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Theabdomenasasourceofsepsisincriticallyillpatient
RonaldCMerrell,M.D.andRifatLatifi,M.D.
DepartmentofSurgery,VirginiaCommonwealthUniversity,Richmond,U.S.A.

Anatomyofintraabdominalsepsis

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Theabdomenmaybeimplicatedastheprimaryoccult,secondarydependentorsecondaryindependent
sourceofsepsis.
Insepticpatientstheabdomenmaybeimplicatedastheprimarybutinapparentsourceoftheproblem
(primaryoccult)secondarydependent,whentheinitialprocessbeganintheabdomen(postoperative
infection,perforation,anastomicleaketcetera)andsecondaryindependent,whenintraabdominal
organsustainaninsultfromsplanchnichypoperfusion(tableI).
TableI

Suspicionofabdomenassourceofsepsisin
criticallyillpatients.
Whenthereisnoclearcauseofclinicaldeteriorationinsepticpatient,orinapatientwithothermultiple
medicalproblems(pneumonia,cardiacdisease,diabetes,etcetera),theabdomenbecomesanatural
targetofsuspicion,investigation,andreasonforsurgicalconsultation.
Anatomicallyandbiologically,theabdomenisregardedasoneunit.Embryologicallyintraabdominal
organsdevelopfromforegut(stomach,liverandbiliarytree,spleen,pancreasandduodenum)midgut
(smallbowel,appendix,andrightcolon)andhindgut(leftcolonandrectum).Theperitoneumrepresent
andorgan,andcanbeinvolvedwithinfectiousorinflammatoryprocesses.Retroperitonealsolidorgans
andstructuresareoftenasourceofsepsis,whichrequirepromptidentificationandtreatment,if
significantmorbidityandmortalityistobeavoided.Consequently,thesepticpatientshouldbe
approachedinastepwisefashion,inordertoidentifythesepticsource.Dependingonthepatient'sage,
andotherconcomitantriskfactors,heartdisease,arrhythmia,pneumonia,urinarytractinfections,
vasculardisease,andmedicationhistory,eachsystemandorganshouldbeconsideredcarefully.
Gastrointestinaltractincludingliver,gallbladder,biliarytree,andpancreasarecommonsourcesof
sepsis.Urinarysystemwithkidney,bladderandprostate,andgynecologicpathologyarealsopossible
causesofsepticsourcesinpatientthatisrenderedseptic.Systematicapproach,accompaniedwith
biochemical,hematologicalandradiographicexamination,willidentifyoreliminateeachorganfrom
thesesystemsasasourceofsepsis.
Diagnosticapproachtopatientwithexpectedabdominalsepsis

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Expeditiousdiagnosisandtherapeuticresponsebyclearlydefinedalgorithmmayreducemortalityof
patientswithsuspectedsepsis.Trulyoccultsepsis(negativecultures,andnositeidentified)mayinfact
representafailuretoidentifyanintraabdominalsourceofbacterialorfungalinfection.
Incriticallyillandsepticpatientwithunknownsource,meningitis,purulentsinusitis,septicsuperficial
ordeepthrombophlebitis,woundinfectionsanddecubiti,perirectalabscesses,andischemicorinfarcted
limbsshouldbeexcluded.Oneshouldseekopportunitiesforastutediagnosisofsimpleconditions.
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Beforeproceeding,withexpensiveandcomplexinvestigationsoftheintraabdominalorgansasasource
ofsepsisincriticallyillpatients,afterurinaryandrespiratorytracthavebeenruleout,afewinfections
thataremorecommonshouldbeexcluded.Theseincludemeningitis,purulentsinusitis,septic
superficialordeepthrombophlebitis,woundinfectionsanddecubiti,perirectalabscessesorischemicand
infarctedlimbs.If,ontheotherhand,patientcontinuestohaveevidenceofSIRSorfullblownsepsis,
butnoobvioussourceofinfections,thantheabdomenbecomesasuspect,andoneneedtoproceedwith
theappropriateinvestigations(tableII).
TableII

Diagnosticapproachtocriticallyillwith
unknownsourceofsepsis.
Patientwithprimaryoccultabdominalpathology:Treatandsearch

