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1089
CT as a Primary Diagnostic Method in Evaluating lntraabdominal Abscess r
M.
K. Wolverson1
B. Jagannadharao M. Sundaram P. F. Joyce M. A. Riaz J. B. Shields
In 1 9 cases, a correct diagnosis of intraabdominal abscess was made by CT body scanning. There was one false-positive diagnosis and initially one false-negative diagnosis. CT proved to be an efficient imaging method for diagnosis, for planning of therapeutic procedures, and in monitoring response to operative or conservative treatment. It has advantages over ultrasound and gallium scanning especially in severely ill, postoperative, and obese subjects. In addition, needle aspiration under CT control is readily performed and can be undertaken at the same examination. Confirmation of the diagnosis and therapeutic aspiration with or without introduction of a
drainage
catheter
We
report
diagnosis
can then be undertaken.
our
experience
with
of intnaabdominal
method. The excellent anatomic ease with which the examination aged
us to initially
CT. We correctly it did not prove
computed
abscess,
evaluate
the
advantages
Materials
and
From patients mented
August
March
2, 1 979;
accepted
after
revi-
1 , 1979.
All authors: Department of Radiology, Firmin Desloge Hospital and St. Louis University Medical School, 1325 S. Grand Blvd., St. Louis, MO 631 04. Address reprint requests to M. K. Wolverson. AJR 133:1089-1095, December 1979 0361 -803X/79/1 336-1089 $00.00 © American Roentgen Ray Society
for
of suspected
features abdominal
persistent
any
abscess
The
abscess
was made
follow-up
patient’s Scanning
abscess
review cases
gallium
if pus did
signs
and was
signs
after was
of
abscess
if the
not result symptoms performed
the
by
cases, except
of these cases are presented
scanning
of A
few
are
abdominal
discussed.
in the discovery
were
in one only the if
docu-
ill. Commonly abdominal
or
radiographs, by
fever
surgery. Eight was inconclusive
from
of an abscess,
with
consecutive had
acutely
investigated
correct
spontaneously,
35
included
patients
a CT study
percutaneously
examined
on conventional
were
Twelve
for
on
patients
abscess
or shown
considered
performed
patients
patients
indication
recovered
on
All
abdominal or pelvic of these the examination
aspirated
was
was
of the
or symptoms.
was
patient
Most examination
recent in four
scan was
scanning abscess.
suspicion
infection.
and
gallium or
and
tract
diagnosis
CT
weeks.
at physical
localizing
scanned
exploration
to
mass
examinations
CT
1 979
to several
urinary
An abnormal
and
intraabdominal
leading
specific
were
ultrasound
intnaabdominal
Retrospective Representative
ultrasound
to January suspected
for 2 days
pelvic without Received
1 978
referred
pain,
in the
diagnostic
Methods
associated and
sion
of CT over
January fever
scanning
as a primary
1 9 abscesses over a 1 year period. In most to resort to any other diagnostic procedure
CT-guided needle aspiration in four cases. was undertaken and the results analyzed. and
(CT)
its role
detail provided by CT as well as the speed and can be performed in acutely ill patients encourall cases
diagnosed necessary
tomographic
emphasizing
CT
and
for
fever
suspected
patients had prior to CT.
patient. if confirmed
lesion.
by
A diagnosis
the subsequent
or if an alternative
clinical cause
surgical of
for the
discovered.
a commercially
available
whole-body
scanner
no
course
(Siemens
1090
WOLVERSON
TABLE
1:
Patients
Case
Examined
No
for Suspected indication
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Urinary tion;
2
Urinary tion;
tract renal
diabetes Fever; renal
3
br
CT
tract infecrenal mass
infecmass; mass
Intraabdominal Pre-CT
4
Fever; pain;
5
GI bleeding
minal
Septicemia; urinary tract infection
6
Chronic fever; mass rt. lower quadrant
7
PlO, elective hysterectomy; postop. fever Postop. partial gastrectomy; fever Recurrent
8
Postop. cholecystojejunostomy; pancreatic carcinoma; fever Postop. pelvic exenteration; fever
9
10
11
Pelvic
pain;
12
Fever
of unknown
fever
origin
13
Abdominal ver
pain; fe-
14
Abdominal
pain;
fe-
ver 15
investigations
mass
Back pain; fever; ?metastatic tumor
gas
1979
CT Diagnosis
Lt.
peninephric
Method
Surgical drainage abscess
ab-
Surgical
scess
Rt. peninephric scess Lt. perirenal
of Treatment
ab-
abscess
Final
of
Diagnosis
Lt. perinephric scess
ab-
drainage
At. perinephnic scess
ab-
Surgery, incision, and drainage
Lt. perinephric scess
ab-
Cholecystectomy
Penicholecystic
lower
pole It. kidney. Plain film #{149}: extralu-
abdominal
December
Abscess
Excretory urogram #{149}: mass It. kidney. Arteriogram avascular mass It. kidney Excretory urogram: mass lower pole rt. kidney. Excretory urogram: nondiagnostic. UItrasound: anechoic
AJR:133,
ET AL.
rt. upper
quadrant. Excretory urogram #{149}: staghorn calculus, poor nephrogram rt. kidney Barium enema: mass rt. lower quadrant, extrinsic pressure on cecum. Excretory urogram: extrinsic pressure right side of bladden Plain film abdomen: unremarkable
Pericholecystic
ab-
scess
and
At. perirenal roperitoneal scess
and retab-
Drainage
of ab-
ab-
scess
pyloroplasty At.
scess, rt. nephrec-
perirenal peritoneal
and retroabscess
tomy
Mass rt. lower quadrant with low attenuation area
Surgery, right hemicolectomy (at surgery thought to be carcinoid tumor)
Appendiceal
Pelvic
Drainage of abscess via vaginal approach Drainage via subcostal approach
Postop.
