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The Inaccessible or Undrainable Abscess: How to Drain It¹

¹ From the Division of Abdominal Imaging and Intervention, Massachusetts General Hospital, White 270, 55 Fruit St, Boston, MA 02114. Recipient of a Certificate of Merit award for an education exhibit at the 2001 RSNA scientific assembly. Received April 9, 2003; revision requested July 8 and received September 22; accepted September 23. All authors have no financial relationships to disclose. Address correspondence to P.R.M. (e-mail: pmueller@partners.org).

View larger version (135K): [in a new window]   Figure 1a.  Value of CT fluoroscopy in gaining access. (a) Contrast material-enhanced CT scan obtained in a 72-year-old man shows a left psoas muscle abscess (arrow) that is difficult to access because of intervening osseous structures. (b) CT fluoroscopic image shows the abscess being drained with the trocar technique. CT fluoroscopy provided excellent real-time guidance, which facilitated access to the collection and significantly reduced the duration of the procedure. (c) Postprocedure CT scan helps confirm excellent catheter position.

View larger version (125K): [in a new window]   Figure 1b.  Value of CT fluoroscopy in gaining access. (a) Contrast material-enhanced CT scan obtained in a 72-year-old man shows a left psoas muscle abscess (arrow) that is difficult to access because of intervening osseous structures. (b) CT fluoroscopic image shows the abscess being drained with the trocar technique. CT fluoroscopy provided excellent real-time guidance, which facilitated access to the collection and significantly reduced the duration of the procedure. (c) Postprocedure CT scan helps confirm excellent catheter position.

View larger version (132K): [in a new window]   Figure 1c.  Value of CT fluoroscopy in gaining access. (a) Contrast material-enhanced CT scan obtained in a 72-year-old man shows a left psoas muscle abscess (arrow) that is difficult to access because of intervening osseous structures. (b) CT fluoroscopic image shows the abscess being drained with the trocar technique. CT fluoroscopy provided excellent real-time guidance, which facilitated access to the collection and significantly reduced the duration of the procedure. (c) Postprocedure CT scan helps confirm excellent catheter position.

View larger version (137K): [in a new window]   Figure 2a.  Inaccessible abscess treated with aspiration. (a) CT scan obtained in a 32-year-old man with Crohn disease reveals an interloop abscess (straight arrows) that is inaccessible with percutaneous catheter placement due to multiple bowel loops (curved arrows). (b) CT scan shows the abscess being aspirated with a 20-gauge needle traversing the bowel as a temporizing measure. (c) Postprocedure CT scan demonstrates excellent results.

View larger version (138K): [in a new window]   Figure 2b.  Inaccessible abscess treated with aspiration. (a) CT scan obtained in a 32-year-old man with Crohn disease reveals an interloop abscess (straight arrows) that is inaccessible with percutaneous catheter placement due to multiple bowel loops (curved arrows). (b) CT scan shows the abscess being aspirated with a 20-gauge needle traversing the bowel as a temporizing measure. (c) Postprocedure CT scan demonstrates excellent results.

View larger version (132K): [in a new window]   Figure 2c.  Inaccessible abscess treated with aspiration. (a) CT scan obtained in a 32-year-old man with Crohn disease reveals an interloop abscess (straight arrows) that is inaccessible with percutaneous catheter placement due to multiple bowel loops (curved arrows). (b) CT scan shows the abscess being aspirated with a 20-gauge needle traversing the bowel as a temporizing measure. (c) Postprocedure CT scan demonstrates excellent results.

View larger version (176K): [in a new window]   Figure 3a.  Transhepatic abscess drainage in an 89-year-old woman who was deemed unfit for surgery. (a) Contrast-enhanced CT scan shows a retroperitoneal abscess (long arrows) secondary to a perforated duodenal diverticulum (short arrow). Three catheters were placed during different stages of the patient’s illness. (b) CT scan shows the abscess being drained with a transhepatic catheter. This approach was used to access a component of the collection located between the liver and the retroperitoneum posterior to the pancreas. (c) Postprocedure CT scan shows satisfactory catheter position with reduction in abscess size. Note the presence of a second catheter (arrow), which was placed with a right paravertebral approach. (d) Fluoroscopic image obtained after catheter placement (arrowhead) shows communication with the duodenal diverticulum (straight arrow) and duodenum (curved arrow).

