Localized abscesses in a patient's peritoneal cavity can be the result of: (1) Generalized peritonitis[md]they are one of its major complications. (2) Some primary focus of infection, such as appendicitis or salpingitis (PID, 6.6). (3) An abdominal injury in which his gut was perforated or devitalized. (4) Any laparotomy.
If abscesses are going to occur after a laparotomy, a patient's temperature does not fall, or it falls and then rises in a characteristic spiky pattern (Fig. 6-6) which shows that there is pus somewhere inside him. He is not well and does not eat, he loses weight, and his white count is raised. If loops of his gut pass through the abscess, they may become obstructed, acutely or subacutely (10.12).
Pus can gather: (1) Under his diaphragm or his liver (6.4). (2) Between loops of his small gut in the folds of his mesentery. (3) In his pelvis. If you are wondering where it has got to, remember that pus usually follows recognized paths. For example, in escaping from the appendix, it usually falls into the pelvis or tracks up his right paracolic gutter to his right subphrenic space, so that you are unlikely to find it on the left of his abdomen.
Provided you remember to examine a patient rectally (or vaginally), diagnosing pus in the pelvis should be easy. Diagnosing it under his diaphragm is much more difficult.
If you catch a localized infection early enough, antibiotics alone may possibly cure him; but once pus has formed they will not make it disappear, although they may limit its spread. So be sure to drain residual abscesses on the indications given below.
Fig. 6-4 ABSCESSES IN THE PERITONEAL CAVITY. A, the common sites. B, a pelvic abscess pointing into the rectum. C, a pelvic abscess pointing into the vagina.
1, between a patient's diaphragm and his liver. 2, under his liver. 3 and 4 in his right and left paracolic gutters. 5, among coils of his gut. 6, around his appendix. 7, in his pelvis.
ABSCESSES [s7]IN THE ABDOMEN If you suspect that a patient has an abdominal abscess, record his temperature 4-hourly, or hourly if he is very ill, especially if he is a young child. Examine him carefully at least once a day. Each time, feel for an abdominal mass, feel under his rib margins anteriorly and posteriorly, do a rectal examination, and in a woman a pelvic examination. The patient's temperature chart and his clinical signs will be of the greatest help, but you may find it helpful to do the following examinations each day: an abdominal X-ray (erect and supine), a chest X-ray, a white count, and blood cultures.
If you feel a mass, mark it out on his abdominal wall. Each day, feel if it has become larger or smaller. If it becomes larger, operate. It may become adherent to his abdominal wall, so you can open it without opening the rest of his peritoneal cavity.
On the appropriate indications, drain pus from his wound (9.12), from between the loops of his gut (see below), from under his diaphragm (6.4), and from his pelvis (6.5). Drainage is paricularly urgent if his general condition is deteriorating, or if he has complete intestinal obstruction which has not responded in 24 hours (10.12).
CAUTION! Don't make a small abdominal incision, his gut will be in less danger if you make a large one.
If you can feel a pelvic abscess vaginally, aspirate it to confirm the presence of pus, then drain it vaginally (6.5). Only drain an abscess abdominally, if you cannot drain it vaginally.
ABSCESSES BETWEEN LOOPS OF GUT. If the swelling is to one side of a patient's abdomen, incise its lateral side. Open the layers of his abdominal wall, then explore his abdomen with your finger until you find pus. If infection is localized, insert a drain.
POSTOPERATIVELY, after you have drained any kind of abscess, watch him carefully, he may have more. Don't neglect his fluid balance or his nutritional state. He will be wasting severely, so do your best to increase his protein and energy intake (9.10). Ideally, he needs feeding parenterally, which is likely to be impossible. Don't try forced feeding, because he will not want to eat. If he will tolerate cautious feeding through a nasogastric tube, he may benefit considerably.