Patientwithprimaryoccultpathologymayhaveacutecalculousoracalculouscholecystitis,cholangitis,
pancreatitis,appendicitis,diverticulitis,subphrenicabscess,retroperitonealabscess(perinephric,psoasor
pancreatic),sealedperforationofstomach,duodenum,gallbladderorcolon,andorbowelischemia.
Patients,whomanifestfullblownSIRSorevensepsis,maynotdemonstrateasourceofinfection
readily.Inthesepatients,thesearchforcauseofabdominalmanifestationscanbeverydifficult.These
patientsaretreatedandsupportedconcomitantlyandempiricallyforrespiratoryandcardiac
compromise.Theevaluationshouldbeexpeditious,wellfocusedandtheendpointsresuscitation
followedclosely.Responsetolifethreateningmanifestationsofinfectionsuchasshock,respiratory
failure,renalfailureorcardiovascularcollapseshouldbecriticallyevaluatedonaminutetominutebasis.
Thisistreatandsearchmode(tableII).
Physiologicsupport

Theclinicalanddiagnosticconcertofphysiologicsupportandtreatment:defineandfollowthe
physiologicendpointsofresuscitation.
Restorationandmaintenanceofoptimalorganperfusioniskeyfactorinbothminimizingtheinitial
ischemiainducedinjuryaswellasdecreasingthelateconsequencesofthestressresponse.Earlyand
latephysiologicendpointsshouldbeclearlydefined.Duringearlystressresponseorearlysepsis,
cardiacindex>4,wedge1216mmHg,O2deliveryandconsumption1.5timesnormalshouldbe
maintained,aswellastheaniongapshouldbenormalized.Yet,sincethereisnoconclusiveevidence
thattissueoxygenationdeptexistinpatientwithsepsis,andthereisnoevidencethatsupranormallevels
ofoxygenationaremoreeffectiveinreducingmorbidityandmortality(gradeCrecommendation),the
resuscitationshouldbeaimedathemodynamicstabilizationandtissueperfusionimprovement.General
perfusion,basedonbloodpressureandurineoutput,mayappearadequate,butimpairmentof
splanchnicperfusionmayexist.Gastrictonometrymeasurementsappearstobeausefulmarkerof
splanchnicperfusion.Persistentsplanchnichypoperfusion,asexpressedbylowgastricmucosalpH
(pH)andinabilitytocorrectgastricpHi,hasbeenassociatedwithincreasedmortalityanddevelopment
ofMOF,althoughlargescalerandomizedclinicaltrialswithhighlevelsofevidenceislacking.Useof
gastricpHiasatoolforresuscitationcurrentlycannotberecommended(gradeC).Maintainingarterial
O2saturation,volumeexpansionwithfluidorbloodandbloodproducts,andjudicioususeofinotropes,
aremethodstomaintainperfusion,whilethesearchforintraabdominalsepticfocusisunderway.
Identificationandcorrectionofbasiccellulardearrangementsisthepriorityinthesepatients.
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Adifficultpatient

Thesearchforsepticsourcemaybeverydifficultinapatient,whoisonarespirator,sedated,obtunded,
orparalyzedwithmedication.
Theremaybefewdetailsfromthehistory,fromthefamilyorfriends,andoftenthesepatientsdonot
havewelldocumentedmedicalhistoryinthechart.Worse,patientsisfoundin23powerful
vasopressorstomaintainbloodpressure,withseverelycompromisedliverorkidneyfunction,andnow
presentwithadistendedabdomen,andapictureofpossibleintraabdominalcatastrophe.Themost
seniormemberoftheconsultingteamshouldperformathoroughphysicalexamination,includingrectal
exam.
Reviewofchestxrays,urine,blood,sputum,andothercultures,aswellasreviewofthehemograms,
andallbiochemicalindicesavailable,shouldbethefirstphaseoftheevaluation,andwillidentifya
likelysourceingreaterthan85%ofpatients.WhenfacedwithapatientwhohasdevelopedSIRSwith
respiratoryfailureandapictureofadultrespiratorydistresssyndrome(ARDS),andwhohasfindingsof
positivebloodcultureforaputativeentericorganism,thentheabdomenbecomescertainlyalogical
suspectharboringthesepticfocus.Oftentimesthough,thisscenarioiscomplicatedinthepatientwhoin
additiontopositivebloodcultures,haspositivesputumculturesandradiographicevidenceof
pneumonia,yettheclinicalconglomerateiscomplicatedwithlacticacidosis,leukocytosis,failing
kidneysandworseningabdominalexam.
Diagnosticstudies(tableII)

