Tag Archives: abscess

foley as improvised Word catheter for Bartholin’s abscess

10 Jan

can’t find a Word catheter to keep a Bartholin’s gland abscess open after an I&D?  try this nice MacGuyver move from a recent ACEP News article:

 

WHY DOES THIS MATTER?

“Bartholin glands normally secrete lubrication into the vaginal vestibule via small ducts, but if they become occluded, cyst and abscess formation may follow.”

“…likely to recur if we do not ensure that a new duct can form to allow the gland to drain normally.”

one common way is to leave a Word catheter in place for 2-4 weeks

 

WHAT WOULD MACGUYVER (or Dr. Fisher, article author) DO?

YOU NEED:

  • peds foley catheter (8 or 10 French)
  • hemostats
  • scissors
  • cyanoacrylate tissue adhesive (e.g. Dermabond)
  • PPD or insulin syringe
  • usual I&D kit

 

MAKE IT WORK:

  • I&D as usual
  • insert deflated foley into abscess cavity
  • inflate with 3-4mL saline/water
  • clamp foley with hemostat a few cm distal to baloon
  • cut catheter distal to clamp
  • draw up some Dermabond into insulin/PPD syringe
  • inject adhesive directly into balloon channel (smaller, non-central, not-for-urine) 
  • may need more than one round of adhesive
  • give it a few minutes, then remove hemostat
  • balloon can be deflated after 2-4 weeks by cutting the catheter again (include discharge instructions if the follow-up doc may be unfamiliar with these)

 

Sounds cool.  Nice to have options.

 

References: acepnews article; word pic; foley pic

 

 

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abscess packing after I & D?

28 Oct

2013 Peds Surg article:

N = 85, (43 packing, 42 non-packing)

excluded: diabetic/immunosuppressed, perianal or pilonidal, post-op abscess

everyone got I&D, 7 days oral abx (puts a damper on this data, a bit) warm soaks

two groups were not statistically different with respect to

  • recurrent abscesses (one in each group),
  • MRSA incidence (81.4% PG/85.7% NPG)

 

FROM AN OLD POST:

–prospective, randomized, single-blinded trial, N =48

  • no significant difference in need for a second intervention at the 48-hour follow-up
    • packed (4 of 23 subjects)
    • nonpacked (5 of 25 subjects)
    • (p = 0.72 (NOT SO GOOD))
  • higher pain scores immediately postprocedure in packed group and at 48 hours postprocedure
  • greater use of ibuprofen and oxycodone/acetaminophen in packed group 

 

PERIANAL ABSCESSES:
–“designed to show that perianal abscess may be safely treated by incision and drainage alone” vs. I&D + packing
–50 patients were recruited (7 lost to follow-up); 20 in the packing and 23 in the nonpacking arm

  • Mean healing times were similar ( P = 0.214).
  • The rate of abscess recurrence was similar ( P = 0.61).
  • Postoperative fistula rates were similar ( P = 0.38).
  • Pain scores at the first dressing change were similar ( P = 0.296).
  • Although pain scores appeared much reduced in the nonpacking arm, this did not attain statistical significance

 

BOTTOM LINE:

limited data out there on packing abscesses
–packing doesn’t seem to improve healing or reduce recurrence in limited studies, some with Abx
–packing might hurt more
might be ok NOT to pack abscess after I&D, but limited size studies limit the statistical significance.  small data is suggestive, though.

 

Reference(s): peds surg article;   ; previous post on abscess packing; picture

Perirectal abscess

10 Oct

from a 1995 Annals article by Marcus et al:

retrospective chart review, 92 patients with discharge dx of perirectal abscess

 

TAKEAWAYS:

Patients with perirectal abscesses often delay seeking medical attention.

Pain is almost always a presenting symptom (98.9% of cases)

  • Thus, in communicative patients, perirectal abscess is unlikely in the absence of pain.

External perianal and digital rectal examination identified an abscess in 94.6% of patients.

 

Missed diagnosis of a perirectal abscess is common. Perirectal abscesses are most commonly misdiagnosed as hemorrhoids.

The presence of severe pain, however, should suggest the possibility of a perirectal abscess.

Culture results indicate that aerobic and anaerobic bacteria from the skin, bowel, and, rarely, vagina are the causative agents…Mixed infections are common.

mainstay of treatment is I&D, usually in the OR; +/- antibiotics as adjunct therapy (WITH I&D), particularly for:

  • systemic symptoms,
  • immunocompromised,
  • heart valve abnormalities,
  • associated cellulitis or extensive abscesses.

 

Perirectal abscesses frequently recur, probably as a result of

  • fistula-in-ano formation (after incision and drainage),
  • underlying disease (eg, inflammatory bowel disease, hidradenitis suppurativa, immunocompromised state),
  • inadequate drainage (eg, missed abscess component).

 

Submitted by H. Reed-Day.

