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  • Snapshot
    • A 27-year-old female presents to the hospital with a 4-day history of fever and lower right quadrant abdominal pain. Three weeks ago she underwent an emergency cesarean for an active phase arrest. Her temperature is 102.8°F (39.3°C). A tender fluctuant mass is palpated in the lower right quadrant of her abdomen. A pelvic CT scan confirms the diagnosis. She is admitted to the hospital and started on intravenous antibiotics and percutaneous drainage.
  • Introduction
    • Overview
      • a pelvic abscess is an inflammatory collection of purulent material that forms secondary to an infection within the pelvis
      • it is a rare complication of pelvic infections (e.g., pelvic inflammatory disease (PID), endometritis) or pelvic surgeries (e.g., ceserean section)
        • treatment is broad spectrum antibiotics and possible drainage
  • Epidemiology
    • Incidence
      • rare, occurs in < 1% of pelvic surgeries or infections
    • Demographic
      • occurs several weeks-months following surgery or infection
    • Risk factors
      • history of PID
        • most common etiology for pelvic abscess
      • prior pelvic surgery
      • bacterial vaginosis
      • postoperative hematoma
  • Etiology
    • Pathogenesis
      • mechanism
        • ascension of bacteria from the lower genital tract, extension of an existing infection in the pelvis, or seeding of new infection from surgery
    • Usually polymicrobial with predominance of anearobic bacteria (e.g., Bacteroides and Peptostreptococcus spp.)
  • Presentation
    • Symptoms
      • lower abdominal pain
      • malaise
      • chills
    • Physical exam
      • fever
      • abdominal tenderness in lower quadrants
      • fluctuant pelvic, vaginal, or adnexal mass
      • tachycardia
      • tachypnea
      • hypotension in severe or ruptured abscesses
  • Imaging
    • Computed tomography (CT) of pelvis
      • indication
        • imaging study of choice for the evaluation of pelvic abscess
      • findings
        • pelvic mass and low-attenuation centrally and ring enhancement with contrast
    • Ultrasonography
      • indication
        • alternative study for the evaluation of pelvic abscess
      • findings
        • anechoic or hypoechoic pocket, possibly multiloculated
  • Studies
    • Serum labs
      • leukocytosis
      • elevated C-reactive protein (CRP)
      • elevated erythrocyte sedimentation rate (ESR)
  • Differential
    • Septic pelvic thrombophlebitis
      • key distinguishing features
        • will present with persistent fever that does not respond to antibiotics and no evidence of an abscess on imaging
    • Appendicitis
      • key distinguishing features
        • will present with migratory abdominal pain, McBurney point tenderness, Rovsing sign, psoas sign, or obturator sign
    • Pyelonephritis
      • key distinguishing features
        • will present with flank pain, costovertebral angle (CVA) tenderness, and pyuria
  • Treatment
    • Management approach
      • pelvic abscesses are managed conservatively when possible with intravenous antibiotics covering both aerobic and anaerobic bacteria
      • percutaneous drainage and laparotomy are only used in select cases
    • Medical
      • intravenous broad spectrum antibiotics
        • indications
          • first line treatment
        • modalities
          • piperacillin-tazobactam
          • ceftriaxone with either clindamycin or metronidazole
    • Surgical
      • percutaneous drainage
        • indications
          • large abscesses (> 7 cm)
          • no response to antibiotic therapy within 72 hours
      • laparotomy
        • indications
          • suspected ruptured abscess
          • hemodynamic instability
          • no response to medical therapy or percutaneous drainage
  • Complications
    • Ruptured abscess
      • surgical emergency
  • Prognosis
    • > 70% of cases respond to intravenous antibiotics alone
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