Inacaseofpatientwithasepticpicturebutwithnoclearevidenceofintraabdominalinfection,one
shouldstartwiththeroutine3wayabdominalfilm,bearinginmindverylowyieldofthisdiagnostic
test.Inaseriesof143patientswithsurgicallyprovenabdominalabscess,abdominalfilmswereofvalue
inonly15%ofpatients.Duetolowlevelofassociatedclinicalconfidence,thisstudy,unlessit
demonstratesfreeairorintestinalobstruction,rarelyisthesolebasisuponwhichaclinicaldecisionfor
operationismade.Whilesomeauthorshavereportedupto50%levelofdiagnosticvalueforthisstudy,
theavailabilityofothertechniquesmakesthisstudylessfavorable(gradeC).
Ifthisstudyisofnodiagnosticvalue,thanoneshouldproceedwithultrasound(US)toexamliver,gall
bladder,biliarytree,pancreas,pelvis,andpelvicorgans.UShavehighsensitivityforliverandpelvic
pathology.TheuseofUSindiagnosingintraabdominalabscessesmayhaveanaccuracyexceeding
90%inexperiencedhands(gradeA,B).Itisportable,canbeperformedatbedsite,itisreproducible
andcanberepeatedeasily.Majordrawbacksareileus,obesityandinexperienceoftheoperator.
Dependingonthesuspectedpathology,aCTscanoftheabdomenwithoralandintravenouscontrast,
maybethenextstepinthediagnosticworkup,ifultrasoundnegativeornondiagnostic.
CholangitismaypresentwithCharcot'striad(rightupperquadrantpain,fever,andjaundice),or
Reynolds'spentad(Charcot'striadplusshockandmentalstatuschanges).
Ifacutecholecystitisisexpected,butUSisnotdiagnostic,oneshouldobtainamorphineinjectedHIDA
scanasthemostdefinitivestudytodiagnosecysticductocclusion(gradeA,B).
Inapatientwithpainoutofproportiontophysicalfindings,metabolicacidosis,leukocytosis,lactate
dehydrogenaseelevation,ischemiaofthebowelshouldbeveryhighonthelist.Intestinalvascular
catastrophes(arterialorvenous)willhavegraveconsequencesifnotidentifiedearlyandtreated
effectively.Because,evenasmallareaofnecrosismayprovefatalbecauseofprolongedobservation,a
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patientwithcorrectablepathologymaydieforalackofwelltimedandwellexecutedlaparotomy.
InthesepatientsaCTscanmay,ormaynotbeofdiagnosticvalue(gradeC).Asarule,aCTscanwill
demonstrateanileuspatternofthesmallbowel,andabowelwalledema(fig.1).Whenpneumatosis
intestinallyispresent,thisisalatesignofinfarctedbowel(fig.2).Whenischemiaoftheintestinesis
expected,inthefaceofnormalornondiagnosticCTscan,threevesselabdominalangiogramshouldbe
performed.
Figure1

ACTscanofa33yearoldfemalewho
sustainedamyocardialinfarction,forwhich
sheunderwentangiplastyandcoronarystent
placement.Fivedaysaftertheprocedure,she
wascomplainingofrightflankpainassociated
withabdominaldistention,and
increased(more...)
Figure2