CT-guided
Postop.
liver abscess
pelvic
mass
pelvic
abscess
Postop. It. subphrenic abscess
Chest film: It. pleural effusion. Ultrasound: inconclusive Chest film: negative. CT prior to surgery: negative
Lt. subphrenic scess
Plain film abdomen: soft tissue mass in pelvis. Ultrasound: inconclusive. Barium enema: pelvic mass suggested. Chest film: negative. Excretory urogram: negative. Barium enema: negative. Ultrasound: inconclusive. Chest film #{149} : negative. Excretory urogram #{149} : negative. Barium enema’ : negative. Chest film: negative. Plain film abdomen: negative. Lumbar spine : negative
Pelvic
abscess
Drainage via pelvic approach
Postop.
Pelvic
abscess
Appendectomy and drainage of abscess
Appendiceal
abscess
Diagnosis confirmed by CT-guided aspiration
Right iliacus abscess
muscle
Liver
Abscess liver
ab-
abscess
It. lobe of
At. iliacus abscess
muscle
aspiration
Liver
abscess
Drainage
Liver
abscess
Surgery; open drainage followed by antibiotics CT-guided aspiration
Left psoas abscess
muscle vs tumor
at surgery
abscess
abscess
Liver abscess
Metastatic
tumor
of
psoas muscle with necrosis and abscess formation
Note-Five distribution .
Done
patients had investigations after CT. Case 2 had CT-guided aspiration of right flank of isotope, no focai defect. Case 1 6 had foiiow-up CT. Case 1 8 had positive uitrasound. at outside
hospital
mass; abscess confirmed. Case 9 had a liver-spleen scan Case 1 9 had positive ultrasound and gallium scan.
that showed
inhomogeneous
AJR:133,
TABLE
December
1 : Patients Case
CT OF INTRAABDOMINAL
1979
Examined
No.
for Suspected
Indication
Pre-CT
for CT
Salmonella
16
lntraabdominal
cemia;
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graft Fever
of
origin; 1
9
unknown
Excretory
diabetes
suspected mass kidney. Excretory urogram negative.
Persistent urinary tract infection; diabetes
drainage
transrectal
Abscess or hematoma around abdominal aortic graft
urogram
#{149} :
It.
Perinephnic
abscess
:
Abscess
Pelvic
via
ap-
Infected
Surgery
At.
and
open
graft
perinephric
ab-
scess
drainage
rt. kidney
Diagnosis
abscess
proach; subsequently drained via suprapubic approach Surgery
rt. kidney
#{149}
Final
of Treatment
Initially
upper
Plain film abdomen: negative. Ultrasound: inconclusive.
Fever; postop. abdominal aortic
18
abscess
quadrant of abdomen and pelvis.
Ga scan
17
left
Method
CT Diagnosis
Pelvic
increased
uptake
abnormal
Abscess-cont.
investigations
Ga scan:
septi-
1091
ABSCESSES
Conservative agement
At. renal
man-
abscess
Somatom). The scan time was 5 sec, slice thickness, 8 mm. Image reconstruction time was less than 5 sec. Scans were obtained at 1 .6 cm intervals from xiphisternum to perineum in all patients and at 8 mm intervals in areas suspicious of abnormality. Contrast material administered orally was 250-500 ml of dilute (2%) diatrizoate, meglumine diatrizoate sodium (Gastrografmn), used routinely and
given
1 5 mm
administered
abscess initial
before
rectally
either CT
by clinical
scans.
received
50
scanning.
in any
of
of definite
60%
or suspicious
(1
L) was
having
contraindicated,
a pelvic
on the
all
intravenously.
rapid intravenous injection of a bolus was made to demonstrate the relations to areas
of
or by the appearances
specifically
Renografin
solution
suspected
evidence
Unless
ml
A similar
patient
On
patients occasion,
of 50 ml of Aenografin 60% of major vascular structures
abnormality
and
to demonstrate
the vascularity of demonstrated lesions. All examinations were carefully monitored by a staff radiologist or resident. Often one or more follow-up examinations were performed to evaluate the effectiveness
of conservative
or operative
Fig. 1 -Case 7: postoperative center of poorly defined pelvic lesion and antenior abdominal wall.
pelvic mass
of the 35 1 9 cases,
wounds. The third lesion was missed
(case 1 2) was an apparently
due to examina-
amination.
near
treatment.
abscess. Area of low attenuation and gas-filled bowel loops between
Results lntnaabdominal abscess was diagnosed patients and proved connect in 1 9. In one the study combination
was initially of observer
interpreted error and
as negative an incomplete
tion (case 1 6). The correct diagnosis at a subsequent CT examination. positive
diagnosis
in a patient
in 20 of the
of abscess There was
whose
signs
was one
and
a
made false-
symptoms
operate
found
amination
(cases
nations
these
of abscess
the
made
patients diagnosed up periods of 9-1 sion
that
there
are given
was
no false-negative
patients had was an abscess
firmed clusive
the in
postoperative examination
1 . The
records
as no abscess were examined 8 months. These data support
Eight patient
abscess
in table
abdominal diagnosed
case
and was
of these severely
hindered
patients ill,
and
by excess
for followthe conclu-
in this
series.
ultrasound. In only prior to CT which
diagnosis (case 3). The examination four subjects subsequently shown
at CT. Two
of all
(cases the
was inconto have an
8 and
performance
bowel
one con-
gas and
1 7) were of the surgical
fourth
were
at CT
were
1 8 and
negative
(case was
and
1 1 ) was
The
no
unable
incomplete. by
other
abscess
the ex-
to co-
In two
confirmed
1 9).
obese and satisfactory
patients
ultrasound
ex-
ultrasound was found
examilater in
patients.
Gallium
scanning
scan
was
abnormal
isotope
quadrant
and
pelvis and determined CT and the a splenectomy, bowel for
patient
the examination
abscesses
were later shown to be due to a hemorrhagic tumour (see fig. 4). Details of the 1 9 patients in whom a correct diagnosis was
The and
patient despite
the
high
was
positive.
performed In one
accumulation pelvis.
in four patient were
At CT
subjects.
(case noted
an abscess
In two
1 6) in the
was
areas left
found
of
upper in the
was confirmed at surgical exploration. It was the left upper quadrant was free of disease by subsequent clinical course. The patient had had and
a colon
in the left upper
false-positive
examination quadrant.
isotope
uptake
The
indicated
loops
latter
account
in this
may region.
second patient, a gallium scan confirmed the presence renal abscess found at CT (case 1 9). The two subjects
of
In the of a with
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1092
WOLVERSON
ET AL.
