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9
lntraabdominal Abscess: Current Concepts in Radiologic Evaluation
Michael Richard
D. Halber,1 H. Daffner,
Carlisle William
S. Trought,
William and
Forty patients with suspected abdominal abscess had computed tomography (CT) and plain film examinations; 1 5 also had ultrasound study. CT was found to be the most consistently accurate examination, both for the detection of abscess and evaluation of its extent. Ultrasound was positive in a high percentage of cases in which it was used. Although plain films correctly suggested the presence of an abscess in over half the proven cases, confirmatory evidence from CT or ultrasound was often required to persuade clinicians of the presence of an abscess and to provide detailed information regarding its extent and configuration.
L. Morgan, M. Thompson, Reed P. Rice,
Melvyn
Korobkin
The 1 00%
mortality [1
rate
in untreated
2]. Therefore,
,
the presence armamentarium
of
and extent of for the evaluation
and interpretative expertise, pletion of the examination. positive contrast examinations and
upper
gastrointestinal
ultrasound [8, reports describe of different plain films
August 14, 29. 1979.
1978:
accepted
after
re-
All
authors:
is a Picker
Foundation
Department
of
Scholar.
Radiology,
Vet-
erans Administration Medical Center. and Duke University Medical Center, Durham, NC 27705. Address reprint requests to M. D. Halber at VA. AJR 133:9-13,JuIy © 1979 American 0361 -803X/79/
1979 Roentgen 1331-0009
Ray Society $00.00
an intraabdominal of abscess varies
patient Imaging such series;
[7-9, 13, sophisticated
both
as for
discomfort, and time required for the comstudies available include plain films [3]; as intravenous urography, barium enema, arteriography
21].
be as high
diagnosis
abscess. The radiologist’s in cost, complexity, technical
[4];
10-15]; and computed tomography the virtues of these methods; a few
methods and more
may
an early
A still methods
gallium-67
scanning
[5-9];
(CT) [9, 13, 15-20]. reports compare the
Many results
smaller number of reports describe in the evaluation of abscess [13,
report compares the of patients considered
Subjects
and
Between department
March 1 977 and December 1 978, 40 patients were referred to the radiology for CT examinations to rule out intraabdominal abscess. All patients were a General Electric Model 7800 CT/T body scanner with a scanning time of 4.8 With one exception, all patients received 240 ml of dilute diatrizoate orally
sec/slice. (Gastrografin,
C. L. Morgan
abscesses
to establish
21]. This evaluation
studied Received vision March
intraabdominal
it is imperative
on
results of plain films, to have intraabdominal
CT,
and ultrasound abscesses.
in the
Methods
Squibb).
All
patients
with
suspected
liver,
pancreatic,
or
renal
abscesses
also received a 1 00 ml intravenous bolus of 60% diatrizoate (Renografin-60, Squibb). CT was considered positive if at least two of the following criteria were met: (1 ) a mass distinct from bowel (fig. 1 ); (2) an area of low attenuation (density) that did not enhance centrally but occasionally enhanced peripherally after intravenous injection of contrast material (fig. 2); and (3) gas within the mass (figs. 1 and 2). Of the 40 patients in this series only 15 had ultrasound examinations. The smaller number of ultrasound examinations was due in part to the greater inexperience with this
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10
Low
HALBER
Fig. 1 .-Left upper density mass (m)
quadrant abscess. in left upper quadrant
CT scan after with air-fluid
total level.
ET
AL.
AJR:133,
July
1979
gastrectomy.
Fig. (arrows)
3.-Pancreatic with typical
kidney (k). Immature in similar sonographic
patients
signs the
abscess. ultrasonic or infected appearance.
and
Prone longitudinal ultrasonic scan. characteristics of abscess anterior pseudocyst or hematoma could also
symptoms
review
of
plain
film
whose
CT examination
was
examination
discovered. was
suggested
A
Mass to left result
retrospective
on all patients
performed
an abscess.
Results CT
correctly
identified
24
and correctly suggested the 1 5 cases table 1 . A region
area
Fig. 2.-Hepatic abscess. where CT number was
CT scan 1 2. Air-fluid
in identification mode. levels in liver.
