioration, who has had

rapid advancement of tube feeds, in the face of inadequate

resuscitation, such as trauma patients. If intestinal ischemia is

suspected than patient should be promptly resuscitated and operated

upon. Angiography should be performed in proper clinical setting, and

the heart should be examined for the source of emboli. Clinical

examination and biochemical response to ischemia is particularly

unreliable in elderly patients. Measurements of splanchnic perfusion,

with gastric tonometry may have some diagnostic value in these settings.

Following operation for intestinal ischemia, these patients are great

candidates for further infarction and planned re-exploration may be

warranted.

Patient with secondary independent pathology

Acalculous cholecystitis, small and large bowel ischemia with or without

perforation, and pancreatitis, are the most common and life-threatening

complications in severely ill patients recovering from variety of

medical or surgical procedures outside the abdomen. Typically, these

patients have had a prolonged episode of hypotension due to myocardial

infarction or sepsis from urinary tract, blood stream line sepsis or

during a surgical procedure such as cardiovascular surgery. Patients

with cardiac arrhythmia or ventricle clot may emit emboli that can

infarct the bowel. Furthermore, hypotension may permitt thrombosis of a

compromised vascular bed in the intestinal tract.

Acute cholangitis

Patient with cholangitis may present with Charcot's triad (right upper quadrant

pain, fever, and jaundice), or Reynolds's pentad (Charcot's triad plus

shock and mental status changes). Once the diagnosis is established,

most patients will respond to intravenous hydration and antibiotics,

allowing non-emergent decompression of biliary tract. If, however

patient fails to respond to such measures, endoscopic or transhepatic

emergent decompression is indicated. In case of difficult or prohibitive

anatomy or failed ERCP, an emergent open decompression of common bile

tract is indicated, while aggressive resuscitation with intravenous

fluid and antibiotics is underway, if mortality is to be avoided.

Factors that are associated with poor prognosis in patients with acute

cholangitis are: old age, female sex, acute renal failure, acidosis,

hyperbilirubinemia, hypoalbuminemia, cirrhosis, concomitant medical

problems, malignant obstruction or the presence of liver abscesses.

Acute acalculous cholecystitis

Acute acalculous cholecystitis (AAC) is associated with complicated and

emergent vascular surgery. In one series of surgery for ruptured

aneurysm, there was a 13.6% incidence of AAC, while in elective AAA

repair the incidence of AAC is 0.1%. Angiografic studies have

demonstrated that AAC is characterized by arterial occlusion and absent

venous filling, while in acute calculous cholecystitis gall bladder wall

is characterized by arterial dilatation and venous filling.

AAC shows a striking predilection to occur in trauma and burn patients, with

nearly 90% of patients who develop cholecystitis have AAC. Other

setting where AAC may be seen are malignancy of the porta hepatis,

during hepatic infusion of chemotherapy and after therapy with

interleukin (IL)-2 and lymphokine activated killer cells for metastatic

renal cell carcinoma. Other conditions associated with AAC may be stent

placement for biliary obstruction, bone marrow transplantation,

disseminated Candida infections, systemic leptospirosis, Salmonella in

the biliary tree, and in patients with diabetes, tuberculosis, AIDS, and

patients with cytomegalovirus infection, microsporida and

cryptosporidia. AAC should also be suspected in critically ill patients

who are supported by TPN and render septic with no other obvious source.

Although AAC is a relatively rare condition (0.19% of all SICU patients),

nonetheless 14% of patients with acute cholecystitis have AAC. Patients

with AAC have very high mortality (41%). In one series, most of cases

with AAC (63%) occurred in patients recovering from major non-biliary

operations and 52% (14/24 patients) were critically ill that were

treated in the ICU.

The presenting symptoms of AAC are not

specific (abdominal pain in 78%, right upper quadrant pain in 56%, fever

37%, leukocytosis 70%). Of 25 patients with AAC, 20% had normal liver

function test, while 64% had elevated bilirubin, 40% alkaline

phosphatase, 40% alanine aminotransferase and 13% aspartate

aminotransferase. Delay in diagnosis of AAC is almost a rule, and

results in gangrene (63%), perforation (15%) or abscess formation (4%).