View larger version (153K): [in a new window]   Figure 3b.  Transhepatic abscess drainage in an 89-year-old woman who was deemed unfit for surgery. (a) Contrast-enhanced CT scan shows a retroperitoneal abscess (long arrows) secondary to a perforated duodenal diverticulum (short arrow). Three catheters were placed during different stages of the patient’s illness. (b) CT scan shows the abscess being drained with a transhepatic catheter. This approach was used to access a component of the collection located between the liver and the retroperitoneum posterior to the pancreas. (c) Postprocedure CT scan shows satisfactory catheter position with reduction in abscess size. Note the presence of a second catheter (arrow), which was placed with a right paravertebral approach. (d) Fluoroscopic image obtained after catheter placement (arrowhead) shows communication with the duodenal diverticulum (straight arrow) and duodenum (curved arrow).

View larger version (145K): [in a new window]   Figure 3c.  Transhepatic abscess drainage in an 89-year-old woman who was deemed unfit for surgery. (a) Contrast-enhanced CT scan shows a retroperitoneal abscess (long arrows) secondary to a perforated duodenal diverticulum (short arrow). Three catheters were placed during different stages of the patient’s illness. (b) CT scan shows the abscess being drained with a transhepatic catheter. This approach was used to access a component of the collection located between the liver and the retroperitoneum posterior to the pancreas. (c) Postprocedure CT scan shows satisfactory catheter position with reduction in abscess size. Note the presence of a second catheter (arrow), which was placed with a right paravertebral approach. (d) Fluoroscopic image obtained after catheter placement (arrowhead) shows communication with the duodenal diverticulum (straight arrow) and duodenum (curved arrow).

View larger version (161K): [in a new window]   Figure 3d.  Transhepatic abscess drainage in an 89-year-old woman who was deemed unfit for surgery. (a) Contrast-enhanced CT scan shows a retroperitoneal abscess (long arrows) secondary to a perforated duodenal diverticulum (short arrow). Three catheters were placed during different stages of the patient’s illness. (b) CT scan shows the abscess being drained with a transhepatic catheter. This approach was used to access a component of the collection located between the liver and the retroperitoneum posterior to the pancreas. (c) Postprocedure CT scan shows satisfactory catheter position with reduction in abscess size. Note the presence of a second catheter (arrow), which was placed with a right paravertebral approach. (d) Fluoroscopic image obtained after catheter placement (arrowhead) shows communication with the duodenal diverticulum (straight arrow) and duodenum (curved arrow).

View larger version (127K): [in a new window]   Figure 4a.  Arterial injury and hematoma due to non-imaging-guided paracentesis performed in a 60-year-old man with ascites. The patient experienced abdominal pain and hypotension after undergoing the procedure. (a) Unenhanced CT scan shows a large left rectus sheath hematoma (arrow). (b) Selective angiogram of the inferior epigastric artery shows extravasation of contrast material (arrow), a finding that is consistent with arterial injury. The patient was successfully treated with catheter embolization.

View larger version (117K): [in a new window]   Figure 4b.  Arterial injury and hematoma due to non-imaging-guided paracentesis performed in a 60-year-old man with ascites. The patient experienced abdominal pain and hypotension after undergoing the procedure. (a) Unenhanced CT scan shows a large left rectus sheath hematoma (arrow). (b) Selective angiogram of the inferior epigastric artery shows extravasation of contrast material (arrow), a finding that is consistent with arterial injury. The patient was successfully treated with catheter embolization.

View larger version (20K): [in a new window]   Figure 5a.  (a) Drawing illustrates a peel-away sheath mounted on the back of a US probe, where the needle guide is normally placed. The sheath is fixed in position with additional rubber bands. Note the strict alignment of the sheath along the midline of the back of the probe. (b) Drawing illustrates a gel-lined outer condom covering the probe-sheath combination. The catheter is inserted through the sheath and will perforate the condom before entering the abscess cavity. (Fig 5 reprinted, with permission, from reference 4.)

View larger version (19K): [in a new window]   Figure 5b.  (a) Drawing illustrates a peel-away sheath mounted on the back of a US probe, where the needle guide is normally placed. The sheath is fixed in position with additional rubber bands. Note the strict alignment of the sheath along the midline of the back of the probe. (b) Drawing illustrates a gel-lined outer condom covering the probe-sheath combination. The catheter is inserted through the sheath and will perforate the condom before entering the abscess cavity. (Fig 5 reprinted, with permission, from reference 4.)