Arrow
indicates
method on the part of two authors (M. H., R. D.). In addition, a number of patients had ileus with large amounts of intestinal gas on plain abdominal radiographs, and it was felt that CT would be a more optimal evaluation for these patients. All ultrasound examinations with one exception were performed on a Picker model 801 gray scale unit. The following findings were felt to be compatible with an abscess by ultrasound: (1 ) mass lesion distinct from normal intraabdominal, retroperitoneal, or intrapelvic structures (fig. 3) and/or (2) a mass with the sonographic characteristics of aircontaining abscess which have been described in the literature [8, 10, 15, 22]. All patients in the series had routine radiographs ofthe abdomen. These usually, but not always, consisted of supine and some type of horizontal beam film-upright anteroposterior, cross-table lateral, or lateral decubitus. Diagnostic criteria used to suggest the presence of an abscess were: (1) loculated extraluminal gas (fig. 4A) and/or (2) a mass or mass effect on normal intraabdominal, intrapelvic, or retroperitoneal structures (fig. 4B) The accuracy of the imaging methods described is based on the results reported at the time each examination was performed. An abscess was concidered present only if proven surgically. An abscess was considered absent if the patient spontaneously recovered without surgery or antibiotic therapy, or if another cause for the
of the
25
proven
abscesses
absence of an abscess in 1 3 of of abnormally low attenuation
value was found in all 24 abscesses detected by CT. Attenuation values were 8-1 5 U (based on a scale of -500 for air, 0 for water, and + 500 for dense bone). After intravenous injection of contrast material, a rim of increased attenuation value (fig. 4C) surrounding the abscess was detected in five of the patients. Gas was seen in the abscess patients, and was freely moveable on decubitus of the patient (fig. A false positive
5). diagnosis
of abscess
was
in 1 4 of the positioning made
by CT in
two cases. In one, the pancreas was diffusely enlarged and irregular in contour, with an abnormally low attenuation value. However, a focal mass was not defined and gas was not seen in the pancreas. A pancreatic phlegmon without abscess
was
found
at surgery
(fig.
6).
positive case was performed early in occurred because we did not use oral fluid and gas content of the stomach preted as abscess. Reexamination with dium showed no evidence of abscess. cussed tive
in detail
CT examination
abscess. appreciated this case.
report
occurred
[23].
The
in a patient
Some bubbles of gas only on retrospective
Plain films in 13 of the patients,
in another
The
second
false
our experience; it contrast agent and were initially interoral contrast meThis patient is disone with
within the evaluation
false
nega-
a pancreatic
pancreas were of the scans in
correctly predicted the presence of an abscess 25 patients. Extraluminal gas was seen in 10
a mass
or mass
effect
in seven
patients,
and
both
Downloaded from www.ajronline.org by NYU Langone Med Ctr-Sch of Med on 06/01/15 from IP address 128.122.253.212. Copyright ARRS. For personal use only; all rights reserved
AJR:133.
July
INTRAABDOMINAL
1979
11
ABSCESS
.s
,.
.
Fig. 4.-Pelvic abscess. A, Mottled gas densities bladder (B). B, Excretory urogram. Mass effect on pelvis. Enhanced rim surrounds low density mass, of bowel (arrows) floating in abscess.
in mass bladder. air-fluid
(M)
depressing
c, CT scan of level,
and
loop
extraluminal gas and a mass effect in three patients. When the plain films were reexamined with knowledge of the CT results, findings compatible with an abscess were found in three
additional
normal
patients.
or having
1 3 of the abscess.
no findings
1 5 patients Two patients
positive. Of the 40 patients examinations. One of inadequate technically results. In the patients identified
eight
The
plain
films
compatible
subsequently had plain
were
interpreted
with
an abscess
in this series, 1 5 had ultrasound these examinations was felt to be and is not used in compiling our with ultrasound study, it correctly
of 10 abscesses
and
correctly
predicted
.
in
determined to have no films incorrectly called
absence of an abscess in all four used. There were no false positive tions.
rS
as
‘;
-
L C
TABLE
of CT, Plain
Films,
1
and Ultrasound
Discussion
Diagnosis
radiologic with plain
include
both
evaluation radiographs
vertical
and
of intraabdominal of the abdomen. horizontal
beam
abscess These films.
often should
They
are
easy to obtain for the patient and technologist, are of little discomfort to the patient, and are readily available. Predicting the presence of an abscess by plain films in a patient with gas in the flank, overlying the liver in the right upper quadrant, or in the lesser sac is little However, frequently the plain film are
subtle.
These
gas bubbles that guish from small they may consist
may
consist
diagnostic findings
of only
may be difficult if not intestine or colonic of subtle obliteration
a small
challenge. of an abscess collection
Examinations of Abscess
Method Absent
Present
CT: Positive Negative Plain film: Positive Negative Ultrasound: Positive Negative
24 1
2 13
13 12
13
2
8 2
0 4
of
impossible to distincontents. Likewise, of a portion of the
of plain Masters
abdominal films has been [3]. Review of our plain
psoas margin or displacement of the kidney or other intraabdominal organs. The presence of an ileus or abdominal
sound tional
dressings interpretative
abscesses
in a surgical difficulty.
