retroperitoneal abscess
Introduction
Introduction to retroperitoneal abscess Retroperitoneal abscess refers to a localized purulent infection that occurs in the retroperitoneal space. It occurs often in the abdominal organs, retroperitoneal organs, spinal or twelfth rib infections, pelvic retroperitoneal abscesses, As well as bacteremia and other diseases, abscess can invade and mediastinum, down the femoral condyle into the thigh, can also penetrate into the abdominal cavity, gastrointestinal tract, pleura, bronchus, and even form a chronic persistent fistula. Retroperitoneal abscess is more clinically less common than abdominal abscess. If it can not be diagnosed and effectively treated, it can often induce multiple organ dysfunction syndrome (MODS) and cause death. basic knowledge The proportion of illness: 0.004% Susceptible people: no special people Mode of infection: non-infectious Complications: gastrointestinal bleeding peritonitis
Cause
Cause of retroperitoneal abscess
(1) Causes of the disease
Inflammation or perforation secondary to the retroperitoneal organs, especially the part of the digestive tract in the anterior retroperitoneal space, partially secondary to blood-borne infections, a small number of causes are unknown.
1. Biliary perforation: 2/3 of the common bile duct is located in the retroperitoneal space. The stone incarceration compresses the common bile duct wall to cause necrosis, or the gallbladder is removed. When the common bile duct probes the stone, the common bile duct is damaged, which can cause bile leakage and cause bile source. Retroperitoneal abscess.
2. Duodenal trauma or posterior wall ulcer perforation: Most of the duodenum is located in the retroperitoneal space. After suffering from injury or perforation of the ulcer, if the diagnosis and treatment are delayed, a large amount of digestive juice can accumulate in the retroperitoneal space and secondary infection causes the peritoneum. Post-abscess, surgical exploration of duodenal injury missed diagnosis and improper treatment of duodenal rupture, can cause duodenal fistula and lead to serious infection of the retroperitoneal space, in addition to endoscopy or intubation (including Nasal bile duct drainage may also cause minimally invasive posterior side of the duodenum, especially when endoscopy is inevitable, such as torsion, compression, etc., more likely to cause different degrees of trauma of the duodenum, duodenal juice may seep Leakage into the peritoneum leads to infection of the retroperitoneal space.
3. Colitis, injury perforation: Ascending colon and descending colon are located in the retroperitoneum, its inflammation, traumatic perforation can cause retroperitoneal infection and often form a retroperitoneal abscess.
4. Appendicitis: especially after the appendix is located behind the mesenteric mesenteric or posterior cecum, the symptoms of appendicitis are atypical, and it is easy to delay the diagnosis and treatment to form an abscess around the appendix, and then spread to form a retroperitoneal abscess.
5. Perirenal inflammation, perirenal abscess spread or renal traumatic extravasation caused by retroperitoneal infection, followed by the formation of retroperitoneal abscess.
6. Acute necrotizing pancreatitis: After the infection of the tissue around the pancreas and pancreas, it is easy to invade the pancreas, and can reach the small omental sac, the mesenteric root, the bilateral renal periplasmic space, the posterior colon, the iliac fossa, and even The entire retroperitoneal space is one of the most common causes of retroperitoneal abscess. Lei Daoxiong et al reported that 23 cases of retroperitoneal abscess confirmed by B-ultrasound or CT examination were performed in 1993-2000, including 18 cases of acute necrotizing pancreatitis. Accounted for 78.3%.
The pathogenic bacteria are mostly from the large intestine and urinary system, mainly Escherichia coli, Proteus, followed by Staphylococcus, Streptococcus, Anaerobic bacteria and other infections.
(two) pathogenesis
Due to the anatomical features of the retroperitoneal space, retroperitoneal infection and suppuration are easy to spread, and the ability to resist bacteria is worse than that of the peritoneal cavity. It is a physiological factor in the development of retroperitoneal abscess. There are three main ways of infection of the retroperitoneal space.
1. Direct invasion: such as renal pelvis, renal surface abscess, etc., which directly invade the peritoneal space of the retroperitoneal space.
2. Spread of infection of surrounding tissues or organs, such as pelvic rectal abscess caused by rectal infection, can spread upward along the retroperitoneal space.
3. Infections such as sepsis that spread through the blood and lymphatic pathways into the retroperitoneal space are rare.
Prevention
Retroperitoneal abscess prevention
The key lies in the early diagnosis. During the suspected period, on the one hand, it should strengthen the nutritional support treatment, on the other hand, strengthen the anti-infection, anti-shock treatment, and improve the various examinations. The drainage in the retroperitoneal space is to prevent secondary infection in the peritoneum. Effective measures for post-gap diffusion.
Complication
Retroperitoneal abscess complications Complications, gastrointestinal bleeding, peritonitis
Because the retroperitoneal space is deep, the cavity is large, and the tissue is loose. Once the infected lesion occurs, it spreads easily to the potential gap.