View larger version (142K): [in a new window]   Figure 6a.  Transvaginal drainage technique. (a) Transvaginal US image obtained in a 32-year-old woman with pelvic inflammatory disease shows loculated pelvic abscesses (arrows). (b) Contrast-enhanced CT scan helps confirm the presence of an abscess anterior to the rectum (arrow). The patient is placed in the lithotomy position, and the vagina (with speculum in place) and perineum are prepared using sterile technique. Under direct US guidance with a biopsy guide, the abscess is initially aspirated with a 20-gauge needle. The aspirated fluid is immediately stained with the Gram method. If sterile, the collection is aspirated dry with a needle or a 7-F hydrophilic catheter, and the needle or catheter is removed. If the collection is infected, an 8-F self-locking hydrophilic catheter is inserted under transvaginal US guidance and left in position for a few days. (c) Transvaginal US image shows the catheter (arrow) being inserted into the collection. (d) Postprocedure CT scan shows good positioning of the catheter (arrow).

View larger version (147K): [in a new window]   Figure 6b.  Transvaginal drainage technique. (a) Transvaginal US image obtained in a 32-year-old woman with pelvic inflammatory disease shows loculated pelvic abscesses (arrows). (b) Contrast-enhanced CT scan helps confirm the presence of an abscess anterior to the rectum (arrow). The patient is placed in the lithotomy position, and the vagina (with speculum in place) and perineum are prepared using sterile technique. Under direct US guidance with a biopsy guide, the abscess is initially aspirated with a 20-gauge needle. The aspirated fluid is immediately stained with the Gram method. If sterile, the collection is aspirated dry with a needle or a 7-F hydrophilic catheter, and the needle or catheter is removed. If the collection is infected, an 8-F self-locking hydrophilic catheter is inserted under transvaginal US guidance and left in position for a few days. (c) Transvaginal US image shows the catheter (arrow) being inserted into the collection. (d) Postprocedure CT scan shows good positioning of the catheter (arrow).

View larger version (151K): [in a new window]   Figure 6c.  Transvaginal drainage technique. (a) Transvaginal US image obtained in a 32-year-old woman with pelvic inflammatory disease shows loculated pelvic abscesses (arrows). (b) Contrast-enhanced CT scan helps confirm the presence of an abscess anterior to the rectum (arrow). The patient is placed in the lithotomy position, and the vagina (with speculum in place) and perineum are prepared using sterile technique. Under direct US guidance with a biopsy guide, the abscess is initially aspirated with a 20-gauge needle. The aspirated fluid is immediately stained with the Gram method. If sterile, the collection is aspirated dry with a needle or a 7-F hydrophilic catheter, and the needle or catheter is removed. If the collection is infected, an 8-F self-locking hydrophilic catheter is inserted under transvaginal US guidance and left in position for a few days. (c) Transvaginal US image shows the catheter (arrow) being inserted into the collection. (d) Postprocedure CT scan shows good positioning of the catheter (arrow).

View larger version (182K): [in a new window]   Figure 6d.  Transvaginal drainage technique. (a) Transvaginal US image obtained in a 32-year-old woman with pelvic inflammatory disease shows loculated pelvic abscesses (arrows). (b) Contrast-enhanced CT scan helps confirm the presence of an abscess anterior to the rectum (arrow). The patient is placed in the lithotomy position, and the vagina (with speculum in place) and perineum are prepared using sterile technique. Under direct US guidance with a biopsy guide, the abscess is initially aspirated with a 20-gauge needle. The aspirated fluid is immediately stained with the Gram method. If sterile, the collection is aspirated dry with a needle or a 7-F hydrophilic catheter, and the needle or catheter is removed. If the collection is infected, an 8-F self-locking hydrophilic catheter is inserted under transvaginal US guidance and left in position for a few days. (c) Transvaginal US image shows the catheter (arrow) being inserted into the collection. (d) Postprocedure CT scan shows good positioning of the catheter (arrow).

View larger version (135K): [in a new window]   Figure 7a.  Transrectal drainage technique. (a) Contrast-enhanced CT scan obtained in a 24-year-old man with recurrent prostatic abscess, severe pain, and fever shows an abscess of the prostate gland (arrow). (b) US image demonstrates successful transrectal drainage of the abscess performed with techniques similar to those used for transvaginal drainage. Note that the guide facilitates positioning of the probe so that the catheter (arrow) can be well visualized as it enters the abscess.