Samepatient,twodayslater,nowinmultiple
organsystemfailure.ArepeatCTscan
demonstratesdiffuseairfluidlevelsofsmall
andlargebowel,withoutwallthickening,
findingsconsistentwithanileus.Onsurgical
exploration,twohoursafterthis(more...)
Increaseofpancreaticenzymesintherightclinicalsettingwilladdtosuspiciousanddiagnosisof
pancreatitis,whichcanbeconfirmedbyaCTscanorUS.Increasingly,aspiralCTisbecomingthe
preferredtechniqueforevaluatingthepancreas.CertainlyaCTscanisthepreferreddiagnosticmethod
fordiverticulitis,perinephricabscesses,orliverabscesses.
Insepticpatientswhoareimmunocompromised(highrisktrauma,severeburns,transplantpatients,
cancerpatientsundergoingchemotherapy,AIDSpatients,andthosewithdiabetes),diagnosticand
therapeuticapproachesmaynotbestraightforward.Theirpresentationmaybeatypical.
Inverycriticallyillpatients,thechoiceofdiagnosticstudyisverydifficult.Transferringthepatient
awayfromtheICUforaCTscanmaybeadangerousundertaken.Inthesesituationonecanutilize
otherstudiessuchasabdominalparacentesisordiagnosticperitoneallavage.AnegativeorpositiveDPL
ishelpful.AreturnfromDPLwilldifferentiatebloodfromtheascitesandfromaninflammatoryor
infectiousexudate.Thelavagewillalsodifferentiateprimaryfromthesecondaryperitonitis.Aspiration
offecalmaterial,bile,orbloodyfluidwillwarrantsurgicalexploration.Isolationofanaerobicflora,may
alsobeanindicationforlaparotomy.
Theusefulnessofendoscopyincriticallyillsepticpatientsdependsonthesuspectedorgan.AnERCP
maybediagnosticandtherapeuticforbiliaryandpancreaticdiseases,whilesigmoidoscopyor
colonoscopymaydiagnoseischemiccolitis,andshouldbeusedinappropriateclinicalsettings.
Mostnuclearstudieshavelimitedroleincriticallyillpatients,astheirarecumbersome,inconclusiveand
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expensive.
OtherthanHIDAscanthatisadiagnostictestofchoiceforacutecholecystitis(gradeA,B)andVQ
scanforpulmonaryembolus,mostnuclearstudieshavelimitedroleincriticallyillpatients,astheirare
forthemostpartcumbersome,inconclusiveandaddtomoreexpenses.Gallium67citrateis
concentratedinareasofinflammationthus,itisthoughtthatthisisotopescanmayhavepotentialvalue
indiagnosingevensmallabscesses.However,duetoconcentrationofgalliumintheareasof
inflammationaswellastheuptakeoftheisotopeinthepostoperativearea,falsepositivescansare
commonanddifficulttointerpret.Additionallyittakes48hoursfortheisotopetoconcentrate,and
requiresmechanicalbowelpreparationtoeliminatetheintraluminalbackground,thusmakingitless
desirableandpractical.
Theindium111labeledleukocytescanalthoughhasgreaterspecificityandimageresolutionthan
galliumscan,andisrelativelysimpletoperform,itisalsonotsuggestedtobeusedinpostoperative
patientduetoleukocyteaggregationinotherareasofinflammation(gradeC).
Incaseswhenstandardclinical,biochemicalandradiologicaldiagnosticstudiesareexosted,andthe
abdomenisstillsuspectbyexclusion,itisjustifiabletoexploretheabdomenasadiagnosticendeavorof
desperation.LaparoscopicdiagnosticexplorationinthesettingofICUmaybeamethodofchoice,
shorterofopentraditionalabdominalexploration,althoughtheevidenceisstilllacking(gradeC).Few
nonrandomized,caseseriesreportswithmixedgroupofpatientswithperitonitis,minimallyinvasive
diagnosticandtherapeutictechniquehavereportedfavorableresults,whiletheexperiencewithopen
approachhasmixedreports(gradeC).
Patientwithsecondarydependentpathology

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Patientswithsecondary,dependentpathologyisinpostoperativestate,treatedinICU,orreturntoICU
becauseofcomorbiddiseasesorforunexpectedclinicalorapruptdeclineandworsenSIRS.
Thismayfollowsurgeryuponahollowviscus,inwhichthepossibilityofanastomoticleakorabscess
shouldbeconsidered.Inofsuchpatients,nonabdominalsourcesofsepsissuchaspneumonia,urinary
tractinfections,bloodstreamlineinfections,evaluationshouldbedoneasoutlinedontablesIIandIII.
Precipitousreoperationintheabdomenmightnotbeappropriate,butshouldnotbedelayedeither,in
properclinicalsetting.Iftheabdomenisstilltheleadingcandidateafterexcludingotherpossibilities,the
imagingsequenceisinvoked.
TableIII

Diagnosticapproachtopostoperativepatient
withSIRS.
Watersolublecontraststudiesshouldbeusedforaccessibleanastomosisoftheesophagus,stomachand
rectumandlowercolon,whileuseofbariumisnotadvised.Endoscopy,onotherhandisnotadvocated
inassessmentoffreshanastomosis.Woundinfectionmaybeeasilymissedifpatientisnotexamined
carefully.AtriplecontrastCTscanordelayedrescansareusefultechniquesindiagnosinglowcolon
anastomicleak.
Inpatientwhoispostcholecystectomyorotherbiliaryorliversurgery,thepresentationofSIRS
mandatesexclusionofbiliarytreeleakorobstruction,whichcanbedonewithUS,HIDAscan,ERCP
orpercutaneoustranshepaticcholangiography(PTC).Theadvantagesoflattermodalitiesareinthe
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abilitytoprovidetherapeuticoptions.
Intestinalischemiamayrapidlyprogresstofullthicknessinfarction,anddramaticclinicaldeterioration.
Thismayhappenduetoobstructionorduringlowflowstateinacompromisedelderlypatient,dueto
arterialorvenousocclusion.Smallbowelischemiaornecrosisshouldbesuspectedinapatientswho
presentwithrapidclinicaldeterioration,whohashadrapidadvancementoftubefeeds,inthefaceof
inadequateresuscitation,suchastraumapatients.Ifintestinalischemiaissuspectedthanpatientshould
bepromptlyresuscitatedandoperatedupon.Angiographyshouldbeperformedinproperclinical
setting,andtheheartshouldbeexaminedforthesourceofemboli.Clinicalexaminationand
biochemicalresponsetoischemiaisparticularlyunreliableinelderlypatients.Measurementsof
splanchnicperfusion,withgastrictonometrymayhavesomediagnosticvalueinthesesettings.
Followingoperationforintestinalischemia,thesepatientsaregreatcandidatesforfurtherinfarctionand
plannedreexplorationmaybewarranted.
Patientwithsecondaryindependentpathology