S
S
the
cases in which it was ultrasound interpreta-
Results
The begins
SSSSS,
Le,;.. -=
-‘4
;
:
-s,
patient may further compound the The importance of careful scrutiny
results cases
scess.
were known demonstrating
However, had
in our plain
films
emphasized films after
allowed findings series that
nine were
by Rice and CT and ultra-
detection of three addisuggestive of an abpatients felt
with
to be normal
proven even
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12
HALBER
ET AL.
AJR:133,
open ness
wounds, abdominal may prevent optimal
be more
1979
Fig. 5.-Hepatic scan. Shift of air-fluid tioning of patient. A,
abscess on CT levels on reposiPatient supine. B,
Left
position.
lateral
decubitus
dressings, examination.
of a theoretical
a tendency push bowel
July
limitation
and
abdominal However,
because
tenderileus may
abscesses
have
to gravitate toward the body wall. They tend to and abdominal contents to the side and may
allow examination correctly identified
of the patients. an abscess
in
In our eight
series ultrasound of 1 0 cases.
In
addition to its diagnostic benefit, ultrasound may also be used as a guide for percutaneous drainage of an abscess [24]. Computed tomography is of proven benefit in both the diagnosis 1 7-20,
25].
and
drainage
of
CT
treatment can also
abdominal
of abdominal abscesses [7, be used to guide percutaneous abscesses
[1 8].
and interpretation of CT is not hampered or abdominal dressings. The examination and noninvasive except when intravenous
Fig. pancreas presence
with
6.-Pancreatic necrosis on CT scan. Diffusely enlarged, with indistinct margins and mottled density. Lack of focal of gas differentiates this from abscess.
knowledge Despite the
of the CT examination presence of positive
results. findings on
further evaluation is often necessary. our study, the clinician required further diagnosis, suggestive
even
in the presence
of abscess.
of plain
In addition,
abscess may not be sufficient is to be undertaken, knowledge abscess may be useful for adequate drainage. is particularly patient. A good technical
desirable
the
irregular mass or
plain
films,
diagnosis.
ultrasonic
strongly
diagnosis
surgical surgical
in
critically
ill
requires of
noninfected
CT or ultrasound. minimal obliteration
findings
the best directed
presence
or
film
to plan A highly
examination The
Infected
tissue, chronic hematomas, be difficult, if not impossible,
of an
approach approach
postoperative
to detect, abscess.
phrosis
considerable
postoperative
ileus,
and if seen Demonstration
[5].
examination,
On
must
are certainly of a peripheral
for an structures, plain
or intestinal
Findings
pseudocysts,
films,
material be and
necrotic
and other fluid collections to distinguish from abscess
Subtle shift in the axis of the left psoas margin
CT is not specific tumors, normal stool
expertise.
is used. It had the highest accuracy rate of the that we used for the diagnosis of abscess. for diagnosis of an abscess by plain film,
For several cases in imaging proof of the mere
performance
by wounds, ileus, is fast, accurate, injection of con-
ultrasound, and CT are reliable in the appropriate clinical setting. However, other entities may have a similar appearance and at times should be considered in the differential
for optimal therapy. If surgery of the precise extent of the
the
trast material three methods The criteria
The
15,
of the kidney or may be difficult
not specific enhancing
abscess; it may pseudocysts, than
sensibly
correlated
laboratory
findings.
gas
gas within with
for rim
an by
also be seen in and hydrone-
mottled-appearing rather
may by
may
be
an abscess.
clinical
history,
AJR:133,
July
INTRAABDOMINAL
1979
ACKNOWLEDGMENTS
13
ABSCESS
1 2.
Laing
FC,
Jacobs
AP:
Downloaded from www.ajronline.org by NYU Langone Med Ctr-Sch of Med on 06/01/15 from IP address 128.122.253.212. Copyright ARRS. For personal use only; all rights reserved
of retroperitoneal We
thank
Hazel
Underwood
and
Robin
Copley
for
secretarial
172,
assistance.
1
2.
.
4.
Rice
Baltimore,
RP,
genol
8:365-374,
Miller
FJ
Jr,
Williams
& Wilkins,
SJ: lntraabdominal
Masters
ONeil
MJ,
in splenic
abscess.