View larger version (144K): [in a new window]   Figure 7b.  Transrectal drainage technique. (a) Contrast-enhanced CT scan obtained in a 24-year-old man with recurrent prostatic abscess, severe pain, and fever shows an abscess of the prostate gland (arrow). (b) US image demonstrates successful transrectal drainage of the abscess performed with techniques similar to those used for transvaginal drainage. Note that the guide facilitates positioning of the probe so that the catheter (arrow) can be well visualized as it enters the abscess.

View larger version (115K): [in a new window]   Figure 8a.  Transgluteal drainage technique. (a) CT scan obtained in a 40-year-old patient with a postoperative pelvic abscess (arrows) shows a localizing needle placed as close as possible to the sacrum at the level of the sacrospinous ligament. At this level, the sciatic nerve and adjacent vessels are situated more laterally and can easily be avoided. At a slightly higher level, the sacral plexus and branches of the superior gluteal vessels lie adjacent to the piriformis muscle. (b) CT scan obtained after satisfactory needle position was confirmed shows a hydrophilic catheter that has been advanced with the trocar technique in tandem with the localizing needle to a predetermined depth in the pelvis.

View larger version (127K): [in a new window]   Figure 8b.  Transgluteal drainage technique. (a) CT scan obtained in a 40-year-old patient with a postoperative pelvic abscess (arrows) shows a localizing needle placed as close as possible to the sacrum at the level of the sacrospinous ligament. At this level, the sciatic nerve and adjacent vessels are situated more laterally and can easily be avoided. At a slightly higher level, the sacral plexus and branches of the superior gluteal vessels lie adjacent to the piriformis muscle. (b) CT scan obtained after satisfactory needle position was confirmed shows a hydrophilic catheter that has been advanced with the trocar technique in tandem with the localizing needle to a predetermined depth in the pelvis.

View larger version (132K): [in a new window]   Figure 9a.  Transgluteal drainage with an angled CT gantry. (a) Contrast-enhanced CT scan obtained in a 24-year-old man with Crohn disease shows an abscess located high in the pelvis (arrow). (b) CT fluoroscopic image obtained with the gantry at a 22o angle shows a catheter that was successfully advanced into the collection with the trocar technique. In this case, the abscess was very difficult to access due to intervening bowel and osseous structures. Occasionally, if an abscess is located high in the pelvis, angulation of the CT gantry in a cephalic direction can facilitate transgluteal drainage. (c) Postprocedure CT scan shows the catheter in good position within the abscess.

View larger version (149K): [in a new window]   Figure 9b.  Transgluteal drainage with an angled CT gantry. (a) Contrast-enhanced CT scan obtained in a 24-year-old man with Crohn disease shows an abscess located high in the pelvis (arrow). (b) CT fluoroscopic image obtained with the gantry at a 22o angle shows a catheter that was successfully advanced into the collection with the trocar technique. In this case, the abscess was very difficult to access due to intervening bowel and osseous structures. Occasionally, if an abscess is located high in the pelvis, angulation of the CT gantry in a cephalic direction can facilitate transgluteal drainage. (c) Postprocedure CT scan shows the catheter in good position within the abscess.

View larger version (140K): [in a new window]   Figure 9c.  Transgluteal drainage with an angled CT gantry. (a) Contrast-enhanced CT scan obtained in a 24-year-old man with Crohn disease shows an abscess located high in the pelvis (arrow). (b) CT fluoroscopic image obtained with the gantry at a 22o angle shows a catheter that was successfully advanced into the collection with the trocar technique. In this case, the abscess was very difficult to access due to intervening bowel and osseous structures. Occasionally, if an abscess is located high in the pelvis, angulation of the CT gantry in a cephalic direction can facilitate transgluteal drainage. (c) Postprocedure CT scan shows the catheter in good position within the abscess.

View larger version (104K): [in a new window]   Figure 10a.  Transperineal drainage with US guidance. (a) Contrast-enhanced CT scan obtained in a 63-year-old woman who had undergone hysterectomy shows an abscess in the perineum (arrows). (b) US image shows the guide wire (arrows) that was used to help drain the abscess with the Seldinger technique. (c) Fluoroscopic image obtained after catheter placement helps confirm optimal catheter position. The main disadvantage of using the transperineal route is patient discomfort. The liberal use of local anesthetic and conscious sedation is advised.