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Acalculouscholecystitis,smallandlargebowelischemiawithorwithoutperforation,andpancreatitis,
arethemostcommonandlifethreateningcomplicationsinseverelyillpatientsrecoveringfromvariety
ofmedicalorsurgicalproceduresoutsidetheabdomen.Typically,thesepatientshavehadaprolonged
episodeofhypotensionduetomyocardialinfarctionorsepsisfromurinarytract,bloodstreamlinesepsis
orduringasurgicalproceduresuchascardiovascularsurgery.Patientswithcardiacarrhythmiaor
ventricleclotmayemitembolithatcaninfarctthebowel.Furthermore,hypotensionmaypermitt
thrombosisofacompromisedvascularbedintheintestinaltract.
Acutecholangitis

PatientwithcholangitismaypresentwithCharcot'striad(rightupperquadrantpain,fever,and
jaundice),orReynolds'spentad(Charcot'striadplusshockandmentalstatuschanges).Oncethe
diagnosisisestablished,mostpatientswillrespondtointravenoushydrationandantibiotics,allowing
nonemergentdecompressionofbiliarytract.If,howeverpatientfailstorespondtosuchmeasures,
endoscopicortranshepaticemergentdecompressionisindicated.Incaseofdifficultorprohibitive
anatomyorfailedERCP,anemergentopendecompressionofcommonbiletractisindicated,while
aggressiveresuscitationwithintravenousfluidandantibioticsisunderway,ifmortalityistobeavoided.
Factorsthatareassociatedwithpoorprognosisinpatientswithacutecholangitisare:oldage,female
sex,acuterenalfailure,acidosis,hyperbilirubinemia,hypoalbuminemia,cirrhosis,concomitantmedical
problems,malignantobstructionorthepresenceofliverabscesses.
Acuteacalculouscholecystitis

Acuteacalculouscholecystitis(AAC)isassociatedwithcomplicatedandemergentvascularsurgery.In
oneseriesofsurgeryforrupturedaneurysm,therewasa13.6%incidenceofAAC,whileinelective
AAArepairtheincidenceofAACis0.1%.AngiograficstudieshavedemonstratedthatAACis
characterizedbyarterialocclusionandabsentvenousfilling,whileinacutecalculouscholecystitisgall
bladderwallischaracterizedbyarterialdilatationandvenousfilling.
AACshowsastrikingpredilectiontooccurintraumaandburnpatients,withnearly90%ofpatients
whodevelopcholecystitishaveAAC.OthersettingwhereAACmaybeseenaremalignancyofthe
portahepatis,duringhepaticinfusionofchemotherapyandaftertherapywithinterleukin(IL)2and
lymphokineactivatedkillercellsformetastaticrenalcellcarcinoma.Otherconditionsassociatedwith
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AACmaybestentplacementforbiliaryobstruction,bonemarrowtransplantation,disseminated
Candidainfections,systemicleptospirosis,Salmonellainthebiliarytree,andinpatientswithdiabetes,
tuberculosis,AIDS,andpatientswithcytomegalovirusinfection,microsporidaandcryptosporidia.AAC
shouldalsobesuspectedincriticallyillpatientswhoaresupportedbyTPNandrendersepticwithno
otherobvioussource.
AlthoughAACisarelativelyrarecondition(0.19%ofallSICUpatients),nonetheless14%ofpatients
withacutecholecystitishaveAAC.PatientswithAAChaveveryhighmortality(41%).Inoneseries,
mostofcaseswithAAC(63%)occurredinpatientsrecoveringfrommajornonbiliaryoperationsand
52%(14/24patients)werecriticallyillthatweretreatedintheICU.
ThepresentingsymptomsofAACarenotspecific(abdominalpainin78%,rightupperquadrantpainin
56%,fever37%,leukocytosis70%).Of25patientswithAAC,20%hadnormalliverfunctiontest,
while64%hadelevatedbilirubin,40%alkalinephosphatase,40%alanineaminotransferaseand13%
aspartateaminotransferase.DelayindiagnosisofAACisalmostarule,andresultsingangrene(63%),
perforation(15%)orabscessformation(4%).
ThediagnosisofAACprincipallyshouldbemadebyHIDAscan,whichhasasensitivityofalmost
100%,buthasahighfalsepositivity,makingthistestimperfect.UShasaverylowsensitivityrate
(29%),whileCTscanhasasensitivityof67%.Thickenedgallbladderwall(>4mm),pericholecystic
fluid,subserosaledema,intramuralgas,sloughedmucosa,completelackofresponsetochoecystokinin
(CCK),andapositivesonographicMurphy'ssignaremajorradiographiccriteria.Thepresenceof
sludge,distentionsofthegallbladderandpartialresponsetoCCKareconsideredminorcriteria.
Acutepancreatitis