The diagnosis of AAC principally should be made by HIDA scan, which has a

sensitivity of almost 100%, but has a high false positivity, making this

test imperfect. US has a very low sensitivity rate (29%), while CT scan

has a sensitivity of 67%. Thickened gall bladder wall (> 4 mm),

pericholecystic fluid, subserosal edema, intramural gas, sloughed

mucosa, complete lack of response to choecystokinin (CCK), and a

positive sonographic Murphy's sign are major radiographic criteria. The

presence of sludge, distentions of the gall bladder and partial response

to CCK are considered minor criteria.

Acute pancreatitis

Acute pancreatitis is diagnosed clinically and by CT scan or US. Its

management mostly is conservative with nutrition, intravenous fluid

support and antibiotic (when appropriate) and is discussed extensively

elsewhere in this book. For patient who is treated with nonoperative

treatment for pancreatitis, clinical deterioration mandates a CT scan

and evaluation for necrosis, abscess, or infected pseudocyst. In these

cases CT, guided aspiration biopsy of the peripancreatic fluid is

mandatory. Developments of a sequestrum or infected necrosis, as well as

the presence of pancreatic abscess require open drainage and

necrosectomy. Attempts for percutaneous aspiration of the infection

should be avoided.

Trauma patients with sepsis and MOF

The incidence of intra-abdominal infections following trauma has been

decreased significantly in recent years, as well as role precipitating

MOF. However, if trauma patients upon admission are hypotensive, the

rate of infection may be as high as 30%. In a prospective study of 457

patients with major trauma (ISS > 15) intra-abdominal abscesses

occurred in only 13 patients, while only in 9 patients abscess was

associated with MOF, although in 3 patients the abscess did not appear

to play a role in the pathogenesis of MOF. In trauma patients that

become septic, a major missed injury need to be excluded primarily,

while other causes such as UTI, pneumonia, AAC need to be investigated

accordingly. One should bear in mind when treating with antibiotics

trauma patients who have undergone massive resuscitation that, based on

experimental data, the clearance and the steady state of antibiotics is

altered, thus the magnitude of dosing should be adjusted.

Treatment options of intra-abdominal pathology in critically ill patients

Traditional approach

The principle treatment of intra-abdominal source of sepsis in critically

ill patients is control of the underlying cause of the source it self.

Thus, the effective treatment of abdominal sepsis requires surgical

control of the leakage from the hollow viscus, removal of infected or

necrotic contaminated tissue, drainage of the pus or release of the

obstructed biliary tree. Although, these principles of control of the

septic source by prompt extraperitoneal drainage have not changed for

centuries, the means, optimal techniques, timing and combination of

different approaches has evolved. Nonetheless, mechanical control of the

septic source remains the cornerstone of the therapy, although

occasionally antibiotic therapy and physiologic support may achieve

temporary control of cholecystitis, diverticulitis or peritonitis

related to peritoneal dialysis.

Secondary peritonitis is associated with a significant cytokines release that is

compartmentalized in the peritoneal cavity, and the magnitude of this

release reflects the severity of the process and prognosis. The extent

of an intra-abdominal infection determines the magnitude of the

peritoneal response. In critically ill and septic patients undergoing

relaparotomy for severe secondary peritonitis endotoxin, tumor necrosis

factor alpha, interleukin-1, interleukin-6, elastase, and neopterin were

found significantly higher in the peritoneal cavity then in plasma.

When these patients underwent relaparotomy, the level of these cytokines

was decreased significantly in survivors.

This local decrease of inflammatory response, may be best achieved with mechanical control by

reducing the load of cytokines and other inflammatory substances and by

preventing further production of them, thus removing the source it self.

In ability to control or decrease significantly or interrupt the local

inflammatory response is associated with non-survival of these patients.

Successful control of septic source reduces the bacterial load and

prevents recurrent infections. A prospective, open, consecutive

multi-center nonrandomized trial examined different management

techniques and outcome in 239 patients with severe peritonitis and

APACHE score > 10. Overall, mortality was 32%. There were no

statistical significant differences in mortality between closed abdomen

techniques and those treated with variations of open abdomen technique.

Patients who underwent planned re-laparotomy had a mortality of 42%

(35/83 patients), while those who did not undergo planned re-operation

had a mortality rate of 27% (42/156). It is not clear which patients

need to undergo planned re-laparotomy, and who will benefit from planned

re-laparotomy, since there is a lack of prospective randomized study of

management of high risk patients following initial operation for

intra-abdominal infection (grade C). In another study, although there

was no difference between treatments groups as far as mortality and the

necessity for unplanned re-laparotomy, the incidence of infectious

postoperative complications such as anastomotic leaks and septicemia, as

well as post operative MOF was increased in patients undergoing planned

re-laparotomy.