View larger version (157K): [in a new window]   Figure 10b.  Transperineal drainage with US guidance. (a) Contrast-enhanced CT scan obtained in a 63-year-old woman who had undergone hysterectomy shows an abscess in the perineum (arrows). (b) US image shows the guide wire (arrows) that was used to help drain the abscess with the Seldinger technique. (c) Fluoroscopic image obtained after catheter placement helps confirm optimal catheter position. The main disadvantage of using the transperineal route is patient discomfort. The liberal use of local anesthetic and conscious sedation is advised.

View larger version (140K): [in a new window]   Figure 10c.  Transperineal drainage with US guidance. (a) Contrast-enhanced CT scan obtained in a 63-year-old woman who had undergone hysterectomy shows an abscess in the perineum (arrows). (b) US image shows the guide wire (arrows) that was used to help drain the abscess with the Seldinger technique. (c) Fluoroscopic image obtained after catheter placement helps confirm optimal catheter position. The main disadvantage of using the transperineal route is patient discomfort. The liberal use of local anesthetic and conscious sedation is advised.

View larger version (130K): [in a new window]   Figure 11a.  Subcostal approach to a subphrenic collection in a 53-year-old man who had undergone gastric surgery. The patient was initially treated with percutaneous placement of two standard 12-F drainage catheters but remained febrile, and it was decided to attempt percutaneous placement of a large-bore catheter. (a) Fluoroscopic image shows a left-sided subphrenic abscess (arrow) being accessed with the Seldinger technique. (b, c) Fluoroscopic images show a guide wire that has been directed into the subphrenic space (b) and an optimally positioned large-bore catheter (c). Fluoroscopic guidance and torquing catheters were used for the procedure.

View larger version (127K): [in a new window]   Figure 11b.  Subcostal approach to a subphrenic collection in a 53-year-old man who had undergone gastric surgery. The patient was initially treated with percutaneous placement of two standard 12-F drainage catheters but remained febrile, and it was decided to attempt percutaneous placement of a large-bore catheter. (a) Fluoroscopic image shows a left-sided subphrenic abscess (arrow) being accessed with the Seldinger technique. (b, c) Fluoroscopic images show a guide wire that has been directed into the subphrenic space (b) and an optimally positioned large-bore catheter (c). Fluoroscopic guidance and torquing catheters were used for the procedure.

View larger version (136K): [in a new window]   Figure 11c.  Subcostal approach to a subphrenic collection in a 53-year-old man who had undergone gastric surgery. The patient was initially treated with percutaneous placement of two standard 12-F drainage catheters but remained febrile, and it was decided to attempt percutaneous placement of a large-bore catheter. (a) Fluoroscopic image shows a left-sided subphrenic abscess (arrow) being accessed with the Seldinger technique. (b, c) Fluoroscopic images show a guide wire that has been directed into the subphrenic space (b) and an optimally positioned large-bore catheter (c). Fluoroscopic guidance and torquing catheters were used for the procedure.

View larger version (134K): [in a new window]   Figure 12a.  Value of a catheter with multiple side holes. The patient was a 45-year-old woman with a subphrenic biloma who had undergone laparoscopic cholecystectomy. The biloma was initially drained with a CT-guided intercostal approach and a 10-F pigtail catheter. (a) CT scan shows a residual subphrenic collection (arrows) located cephalad to the catheter. (b) Fluoroscopic image obtained after catheter placement shows that the catheter (arrow) is located at the periphery of the collection. A stiff guide wire was advanced through the indwelling catheter. The catheter was removed, and torquing catheters were used to manipulate the guide wire into a more medial and cephalic position (cf Fig 11). Once the guide wire was in satisfactory position, a catheter with multiple side holes was advanced into a more cephalic location. (c) Fluoroscopic image shows the catheter in a more cephalic position within the collection. (d) CT scan shows the catheter with multiple side holes (arrows) in excellent position high in the subphrenic space.