AJR:133,
Fig. 2.-Case lower pant of right
14:
December
1979
abscess. A, Well defined low attenuation area of liven. No mass effect. B, 7 weeks after operative
liven
lobe
in
drainage. Recurrent abscess above and medial to original lesion. Proximity to and mass effect on inferior vena cava, which was opacified by intravenous bolus technique. Rim of contrast enhancement around periphery of lesion. C, 7 weeks after treatment with antibiotics. Considerable diminution of abscess.
surgery was required (case 9). In two patients, aspiration confirmed the diagnosis of abscess and further confirmation was obtained at surgery (cases 2 and 1 2). In the fourth patient material;
the aspiration procedure cytology of the aspirate
mous cell carcinoma of a drainage catheter of the apy.
abscess,
(case was
the
patient
revealed revealed
infected punulent metastatic squa-
1 5). Percutaneous undertaken and was
treated
after
with
introduction resolution
radiation
then-
Discussion negative gallium scans by CT or at follow-up. The three
sites
of the
were
not
abscesses
shown
shown
to have
an abscess
at CT were
The 80%-i
as follows:
Many
were intrahepatic, six were renal on penirenal, and two in skeletal muscle (one in the iliacus muscle in the and one in the psoas muscle in the mid abdomen).
were
pelvis There
was
hepatic
one
left
abscess.
occurred
subphnenic
In one
in association
abscess
instance, with
and
one
a netropenitoneal an
arterial
At CT the
lesions
that
occurred
as areas of low attenuation cases) as mass lesions
in solid
and
viscera
the
mass (fig. of adjacent
soft rim
(1 4 cases), inappropriate after intravenous contrast
aortic
of these
patients,
the
(14 low
1 ). Other signs noted inorgans (1 2 cases), loss of
aspiration
was
gas (4 cases), material (15
curative
and
with
intnaabdominal 30% in treated
intraabdominal
abscess
abscess patients are
is [1].
severely
ill
and the performance of diagnostic procedures on them is often difficult. This is especially so in postoperative and obese subjects. A test that is simple to undertake under all circumstances Before several with tions
appeared
cases) (fig. 2B). Thickening of fascial planes was noted in 1 5 cases (fig. 3). Needle aspiration biopsy under CT control was performed on four occasions (cases 2, 9, 1 2, 1 5). In one
patients
in untreated as high as
and
that
can
be performed
rapidly
is clearly
advantageous.
in three
(5 cases) and at other sites with one or more areas of
attenuation within cluded displacement tissue planes enhancement
sub-
abscess
abdominal
graft. There were two appendiceal abscesses instances the lesion was in the pelvis.
right
mortality 00% and
no
and early inconclusive
during the ultrasound
suspected abdominal were often difficult
operative
patients,
difficulty
in distinguishing
and
abscess. to obtain free
loops from abscess Very few of our patients
quickly detailed ning
acutely and
ill and gave
anatomic operative
satisfactorily several other
the
reliable procedures.
completed limitations
ill. We also
peritoneal
we had patients
fluid
experienced and
fluid
[2]. had
gallium
scans
because
CT
studies
could
be performed
results.
information
study, in
Satisfactory examinain obese subjects, post-
the severely
bowel
were
course of this examinations
In addition,
useful Gallium
in less than in the diagnosis
CT
to the surgeon scanning 24 hr [3] of abscess,
in
most provided in plan-
cannot
be
and has includ-
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AJR:133,
December
CT
1979
Fig. 3.-Case 1 1 : small peniappendiceal administered pen rectum. B, 7.5 cm below
ing
a significant
negative
incidence
diagnoses
More
rapid
newer
OF
abscess in obese patient. A, Abscess fig. 3A. No mass is seen at this level,
of both
false-positive
and
scanning
CT units
as the
distinguish
and
provide
reconstruction
better
administration bowel
mented.
images
times
and
would have but considerable
been
confused thickening
with loop of fascial
of colon planes.
had
contrast
material
not
been
false-
of additional
loops
from
Interventional
CT
can
procedures
studies can procedure can in technique, material
be quickly
can
Radiation
exposure
the
examina-
contrast
abscess,
with
faster
to
imple-
be conveniently
performed at the same examination. For all these we now recommend CT as the primary diagnostic for suspected abscess in preference to ultrasound scanning.
1093
ABSCESSES
[4-7].
tions than previously. Consistently satisfactory now be obtained in severely ill patients. The be monitored image by image. Adjustments such
INTRAABDOMINAL
is associated
reasons, method on gallium
with
the
proce-
dune, but is no more than that obtained from the average barium examination. However, we do not recommend CT as the initial procedure for young children on for suspected pelvic lesions in women of child beaning age. Of the three procedures, CT is the least time-consuming procedure patient
at our
hospital.
is comparable
The
to that
cost
of a gallium
of a CT
scan.
saving may be achieved by reduction and avoidance of additional procedures confidence The CT abscess areas viscus
in the finding
of soft
tissue
of low attenuation [8-i such as liven on kidney,
0]. When an area
A sign
vicinity. supporting
one
on more
the
confined to a solid of diminished atten-
us
tumor. Left attenuation
(fig.
search
we
have
renal area.
found
of an often extended Demonstration
diagnosis
This
lesion to
that
the
thickening.
intnaabdominal
with
Wilms low
defined
mass,
has 3B).
for small, missed
on
low
consistently
attenuation
be
initial
inspection
with fluid-filled loops of bowel. sign is not specific for abscess,
of
confused
crosis
or into
have
a similar
attenuation
within
also be seen with intraabdominal hemorrhage infiltration. Inappropriate gas within the lesion
appearance.
In general,
an abscess cleanly
are
defined
the
of lower
areas
of low
density
and
signs
organs
by
have
smoothen,
more
of the
abscess lesion
This
ports
the
exhibited
margins.