 

References: article; picture

Epidural Abscess (quick review)

5 Dec

Epidemiologyhttps://i1.wp.com/www.jaaos.org/content/12/3/155/F1.large.jpg

Relatively rare disease process, affecting 0.2-1.2 patients per 10,000 hospital admissions.

-Incidence has increased over the past 25 years

Causative Organisms

Staphylococcus aureus is present in up to 70% of cases

Steptococcus is the second most common, with a rate of about 7% of cases

Gram negative bacilli can be found in patients with Epidural Abscesses associated with IVDA

Mycobacterium tuberculosis

Factors that Predispose Patients to Epidural Abscesses

  • DM has a very high risk for forming epidural abscess
  • ESRD
  • HIV
  • Malignancy
  • IVDA
  • Indwelling catheter
  • Distant site of infection

Pathophysiology: Three primary methods for forming Epidural Abscess

Hematogenous spread from distant infection sites

  • skin and soft tissue is a common source but other sites can include infective endocarditis, respiratory infections, and genitourinary systems infections

Direct Extension

  • Usually originate from osteomyelitis of the spine but can also originate from paravertebral, retropharyngeal, or psoas abscesses.

Iatrogenic inoculation-

  • Some studies have shown rates as high as 14-22% of all epidural abscesses originate from spine surgeries or spinal procedures.

Clinical Manifestations/Exam Findings

  • Back/neck pain
  • Fever
  • Bowel/bladder dysfunction
  • Paresis/paraplegia (Up to 71% of patients have abnormal neurological exams on presentation)
  • Sepsis
  • Note: Classic triad of Back pain, fever, and neurologic deficit is present in only 8-37% of cases

Diagnosis:

  • ESR and CRP are best laboratory tests
  • WBC is less helpful than ESR and CRP
  • Blood cultures are positive in about 60% of cases, likely because most cases of Epidural Abscesses originate from sources outside of the vertebral canal
  • MRI with contrast is the study of choice
  • CT is less specific

Treatment

Emergent laminectomy, drainage of abscess, and appropriate antibiotic coverage

Prognosis

-Many studies have shown that preoperative neurologic status is the major prognostic factor

Submitted by J. Grover.

References: Cheng-Hsien L, et al. “Adult Spinal Epidural Abscess: Clinical Features and Prognostic Factors.” Clinical Neurology and Neurosurgery. September 2002. 104:4;306-310.  Tompkins M et al. “Spinal Epidural Abscess.” Journal of Emergency Medicine. September 2010. 39:3;384-390. Uptodate. Epidural Abscess; picture

Bartholin’s Gland Cyst/Abscess

26 Oct

Common in women of reproductive age, perimenopausal women should have cancer ruled out.

Pea size glands at the 4 and 8 O’Clock position, not normally palpable.

The purpose of the glands are to provide moisture for the vulva.

Duct obstruction causes cyst and abscess formation.

Usually a 2-4cm fluctuant mass on the labia.

 

Treatment includes I&D (gown/glove/mask recommended, for your own protection), catheter placement, and marsupialization.

  • For catheter, an elliptical incision is made along the vaginal mucosa with expression of pus.
  • Insert a Word catheter deep into the cavity, inflate the catheter balloon with saline.
  • If a Word catheter is not available, gauze can be used to pack the cavity.

 

Antibiotics, if indicated (controversial, as with many abscess/antibiotic discussions):

  • typically Keflex and/or Flagyl for polymicrobial vaginal flora
  • ceftriaxone/azithromycin for possible Neisseria/Chlamydia.

 

See OB in 2-7 days depending on severity.

 

Submitted by C. Stokes.

References: Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th Edition; Rosen’s Emergency Medicine. (2010); picture above; a less ‘safe for work’ photo illustration

Iliopsoas abscess: quick review

10 Jul

Iliopsoas abscesses are very rare, but the frequency of diagnosis has increased with increased use of CT.  This used to be more commonly a post-mortem diagnosis.

Risk factors include:

  • diabetes,
  • IV drug use,
  • HIV,
  • renal failure, 
  • other forms of immunosuppression

The abscess can also be secondary as a result of spread from local infection.

Risk factors for secondary abscesses include:

  • trauma,
  • instrumentation in the inguinal region, lumbar spine, or hip region.

Bony sites such as vertebrae are the most frequent contiguous infected site.  It has also been described in the setting of appendicitis, colorectal CA, ulcerative colitis, or following abdominal surgery.

They more commonly occur in males than females. Median age is 44-58 years old.

Signs and symptoms include:

  • back/flank pain, 
  • fever, 
  • inguinal mass, 
  • a limp, 
  • anorexia, 
  • weight loss.  
  • Pain with localization to the back, flank, or lower abdomen +/- radiation to the hip (present in 91% of cases)

Treatment includes drainage and antibiotics. 

Mortality approaches 100% if undiagnosed/untreated.

Submitted by W. Brooks.

Reference(s): uptodate.com: psoas abscess; picture