Retroperitoneal abscess
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Ahmed Younes M.B.B.CH [2]
Overview
Retroperitoneal abscess is an unusual type of abscess in surgical practice. It is often underdiagnosed due to the insidious onset of symptoms and its location in the retroperitoneal space making it hard to be accessible for the regular abdominal examination. It is most often due to Genitourinary infection (like Pyelonephritis) or gastrointestinal cause (like Inflammatory Bowel Syndrome). CT & MRI are the cornerstones for diagnosis. Treatment is usually focused on surgical drainage either through open or percutaneous approaches under the umbrella of IV antibiotics.
Historical perspective
- Retroperitoneal abscess was first described by Grassi and Serge in 1887.
- Dr. Hugh Cabbot presented the first case of retroperitonal abscess in a case report in 1922.
Classification
Retroperitoneal abscess may be classified according to the location in the retroperitoneal space into 5 categories [1] :
- Perinephric
- Upper retroperitoneal
- Pelvic
- Combined retroperitoneal and pelvic
- Lٍٍocalized musculoskeletal
Pathophysiology
 |
Pathogenesis
Retroperitoneal abscess is usually secondary to spread from other primary site either hematogenous or by contiguous spread. The bacteria causing the abscess depends on the primary site. When the bacteria invades the retroperitoneal tissue, toxins released from it destroy the tissue & trigger an inflammatory response. As a result of the inflammatory response, White Blood Cells get recruited. They phagocytose the invading bacteria but at the same time they break down the infected tissue. The healthy tissues around enclose the area with a membrane surrounding the abscess. After pus evacuation, the membrane grows in to fill the cavity.
Microscopic Findings
Abscess consists of a mixture of inflammatory cells together with debris tissue. From the surrounding wall grows some capillaries to form granulation tissue. If body defenses are successful in eliminating the infection, the granulation tissue continues to grow and the abscess continues to shrink in size until it is only a scar. If the offending pathogen is not cleared, the process goes on and may even spread.
Causes
Retroperitoneal Abscess may be caused by[2] :
- E. Coli or Proteus spp (if primary is from the urinary tract)
- Multibacterial & anaerobes (if gastrointestinal tract (GIT) is the primary source)
- Staphylococcus aureus (if from distant septic focus)
- Tuberculosis (if secondary to Pott’s disease)
Differentiating Retroperitoneal abscess from other Diseases
| Disease | Clinical feature | Laboratory findings | Imaging findings | ||
|---|---|---|---|---|---|
| Fever | Weight loss | Abdominal pain | |||
| Retroperitoneal abscess | ✔ | ✔ | Leukocytosis, positive inflammatory markers | MRI is the best radiologic tool to differentiate between retroperitoneal masses. | |
| Retroperitoneal hematoma | ✔ | Anemia | |||
| Retroperitoneal tumors (.e.g. liposarcoma) | ✔ | ✔ | ✔ | positive tumor marker | |
| Chronic pancreatitis | ✔ | ✔ | DM type II, amylase and lipase levels may be slightly elevated | ||
Epidemiology and Demographics
Retroperitoneal abscess is far less common than Intraperitoneal abscesses[3].
- Males are slightly more susceptible than females.
- increased incidence between third and sixth decades.
- Most common cause in developing countries is spread from distant septic focus.
- Most common cause in developed countries are Renal and GI causes [2].
Risk Factors
Any septic focus can theoretically lead to retroperitoneal abscess. These are the primary foci in order of frequency to cause retroperitoneal abscess.
- Renal infections : spread from the urinary tract is the most common cause.
- Gastrointestinal diseases : Spread from the gastrointestinal tract is the second common cause like perforated appendix, perforated colon cancer, Diverticulitis and Crohn’s disease.
- Bone infection : pott's disease or osteomyelitis
- Hematogenous spread : from distant septic foci.
- Iatrogenic : following abdominal or pelvic surgery.
Any condition compromising the immune system is a risk factor for developing retroperitoneal abscess. The following were the risk factors in order of frequency in observed patients [1]
- Diabetes Mellitus
- Cirrhosis
- Malignancy
- Remote infection
- Glucocorticoids intake
- Chronic renal failure
Screening
According to the USBTSF, screening for retroperitoneal abscess is not recommended.
Natural History, Complications and Prognosis:
Natural History
If left untreated, Retroperitoneal abscess may cause septicemia with very high incidence of morbidity and mortality.
Complications :
Most complications result from septicemia which presents late in the disease[1]
- Pneumonia and respiratory failure type 1 is the most common complication with very high mortality.
- Recurrent Abscess after drainage.
- Renal Failure
- DVT
- Small Bowel Obstruction
- Arterial Thrombosis
- UTI
- Brain Abscess
- Empyema
- Osteomyelitis
Prognosis
Depending on the extent of the abscess at the time of diagnosis, the prognosis may vary. However, with the presence of the mentioned factors below, the prognosis is generally regarded as poor.[1]
- Septicemia (Positive Blood Culture) : Not present in every patient but When present, it is a very poor prognostic sign.
- Number of days for fever to fade away after drainage : Persistence of fever more than 4 days carries a mortality more than 70%.
Diagnosis
History
Detailed history should be obtained from the patient presenting with insidious onset of abdominal pain. Common causes should be investigated (Kidney and gastrointestinal diseases) especially in the presence of any of the risk factors (DM, corticosteroid intake, etc ..).