Some have suggested continuos postoperative irrigation of the peritoneal cavity in selected patients, although there are no differences between planned re-laparotomy and continuous lavage.

Since each re-opening of the abdomen triggers powerful inflammatory

response, we favor re-laparotomy on demand, unless dealing with

narcotizing infected pancreatitis, or second look laparotomy when

suspected ischemia, following resection of gangrenous bowel

Early decompression of abdominal compartment syndrome, as manifested by renal,

cardiac, pulmonary, hepatic dysfunction and decreased visceral

perfusion, as well as by increase of intra-abdominal pressure above

15–20 torr with advanced operations such as abdominostomy, mesh

abdominostomy and staged abdominal repair abdominostomy (STAR) may prove

life saving. Indications for STAR have been established and include:

hemodynamic instability precluding definitive repair, excessive

peritoneal edema, inability to eliminate or control the source of

infection, incomplete debridement of necrotic tissue, uncertainty about

the viability of remaining bowel, uncontrolled bleeding, and the need

for packing and resuscitation of cold, acidotic and coagulopathic

patients and massive abdominal wall loss.

At times, the definitive control of the septic focus by resection, excision, closure of hollow

viscus or drainage of the abscess is performed successfully, but in a

number of patients peritonitis persist. In these patients, options are

re-laparotomy on demand or planned re-laparotomy. For the lack of

definitive data, the choice as what to do next belongs to the surgeon.

In any event, attempts should be made to prevent development of tertiary

peritonitis, which is considered a complication, rather then a specific

disease.

Minimally invasive techniques: laparoscopy

The tradition to open every septic abdomen has been challenged with the

ability to clearly identify and localize radiographically the source of

intra-abdominal pathology. In patients with unknown but presumed of

abdominal sepsis such as females of childbearing age, obese,

immunocompromised, or septic patients on steroids, laparoscopy provides

excellent tool for methodical assessment of entire abdominal cavity. In

one study this technique was applied in 145 surgical patients.

Successful identification and laparoscopic operative treatment was

achieved in 96%. In 87 cases the diagnosis of appendicitis was

established and appendectomy was performed. Furthermore, formal

diagnostic exploratory laparoscopy was safe and effective in this study,

although caution is suggested in cases when diminished or increased

volume of abdominal space exist. Addition of laparoscopic ultrasound was

valuable in diagnosis of hepatic, intra splenic or retroperitoneal

masses. The diagnostic and therapeutic versality of laparoscopy may

minimize the extensive pre operative work up and significantly shorten

postoperative course.

In a most recent study, laparoscopy was diagnostic in 100% and therapeutic in 87.9% of 107 patients with peritonitis. In 40% of cases, ruptured appendicitis and intestinal

obstruction were found in equal numbers (20 each). Perforated

cholecystitis was present in 15 patients. In 12% of patients,

laparoscopy was converted into open procedure. In this series, the

mortality was 4.6%, with complication occurring in 14% of patients, 7.4%

of them requiring re-operation. Most of the complications, however,

were minor, with only one requiring operative intervention. Of those

converted to an open technique, only two were due to, one intestinal

injury, and one to bleeding. Most of the conversions were due to

technical and inexperience of the surgeon.

Laparoscopic procedures in patients with acute peritonitis should be carried out by experience

surgeons and expertise in performing advanced laparoscopic skills and

not merely diagnoses of a condition. The ability of laparoscopy to fully

explore the abdomen, and intervene therapeutically as indicated, is

probably the biggest advantage of this technique. In addition to the

ability to apply this technique in the operating room, laparoscopy may

be applied in the intensive care unit, although it may be difficult to

perform definitive procedure in the ICU, requiring the second procedure.

The development of 2-mm laparoscopic cameras and the ability to perform

this under local anesthesia may further improve the acceptability of

this technique as a diagnostic tool in ICU septic patients with no known

source. In addition examination of pelvic organs can be greatly improve

with laparoscopy, while the uterus and the ovaries are manipulated

trans-vaginally. Among other advantages of laparoscopic techniques

approaches is reduced immunosuppression observed in response to the

surgical trauma and all other advantages of minimally invasive surgical

technique.

Percutaneous radiographically directed techniques

Percutaneous drainage of intra-abdominal abscess with CT or US guided technique has

become a method of choice in the management of postoperative abscesses

and collections. It clearly has its advantages. When successful it

avoids the re-operation, and minimizes the morbidity of the operation

(possibility of fistula, bowel injury, wound complications). This

technique is being adopted even for the primary abscesses. Such as

diverticular abscess, appendices abscess.