AcutepancreatitisisdiagnosedclinicallyandbyCTscanorUS.Itsmanagementmostlyisconservative
withnutrition,intravenousfluidsupportandantibiotic(whenappropriate)andisdiscussedextensively
elsewhereinthisbook.Forpatientwhoistreatedwithnonoperativetreatmentforpancreatitis,clinical
deteriorationmandatesaCTscanandevaluationfornecrosis,abscess,orinfectedpseudocyst.Inthese
casesCT,guidedaspirationbiopsyoftheperipancreaticfluidismandatory.Developmentsofa
sequestrumorinfectednecrosis,aswellasthepresenceofpancreaticabscessrequireopendrainageand
necrosectomy.Attemptsforpercutaneousaspirationoftheinfectionshouldbeavoided.
TraumapatientswithsepsisandMOF

Theincidenceofintraabdominalinfectionsfollowingtraumahasbeendecreasedsignificantlyinrecent
years,aswellasroleprecipitatingMOF.However,iftraumapatientsuponadmissionarehypotensive,
therateofinfectionmaybeashighas30%.Inaprospectivestudyof457patientswithmajortrauma
(ISS>15)intraabdominalabscessesoccurredinonly13patients,whileonlyin9patientsabscesswas
associatedwithMOF,althoughin3patientstheabscessdidnotappeartoplayaroleinthepathogenesis
ofMOF.Intraumapatientsthatbecomeseptic,amajormissedinjuryneedtobeexcludedprimarily,
whileothercausessuchasUTI,pneumonia,AACneedtobeinvestigatedaccordingly.Oneshouldbear
inmindwhentreatingwithantibioticstraumapatientswhohaveundergonemassiveresuscitationthat,
basedonexperimentaldata,theclearanceandthesteadystateofantibioticsisaltered,thusthe
magnitudeofdosingshouldbeadjusted.
Treatmentoptionsofintraabdominalpathologyincriticallyillpatients