View larger version (88K): [in a new window]   Figure 12b.  Value of a catheter with multiple side holes. The patient was a 45-year-old woman with a subphrenic biloma who had undergone laparoscopic cholecystectomy. The biloma was initially drained with a CT-guided intercostal approach and a 10-F pigtail catheter. (a) CT scan shows a residual subphrenic collection (arrows) located cephalad to the catheter. (b) Fluoroscopic image obtained after catheter placement shows that the catheter (arrow) is located at the periphery of the collection. A stiff guide wire was advanced through the indwelling catheter. The catheter was removed, and torquing catheters were used to manipulate the guide wire into a more medial and cephalic position (cf Fig 11). Once the guide wire was in satisfactory position, a catheter with multiple side holes was advanced into a more cephalic location. (c) Fluoroscopic image shows the catheter in a more cephalic position within the collection. (d) CT scan shows the catheter with multiple side holes (arrows) in excellent position high in the subphrenic space.

View larger version (114K): [in a new window]   Figure 12c.  Value of a catheter with multiple side holes. The patient was a 45-year-old woman with a subphrenic biloma who had undergone laparoscopic cholecystectomy. The biloma was initially drained with a CT-guided intercostal approach and a 10-F pigtail catheter. (a) CT scan shows a residual subphrenic collection (arrows) located cephalad to the catheter. (b) Fluoroscopic image obtained after catheter placement shows that the catheter (arrow) is located at the periphery of the collection. A stiff guide wire was advanced through the indwelling catheter. The catheter was removed, and torquing catheters were used to manipulate the guide wire into a more medial and cephalic position (cf Fig 11). Once the guide wire was in satisfactory position, a catheter with multiple side holes was advanced into a more cephalic location. (c) Fluoroscopic image shows the catheter in a more cephalic position within the collection. (d) CT scan shows the catheter with multiple side holes (arrows) in excellent position high in the subphrenic space.

View larger version (136K): [in a new window]   Figure 12d.  Value of a catheter with multiple side holes. The patient was a 45-year-old woman with a subphrenic biloma who had undergone laparoscopic cholecystectomy. The biloma was initially drained with a CT-guided intercostal approach and a 10-F pigtail catheter. (a) CT scan shows a residual subphrenic collection (arrows) located cephalad to the catheter. (b) Fluoroscopic image obtained after catheter placement shows that the catheter (arrow) is located at the periphery of the collection. A stiff guide wire was advanced through the indwelling catheter. The catheter was removed, and torquing catheters were used to manipulate the guide wire into a more medial and cephalic position (cf Fig 11). Once the guide wire was in satisfactory position, a catheter with multiple side holes was advanced into a more cephalic location. (c) Fluoroscopic image shows the catheter in a more cephalic position within the collection. (d) CT scan shows the catheter with multiple side holes (arrows) in excellent position high in the subphrenic space.

View larger version (103K): [in a new window]   Figure 13.  Schematic illustrates the common access routes to collections in the epigastric, pancreatic, and peripancreatic areas, including transhepatic (a), transgastric (b), and gastrosplenic (c) routes, left anterior pararenal space access (d), paravertebral access (e), right anterior pararenal space access (f), and the transduodenal approach (g).

View larger version (135K): [in a new window]   Figure 14a.  Pancreatic body abscess. CT scans obtained in a 69-year-old man show a pancreatic body abscess (arrows in a) being accessed via the left anterior pararenal space with the trocar technique. This procedure is facilitated by placing the patient in a nearly right lateral decubitus position, which allows bowel and other organs to fall away from the path of the catheter.

View larger version (153K): [in a new window]   Figure 14b.  Pancreatic body abscess. CT scans obtained in a 69-year-old man show a pancreatic body abscess (arrows in a) being accessed via the left anterior pararenal space with the trocar technique. This procedure is facilitated by placing the patient in a nearly right lateral decubitus position, which allows bowel and other organs to fall away from the path of the catheter.

View larger version (130K): [in a new window]   Figure 15a.  Pancreatic body abscess. (a) Unenhanced CT scan obtained in a 65-year-old man demonstrates a fluid collection in the body of the pancreas (arrows). (b) CT scan shows the collection being accessed through the gastrosplenic ligament.

View larger version (155K): [in a new window]   Figure 15b.  Pancreatic body abscess. (a) Unenhanced CT scan obtained in a 65-year-old man demonstrates a fluid collection in the body of the pancreas (arrows). (b) CT scan shows the collection being accessed through the gastrosplenic ligament.

View larger version (130K): [in a new window]   Figure 16a.  Importance of adequate bowel enhancement. (a) Initial contrast-enhanced CT scan obtained in a 45-year-old renal transplant recipient with sepsis suggests the presence of a pelvic fluid collection with foci of gas (arrows). (b) CT scan obtained after administration of additional oral contrast material reveals that this "fluid collection" represents unenhanced small bowel (arrows).