Arch
1976
5. Gerzof SG, Pugatch RD, Robbins AH, Ricks MD: Nonspecificity of peripheral enhancement (the rim sign) and CT of abdominal masses. Presented at the International Symposium and Course on Computed Tomography, Miami Beach, Fla. , March 1978 6. Hopkins GB, Kan M, Christian WM: Early 67Ga scintigraphy for the localization of abdominal abscesses. J Nuc! Med 1 6 : 990992,
M, Callen
Ressel
HY:
Comparison
Filly RA, Hoffer PB, Shimshak AR, of computed tomography, ultrasonscanning in abscess. Radiology 129:
ography, and gallium-67 89-93, 1978 Kumar B, Alderson P0, Geisse G: The role of Ga-67 citrate imaging and diagnostic ultrasound in patients with suspected abdominal
abscesses.
9. Taylor KJW, of ultrasound Roentgen
Doust
Ray
BD,
abscesses
of Surg
Society,
Quiroz from
125:213-21
Friday
RO,
J Nucl
Med
18:534-537,
1 8.
Barriga
intra-abdominal 110:335-342,
Boston,
September
F, Stewart
other
JM:
intra-abdominal
1977
Ultrasonic fluid
collections.
P, Crummy abscesses 1975
20.
by
Detection diagnostic
and
localization
ultrasound.
Arch
tomography.
Radio!
NG, TA,
Reich
NE,
Seidelmann
Beven FE,
E, Kramer
Namba
AH,
Cook
AJ,
Haaga
JA,
Havrilla
of the
JR,
Alfidi
AJ,
TA,
AJR
liver.
Levitt
AG,
puted
tomography
Sagel
Pepe
TA,
C/in
Stanley
of the
liver
AM,
TA:
AJR
RJ,
Jost
and
biliary
SA:
A, WeinParrish
CM:
report
of
Computed
1976
Cooperman
AJ, Meaney abscesses.
55,
AG,
1 27 : 69-74,
Havrilla
NE, Weinstein of abdominal
Seidelmann
CT detection
and
128:465-474, AG:
1977
Accuracy
of com-
Radiology
1 24:
tomographic
eval-
tract.
1977
RJ, Sagel ofthe
Daffner
55,
Levitt
pancreas.
RH, Halber Rice
abdominal
AP:
AG: Computed
Radiology
MD, Morgan
Computed
abscesses.
124:715-722,
CL, Trought
tomography Ann
Surg
1977
in the
WS, Thompson diagnosis
1 89 : 29-33,
of intra-
1979
Kressel HY, Filly AA: Ultrasonic appearance of gas containing abscesses in the abdomen. AJR 130:71-73, 1978 Daffner AD, Halber MD: Pitfall in the CT diagnosis of abdominal abscess: the full stomach. Comput Tomogr 3 : 33-36, 1979 Gr#{248}nvall J, Gronvall of fluid-containing techniques.
Radiol-
body
Alfidi
WM,
23.
Computed
infec-
127:433-439,
preliminary
Stanley .
ROEFO
cavity.
and
local
CT detection of infected synthetic grafts: a new sign. AJR 131 :317-320, 1978
uation 21
B: Sonographic
1976
Baldwin
123-128,
25. AB:
JR,
E: Sonographicinfections. AJR
of postoperative
peritoneal JR:
A, Havrilla
P, Vogel-Karl
diagnosis
14:563-570,
Haaga
1 9.
of
8, 1977
upper
Haaga
aspiration
24.
distinction
RJ,
RE, Reich
22.
1977
Sullivan D, Rosenfield AT, Simonds BD: The use and gallium for diagnosis of abdominal and pelvic Presented at the annual meeting of American
abscesses.
11.
PW,
of the
tomography
1975
7. Korobkin
ogy
1 7.
K, Eckert
roentgen
1977 Alfidi
stein
Surg
1 23 : 169-
1976 Scherer
tions
Haaga
SJ: Clinical
Schochat
SH,
NorthAm 1 6.
FJ,
findings
111:1156-1159,
10.
Vogel
Roent-
1973 Rothermel
and roentgenographic
8.
1 4.
1 5. Semin
in the detection Radiology
Schneider M, Becker JA, Stainano 5, Campos radiographic correlation of renal and perirenal
conventional
1971
abscess.
masses.
1 3.
Altemeir WA, Culbertson WR, Pullen WD, Shook CD: lntraabdominal abscesses. Am J Surg 1 25 : 70-79, 1973 Ariel IM, Kazarian KK: Diagnosis and Treatment of Abdominal Abscesses.