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Traditionalapproach
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Theprincipletreatmentofintraabdominalsourceofsepsisincriticallyillpatientsiscontrolofthe
underlyingcauseofthesourceitself.Thus,theeffectivetreatmentofabdominalsepsisrequiressurgical
controloftheleakagefromthehollowviscus,removalofinfectedornecroticcontaminatedtissue,
drainageofthepusorreleaseoftheobstructedbiliarytree.Although,theseprinciplesofcontrolofthe
septicsourcebypromptextraperitonealdrainagehavenotchangedforcenturies,themeans,optimal
techniques,timingandcombinationofdifferentapproacheshasevolved.Nonetheless,mechanical
controlofthesepticsourceremainsthecornerstoneofthetherapy,althoughoccasionallyantibiotic
therapyandphysiologicsupportmayachievetemporarycontrolofcholecystitis,diverticulitisor
peritonitisrelatedtoperitonealdialysis.
Secondaryperitonitisisassociatedwithasignificantcytokinesreleasethatiscompartmentalizedinthe
peritonealcavity,andthemagnitudeofthisreleasereflectstheseverityoftheprocessandprognosis.
Theextentofanintraabdominalinfectiondeterminesthemagnitudeoftheperitonealresponse.In
criticallyillandsepticpatientsundergoingrelaparotomyforseveresecondaryperitonitisendotoxin,
tumornecrosisfactoralpha,interleukin1,interleukin6,elastase,andneopterinwerefoundsignificantly
higherintheperitonealcavitytheninplasma.Whenthesepatientsunderwentrelaparotomy,thelevelof
thesecytokineswasdecreasedsignificantlyinsurvivors.
Thislocaldecreaseofinflammatoryresponse,maybebestachievedwithmechanicalcontrolby
reducingtheloadofcytokinesandotherinflammatorysubstancesandbypreventingfurtherproduction
ofthem,thusremovingthesourceitself.Inabilitytocontrolordecreasesignificantlyorinterruptthe
localinflammatoryresponseisassociatedwithnonsurvivalofthesepatients.Successfulcontrolof
septicsourcereducesthebacterialloadandpreventsrecurrentinfections.Aprospective,open,
consecutivemulticenternonrandomizedtrialexamineddifferentmanagementtechniquesandoutcome
in239patientswithsevereperitonitisandAPACHEscore>10.Overall,mortalitywas32%.There
werenostatisticalsignificantdifferencesinmortalitybetweenclosedabdomentechniquesandthose
treatedwithvariationsofopenabdomentechnique.Patientswhounderwentplannedrelaparotomyhad
amortalityof42%(35/83patients),whilethosewhodidnotundergoplannedreoperationhada
mortalityrateof27%(42/156).Itisnotclearwhichpatientsneedtoundergoplannedrelaparotomy,and
whowillbenefitfromplannedrelaparotomy,sincethereisalackofprospectiverandomizedstudyof
managementofhighriskpatientsfollowinginitialoperationforintraabdominalinfection(gradeC).In
anotherstudy,althoughtherewasnodifferencebetweentreatmentsgroupsasfarasmortalityandthe
necessityforunplannedrelaparotomy,theincidenceofinfectiouspostoperativecomplicationssuchas
anastomoticleaksandsepticemia,aswellaspostoperativeMOFwasincreasedinpatientsundergoing
plannedrelaparotomy.
Somehavesuggestedcontinuospostoperativeirrigationoftheperitonealcavityinselectedpatients,
althoughtherearenodifferencesbetweenplannedrelaparotomyandcontinuouslavage.Sinceeachre
openingoftheabdomentriggerspowerfulinflammatoryresponse,wefavorrelaparotomyondemand,
unlessdealingwithnarcotizinginfectedpancreatitis,orsecondlooklaparotomywhensuspected
ischemia,followingresectionofgangrenousbowel
Earlydecompressionofabdominalcompartmentsyndrome,asmanifestedbyrenal,cardiac,pulmonary,
hepaticdysfunctionanddecreasedvisceralperfusion,aswellasbyincreaseofintraabdominalpressure
above1520torrwithadvancedoperationssuchasabdominostomy,meshabdominostomyandstaged
abdominalrepairabdominostomy(STAR)mayprovelifesaving.IndicationsforSTARhavebeen
establishedandinclude:hemodynamicinstabilityprecludingdefinitiverepair,excessiveperitoneal
edema,inabilitytoeliminateorcontrolthesourceofinfection,incompletedebridementofnecrotic
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tissue,uncertaintyabouttheviabilityofremainingbowel,uncontrolledbleeding,andtheneedfor
packingandresuscitationofcold,acidoticandcoagulopathicpatientsandmassiveabdominalwallloss.
Attimes,thedefinitivecontrolofthesepticfocusbyresection,excision,closureofhollowviscusor
drainageoftheabscessisperformedsuccessfully,butinanumberofpatientsperitonitispersist.Inthese
patients,optionsarerelaparotomyondemandorplannedrelaparotomy.Forthelackofdefinitivedata,
thechoiceaswhattodonextbelongstothesurgeon.Inanyevent,attemptsshouldbemadetoprevent
developmentoftertiaryperitonitis,whichisconsideredacomplication,ratherthenaspecificdisease.
Minimallyinvasivetechniques:laparoscopy

