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CHAPTER 113: The Acute Abdomen and Intra-abdominal Sepsis 1083

A postoperative intra-abdominal hematoma usually resolves, but may TABLE 113-6 Occult Sources of intra-abdominal Sepsis
become infected and become an abscess, a consideration when look-
ing for a source of infection, especially in patients with coagulopathy. Acalculous cholecystitis
Reoperation is sometimes needed but percutaneous drainage of an Small intra-abdominal abscess(es)
infected hematoma may be a reasonable option. Ischemic bowel—short segment

Tertiary peritonitis
THE ABDOMEN AS AN OCCULT SOURCE OF SEPSIS
A frequent clinical problem in the ICU is the patient with sepsis, mul-
tiple organ failure, or both, with no obvious etiology. Line sepsis, soft species, and Clostridium difficile. As a result, tertiary peritonitis may
31
tissue infection, foreign body infection, Candida fungemia, endocardi- require stopping unnecessary antibiotics and initiating enteral feeds
https://kat.cr/user/tahir99/
tis, pneumonia, pseudomembranous colitis, and urosepsis can often be if possible. Food in the gut lumen stimulates mucosal growth, which
ruled out. Attention then focuses on the abdomen even if the patient preserves mucosal integrity. Some evidence favors the use of probiotic
35
had no known preexisting gastrointestinal pathologic condition. A CT medications in this population of patients. 25
scan of the abdomen is an excellent screening test but a negative When attempts to determine a cause for a patient’s septic state have
CT scan or ultrasound may not rule out peritoneal infection absolutely failed, the intensivist is often tempted to recommend laparotomy
(see Fig. 113-4). as a diagnostic tool. Some have advocated the use of minilaparos-
Causes of occult abdominal infection, shown in Table 113-6, copy in the ICU for diagnosis, but this is rarely useful. Laparotomy
2
include acute acalculous cholecystitis, described above. Multiple intra- without clinical or laboratory findings pointing to a specific etiology
abdominal abscesses, too small to be seen by CT or ultrasound, may or location of infection is rarely helpful in preventing death. And
37
hide between bowel loops (interloop abscesses) and be diagnosed only once multiple organ failure is far advanced, even definitive treatment
by abdominal exploration prompted by clinical suspicion and exclu- of an intra-abdominal source rarely succeeds in reversing this lethal
sion of other causes of sepsis. A short segment of ischemic or necrotic syndrome. 38-40
bowel may be difficult to detect on imaging. If the segment is in the
small bowel, the patient will usually have a clinical picture of mechani-
cal small bowel obstruction, but if the segment is in the left colon, the
patient may have no obvious symptom or sign. Colonoscopy is a useful KEY REFERENCES
diagnostic adjunct.
Experimental evidence suggests that the gastrointestinal tract itself • Anaya DA, Nathens AB. Risk factors for severe sepsis in secondary
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patients. 35,36 Critical illness may increase permeability of the gut mucosa • Huffman JL, Schenker S. Acute acalculous cholecystitis: a review.
with resulting bacterial translocation, and portal bacteremia. Broad- Clin Gastr Hepat. 2010;8(1):15.
spectrum antibiotics and inhibitors of gastric acid may promote the
growth of microbial opportunistic pathogens not usually associated with • Lamme B, Boermeester MA, Reitsma JB, Mahler CW, Obertop H,
the gastrointestinal tract, such as Staphylococcus epidermidis, Candida Gouma DJ. Meta-analysis of relaparotomy for secondary peritoni-
tis. Br J Surg. 2002;89:1516.
• Malbrain MLNG, Cheatham ML, Kirkpatrick A, et al. Results from
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• Mazuski JE, Sawyer RG, Nathans AB, et al. The surgical infection
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• McClave SA, Martindale RG, Vanek VW, et al. Guidelines for the
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and American Society for Parenteral and Enteral Nutrition
(A.S.P.E.N.). JPEN J Paren Ent Nutr. 2009;33:277.
• Rizoli SB, Marshall JC. Saturday night fever: finding and con-
trolling the source of sepsis in critical illness. Lancet Infect Dis.
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• Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and man-
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FIGURE 113-4. CT scan demonstrates massive amount of free fluid of multiple densities
suggesting blood and feces. This malnourished patient developed septic shock 14 days after REFERENCES
reversal of a Hartman procedure. The anastamosis had broken down and the patient was brought
urgently back to the operating room for a laparotomy following initial resuscitation in the ICU. Complete references available online at www.mhprofessional.com/hall

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