At times, however, the distinction neoplasm may be impossible from tional
may
include and
loss
between the images displacement
of soft
tissue
abscess alone. of
and Addi-
adjacent
planes
in its
a history gas may wound. Finally,
diagnosis this
sign,
of abscess. however,
of recent abdominal enter the lesion from contrast
enhancement
in
four
in three
surgery. the exterior of
the
might
images
however,
Only
and
which the
effect may be and/or ne-
occurs
of which
helpful
masses
easily
alone may be found, although mass [1 1 ]. Tumors undergoing degeneration hemorrhage
pant
abscess is fascial plane to sections well beyond of this sign has alerted
uation present
which
lange
cost
in management time because of the high
density
4.-Haemorrhagic of fairly well
to the
At times,
CT diagnosis of abscess. most suggestive of an
is a mass
scan
Fig. consists
or
as it may on neoplastic strongly sup-
of our
patients
of these
there
In some through
instances a surgical
periphery
was
of
the
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1094
WOLVERSON
Fig. 5.-Case
16: Salmonella
rectum. B, Subsequent diagnosed. C, 1 week
examinaton. after rectal
of abscess.
have
lesion
All locules
after
the
pelvic abscess. Renal Three low attenuation drainage of abscess.
been
evacuated.
intravenous
Note
AL.
material
in locule
of iodinated
con-
that
has
drained
in
from
clinical
simple curate
seen with neoplasm. The single false-positive
and image examinations
fever most
was
in a child
with
and an abdominal mass. An abscess was thought the likely diagnosis at CT. At surgery, it was found that a
Wilms’
had
tumor
hemorrhaged,
resulting
in a hematoma
(case
1 6).
cemia 1 year glomerulonephnitis. pelvis were filled rectum, 5A).
The
This
after
patient
receiving Several
developed
noted and were mistakenly as the patient was known
patient
refused
the
that would diagnosis
abscess
at
months CT sound
was later
(fig.
scanning and
inal abscess. and severely images
made
subsequent
of rectal
CT
can
of
the
assists
considerable
scanning
in the diagnosis
is an advantage
over
We thank
error pelvic
when
quick
allow faster, procedures
be undertaken images
in the
The
planning
of
the
of operative of
controlled diagnosis
examination. intraabdominal
procedures
operative
is
and acFast scan
more for
at the same
obtained
method
is sensitive abscess.
and
on conservative
Jean
Hutson
for assisting
in manuscript
preparation.
2’/2
REFERENCES 1
ultra-
.
Ariel
2. Taylor sound
of intraabdom-
in postoperative, wide acceptance
made.
contrast this
examination
advantages
be
ACKNOWLEDGMENT
IM,
Kazarian
Abscesses.
It is of particular value ill patients, and the
by clinicians
chronic in the
SB). has
gallium
for areas
have prevented of a multiloculated
therapy
in determining the adequacy treatment at followup studies.
interpreted as fluidto have diarrhea (fig.
installation
material, a procedure in interpretation. The
to
septi-
Salmonella
a renal transplant low attenuation
need
reconstruction times and interventive
detail
contents
about three times the size of the solid part of the mass (fig. 4). The initially false-negative case was due to observer error
The
1979
in pelvis misintenpreted as fluid-filled material. Multiloculated abscess was after suprapubic operative drainage
to perform on all subjects and in the diagnosis of intraabdominal
and/on
December
rectum.
management
trast material may assist in the recognition of an abscess [1 2]. Again, this sign is not specific for abscess as it may be diagnosis
AJR:133,
transplant 1 year earlier. A, Rounded low attenuation areas deep areas in pelvis did not opacify after instillation of rectal contrast Only night posterior locule of lesion has been drained. D, 1 week
contrast
administration
ET
obese, of CT decisions
KJW, and
Korobkin
Diagnosis
M,
Sullivan
Callen
and
Williams
PW,
Treatment
& Wilkins,
DC, Wasson
gallium for Gastrointest
abscesses. 3.
KK:
Baltimore,
JFMcI,
of Abdominal
1971
Rosenfield
the diagnosis of abdominal Radiol 3 : 281 -286, 1978 Filly
RA,
Hotter
PB,
Kressel HY: Comparison of computed tomography, raphy and gallium-67 scanning in the evaluation
AT: Ultraand
Shimshak
pelvic AR,
ultrasonogof suspected
AJR:133,
December
1979
CT
OF
INTRAABDOMINAL
abdominal abscess. Radiology 1 29 : 89-93, 1978 Hauser MF, Alderson P0: Gallium-67 imaging in abdominal disease. Semin NucI Med 8 : 251 -270, 1978 5. Tedesco FJ, Coleman RD, Siegel BA: Gallium citrate Ga67 accumulation in pseudomembraneous colitis. JAMA 235 : 5960, 1976 6. Forgacs P, Wahner HW, Keys TF, Van Scoy RE: Gallium scanning for the detection of abdominal abscesses. Am J Med
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EV, McCartney WH: Role of gallium-67 disease. Semin Nucl Med 8: 21 9-234, 1978
in inflammatory
8. Haaga JA, Alfidi RJ, Havrilla TA, Cooperman AM, Seidelmann FE, Reich NE, Weinstein AJ, Meaney TF: CT detection and
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1095
aspiration of abdominal abscesses. AJR 1 28 : 465-474, 1977 Aronberg DJ, Stanley RJ, Levitt AG, Sagel S: Evaluation of abdominal abscess with computed tomography. J Comput Assist Tomogr 2 :384-387, 1978 1 0. Chiu LC, Schapiro AL, Yiu VS: Abdominal abscess I. Computed tomographic appearance, differential diagnosis and pitfalls in diagnosis. J Comput Assist Tomogr 2 : 1 95-280, 1978 1 1 . Levitt AG, Sagel SS, Stanley RJ, Jost RG: Accuracy of cornputed tomography of the liver and biliary tract. Radiology 124: 123-128, 1977 1 2. Gerzof SG, Robbins AH, Birkett DH: Computed tomography in the diagnosis and management of abdominal abscesses. Gastrointest Radiol 3:287-294, 1978 9.
1089
CT as a Primary Diagnostic Method in Evaluating lntraabdominal Abscess r
M.