3.
of ultrasonography
1977
127:1007-1014,
REFERENCES
Value
inflammatory
Stanley body:
AJR
AJ, early 127:53-67,
5, Heged#{252}s V: Ultrasound-guided masses
AJR
129:997-1002,
Sagel
SS, Levitt
trends
using
in application 1976
angiographic
drainage catheterization
1977
AG: Computed and
accuracy
tomography of the
of the method.
9
lntraabdominal Abscess: Current Concepts in Radiologic Evaluation
Michael Richard
D. Halber,1 H. Daffner,
Carlisle William
S. Trought,
William and
Forty patients with suspected abdominal abscess had computed tomography (CT) and plain film examinations; 1 5 also had ultrasound study. CT was found to be the most consistently accurate examination, both for the detection of abscess and evaluation of its extent. Ultrasound was positive in a high percentage of cases in which it was used. Although plain films correctly suggested the presence of an abscess in over half the proven cases, confirmatory evidence from CT or ultrasound was often required to persuade clinicians of the presence of an abscess and to provide detailed information regarding its extent and configuration.
L. Morgan, M. Thompson, Reed P. Rice,
Melvyn
Korobkin
The 1 00%
mortality [1
rate
in untreated
2]. Therefore,
,
the presence armamentarium
of
and extent of for the evaluation
and interpretative expertise, pletion of the examination. positive contrast examinations and
upper
gastrointestinal
ultrasound [8, reports describe of different plain films
August 14, 29. 1979.
1978:
accepted
after
re-
All
authors:
is a Picker
Foundation
Department
of
Scholar.
Radiology,
Vet-
erans Administration Medical Center. and Duke University Medical Center, Durham, NC 27705. Address reprint requests to M. D. Halber at VA. AJR 133:9-13,JuIy © 1979 American 0361 -803X/79/
1979 Roentgen 1331-0009
Ray Society $00.00
an intraabdominal of abscess varies
patient Imaging such series;
[7-9, 13, sophisticated
both
as for
discomfort, and time required for the comstudies available include plain films [3]; as intravenous urography, barium enema, arteriography
21].
be as high
diagnosis
abscess. The radiologist’s in cost, complexity, technical
[4];
10-15]; and computed tomography the virtues of these methods; a few
methods and more
may
an early
A still methods
gallium-67
scanning
[5-9];
(CT) [9, 13, 15-20]. reports compare the
Many results
smaller number of reports describe in the evaluation of abscess [13,
report compares the of patients considered
Subjects
and
Between department
March 1 977 and December 1 978, 40 patients were referred to the radiology for CT examinations to rule out intraabdominal abscess. All patients were a General Electric Model 7800 CT/T body scanner with a scanning time of 4.8 With one exception, all patients received 240 ml of dilute diatrizoate orally
sec/slice. (Gastrografin,
C. L. Morgan
abscesses
to establish
21]. This evaluation
studied Received vision March
intraabdominal
it is imperative
on
results of plain films, to have intraabdominal
CT,
and ultrasound abscesses.
in the
Methods
Squibb).
All
patients
with
suspected
liver,
pancreatic,
or
renal
abscesses
also received a 1 00 ml intravenous bolus of 60% diatrizoate (Renografin-60, Squibb). CT was considered positive if at least two of the following criteria were met: (1 ) a mass distinct from bowel (fig. 1 ); (2) an area of low attenuation (density) that did not enhance centrally but occasionally enhanced peripherally after intravenous injection of contrast material (fig. 2); and (3) gas within the mass (figs. 1 and 2). Of the 40 patients in this series only 15 had ultrasound examinations. The smaller number of ultrasound examinations was due in part to the greater inexperience with this
Downloaded from www.ajronline.org by NYU Langone Med Ctr-Sch of Med on 06/01/15 from IP address 128.122.253.212. Copyright ARRS. For personal use only; all rights reserved
10
Low
HALBER
Fig. 1 .-Left upper density mass (m)
quadrant abscess. in left upper quadrant
CT scan after with air-fluid
total level.
ET
AL.
AJR:133,
July
1979
gastrectomy.
Fig. (arrows)
3.-Pancreatic with typical
kidney (k). Immature in similar sonographic
patients
signs the
abscess. ultrasonic or infected appearance.
and
Prone longitudinal ultrasonic scan. characteristics of abscess anterior pseudocyst or hematoma could also
symptoms
review
of
plain
film
whose
CT examination
was
examination
discovered. was
suggested
A
Mass to left result
retrospective
on all patients
performed
an abscess.