Symptoms [1]:
Presentation is usually insidious and nonspecific besides that it’s unusual condition, this all delays the diagnosis.
common symptoms
- Fever is the most common complaint usually, more than 101 F.
- Constitutional symptoms : chills, malaise, anorexia and weight loss.
- Abdominal pain : Non localized due to the unusual site of the abscess.
less common symptoms
- Gastrointestinal complaints which varied from case to case
- If abscess involves psoas major muscle, pain is usually referred to the hip, groin and knee.
Physical Exam[1]
General Appearance
The patient is usually fatigued & looking ill due to the preexisting risk factor. In advanced cases with septicemia, the patient may be drowsy with decreased level of consciousness.
Vital signs
- Fever
- Tachycardia
- Tachypnea
- Hypotension (if shocked)
Abdominal Examination
- Abdominal tenderness is often present (localized)
- Positive psoas sign if the psoas muscle is involved.
- The classic signs of peritonitis is absent (making the diagnosis more difficult).
Lab Findings
- Classic lab findings of inflammation as leukocytosis, high ESR, high CRP ,etc, ...Leukocytosis is usually not very high (between 10.000 and 20.000 in most cases)
- Blood culture is not always positive (but carries a grave prognosis if +ve).Organism depends on the source of abscess as mentioned above in pathophysiology.
Radiological Findings
CT & MRI are the 2 most important radiological diagnostic tools.
- The image shows retroperitoneal abscess in left side with gas bubbles inside (circled area)
CT
- CT shows fluid collection in the retroperitoneal space and may also show gas bubbles. It is also helpful in determining the primary source of the abscess.
MRI
- shows the same findings as CT, but more accurate.
Ultrasonography
- Not the preferred diagnostic tool because of the remote site of the abscess.
Treatment[1]
Medical Treatment
- Intravenous empiric antibiotics should be started till results of the cultures are available.
| Regimen | In pediatrics | In adults | |
|---|---|---|---|
| Mild - Moderate infection | Severe infection | ||
| Single agent | Ertapenem, meropenem, imipenem, cilastatin, ticarcillin-clavulanate, and piperacillin-tazobactam | Cefoxitin, ertapenem, moxifloxacin, tigecycline, and ticarcillin-clavulanic acid | Imipenem-cilastatin, meropenem, doripenem, and piperacillin-tazobactam |
| Combination | Ceftriaxone, cefotaxime, cefepime, or ceftazidime, each in combination with metronidazole; gentamicin or tobramycin, each in combination with metronidazole or clindamycin, and with or without ampicillin | Cefepime, ceftazidime, ciprofloxacin, or levofloxacin, each in combination with metronidazole. | Cefepime, ceftazidime, ciprofloxacin, or levofloxacin, each in combination with metronidazole. |
Initial Empiric antibiotic therapy for community acquired intraabdominal infections.[4]
| Organisms that are common in health care facility | Regimen† | ||||
|---|---|---|---|---|---|
| Carbapenem | Aminoglycoside | Ceftazidime or cefepime, each with metronidazole | Piperacillin-tazobactam | Vancomycin | |
| <20% Resistant Pseudomonas aeruginosa, extended-spectrum b-lactamase-producing Enterobacteriaceae, Acinetobacter, or other multidrug resistant gram-negative bacilli | Recommended | Not recommended | Recommended | Recommended | Not recommended† |
| Extended-spectrum b-lactamase-producing Enterobacteriaceae | Recommended | Recommended | Not recommended | Recommended | Not recommended |
| P. aeruginosa 120% resistant to ceftazidime | Recommended | Recommended | Not recommended | Recommended | Not recommended |
| Methicillin-resistant Staphylococcus aureus | Not recommended | Not recommended | Not recommended | Not recommended | Recommended |
Initial Empiric antibiotic therapy for health care associated intraabdominal infections.[4]
- Drainage of the abscess is a must and using medical treatment alone carries a mortality rate approaching 100 % in some studies.
Surgical Treatment [1]:
- Operative treatment is usually preferred unless in special cases when it is contraindicated.
- Retroperitoneal or pelvic approaches are much preferred than transperitoneal approach due to better outcomes and decreased probability of intraperitoneal spread.
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Grollier G, Burucoa C, Bonnin M, de Rautlin de La Roy Y (1992). "Identification and susceptibility testing for obligate anaerobic bacteria using a semi-automated API ATB plus system". Ann Biol Clin (Paris). 50 (6–7): 393–7. PMID 1492717.
- ↑ 2.0 2.1 Winter BM, Gajda M, Grimm MO (2016). "[Diagnosis and treatment of retroperitoneal abscesses]". Urologe A. 55 (6): 741–7. doi:10.1007/s00120-016-0118-1. PMID 27220893.
- ↑ Vitale L, Kiss A, Drago GW (1994). "[Retroperitoneal abscesses: clinical and therapeutical aspects]". Minerva Chir. 49 (3): 163–5. PMID 8028724.
- ↑ 4.0 4.1 Jaton JC, Huser H, Blatt Y, Pecht I, Bose KS, Sarma RH, Schmoldt A, Benthe HF, Haberland G, Zurawski VR, Kohr WJ, Foster JF, Crouch MD, Short CR, Bose KS, Sarma RH, Jaton JC, Huser H, Blatt Y, Pecht I, Bose KS, Sarma RH, Fook TJ, Ranadive NS, Basu PK (1975). "Circular dichroism and fluorescence studies of homogeneous antibodies to type III pneumococcal polysaccharide". Biochemistry. 14 (24): 5308–11. PMID 50.