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Percutaneous Imaging-guided Abdominal and Pelvic Abscess Drainage in Children¹

¹ From the Department of Radiology, Massachusetts General Hospital, 34 Fruit St, White 270, Boston, MA 02115 (D.A.G., S.L.B., M.G.H., P.R.M.); and Department of Radiology, Children’s Hospital, Boston, Mass (S.D.B., S.A.C.). Recipient of a Certificate of Merit award at the 2002 RSNA scientific assembly. Received April 14, 2003; revision requested July 1; revision received August 4 and accepted August 11. All authors have no financial relationships to disclose. Address correspondence to D.A.G. (e-mail: dgervais@partners.org).

View larger version (124K): [in a new window]   Figure 1.  Axial CT image obtained in a 13-year-old male patient shows an appendiceal abscess (solid arrows) surrounded by bowel (open arrows), a finding that precluded drainage with a percutaneous approach. Because the abscess was also located too far cephalad to allow use of a transrectal approach (compare with Fig 5), surgery was performed.

View larger version (112K): [in a new window]   Figure 2a.  Imaging-guided drainage of an appendiceal abscess with use of the trocar technique in an 11-year-old male patient. (a-c) Axial CT images obtained with oral and intravenous contrast material show a thick-walled abscess (arrow in a), a guiding needle placed in the abscess (arrow in b), and a 10-F drainage catheter (black arrow in c) deployed parallel to the guiding needle in the abscess (white arrow in c), which has been decompressed.

View larger version (124K): [in a new window]   Figure 2b.  Imaging-guided drainage of an appendiceal abscess with use of the trocar technique in an 11-year-old male patient. (a-c) Axial CT images obtained with oral and intravenous contrast material show a thick-walled abscess (arrow in a), a guiding needle placed in the abscess (arrow in b), and a 10-F drainage catheter (black arrow in c) deployed parallel to the guiding needle in the abscess (white arrow in c), which has been decompressed.

View larger version (129K): [in a new window]   Figure 2c.  Imaging-guided drainage of an appendiceal abscess with use of the trocar technique in an 11-year-old male patient. (a-c) Axial CT images obtained with oral and intravenous contrast material show a thick-walled abscess (arrow in a), a guiding needle placed in the abscess (arrow in b), and a 10-F drainage catheter (black arrow in c) deployed parallel to the guiding needle in the abscess (white arrow in c), which has been decompressed.

View larger version (114K): [in a new window]   Figure 3a.  Imaging-guided drainage of an appendiceal abscess with use of the Seldinger technique in a 12-year-old patient with Crohn disease. (a) Axial CT image shows a large abscess (solid arrows) with a thick enhancing wall. At this axial level, the proximity of the bowel (open arrows) precludes an anterior percutaneous approach. However, inferior to this level, a small anterior projection of the abscess was readily accessed with US guidance (not shown). The bowel directly anterior to the abscess at this level was inflamed, and its appearance is affected by partial-volume averaging. (b, c) Fluoroscopic spot film images show the sheath system (b) used to direct a working wire (arrow) into the largest and farthest cephalic part of the abscess after placement of a needle with US guidance, and the dilated catheter (c) deployed over the wire. Part of the catheter is seen in duplex, an artifact caused by catheter motion during pulsed fluoroscopy for dose reduction.

View larger version (124K): [in a new window]   Figure 3b.  Imaging-guided drainage of an appendiceal abscess with use of the Seldinger technique in a 12-year-old patient with Crohn disease. (a) Axial CT image shows a large abscess (solid arrows) with a thick enhancing wall. At this axial level, the proximity of the bowel (open arrows) precludes an anterior percutaneous approach. However, inferior to this level, a small anterior projection of the abscess was readily accessed with US guidance (not shown). The bowel directly anterior to the abscess at this level was inflamed, and its appearance is affected by partial-volume averaging. (b, c) Fluoroscopic spot film images show the sheath system (b) used to direct a working wire (arrow) into the largest and farthest cephalic part of the abscess after placement of a needle with US guidance, and the dilated catheter (c) deployed over the wire. Part of the catheter is seen in duplex, an artifact caused by catheter motion during pulsed fluoroscopy for dose reduction.

View larger version (163K): [in a new window]   Figure 3c.  Imaging-guided drainage of an appendiceal abscess with use of the Seldinger technique in a 12-year-old patient with Crohn disease. (a) Axial CT image shows a large abscess (solid arrows) with a thick enhancing wall. At this axial level, the proximity of the bowel (open arrows) precludes an anterior percutaneous approach. However, inferior to this level, a small anterior projection of the abscess was readily accessed with US guidance (not shown). The bowel directly anterior to the abscess at this level was inflamed, and its appearance is affected by partial-volume averaging. (b, c) Fluoroscopic spot film images show the sheath system (b) used to direct a working wire (arrow) into the largest and farthest cephalic part of the abscess after placement of a needle with US guidance, and the dilated catheter (c) deployed over the wire. Part of the catheter is seen in duplex, an artifact caused by catheter motion during pulsed fluoroscopy for dose reduction.

View larger version (133K): [in a new window]   Figure 4a.  Imaging-guided drainage of an abscess in a 13-year-old female patient after appendectomy. At US, the abscess could not be differentiated from the adjacent bowel. (a) Axial CT image shows a large abscess (arrows) that has a thick enhancing wall and contains air. (b) Axial CT image shows the decompressed abscess after drainage with the trocar technique and an 8.5-F catheter (arrows).