View larger version (132K): [in a new window]   Figure 16b.  Importance of adequate bowel enhancement. (a) Initial contrast-enhanced CT scan obtained in a 45-year-old renal transplant recipient with sepsis suggests the presence of a pelvic fluid collection with foci of gas (arrows). (b) CT scan obtained after administration of additional oral contrast material reveals that this "fluid collection" represents unenhanced small bowel (arrows).

View larger version (139K): [in a new window]   Figure 17a.  Inadvertent catheter placement in bowel. (a) CT scan obtained in an 83-year-old man shows a pelvic abscess (arrows). The abscess was originally drained percutaneously under CT guidance, and the catheter was removed. During placement of a new catheter under US guidance, the fluid-filled sigmoid colon (arrowhead) was mistaken for an abscess. (b) CT scan shows the catheter inadvertently placed in the sigmoid colon. In the setting of dilated fluid-filled loops of bowel, CT guidance helps avoid this complication.

View larger version (180K): [in a new window]   Figure 17b.  Inadvertent catheter placement in bowel. (a) CT scan obtained in an 83-year-old man shows a pelvic abscess (arrows). The abscess was originally drained percutaneously under CT guidance, and the catheter was removed. During placement of a new catheter under US guidance, the fluid-filled sigmoid colon (arrowhead) was mistaken for an abscess. (b) CT scan shows the catheter inadvertently placed in the sigmoid colon. In the setting of dilated fluid-filled loops of bowel, CT guidance helps avoid this complication.

View larger version (160K): [in a new window]   Figure 18a.  Drainage of a large, infected, unresectable desmoid tumor. (a) Contrast-enhanced CT scan obtained in a 36-year-old man with Gardner syndrome shows a large desmoid tumor (arrows) containing an air-fluid level, a finding that suggests bowel communication. The tumor was drained under US-fluoroscopic guidance, and the patient improved clinically. (b) Repeat CT scan shows that the abscess cavity has not contracted around the catheter (arrows) despite excellent catheter position. Oral contrast material is now seen within the lesion, a finding that also suggests communication with bowel. The catheter remains in position 1 years later.

View larger version (164K): [in a new window]   Figure 18b.  Drainage of a large, infected, unresectable desmoid tumor. (a) Contrast-enhanced CT scan obtained in a 36-year-old man with Gardner syndrome shows a large desmoid tumor (arrows) containing an air-fluid level, a finding that suggests bowel communication. The tumor was drained under US-fluoroscopic guidance, and the patient improved clinically. (b) Repeat CT scan shows that the abscess cavity has not contracted around the catheter (arrows) despite excellent catheter position. Oral contrast material is now seen within the lesion, a finding that also suggests communication with bowel. The catheter remains in position 1 years later.

View larger version (155K): [in a new window]   Figure 19a.  Value of intracavitary streptokinase. The patient was a 52-year-old woman with subphrenic biloma who had undergone laparoscopic cholecystectomy. (a) Contrast-enhanced CT scan obtained after CT-guided drainage shows a residual pericatheter collection (arrows). The patient remained febrile and complained of right upper quadrant pain. (b) On a CT scan obtained after 3 days of treatment with intracavitary streptokinase (125,000 IU in 50 mL of saline solution twice daily), the collection is smaller (arrows). The patient’s fever abated, and her abdominal pain lessened.

View larger version (164K): [in a new window]   Figure 19b.  Value of intracavitary streptokinase. The patient was a 52-year-old woman with subphrenic biloma who had undergone laparoscopic cholecystectomy. (a) Contrast-enhanced CT scan obtained after CT-guided drainage shows a residual pericatheter collection (arrows). The patient remained febrile and complained of right upper quadrant pain. (b) On a CT scan obtained after 3 days of treatment with intracavitary streptokinase (125,000 IU in 50 mL of saline solution twice daily), the collection is smaller (arrows). The patient’s fever abated, and her abdominal pain lessened.

View larger version (158K): [in a new window]   Figure 20.  Imaging-guided drainage versus surgery in perforated appendicitis. Contrast-enhanced CT scan obtained in a 28-year-old woman with perforated appendicitis and peritonitis shows a pelvic abscess and multiple interloop abscesses (arrows). The case was discussed with the surgeons, and it was jointly decided that surgery was the preferred treatment.