Results CT
correctly
identified
24
and correctly suggested the 1 5 cases table 1 . A region
area
Fig. 2.-Hepatic abscess. where CT number was
CT scan 1 2. Air-fluid
in identification mode. levels in liver.
Arrow
indicates
method on the part of two authors (M. H., R. D.). In addition, a number of patients had ileus with large amounts of intestinal gas on plain abdominal radiographs, and it was felt that CT would be a more optimal evaluation for these patients. All ultrasound examinations with one exception were performed on a Picker model 801 gray scale unit. The following findings were felt to be compatible with an abscess by ultrasound: (1 ) mass lesion distinct from normal intraabdominal, retroperitoneal, or intrapelvic structures (fig. 3) and/or (2) a mass with the sonographic characteristics of aircontaining abscess which have been described in the literature [8, 10, 15, 22]. All patients in the series had routine radiographs ofthe abdomen. These usually, but not always, consisted of supine and some type of horizontal beam film-upright anteroposterior, cross-table lateral, or lateral decubitus. Diagnostic criteria used to suggest the presence of an abscess were: (1) loculated extraluminal gas (fig. 4A) and/or (2) a mass or mass effect on normal intraabdominal, intrapelvic, or retroperitoneal structures (fig. 4B) The accuracy of the imaging methods described is based on the results reported at the time each examination was performed. An abscess was concidered present only if proven surgically. An abscess was considered absent if the patient spontaneously recovered without surgery or antibiotic therapy, or if another cause for the
of the
25
proven
abscesses
absence of an abscess in 1 3 of of abnormally low attenuation
value was found in all 24 abscesses detected by CT. Attenuation values were 8-1 5 U (based on a scale of -500 for air, 0 for water, and + 500 for dense bone). After intravenous injection of contrast material, a rim of increased attenuation value (fig. 4C) surrounding the abscess was detected in five of the patients. Gas was seen in the abscess patients, and was freely moveable on decubitus of the patient (fig. A false positive
5). diagnosis
of abscess
was
in 1 4 of the positioning made
by CT in
two cases. In one, the pancreas was diffusely enlarged and irregular in contour, with an abnormally low attenuation value. However, a focal mass was not defined and gas was not seen in the pancreas. A pancreatic phlegmon without abscess
was
found
at surgery
(fig.
6).
positive case was performed early in occurred because we did not use oral fluid and gas content of the stomach preted as abscess. Reexamination with dium showed no evidence of abscess. cussed tive
in detail
CT examination
abscess. appreciated this case.
report
occurred
[23].
The
in a patient
Some bubbles of gas only on retrospective
Plain films in 13 of the patients,
in another
The
second
false
our experience; it contrast agent and were initially interoral contrast meThis patient is disone with
within the evaluation
false
nega-
a pancreatic
pancreas were of the scans in
correctly predicted the presence of an abscess 25 patients. Extraluminal gas was seen in 10
a mass
or mass
effect
in seven
patients,
and
both
Downloaded from www.ajronline.org by NYU Langone Med Ctr-Sch of Med on 06/01/15 from IP address 128.122.253.212. Copyright ARRS. For personal use only; all rights reserved
AJR:133.
July
INTRAABDOMINAL
1979
11
ABSCESS
.s
,.
.
Fig. 4.-Pelvic abscess. A, Mottled gas densities bladder (B). B, Excretory urogram. Mass effect on pelvis. Enhanced rim surrounds low density mass, of bowel (arrows) floating in abscess.
in mass bladder. air-fluid
(M)
depressing
c, CT scan of level,
and
loop
extraluminal gas and a mass effect in three patients. When the plain films were reexamined with knowledge of the CT results, findings compatible with an abscess were found in three
additional
normal
patients.
or having
1 3 of the abscess.
no findings
1 5 patients Two patients
positive. Of the 40 patients examinations. One of inadequate technically results. In the patients identified
eight
The
plain
films
compatible
subsequently had plain
were
interpreted
with
an abscess
in this series, 1 5 had ultrasound these examinations was felt to be and is not used in compiling our with ultrasound study, it correctly
of 10 abscesses
and
correctly
predicted
.
in
determined to have no films incorrectly called
absence of an abscess in all four used. There were no false positive tions.
rS
as
‘;
-
L C
TABLE
of CT, Plain
Films,
1
and Ultrasound
Discussion
Diagnosis
radiologic with plain
include
both
evaluation radiographs
vertical
and
of intraabdominal of the abdomen. horizontal
beam
abscess These films.
often should
They
are
easy to obtain for the patient and technologist, are of little discomfort to the patient, and are readily available. Predicting the presence of an abscess by plain films in a patient with gas in the flank, overlying the liver in the right upper quadrant, or in the lesser sac is little However, frequently the plain film are
subtle.