1. Urinary system purulent infection: Abscess invades the kidney, urinary tract or bladder may have urinary urgency, urinary frequency pyuria and other urinary tract infection symptoms.
2. Diffuse infection of abdominal organs and tissues: Abscess can be ulcerated in the chest, abdominal cavity, mediastinum, anterior abdominal wall, psoas muscle, buttocks or thighs, etc., causing purulent lesions such as empyema and peritonitis.
3. Gastrointestinal hemorrhage or intestinal fistula: acute necrotizing pancreatitis complicated with retroperitoneal abscess due to extensive invasion of the posterior pancreas, transverse colon and small mesenteric root, perirenal space, etc., diffuse retroperitoneal lesions contain a large number of necrotic tissue, Inflammatory exudate and bacterial toxins, in addition to aggravating the condition of acute pancreatitis, often cause gastrointestinal bleeding and intestinal fistula.
4.ARDS and acute renal failure: diffuse lesions of the retroperitoneum, the massive absorption of necrotic tissue, inflammatory exudate and bacterial toxins can cause diffuse coagulation, hemorrhage, renal failure and even multiple organ dysfunction. complication.
Symptom
Retroperitoneal abscess symptoms Common symptoms intestinal paralysis diarrhea intestinal flatulence abdominal distension abdominal pain peritoneal irritation ridge rib bulging abdominal mass
The clinical features of retroperitoneal abscess are systemic symptoms and abdominal signs are not consistent, systemic symptoms are heavy, abdominal signs are light, the main performances are:
1. Symptoms and signs of the primary disease.
2. Systemic poisoning symptoms: Most patients often have chills, high fever, neutrophil counts are significantly increased, and even the left side of the nucleus.
3. Local symptoms: abdominal pain, bloating, diarrhea, vomiting, severe pain in the lower back, intestinal paralysis, lumbar muscle rigidity, abdominal mass, rib waist allergy, hypostatic edema, peritoneal irritation is mild or not obvious Characteristic signs.
Examine
Examination of retroperitoneal abscess
Laboratory inspection
1. Blood routine examination: visible white blood cell count and neutrophils are significantly elevated, nuclear left shift, and even toxic particles appear.
2. Urine routine examination: red blood cells, white blood cells or pus cells may appear in the urine when the abscess invades the kidney, the ureter or the bladder.
Film degree exam
X-ray inspection
(1) Abdominal plain film: can show abnormal lumbar muscle shadow, scoliosis, kidney contour disappeared or soft tissue block shadow.
(2) Chest X-ray: visible diaphragmatic elevation, decreased or fixed respiratory motility, pleural effusion or atelectasis.
(3) intravenous pyelography: can show renal fixation, renal filling defects or ureteral displacement.
(4) sputum digestive tract angiography: can show visceral displacement, if there is gastrointestinal perforation, see phlegm extravasation, according to statistics, this abnormal signs accounted for 38% to 90%.
2.B-ultrasound
Can show the retroperitoneal hypoechoic sound shadow and the size and extent of abscess, some scholars report that the sensitivity of this test is about 67%. It is of great help to the diagnosis and localization of retroperitoneal abscess. Its sensitivity can reach 100%, especially for the diagnosis of multiple abscesses. The choice of reoperation approach and the determination of the scope of surgery are of special significance.
Diagnosis
Diagnosis and differentiation of retroperitoneal abscess
diagnosis
Because the retroperitoneal abscess is secondary to inflammation of the retroperitoneal organ, traumatic perforation or acute necrotizing pancreatitis and other serious diseases, a small number of secondary symptoms after surgery, the symptoms and signs are mostly primary lesions and post-operative state masking, Early diagnosis is difficult, and the disease should be considered in combination with the following points:
1. Clinical features: In addition to the clinical manifestations of the primary disease, the patient developed abdominal pain, bloating, diarrhea, vomiting, urgency, frequent urination, and symptoms of systemic poisoning that are inconsistent with abdominal signs. The symptoms of peritoneal irritation are not obvious, and the psoas muscle is stiff. Sign.
2. Blood: The neutrophil count is significantly increased and the nucleus is shifted to the left.
3. B-ultrasound or CT examination: B-ultrasound shows retroperitoneal hypoechoic sound and shadow, under the guidance of puncture and extraction of purulent effusion can be clearly diagnosed, but due to trauma, inflammation can cause flatulence, and retroperitoneal space infection can make Abdominal swelling is further aggravated, which may affect the accuracy of B-ultrasound examination. Therefore, the source of infection with negative B-test multiple times and no other reasons should not be easily ruled out. CT examination should be performed as early as possible to facilitate early diagnosis and localization of peritoneum. After the abscess.
4. Clinically, many patients with retroperitoneal abscess are concealed. The symptoms of the primary disease are stable or even no obvious discomfort. However, this disease should be thought of when a serious infection of unknown cause suddenly occurs. This is often the only diagnosis of retroperitoneal abscess. clue.