Thetraditiontoopeneverysepticabdomenhasbeenchallengedwiththeabilitytoclearlyidentifyand
localizeradiographicallythesourceofintraabdominalpathology.Inpatientswithunknownbut
presumedofabdominalsepsissuchasfemalesofchildbearingage,obese,immunocompromised,or
septicpatientsonsteroids,laparoscopyprovidesexcellenttoolformethodicalassessmentofentire
abdominalcavity.Inonestudythistechniquewasappliedin145surgicalpatients.Successful
identificationandlaparoscopicoperativetreatmentwasachievedin96%.In87casesthediagnosisof
appendicitiswasestablishedandappendectomywasperformed.Furthermore,formaldiagnostic
exploratorylaparoscopywassafeandeffectiveinthisstudy,althoughcautionissuggestedincases
whendiminishedorincreasedvolumeofabdominalspaceexist.Additionoflaparoscopicultrasound
wasvaluableindiagnosisofhepatic,intrasplenicorretroperitonealmasses.Thediagnosticand
therapeuticversalityoflaparoscopymayminimizetheextensivepreoperativeworkupandsignificantly
shortenpostoperativecourse.
Inamostrecentstudy,laparoscopywasdiagnosticin100%andtherapeuticin87.9%of107patients
withperitonitis.In40%ofcases,rupturedappendicitisandintestinalobstructionwerefoundinequal
numbers(20each).Perforatedcholecystitiswaspresentin15patients.In12%ofpatients,laparoscopy
wasconvertedintoopenprocedure.Inthisseries,themortalitywas4.6%,withcomplicationoccurring
in14%ofpatients,7.4%ofthemrequiringreoperation.Mostofthecomplications,however,were
minor,withonlyonerequiringoperativeintervention.Ofthoseconvertedtoanopentechnique,only
twoweredueto,oneintestinalinjury,andonetobleeding.Mostoftheconversionsweredueto
technicalandinexperienceofthesurgeon.
Laparoscopicproceduresinpatientswithacuteperitonitisshouldbecarriedoutbyexperiencesurgeons
andexpertiseinperformingadvancedlaparoscopicskillsandnotmerelydiagnosesofacondition.The
abilityoflaparoscopytofullyexploretheabdomen,andintervenetherapeuticallyasindicated,is
probablythebiggestadvantageofthistechnique.Inadditiontotheabilitytoapplythistechniqueinthe
operatingroom,laparoscopymaybeappliedintheintensivecareunit,althoughitmaybedifficultto
performdefinitiveprocedureintheICU,requiringthesecondprocedure.Thedevelopmentof2mm
laparoscopiccamerasandtheabilitytoperformthisunderlocalanesthesiamayfurtherimprovethe
acceptabilityofthistechniqueasadiagnostictoolinICUsepticpatientswithnoknownsource.In
additionexaminationofpelvicorganscanbegreatlyimprovewithlaparoscopy,whiletheuterusandthe
ovariesaremanipulatedtransvaginally.Amongotheradvantagesoflaparoscopictechniquesapproaches
isreducedimmunosuppressionobservedinresponsetothesurgicaltraumaandallotheradvantagesof
minimallyinvasivesurgicaltechnique.
Percutaneousradiographicallydirectedtechniques

PercutaneousdrainageofintraabdominalabscesswithCTorUSguidedtechniquehasbecomea
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methodofchoiceinthemanagementofpostoperativeabscessesandcollections.Itclearlyhasits
advantages.Whensuccessfulitavoidsthereoperation,andminimizesthemorbidityoftheoperation
(possibilityoffistula,bowelinjury,woundcomplications).Thistechniqueisbeingadoptedevenforthe
primaryabscesses.Suchasdiverticularabscess,appendicesabscess.
Percutaneouscholecystostomy(PC)hasbeenshowntobeaviablealternativeprocedureinacute
cholecystitisincriticallyillandelderlypatientsinwhomemergentcholecystectomyisassociatedwith
prohibitiverisks.Thisprocedurewasappliedprospectivelyandsuccessfullyto38patientsagegreater
than80yearsold.Ofthesepatients,25hadacutecalculouscholecystitis,while13hadAAC.Prompt
clinicalimprovementwasdemonstratedin95%ofpatients,whilethemorbidityandmortalitywasonly
3%respectively,although21%ofthemhadevidenceofsevereacutecholecystitisassociatedwithseptic
shock,respiratorysyndrome,disseminatedintravascularcoagulopathy,oracuterenalfailure.Once
improvedfromtheiracuteillness10patientsunderwentelectivecholecystectomy,while12/13patients
withAAChadnorecurrentcholecystitisaftercatheterwasremoved,duringthefollowupof1.8years.
OnepatientwithrecurrentAACdiedinthisseries.Afterdrainage,acutecalculouscholecystitisrelapsed
in33%ofpatients.Thisandotherstudiessuggestthatcholecystostomyissimple,safe,effectiveand
maybeadefinitiveprocedureforAACinthisgroupofpatients,althoughtherearenoRCTto
recommendthistherapyinpatientswithAAC(gradeC).
Summary

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Despitesignificantclinicalandtechnologicaladvancesinphysiologicmonitoringofcriticallyilland
septicpatients,intraabdominalsepsiscontinuostobeassociatedwithhighrateofmorbidityand
mortality.Whilethetrueincidenceofabdomenasasourceofsepsisisnotknown,intraabdominal
infectionsarepresentinupto25%ofpatientswithMOF.Sepsishasadeathrateashighas50%.If,on
theotherhand,patientsprogressintomultipleorganfailure(MOF)withmorethanthreeorgansystems,
themortalitymayapproach100%.Identifyingandcorrectingabdominalsepticsourceincriticallyill
patientintimelyfashion,mayrepresentadifficulttask,unlesssystematic,evidencebasedandthorough
multispecialtyapproachispracticed.
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