K. Wolverson1
B. Jagannadharao M. Sundaram P. F. Joyce M. A. Riaz J. B. Shields
In 1 9 cases, a correct diagnosis of intraabdominal abscess was made by CT body scanning. There was one false-positive diagnosis and initially one false-negative diagnosis. CT proved to be an efficient imaging method for diagnosis, for planning of therapeutic procedures, and in monitoring response to operative or conservative treatment. It has advantages over ultrasound and gallium scanning especially in severely ill, postoperative, and obese subjects. In addition, needle aspiration under CT control is readily performed and can be undertaken at the same examination. Confirmation of the diagnosis and therapeutic aspiration with or without introduction of a
drainage
catheter
We
report
diagnosis
can then be undertaken.
our
experience
with
of intnaabdominal
method. The excellent anatomic ease with which the examination aged
us to initially
CT. We correctly it did not prove
computed
abscess,
evaluate
the
advantages
Materials
and
From patients mented
August
March
2, 1 979;
accepted
after
revi-
1 , 1979.
All authors: Department of Radiology, Firmin Desloge Hospital and St. Louis University Medical School, 1325 S. Grand Blvd., St. Louis, MO 631 04. Address reprint requests to M. K. Wolverson. AJR 133:1089-1095, December 1979 0361 -803X/79/1 336-1089 $00.00 © American Roentgen Ray Society
for
of suspected
features abdominal
persistent
any
abscess
The
abscess
was made
follow-up
patient’s Scanning
abscess
review cases
gallium
if pus did
signs
and was
signs
after was
of
abscess
if the
not result symptoms performed
the
by
cases, except
of these cases are presented
scanning
of A
few
are
abdominal
discussed.
in the discovery
were
in one only the if
docu-
ill. Commonly abdominal
or
radiographs, by
fever
surgery. Eight was inconclusive
from
of an abscess,
with
consecutive had
acutely
investigated
correct
spontaneously,
35
included
patients
a CT study
percutaneously
examined
on conventional
were
Twelve
for
on
patients
abscess
or shown
considered
performed
patients
patients
indication
recovered
on
All
abdominal or pelvic of these the examination
aspirated
was
was
of the
or symptoms.
was
patient
Most examination
recent in four
scan was
scanning abscess.
suspicion
infection.
and
gallium or
and
tract
diagnosis
CT
weeks.
at physical
localizing
scanned
exploration
to
mass
examinations
CT
1 979
to several
urinary
An abnormal
and
intraabdominal
leading
specific
were
ultrasound
intnaabdominal
Retrospective Representative
ultrasound
to January suspected
for 2 days
pelvic without Received
1 978
referred
pain,
in the
diagnostic
Methods
associated and
sion
of CT over
January fever
scanning
as a primary
1 9 abscesses over a 1 year period. In most to resort to any other diagnostic procedure
CT-guided needle aspiration in four cases. was undertaken and the results analyzed. and
(CT)
its role
detail provided by CT as well as the speed and can be performed in acutely ill patients encourall cases
diagnosed necessary
tomographic
emphasizing
CT
and
for
fever
suspected
patients had prior to CT.
patient. if confirmed
lesion.
by
A diagnosis
the subsequent
or if an alternative
clinical cause
surgical of
for the
discovered.
a commercially
available
whole-body
scanner
no
course
(Siemens
1090
WOLVERSON
TABLE
1:
Patients
Case
Examined
No
for Suspected indication
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Urinary tion;
2
Urinary tion;
tract renal
diabetes Fever; renal
3
br
CT
tract infecrenal mass
infecmass; mass
Intraabdominal Pre-CT
4
Fever; pain;
5
GI bleeding
minal
Septicemia; urinary tract infection
6
Chronic fever; mass rt. lower quadrant
7
PlO, elective hysterectomy; postop. fever Postop. partial gastrectomy; fever Recurrent
8
Postop. cholecystojejunostomy; pancreatic carcinoma; fever Postop. pelvic exenteration; fever
9
10
11
Pelvic
pain;
12
Fever
of unknown
fever
origin
13
Abdominal ver
pain; fe-
14
Abdominal
pain;
fe-
ver 15
investigations
mass
Back pain; fever; ?metastatic tumor
gas
1979
CT Diagnosis
Lt.
peninephric
Method
Surgical drainage abscess
ab-
Surgical
scess
Rt. peninephric scess Lt. perirenal
of Treatment
ab-
abscess
Final
of
Diagnosis
Lt. perinephric scess
ab-
drainage
At. perinephnic scess
ab-
Surgery, incision, and drainage
Lt. perinephric scess
ab-
Cholecystectomy
Penicholecystic
lower
pole It. kidney. Plain film #{149}: extralu-
abdominal
December
Abscess
Excretory urogram #{149}: mass It. kidney. Arteriogram avascular mass It. kidney Excretory urogram: mass lower pole rt. kidney. Excretory urogram: nondiagnostic. UItrasound: anechoic
AJR:133,
ET AL.
rt. upper
quadrant. Excretory urogram #{149}: staghorn calculus, poor nephrogram rt. kidney Barium enema: mass rt. lower quadrant, extrinsic pressure on cecum. Excretory urogram: extrinsic pressure right side of bladden Plain film abdomen: unremarkable
Pericholecystic
ab-
scess
and
At. perirenal roperitoneal scess
and retab-
Drainage
of ab-
ab-
scess
pyloroplasty At.
scess, rt. nephrec-
perirenal peritoneal
and retroabscess
tomy
Mass rt. lower quadrant with low attenuation area
Surgery, right hemicolectomy (at surgery thought to be carcinoid tumor)
Appendiceal
Pelvic
Drainage of abscess via vaginal approach Drainage via subcostal approach
Postop.
CT-guided
Postop.
liver abscess
pelvic
mass
pelvic
abscess
Postop. It. subphrenic abscess
Chest film: It. pleural effusion. Ultrasound: inconclusive Chest film: negative. CT prior to surgery: negative
Lt. subphrenic scess
Plain film abdomen: soft tissue mass in pelvis. Ultrasound: inconclusive. Barium enema: pelvic mass suggested. Chest film: negative. Excretory urogram: negative. Barium enema: negative. Ultrasound: inconclusive. Chest film #{149} : negative. Excretory urogram #{149} : negative. Barium enema’ : negative. Chest film: negative. Plain film abdomen: negative. Lumbar spine : negative
Pelvic
abscess
Drainage via pelvic approach
Postop.
