Retroperitoneal space abscesses are unusual clinical problems encountered by general surgeons, internists, and surgical subspecialists. An insidious, occult illness marked by diagnostic delay, inadequate drainage, and considerable morbidity and mortality is common. Anatomic reviews detailing the complex extraperitoneal spaces have been published, but less attention has been focused on diagnostic and drainage techniques useful to the practicing surgeon. In a retrospective review of 50 extraperitoneal abscesses, attention was directed to clinical presentation, diagnosis, and therapy. On the average, 12.7 days were required to establish the diagnosis; 50% of patients suffered major complications. A strikingly high mortality was associated with positive blood cultures and persistent fever within 48 hours of drainage (75% and 71%, respectively). Computed tomography has greatly enhanced the diagnosis of extraperitoneal abscesses, and radiologic drainage in selected cases appears to be a useful initial approach. A simplified anatomic classification and treatment plan is proposed to facilitate comparison between clinical series.
A CT study of the abdomen was obtained using a GE 9800 scanner. The patient recalved oral contrast (i20 ml of i % oral diatnzoate sodium in two divided doses 1 hr before and immediately before the CT study) and IV contrast material (a 50-mI bolus of 60% diatrizoate meglumine), followed by a rapid IV drip of 30% diatrizoate meglurnine.The scan was interpreted as normal (Fig. iA). On admission, the patient's hematocrit was 49%; after IV fluids were given, it dropped to 44%. The patient was discharged to home care the following day and CT study using the same protocol as that described above showed an enlarged spleen, with layers of liquified and partially clotted subcapsular hematoma. Hemorrhagic ascites was noted around theliver (Fig. i B). The patient was managed without surgery and a repeat CT study 12 days later showed a mild increase in the quantity of subcapsular hemorrhagic fluid, but cornplete resolution of hemorrhagic ascites.The patient was discharged on the i 4th hospital day with instructions to limit strenuous physical activity. A further follow-up CT study obtained 1 month after he was discharged revealed persistence of a large subcapsular fluid collection, with resolution of high-density clotted blood and a thickened spienic capsule. The patient has since remaIned clinically well. On initial presentation, there may be a fracture of the spleen with minimal or no hemorrhage.
DiscussionA distinct fracture line there-
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