What is the treatment for multiple abdominal loculations (fluid collections)?

From the Guidelines

Treatment for multiple abdominal loculations typically involves a combination of percutaneous drainage and antimicrobial therapy, with the initial approach being image-guided percutaneous catheter drainage of accessible loculations, preferably using ultrasound or CT guidance, as supported by the most recent guidelines and studies 1.

Key Considerations

• The choice of treatment options for a given collection may vary among operators and depends on size, location, and clinical presentation, with options including antibiotics coupled with supportive measures, needle aspiration for drainage, percutaneous catheter drainage (PCD), PCD with thrombolytic therapy, endoscopic drainage, immediate surgery, or delayed surgery 1.
• For cases of fistulization of the abscess cavity to enteric, biliary, genitourinary, pancreatic, or bronchial systems, PCD may be successful with prolonged catheterization 1.
• Surgical source control entails resection or suture of a diseased or perforated viscus, removal of the infected organ, debridement of necrotic tissue, resection of ischemic bowel, and repair/resection of traumatic perforations with primary anastomosis or exteriorization of the bowel 1.

Treatment Approach

• Image-guided percutaneous catheter drainage of accessible loculations, preferably using ultrasound or CT guidance, is the initial approach, with multiple catheters potentially required for adequate drainage of separate collections.
• Appropriate broad-spectrum antibiotics should be started empirically, such as piperacillin-tazobactam 4.5g IV every 6 hours or meropenem 1g IV every 8 hours, along with metronidazole 500mg IV every 8 hours if anaerobic coverage is needed.
• Antibiotic therapy should be adjusted based on culture results and continued for 7-14 days depending on clinical response.
• Drainage catheters should remain in place until output is minimal (less than 10-20 mL/day) and follow-up imaging confirms resolution of collections.

Surgical Intervention

• For persistent or complex loculations, surgical intervention may be necessary, including laparoscopic or open surgical debridement.
• Nutritional support is essential during treatment, often requiring parenteral nutrition initially.
• The underlying cause of loculations (such as perforated viscus, pancreatitis, or postoperative complications) must be addressed to prevent recurrence.

Recent Guidelines and Studies

• The 2017 WSES guidelines for management of intra-abdominal infections recommend a combination of source control and antibiotic therapy for the treatment of patients with complicated intra-abdominal infections 1.
• A study published in 2020 reported a high success rate for non-operative management in patients with acute diverticulitis and a pneumoperitoneum, excluding those with hemodynamic instability 1.
• Another study published in 2018 reported the use of intra-pleural fibrinolytic agents to improve fluid drainage in loculated pleural infection 1.

From the Research

Treatment Options for Multiple Abdominal Loculations

The treatment for multiple abdominal loculations (fluid collections) can be challenging and may require a combination of approaches.

• Surgical intervention is often the preferred treatment for abdominal abscesses with multiple loculations, as percutaneous drainage may not be effective in all cases 2.
• However, percutaneous image-guided catheter drainage can be successful in properly selected patients, especially when used in conjunction with adjunctive therapies such as intracavitary fibrinolytic therapy 3.
• CT-guided percutaneous drainage has been shown to be effective in treating loculated intra-abdominal collections consisting entirely of gas, with a high rate of positive microbacterial cultures from aspirated fluid 4.
• A step-up approach to infected abdominal fluid collections, including minimally invasive debridement techniques, can be employed as part of a treatment strategy for refractory cases 5.
• Transcatheter intracavitary urokinase therapy has also been shown to be a safe and effective method to facilitate drainage of loculated pleural fluid collections, including those that are hemorrhagic or fibrinous 6.

Key Considerations

• The presence of multiple loculations requires careful consideration of the treatment approach, as percutaneous drainage may not be effective in all cases.
• The use of imaging guidance, such as CT or ultrasound, is crucial in planning and performing percutaneous drainage procedures.
• Adjunctive therapies, such as intracavitary fibrinolytic therapy, may be necessary to facilitate complete drainage of fluid collections.
• A step-up approach to treatment, including minimally invasive debridement techniques, may be necessary for refractory cases.
• The choice of treatment approach should be individualized based on the specific characteristics of the patient and the fluid collection.