Pelvic
abscess
Appendectomy and drainage of abscess
Appendiceal
abscess
Diagnosis confirmed by CT-guided aspiration
Right iliacus abscess
muscle
Liver
Abscess liver
ab-
abscess
It. lobe of
At. iliacus abscess
muscle
aspiration
Liver
abscess
Drainage
Liver
abscess
Surgery; open drainage followed by antibiotics CT-guided aspiration
Left psoas abscess
muscle vs tumor
at surgery
abscess
abscess
Liver abscess
Metastatic
tumor
of
psoas muscle with necrosis and abscess formation
Note-Five distribution .
Done
patients had investigations after CT. Case 2 had CT-guided aspiration of right flank of isotope, no focai defect. Case 1 6 had foiiow-up CT. Case 1 8 had positive uitrasound. at outside
hospital
mass; abscess confirmed. Case 9 had a liver-spleen scan Case 1 9 had positive ultrasound and gallium scan.
that showed
inhomogeneous
AJR:133,
TABLE
December
1 : Patients Case
CT OF INTRAABDOMINAL
1979
Examined
No.
for Suspected
Indication
Pre-CT
for CT
Salmonella
16
lntraabdominal
cemia;
Downloaded from www.ajronline.org by 36.1.205.220 on 11/03/15 from IP address 36.1.205.220. Copyright ARRS. For personal use only; all rights reserved
graft Fever
of
origin; 1
9
unknown
Excretory
diabetes
suspected mass kidney. Excretory urogram negative.
Persistent urinary tract infection; diabetes
drainage
transrectal
Abscess or hematoma around abdominal aortic graft
urogram
#{149} :
It.
Perinephnic
abscess
:
Abscess
Pelvic
via
ap-
Infected
Surgery
At.
and
open
graft
perinephric
ab-
scess
drainage
rt. kidney
Diagnosis
abscess
proach; subsequently drained via suprapubic approach Surgery
rt. kidney
#{149}
Final
of Treatment
Initially
upper
Plain film abdomen: negative. Ultrasound: inconclusive.
Fever; postop. abdominal aortic
18
abscess
quadrant of abdomen and pelvis.
Ga scan
17
left
Method
CT Diagnosis
Pelvic
increased
uptake
abnormal
Abscess-cont.
investigations
Ga scan:
septi-
1091
ABSCESSES
Conservative agement
At. renal
man-
abscess
Somatom). The scan time was 5 sec, slice thickness, 8 mm. Image reconstruction time was less than 5 sec. Scans were obtained at 1 .6 cm intervals from xiphisternum to perineum in all patients and at 8 mm intervals in areas suspicious of abnormality. Contrast material administered orally was 250-500 ml of dilute (2%) diatrizoate, meglumine diatrizoate sodium (Gastrografmn), used routinely and
given
1 5 mm
administered
abscess initial
before
rectally
either CT
by clinical
scans.
received
50
scanning.
in any
of
of definite
60%
or suspicious
(1
L) was
having
contraindicated,
a pelvic
on the
all
intravenously.
rapid intravenous injection of a bolus was made to demonstrate the relations to areas
of
or by the appearances
specifically
Renografin
solution
suspected
evidence
Unless
ml
A similar
patient
On
patients occasion,
of 50 ml of Aenografin 60% of major vascular structures
abnormality
and
to demonstrate
the vascularity of demonstrated lesions. All examinations were carefully monitored by a staff radiologist or resident. Often one or more follow-up examinations were performed to evaluate the effectiveness
of conservative
or operative
Fig. 1 -Case 7: postoperative center of poorly defined pelvic lesion and antenior abdominal wall.
pelvic mass
of the 35 1 9 cases,
wounds. The third lesion was missed
(case 1 2) was an apparently
due to examina-
amination.
near
treatment.
abscess. Area of low attenuation and gas-filled bowel loops between
Results lntnaabdominal abscess was diagnosed patients and proved connect in 1 9. In one the study combination
was initially of observer
interpreted error and
as negative an incomplete
tion (case 1 6). The correct diagnosis at a subsequent CT examination. positive
diagnosis
in a patient
in 20 of the
of abscess There was
whose
signs
was one
and
a
made false-
symptoms
operate
found
amination
(cases
nations
these
of abscess
the
made
patients diagnosed up periods of 9-1 sion
that
there
are given
was
no false-negative
patients had was an abscess
firmed clusive
the in
postoperative examination
1 . The
records
as no abscess were examined 8 months. These data support
Eight patient
abscess
in table
abdominal diagnosed
case
and was
of these severely
hindered
patients ill,
and
by excess
for followthe conclu-
in this
series.
ultrasound. In only prior to CT which
diagnosis (case 3). The examination four subjects subsequently shown
at CT. Two
of all
(cases the
was inconto have an
8 and
performance
bowel
one con-
gas and
1 7) were of the surgical
fourth
were
at CT
were
1 8 and
negative
(case was
and
1 1 ) was
The
no
unable
incomplete. by
other
abscess
the ex-
to co-
In two
confirmed
1 9).
obese and satisfactory
patients
ultrasound
ex-
ultrasound was found
examilater in
patients.
Gallium
scanning
scan
was
abnormal
isotope
quadrant
and
pelvis and determined CT and the a splenectomy, bowel for
patient
the examination
abscesses
were later shown to be due to a hemorrhagic tumour (see fig. 4). Details of the 1 9 patients in whom a correct diagnosis was
The and
patient despite
the
high
was
positive.
performed In one
accumulation pelvis.
in four patient were
At CT
subjects.
(case noted
an abscess
In two
1 6) in the
was
areas left
found
of
upper in the
was confirmed at surgical exploration. It was the left upper quadrant was free of disease by subsequent clinical course. The patient had had and
a colon
in the left upper
false-positive
examination quadrant.
isotope
uptake
The
indicated
loops
latter
account
in this
may region.
second patient, a gallium scan confirmed the presence renal abscess found at CT (case 1 9). The two subjects
of
In the of a with
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1092
WOLVERSON
ET AL.
