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Intraperitoneal abscesses.
Last reviewed: 12.07.2025
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Abscesses can form in any part of the abdominal cavity and retroperitoneum. Intraperitoneal abscesses are mainly a consequence of surgery, trauma or certain conditions that cause infection of the abdominal cavity and inflammation, especially in cases of peritonitis or perforations. Symptoms of intraperitoneal abscesses include malaise, fever and abdominal pain. Diagnosis is established by CT. Treatment of intraperitoneal abscesses involves drainage of the abscess by open or percutaneous method. Antibiotic therapy is used as a second-line method.
[ What causes intra-abdominal abscesses?
Intraperitoneal abscesses are classified as intraperitoneal, retroperitoneal, and visceral. Most intra-abdominal abscesses result from perforation of hollow organs or malignant tumors of the colon. Others arise from the spread of infection or inflammation in a number of diseases such as appendicitis, diverticulitis, Crohn's disease, pancreatitis, pelvic inflammatory disease, and other causes of generalized peritonitis. Abdominal surgery, especially of the digestive or biliary tract, is a significant risk factor: the peritoneum may become contaminated during or after the procedure under conditions such as anastomotic leakage. Traumatic abdominal injuries - mainly lacerations and hematomas of the liver, pancreas, spleen, and intestine - lead to the development of abscesses, regardless of whether surgery has taken place.
The infection usually involves the normal intestinal microflora, which is a complex mixture of anaerobic and aerobic bacteria. The most common organisms isolated are aerobic gram-negative bacilli (e.g., Escherichia coli and Klebsiella ) and anaerobes (especially Bacteroides fragilis).
Undrained abscesses may extend into adjacent structures, erode adjacent vessels (causing bleeding or thrombosis), rupture into the peritoneal cavity or intestinal lumen, or form external fistulas. Subdiaphragmatic abscesses may rupture into the chest cavity, causing empyema, lung abscess, or pneumonia. Splenic abscess is a rare cause of persistent bacteremia in endocarditis despite chronic appropriate antibiotic therapy.
Symptoms of intra-abdominal abscesses
Intraperitoneal abscesses may form within 1 week of perforation or severe peritonitis, whereas postoperative abscesses do not form until 2–3 weeks after surgery and often for several months. Although the presentation is variable, most abscesses are accompanied by fever and abdominal discomfort, ranging from minimal to severe (usually in the area of the abscess). Paralytic ileus, generalized or localized, may develop. Nausea, anorexia, and weight loss are common.
Douglas pouch abscesses, when adjacent to the colon, can cause diarrhea; when located near the bladder, can cause frequent and painful urination.
Subphrenic abscesses may cause chest symptoms such as nonproductive cough, chest pain, dyspnea, and shoulder pain. Crackles or pleural friction rubs may be heard. Dullness to percussion and decreased breath sounds are characteristic of basilar atelectasis, pneumonia, or pleural effusion.
Common is pain on palpation in the area of the abscess. Large abscesses can be palpated as a volumetric formation.
Diagnosis of intraperitoneal abscesses
CT of the abdomen and pelvis with oral contrast is the leading diagnostic method for suspected abscess. Other imaging studies may show specific changes; plain abdominal radiography may show gas in the abscess, displacement of adjacent organs, density of tissue representing the abscess, or loss of the psoas shadow. Abscesses near the diaphragm may cause changes in the chest radiographic picture, such as pleural effusion on the side of the abscess, high standing and immobility of the diaphragm on one side, lower lobe infiltration, and atelectasis.
A complete blood count and blood culture for sterility should be performed. Most patients have leukocytosis and anemia.
Occasionally, radionuclide scanning with In 111 -labeled leukocytes may be informative in identifying intra-abdominal abscesses.
Treatment of intraperitoneal abscesses
All intra-abdominal abscesses require drainage, either by percutaneous drainage or by open drainage. Tube drainage (performed under CT or ultrasound guidance) may be performed under the following conditions: an abscess cavity is present; the drainage tract does not cross the bowel or contaminate organs, pleura, or peritoneum; the source of contamination is localized; the pus is fluid enough to be evacuated through the drainage tube.
Antibiotics are not the primary treatment, but they help prevent hematogenous spread of infection and should be given before and after the procedure. Treatment of intraperitoneal abscesses requires drugs active against the intestinal flora, such as a combination of an aminoglycoside (gentamicin 1.5 mg/kg every 8 hours) and metronidazole 500 mg every 8 hours. Monotherapy with cefotetan 2 g every 12 hours is also appropriate. In patients previously treated with antibiotics or in those with nosocomial infection, drugs active against persistent aerobic gram-negative bacilli (eg, Pseudomonas ) and anaerobes should be given.
Nutritional support with enteral nutrition is important. If enteral nutrition is not possible, parenteral nutrition should be administered as early as possible.
What is the prognosis for intraperitoneal abscesses?
Intra-abdominal abscesses have a mortality rate of 10-40%. The outcome depends mainly on the patient's primary disease, the nature of the injury, and the quality of medical care, rather than on the specific features and location of the abscess.