These
gas bubbles that guish from small they may consist
may
consist
diagnostic findings
of only
may be difficult if not intestine or colonic of subtle obliteration
a small
challenge. of an abscess collection
Examinations of Abscess
Method Absent
Present
CT: Positive Negative Plain film: Positive Negative Ultrasound: Positive Negative
24 1
2 13
13 12
13
2
8 2
0 4
of
impossible to distincontents. Likewise, of a portion of the
of plain Masters
abdominal films has been [3]. Review of our plain
psoas margin or displacement of the kidney or other intraabdominal organs. The presence of an ileus or abdominal
sound tional
dressings interpretative
abscesses
in a surgical difficulty.
S
S
the
cases in which it was ultrasound interpreta-
Results
The begins
SSSSS,
Le,;.. -=
-‘4
;
:
-s,
patient may further compound the The importance of careful scrutiny
results cases
scess.
were known demonstrating
However, had
in our plain
films
emphasized films after
allowed findings series that
nine were
by Rice and CT and ultra-
detection of three addisuggestive of an abpatients felt
with
to be normal
proven even
Downloaded from www.ajronline.org by NYU Langone Med Ctr-Sch of Med on 06/01/15 from IP address 128.122.253.212. Copyright ARRS. For personal use only; all rights reserved
12
HALBER
ET AL.
AJR:133,
open ness
wounds, abdominal may prevent optimal
be more
1979
Fig. 5.-Hepatic scan. Shift of air-fluid tioning of patient. A,
abscess on CT levels on reposiPatient supine. B,
Left
position.
lateral
decubitus
dressings, examination.
of a theoretical
a tendency push bowel
July
limitation
and
abdominal However,
because
tenderileus may
abscesses
have
to gravitate toward the body wall. They tend to and abdominal contents to the side and may
allow examination correctly identified
of the patients. an abscess
in
In our eight
series ultrasound of 1 0 cases.
In
addition to its diagnostic benefit, ultrasound may also be used as a guide for percutaneous drainage of an abscess [24]. Computed tomography is of proven benefit in both the diagnosis 1 7-20,
25].
and
drainage
of
CT
treatment can also
abdominal
of abdominal abscesses [7, be used to guide percutaneous abscesses
[1 8].
and interpretation of CT is not hampered or abdominal dressings. The examination and noninvasive except when intravenous
Fig. pancreas presence
with
6.-Pancreatic necrosis on CT scan. Diffusely enlarged, with indistinct margins and mottled density. Lack of focal of gas differentiates this from abscess.
knowledge Despite the
of the CT examination presence of positive
results. findings on
further evaluation is often necessary. our study, the clinician required further diagnosis, suggestive
even
in the presence
of abscess.
of plain
In addition,
abscess may not be sufficient is to be undertaken, knowledge abscess may be useful for adequate drainage. is particularly patient. A good technical
desirable
the
irregular mass or
plain
films,
diagnosis.
ultrasonic
strongly
diagnosis
surgical surgical
in
critically
ill
requires of
noninfected
CT or ultrasound. minimal obliteration
findings
the best directed
presence
or
film
to plan A highly
examination The
Infected
tissue, chronic hematomas, be difficult, if not impossible,
of an
approach approach
postoperative
to detect, abscess.
phrosis
considerable
postoperative
ileus,
and if seen Demonstration
[5].
examination,
On
must
are certainly of a peripheral
for an structures, plain
or intestinal
Findings
pseudocysts,
films,
material be and
necrotic
and other fluid collections to distinguish from abscess
Subtle shift in the axis of the left psoas margin
CT is not specific tumors, normal stool
expertise.
is used. It had the highest accuracy rate of the that we used for the diagnosis of abscess. for diagnosis of an abscess by plain film,
For several cases in imaging proof of the mere
performance
by wounds, ileus, is fast, accurate, injection of con-
ultrasound, and CT are reliable in the appropriate clinical setting. However, other entities may have a similar appearance and at times should be considered in the differential
for optimal therapy. If surgery of the precise extent of the
the
trast material three methods The criteria
The
15,
of the kidney or may be difficult
not specific enhancing
abscess; it may pseudocysts, than
sensibly
correlated
laboratory
findings.
gas
gas within with
for rim
an by
also be seen in and hydrone-
mottled-appearing rather
may by
may
be
an abscess.
clinical
history,
AJR:133,
July
INTRAABDOMINAL
1979
ACKNOWLEDGMENTS
13
ABSCESS
1 2.