AJR:133,
Fig. 2.-Case lower pant of right
14:
December
1979
abscess. A, Well defined low attenuation area of liven. No mass effect. B, 7 weeks after operative
liven
lobe
in
drainage. Recurrent abscess above and medial to original lesion. Proximity to and mass effect on inferior vena cava, which was opacified by intravenous bolus technique. Rim of contrast enhancement around periphery of lesion. C, 7 weeks after treatment with antibiotics. Considerable diminution of abscess.
surgery was required (case 9). In two patients, aspiration confirmed the diagnosis of abscess and further confirmation was obtained at surgery (cases 2 and 1 2). In the fourth patient material;
the aspiration procedure cytology of the aspirate
mous cell carcinoma of a drainage catheter of the apy.
abscess,
(case was
the
patient
revealed revealed
infected punulent metastatic squa-
1 5). Percutaneous undertaken and was
treated
after
with
introduction resolution
radiation
then-
Discussion negative gallium scans by CT or at follow-up. The three
sites
of the
were
not
abscesses
shown
shown
to have
an abscess
at CT were
The 80%-i
as follows:
Many
were intrahepatic, six were renal on penirenal, and two in skeletal muscle (one in the iliacus muscle in the and one in the psoas muscle in the mid abdomen).
were
pelvis There
was
hepatic
one
left
abscess.
occurred
subphnenic
In one
in association
abscess
instance, with
and
one
a netropenitoneal an
arterial
At CT the
lesions
that
occurred
as areas of low attenuation cases) as mass lesions
in solid
and
viscera
the
mass (fig. of adjacent
soft rim
(1 4 cases), inappropriate after intravenous contrast
aortic
of these
patients,
the
(14 low
1 ). Other signs noted inorgans (1 2 cases), loss of
aspiration
was
gas (4 cases), material (15
curative
and
with
intnaabdominal 30% in treated
intraabdominal
abscess
abscess patients are
is [1].
severely
ill
and the performance of diagnostic procedures on them is often difficult. This is especially so in postoperative and obese subjects. A test that is simple to undertake under all circumstances Before several with tions
appeared
cases) (fig. 2B). Thickening of fascial planes was noted in 1 5 cases (fig. 3). Needle aspiration biopsy under CT control was performed on four occasions (cases 2, 9, 1 2, 1 5). In one
patients
in untreated as high as
and
that
can
be performed
rapidly
is clearly
advantageous.
in three
(5 cases) and at other sites with one or more areas of
attenuation within cluded displacement tissue planes enhancement
sub-
abscess
abdominal
graft. There were two appendiceal abscesses instances the lesion was in the pelvis.
right
mortality 00% and
no
and early inconclusive
during the ultrasound
suspected abdominal were often difficult
operative
patients,
difficulty
in distinguishing
and
abscess. to obtain free
loops from abscess Very few of our patients
quickly detailed ning
acutely and
ill and gave
anatomic operative
satisfactorily several other
the
reliable procedures.
completed limitations
ill. We also
peritoneal
we had patients
fluid
experienced and
fluid
[2]. had
gallium
scans
because
CT
studies
could
be performed
results.
information
study, in
Satisfactory examinain obese subjects, post-
the severely
bowel
were
course of this examinations
In addition,
useful Gallium
in less than in the diagnosis
CT
to the surgeon scanning 24 hr [3] of abscess,
in
most provided in plan-
cannot
be
and has includ-
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AJR:133,
December
CT
1979
Fig. 3.-Case 1 1 : small peniappendiceal administered pen rectum. B, 7.5 cm below
ing
a significant
negative
incidence
diagnoses
More
rapid
newer
OF
abscess in obese patient. A, Abscess fig. 3A. No mass is seen at this level,
of both
false-positive
and
scanning
CT units
as the
distinguish
and
provide
reconstruction
better
administration bowel
mented.
images
times
and
would have but considerable
been
confused thickening
with loop of fascial
of colon planes.
had
contrast
material
not
been
false-
of additional
loops
from
Interventional
CT
can
procedures
studies can procedure can in technique, material
be quickly
can
Radiation
exposure
the
examina-
contrast
abscess,
with
faster
to
imple-
be conveniently
performed at the same examination. For all these we now recommend CT as the primary diagnostic for suspected abscess in preference to ultrasound scanning.
1093
ABSCESSES
[4-7].
tions than previously. Consistently satisfactory now be obtained in severely ill patients. The be monitored image by image. Adjustments such
INTRAABDOMINAL
is associated
reasons, method on gallium
with
the
proce-
dune, but is no more than that obtained from the average barium examination. However, we do not recommend CT as the initial procedure for young children on for suspected pelvic lesions in women of child beaning age. Of the three procedures, CT is the least time-consuming procedure patient
at our
hospital.
is comparable
The
to that
cost
of a gallium
of a CT
scan.
saving may be achieved by reduction and avoidance of additional procedures confidence The CT abscess areas viscus
in the finding
of soft
tissue
of low attenuation [8-i such as liven on kidney,
0]. When an area
A sign
vicinity. supporting
one
on more
the
confined to a solid of diminished atten-
us
tumor. Left attenuation
(fig.
search
we
have
renal area.
found
of an often extended Demonstration
diagnosis
This
lesion to
that
the
thickening.
intnaabdominal
with
Wilms low
defined
mass,
has 3B).
for small, missed
on
low
consistently
attenuation
be
initial
inspection
with fluid-filled loops of bowel. sign is not specific for abscess,
of
confused
crosis
or into
have
a similar
attenuation
within
also be seen with intraabdominal hemorrhage infiltration. Inappropriate gas within the lesion
appearance.
In general,
an abscess cleanly
are
defined
the
of lower
areas
of low
density
and
signs
organs
by
have
smoothen,
more
of the
abscess lesion
This
ports
the
exhibited
margins.
