Management

Precise radiologic identification of an intraabdominal abscess permits the most appropriate route of drainage (Fig. 3-12). Although antibiotics play an important role, drainage remains the cornerstone of therapy. Radiographic localization is particularly important in supra-mesocolic infections.

An abscess compartmentalized to the right posterior subhepatic space is classically drained surgically by Ochsner's extrapleural approach through the bed of the

Subphrenic Space Ultrasound Images

Fig. 3—122. Abscess of the falciform ligament, secondary to suppurative cholangitis.

(a) CT demonstrates a large subphrenic abscess (A) and many small intrahepatic lesions. Another collection occupies the left periportal space and spreads into the falciform ligament (arrows). Arrowhead = ligamentum teres.

(b) Axial ultrasound scan shows the abscess in the falciform ligament as a hyperechoic collection (arrows) within the left lobe of the liver (L).

(c) Sagittal sonogram demonstrates extension through the ligament (arrows) to the anterior abdominal wall, beyond the hepatic edge.

(Reproduced from Arenas et al.75)

Fig. 3—122. Abscess of the falciform ligament, secondary to suppurative cholangitis.

(a) CT demonstrates a large subphrenic abscess (A) and many small intrahepatic lesions. Another collection occupies the left periportal space and spreads into the falciform ligament (arrows). Arrowhead = ligamentum teres.

(b) Axial ultrasound scan shows the abscess in the falciform ligament as a hyperechoic collection (arrows) within the left lobe of the liver (L).

(c) Sagittal sonogram demonstrates extension through the ligament (arrows) to the anterior abdominal wall, beyond the hepatic edge.

(Reproduced from Arenas et al.75)

resected 12th rib. The right posterior subphrenic space is drained via Trendelenburg's transpleural route: the 8th, 9th, 10th, or 11th ribs are resected subperiosteally, and the pleural cavity is entered; the diaphragm is tightly sutured around the pleural opening, and the subphrenic abscess is drained after an incision is made through the diaphragm.

A transperitoneal approach is generally employed for surgical drainage of anterior subphrenic and subhepatic, left subphrenic, lesser sac, and multiple abscesses. It is especially advantageous since it permits a thorough evaluation of the extent of the purulent collection and drainage can be undertaken accordingly.

Ultrasound- and CT-guided aspiration and drainage of intraabdominal abscesses represent recent major advantages in management.90-98 It is generally accepted

Falciform Ligament Ultrasound

Fig. 3-123. Abscesses of the ligamentum teres and the falciform ligament, secondary to cholecystitis.

(a) Longitudinal sonogram demonstrates a hypoechoic mass (M) beneath the abdominal wall, representing a falciform ligament abscess, continuous with a thickened ligamentum teres (arrows).

(b) CT shows a mass of soft-tissue attenuation replacing the falciform ligament (arrow) and surrounding the remnant of the umbilical vein. The fat of the ligamentum teres was also obliterated and thickened.

(Reproduced from Mori, et al.74)

Fig. 3-123. Abscesses of the ligamentum teres and the falciform ligament, secondary to cholecystitis.

(a) Longitudinal sonogram demonstrates a hypoechoic mass (M) beneath the abdominal wall, representing a falciform ligament abscess, continuous with a thickened ligamentum teres (arrows).

(b) CT shows a mass of soft-tissue attenuation replacing the falciform ligament (arrow) and surrounding the remnant of the umbilical vein. The fat of the ligamentum teres was also obliterated and thickened.

(Reproduced from Mori, et al.74)

Anterior Abdominal Wall Abscess

Fig. 3-124. Abscess of the ligamentum teres and anterior abdominal wall consequent to cholangiocarcinoma.

CT shows dilation of the common hepatic duct (black arrow) and the left intrahepatic ducts with papillary or nodular soft tissue vegetations (arrowheads) characteristic ofmucin-hypersecreting papillary cholangiocarcinoma. There is focal liver disruption in the anterior aspect of the atrophic left lateral segment, with an extension of infected biliary fluid to the anterior abdominal wall forming an abscess via the falciform ligament and ligamentum teres (white arrows). (Reproduced from Ko et al.76)

Fig. 3-124. Abscess of the ligamentum teres and anterior abdominal wall consequent to cholangiocarcinoma.

CT shows dilation of the common hepatic duct (black arrow) and the left intrahepatic ducts with papillary or nodular soft tissue vegetations (arrowheads) characteristic ofmucin-hypersecreting papillary cholangiocarcinoma. There is focal liver disruption in the anterior aspect of the atrophic left lateral segment, with an extension of infected biliary fluid to the anterior abdominal wall forming an abscess via the falciform ligament and ligamentum teres (white arrows). (Reproduced from Ko et al.76)

Gastric Ulcer Images Black And White

Fig. 3-125. Hepatic abscess secondary to confined gastric perforation along the gastrohepatic ligament.

(a) An irregular low-attenuation mass (arrows) secondary to confined perforation of a lesser curvature gastric ulcer extends from the stomach (S) into the gastrohepatic ligament.

(b) CT at a higher level demonstrates a hepatic abscess (arrows) in the left lobe. S = stomach. (Reproduced from Jacobs et al.77)

Fig. 3-125. Hepatic abscess secondary to confined gastric perforation along the gastrohepatic ligament.

(a) An irregular low-attenuation mass (arrows) secondary to confined perforation of a lesser curvature gastric ulcer extends from the stomach (S) into the gastrohepatic ligament.

(b) CT at a higher level demonstrates a hepatic abscess (arrows) in the left lobe. S = stomach. (Reproduced from Jacobs et al.77)

Pancreatic Pseudocyst Management

Fig. 3-126. Intrahepatic pancreatic pseudocysts via the gastrohepatic ligament.

(a and b) CT after an acute recurrence of chronic pancreatitis shows a bilobed collection (C) in the gastrohepatic ligament and in the fissure for the ligamentum venosum, invading the left hepatic lobe. Another collection is seen in the upper recess of the lesser sac (LS), medial to the inferior vena cava, indenting the caudate lobe. (Reproduced from Arenas et al.75)

Fig. 3-126. Intrahepatic pancreatic pseudocysts via the gastrohepatic ligament.

(a and b) CT after an acute recurrence of chronic pancreatitis shows a bilobed collection (C) in the gastrohepatic ligament and in the fissure for the ligamentum venosum, invading the left hepatic lobe. Another collection is seen in the upper recess of the lesser sac (LS), medial to the inferior vena cava, indenting the caudate lobe. (Reproduced from Arenas et al.75)

that 80-85% of abscesses can be treated exclusively by percutaneous catheter drainage with a mortality rate of 6%. Percutaneous drainage of abdominal abscesses is less traumatic and disruptive to the normal anatomy than is operative drainage. One-step needle aspiration and lavage has been recently reported as quite effective, when combined with intravenous antibiotic therapy, in curing small abscesses.99

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