Percutaneous cholecystostomy (PC) has been shown to be a viable alternative procedure

in acute cholecystitis in critically ill and elderly patients in whom

emergent cholecystectomy is associated with prohibitive risks. This

procedure was applied prospectively and successfully to 38 patients age

greater than 80 years old. Of these patients, 25 had acute calculous

cholecystitis, while 13 had AAC. Prompt clinical improvement was de-

monstrated in 95% of patients, while the morbidity and mortality was

only 3% respectively, although 21% of them had evidence of severe acute

cholecystitis associated with septic shock, respiratory syndrome,

disseminated intravascular coagulopathy, or acute renal failure. Once

improved from their acute illness 10 patients underwent elective

cholecystectomy, while 12/13 patients with AAC had no recurrent

cholecystitis after catheter was removed, during the follow up of 1.8

years. One patient with recurrent AAC died in this series. After

drainage, acute calculous cholecystitis relapsed in 33% of patients.

This and other studies suggest that cholecystostomy is simple, safe,

effective and may be a definitive procedure for AAC in this group of

patients, although there are no RCT to recommend this therapy in

patients with AAC (grade C).

Summary

Despite significant clinical and technological advances in physiologic

monitoring of critically ill and septic patients, intra-abdominal sepsis

continuos to be associated with high rate of morbidity and mortality.

While the true incidence of abdomen as a source of sepsis is not known,

intra-abdominal infections are present in up to 25% of patients with

MOF. Sepsis has a death rate as high as 50%. If, on the other hand,

patients progress into multiple organ failure (MOF) with more than three

organ systems, the mortality may approach 100%. Identifying and

correcting abdominal septic source in critically ill patient in timely

fashion, may represent a difficult task, unless systematic, evidence

based and thorough multispecialty approach is practiced.

References

1.: Christou N V. et al. Surgical infection society intra-abdominal infection study. Prospective evaluation of management techniques and outcome. Arch Surg. (1993);128:193–199. [PubMed]
2.: Cueto J. et al. The efficacy of laparoscopic surgery in diagnosis and treatment of peritonitis. Surg Endosc. (1997);11:366–370. [PubMed]
3.: Fry D. Noninvasive imaging tests in the diagnosis and treatment of intraabdominal abscesses in the postoperative patient. Surg Clin North Am. (1994);74:693–709. [PubMed]
4.: Fry D E. et al. Determinants of death in patients with intra-abdominal abscess. Surgery. (1980);88:517–523. [PubMed]
5.: Geis W, Kim H C. Use of laparoscopy in diagnosis and treatment of patients with surgical abdominal sepsis. Surg Endosc. (1995);9:178–182. [PubMed]
6.: Gerger D. et al. Management of abdominal sepsis. Langenbeck's Arch Surg. (1998);353:35–43.
7.: Holzheimer R G. et al. Inflammatory response in peritoneal exudate and plasma of patients undergoing planned relaparotomy for severe secondary peritonitis. Arch Surg. (1995);130:1314–1320. [PubMed]
8.: Kalliafas S. et al. Acute acalculous cholecystitis: the incidence, risk factors, diagnosis, and outcome. Am Surgeon. (1998);64:471–475. [PubMed]
9.: Marik P E, Varon J. The hemodynamics derangements in sepsis: Implications for treatment strategies. Chest. (1998);114:854–860. [PubMed]
10.: Mckindly D S. et al. Antibiotic pharmacokinetics following fluid resuscitation from traumatic shock. Arch Surg. (1995);130:1321–1329. [PubMed]
11.: Merrell RC (1995) The abdomen as a source of sepsis in critically ill patients. Crit Care Clin North 255–272 . [PubMed]
12.: Moore F A. et al. Postinjury multiple organ failure: a bimodal phenomenon. J Trauma. (1996);40:501–512. [PubMed]
13.: Raraty M G T. et al. Acute cholangitis and pancreatitis secondary to common duct stones: management update. World J Surg. (1998);22:1156–1161. [PubMed]
14.: Sugiyama M. et al. Is percutaneus cholecystostomy the optimal treatment for acute cholecystitis in very elderly? World J Surg. (1998);22:459–463. [PubMed]
15.: Wittman D H. Operative and non-operative therapy of intra-abdominal infections. Infections. (1998);26:335–341. [PubMed]

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