At times, however, the distinction neoplasm may be impossible from tional
may
include and
loss
between the images displacement
of soft
tissue
abscess alone. of
and Addi-
adjacent
planes
in its
a history gas may wound. Finally,
diagnosis this
sign,
of abscess. however,
of recent abdominal enter the lesion from contrast
enhancement
in
four
in three
surgery. the exterior of
the
might
images
however,
Only
and
which the
effect may be and/or ne-
occurs
of which
helpful
masses
easily
alone may be found, although mass [1 1 ]. Tumors undergoing degeneration hemorrhage
pant
abscess is fascial plane to sections well beyond of this sign has alerted
uation present
which
lange
cost
in management time because of the high
density
4.-Haemorrhagic of fairly well
to the
At times,
CT diagnosis of abscess. most suggestive of an
is a mass
scan
Fig. consists
or
as it may on neoplastic strongly sup-
of our
patients
of these
there
In some through
instances a surgical
periphery
was
of
the
Downloaded from www.ajronline.org by 36.1.205.220 on 11/03/15 from IP address 36.1.205.220. Copyright ARRS. For personal use only; all rights reserved
1094
WOLVERSON
Fig. 5.-Case
16: Salmonella
rectum. B, Subsequent diagnosed. C, 1 week
examinaton. after rectal
of abscess.
have
lesion
All locules
after
the
pelvic abscess. Renal Three low attenuation drainage of abscess.
been
evacuated.
intravenous
Note
AL.
material
in locule
of iodinated
con-
that
has
drained
in
from
clinical
simple curate
seen with neoplasm. The single false-positive
and image examinations
fever most
was
in a child
with
and an abdominal mass. An abscess was thought the likely diagnosis at CT. At surgery, it was found that a
Wilms’
had
tumor
hemorrhaged,
resulting
in a hematoma
(case
1 6).
cemia 1 year glomerulonephnitis. pelvis were filled rectum, 5A).
The
This
after
patient
receiving Several
developed
noted and were mistakenly as the patient was known
patient
refused
the
that would diagnosis
abscess
at
months CT sound
was later
(fig.
scanning and
inal abscess. and severely images
made
subsequent
of rectal
CT
can
of
the
assists
considerable
scanning
in the diagnosis
is an advantage
over
We thank
error pelvic
when
quick
allow faster, procedures
be undertaken images
in the
The
planning
of
the
of operative of
controlled diagnosis
examination. intraabdominal
procedures
operative
is
and acFast scan
more for
at the same
obtained
method
is sensitive abscess.
and
on conservative
Jean
Hutson
for assisting
in manuscript
preparation.
2’/2
REFERENCES 1
ultra-
.
Ariel
2. Taylor sound
of intraabdom-
in postoperative, wide acceptance
made.
contrast this
examination
advantages
be
ACKNOWLEDGMENT
IM,
Kazarian
Abscesses.
It is of particular value ill patients, and the
by clinicians
chronic in the
SB). has
gallium
for areas
have prevented of a multiloculated
therapy
in determining the adequacy treatment at followup studies.
interpreted as fluidto have diarrhea (fig.
installation
material, a procedure in interpretation. The
to
septi-
Salmonella
a renal transplant low attenuation
need
reconstruction times and interventive
detail
contents
about three times the size of the solid part of the mass (fig. 4). The initially false-negative case was due to observer error
The
1979
in pelvis misintenpreted as fluid-filled material. Multiloculated abscess was after suprapubic operative drainage
to perform on all subjects and in the diagnosis of intraabdominal
and/on
December
rectum.
management
trast material may assist in the recognition of an abscess [1 2]. Again, this sign is not specific for abscess as it may be diagnosis
AJR:133,
transplant 1 year earlier. A, Rounded low attenuation areas deep areas in pelvis did not opacify after instillation of rectal contrast Only night posterior locule of lesion has been drained. D, 1 week
contrast
administration
ET
obese, of CT decisions
KJW, and
Korobkin
Diagnosis
M,
Sullivan
Callen
and
Williams
PW,
Treatment
& Wilkins,
DC, Wasson
gallium for Gastrointest
abscesses. 3.
KK:
Baltimore,
JFMcI,
of Abdominal
1971
Rosenfield
the diagnosis of abdominal Radiol 3 : 281 -286, 1978 Filly
RA,
Hotter
PB,
Kressel HY: Comparison of computed tomography, raphy and gallium-67 scanning in the evaluation
AT: Ultraand
Shimshak
pelvic AR,
ultrasonogof suspected
AJR:133,
December
1979
CT
OF
INTRAABDOMINAL
abdominal abscess. Radiology 1 29 : 89-93, 1978 Hauser MF, Alderson P0: Gallium-67 imaging in abdominal disease. Semin NucI Med 8 : 251 -270, 1978 5. Tedesco FJ, Coleman RD, Siegel BA: Gallium citrate Ga67 accumulation in pseudomembraneous colitis. JAMA 235 : 5960, 1976 6. Forgacs P, Wahner HW, Keys TF, Van Scoy RE: Gallium scanning for the detection of abdominal abscesses. Am J Med
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EV, McCartney WH: Role of gallium-67 disease. Semin Nucl Med 8: 21 9-234, 1978
in inflammatory
8. Haaga JA, Alfidi RJ, Havrilla TA, Cooperman AM, Seidelmann FE, Reich NE, Weinstein AJ, Meaney TF: CT detection and
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1095
aspiration of abdominal abscesses. AJR 1 28 : 465-474, 1977 Aronberg DJ, Stanley RJ, Levitt AG, Sagel S: Evaluation of abdominal abscess with computed tomography. J Comput Assist Tomogr 2 :384-387, 1978 1 0. Chiu LC, Schapiro AL, Yiu VS: Abdominal abscess I. Computed tomographic appearance, differential diagnosis and pitfalls in diagnosis. J Comput Assist Tomogr 2 : 1 95-280, 1978 1 1 . Levitt AG, Sagel SS, Stanley RJ, Jost RG: Accuracy of cornputed tomography of the liver and biliary tract. Radiology 124: 123-128, 1977 1 2. Gerzof SG, Robbins AH, Birkett DH: Computed tomography in the diagnosis and management of abdominal abscesses. Gastrointest Radiol 3:287-294, 1978 9.