Laing
FC,
Jacobs
AP:
Downloaded from www.ajronline.org by NYU Langone Med Ctr-Sch of Med on 06/01/15 from IP address 128.122.253.212. Copyright ARRS. For personal use only; all rights reserved
of retroperitoneal We
thank
Hazel
Underwood
and
Robin
Copley
for
secretarial
172,
assistance.
1
2.
.
4.
Rice
Baltimore,
RP,
genol
8:365-374,
Miller
FJ
Jr,
Williams
& Wilkins,
SJ: lntraabdominal
Masters
ONeil
MJ,
in splenic
abscess.
Arch
1976
5. Gerzof SG, Pugatch RD, Robbins AH, Ricks MD: Nonspecificity of peripheral enhancement (the rim sign) and CT of abdominal masses. Presented at the International Symposium and Course on Computed Tomography, Miami Beach, Fla. , March 1978 6. Hopkins GB, Kan M, Christian WM: Early 67Ga scintigraphy for the localization of abdominal abscesses. J Nuc! Med 1 6 : 990992,
M, Callen
Ressel
HY:
Comparison
Filly RA, Hoffer PB, Shimshak AR, of computed tomography, ultrasonscanning in abscess. Radiology 129:
ography, and gallium-67 89-93, 1978 Kumar B, Alderson P0, Geisse G: The role of Ga-67 citrate imaging and diagnostic ultrasound in patients with suspected abdominal
abscesses.
9. Taylor KJW, of ultrasound Roentgen
Doust
Ray
BD,
abscesses
of Surg
Society,
Quiroz from
125:213-21
Friday
RO,
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Med
18:534-537,
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intra-abdominal 110:335-342,
Boston,
September
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other
JM:
intra-abdominal
1977
Ultrasonic fluid
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P, Crummy abscesses 1975
20.
by
Detection diagnostic
and
localization
ultrasound.
Arch
tomography.
Radio!
NG, TA,
Reich
NE,
Seidelmann
Beven FE,
E, Kramer
Namba
AH,
Cook
AJ,
Haaga
JA,
Havrilla
of the
JR,
Alfidi
AJ,
TA,
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liver.
Levitt
AG,
puted
tomography
Sagel
Pepe
TA,
C/in
Stanley
of the
liver
AM,
TA:
AJR
RJ,
Jost
and
biliary
SA:
A, WeinParrish
CM:
report
of
Computed
1976
Cooperman
AJ, Meaney abscesses.
55,
AG,
1 27 : 69-74,
Havrilla
NE, Weinstein of abdominal
Seidelmann
CT detection
and
128:465-474, AG:
1977
Accuracy
of com-
Radiology
1 24:
tomographic
eval-
tract.
1977
RJ, Sagel ofthe
Daffner
55,
Levitt
pancreas.
RH, Halber Rice
abdominal
AP:
AG: Computed
Radiology
MD, Morgan
Computed
abscesses.
124:715-722,
CL, Trought
tomography Ann
Surg
1977
in the
WS, Thompson diagnosis
1 89 : 29-33,
of intra-
1979
Kressel HY, Filly AA: Ultrasonic appearance of gas containing abscesses in the abdomen. AJR 130:71-73, 1978 Daffner AD, Halber MD: Pitfall in the CT diagnosis of abdominal abscess: the full stomach. Comput Tomogr 3 : 33-36, 1979 Gr#{248}nvall J, Gronvall of fluid-containing techniques.
Radiol-
body
Alfidi
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Computed
infec-
127:433-439,
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Stanley .
ROEFO
cavity.
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local
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uation 21
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1976
Baldwin
123-128,
25. AB:
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peritoneal JR:
A, Havrilla
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diagnosis
14:563-570,
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1 9.
of
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upper
Haaga
aspiration
24.
distinction
RJ,
RE, Reich
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1977
Sullivan D, Rosenfield AT, Simonds BD: The use and gallium for diagnosis of abdominal and pelvic Presented at the annual meeting of American
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11.
PW,
of the
tomography
1975
7. Korobkin
ogy
1 7.
K, Eckert
roentgen
1977 Alfidi
stein
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tions
Haaga
SJ: Clinical
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SH,
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Roent-
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Schneider M, Becker JA, Stainano 5, Campos radiographic correlation of renal and perirenal
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