Left Upper Quadrant Pain and Pyrexia in a 50-Year-Old Man

Anusuya Mokashi, MD; Dhana Rekha Selvaraj, MD, MBBS; Chandrasekar Palaniswamy, MD; Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR; Klaus L. Irion, MD, PhD

Disclosures

December 09, 2016

Empiric antibiotic therapy is the initial management in all patients with splenic abscess. In immunodeficient patients, the possibility of fungal and mycobacterial abscesses must also be considered. Therapy is switched to specific antibiotics once cultures and sensitivity reports are obtained. Although splenectomy is associated with a significant mortality rate and can compromise the immune status of a patient, surgical drainage and splenectomy have been the traditional treatment.

Ultrasonography-guided and CT-guided percutaneous aspiration and drainage procedures under antibiotic cover are being used increasingly often, with good success rates.[9,13] In a retrospective study of 39 patients with splenic abscess, the survival rates for splenectomy, open drainage, medical therapy, or percutaneous drainage were, respectively, 94%, 50%, 70%, and 100%.[3] An initial diagnostic aspiration is performed during percutaneous drainage to confirm the diagnosis, and the pus obtained is used for microbiologic assessment. Next, an 8F or 10F pigtail catheter is introduced using the trocar technique and placed in the abscess cavity. Clinical assessment and imaging for the residual abscess follows, and the catheter is removed once resolution is confirmed.

The usual drainage period is 7 to 14 days. Complications associated with percutaneous drainage of splenic abscesses include hemorrhage, pleural empyema, pneumothorax (transpleural catheterization), and fistula formation. Multilocular abscesses with thick septations and necrotic debris, phlegmonous, poorly defined cavities, and multiple collections are less amenable to percutaneous drainage and surgical management should be considered.[9]

Imaging-guided percutaneous aspiration and drainage under antibiotic cover should be considered if the topography and nature of the abscess allow. Surgery can be reserved for cases not amenable to percutaneous drainage and for cases in which catheter drainage has failed. Diagnostic aspiration, using either ultrasonography or CT scanning as a guide, is useful for establishing the diagnosis and for obtaining culture specimens (to guide the choice of antimicrobial therapy).

The patient in this case improved after treatment with broad-spectrum antibiotics, image-guided percutaneous aspiration, and subsequent placement of a drain in the abscess collection. The culture results of the aspiration yielded pansensitive E coli. He was switched to a more targeted antibiotic regimen and, after a follow-up ultrasound, showed resolution of the abscess collection. He was discharged home with the drain in place and with oral antibiotics. At follow-up 2 weeks after discharge, he was doing well and the drainage tube was removed.

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