View larger version (118K): [in a new window]   Figure 4b.  Imaging-guided drainage of an abscess in a 13-year-old female patient after appendectomy. At US, the abscess could not be differentiated from the adjacent bowel. (a) Axial CT image shows a large abscess (arrows) that has a thick enhancing wall and contains air. (b) Axial CT image shows the decompressed abscess after drainage with the trocar technique and an 8.5-F catheter (arrows).

View larger version (117K): [in a new window]   Figure 5a.  Imaging-guided drainage of an appendiceal abscess with the Seldinger technique and a transrectal approach in a 12-year-old female patient. (a) US image shows a large pelvic abscess (solid arrows) and the computer-generated path (open arrows) the needle will follow during its insertion into the abscess with the aid of a guide mounted on the US transducer. (b) US image shows the sheathed needle (open arrow), which has been inserted into the abscess (solid arrows). (c) US image shows a guide wire (arrows) positioned in the abscess. (d, e) Fluoroscopic images (e at a higher magnification than d) show the wire and catheter during placement. (f) Axial CT image obtained 5 days later shows that complete drainage has been achieved.

View larger version (112K): [in a new window]   Figure 5b.  Imaging-guided drainage of an appendiceal abscess with the Seldinger technique and a transrectal approach in a 12-year-old female patient. (a) US image shows a large pelvic abscess (solid arrows) and the computer-generated path (open arrows) the needle will follow during its insertion into the abscess with the aid of a guide mounted on the US transducer. (b) US image shows the sheathed needle (open arrow), which has been inserted into the abscess (solid arrows). (c) US image shows a guide wire (arrows) positioned in the abscess. (d, e) Fluoroscopic images (e at a higher magnification than d) show the wire and catheter during placement. (f) Axial CT image obtained 5 days later shows that complete drainage has been achieved.

View larger version (109K): [in a new window]   Figure 5c.  Imaging-guided drainage of an appendiceal abscess with the Seldinger technique and a transrectal approach in a 12-year-old female patient. (a) US image shows a large pelvic abscess (solid arrows) and the computer-generated path (open arrows) the needle will follow during its insertion into the abscess with the aid of a guide mounted on the US transducer. (b) US image shows the sheathed needle (open arrow), which has been inserted into the abscess (solid arrows). (c) US image shows a guide wire (arrows) positioned in the abscess. (d, e) Fluoroscopic images (e at a higher magnification than d) show the wire and catheter during placement. (f) Axial CT image obtained 5 days later shows that complete drainage has been achieved.

View larger version (142K): [in a new window]   Figure 5d.  Imaging-guided drainage of an appendiceal abscess with the Seldinger technique and a transrectal approach in a 12-year-old female patient. (a) US image shows a large pelvic abscess (solid arrows) and the computer-generated path (open arrows) the needle will follow during its insertion into the abscess with the aid of a guide mounted on the US transducer. (b) US image shows the sheathed needle (open arrow), which has been inserted into the abscess (solid arrows). (c) US image shows a guide wire (arrows) positioned in the abscess. (d, e) Fluoroscopic images (e at a higher magnification than d) show the wire and catheter during placement. (f) Axial CT image obtained 5 days later shows that complete drainage has been achieved.

View larger version (151K): [in a new window]   Figure 5e.  Imaging-guided drainage of an appendiceal abscess with the Seldinger technique and a transrectal approach in a 12-year-old female patient. (a) US image shows a large pelvic abscess (solid arrows) and the computer-generated path (open arrows) the needle will follow during its insertion into the abscess with the aid of a guide mounted on the US transducer. (b) US image shows the sheathed needle (open arrow), which has been inserted into the abscess (solid arrows). (c) US image shows a guide wire (arrows) positioned in the abscess. (d, e) Fluoroscopic images (e at a higher magnification than d) show the wire and catheter during placement. (f) Axial CT image obtained 5 days later shows that complete drainage has been achieved.

View larger version (112K): [in a new window]   Figure 5f.  Imaging-guided drainage of an appendiceal abscess with the Seldinger technique and a transrectal approach in a 12-year-old female patient. (a) US image shows a large pelvic abscess (solid arrows) and the computer-generated path (open arrows) the needle will follow during its insertion into the abscess with the aid of a guide mounted on the US transducer. (b) US image shows the sheathed needle (open arrow), which has been inserted into the abscess (solid arrows). (c) US image shows a guide wire (arrows) positioned in the abscess. (d, e) Fluoroscopic images (e at a higher magnification than d) show the wire and catheter during placement. (f) Axial CT image obtained 5 days later shows that complete drainage has been achieved.

View larger version (115K): [in a new window]   Figure 6a.  Imaging-guided drainage of an appendiceal abscess with use of the tandem trocar technique and a transgluteal approach in a 6-year-old male patient. (a) Axial CT image shows an abscess (arrows) deep in the pelvic cavity, a location in which an anterior percutaneous approach is precluded because of proximity to the bowel. (b) Axial CT image obtained with the patient prone shows the placement of a guiding needle (straight arrow) through the greater sciatic foramen and into the abscess. A medial approach was used to avoid impingement on the sciatic nerve, which courses through the lateral aspect of the foramen (curved arrow). (c) Axial CT image shows a catheter (arrows) that has been inserted alongside the needle.

View larger version (113K): [in a new window]   Figure 6b.  Imaging-guided drainage of an appendiceal abscess with use of the tandem trocar technique and a transgluteal approach in a 6-year-old male patient. (a) Axial CT image shows an abscess (arrows) deep in the pelvic cavity, a location in which an anterior percutaneous approach is precluded because of proximity to the bowel. (b) Axial CT image obtained with the patient prone shows the placement of a guiding needle (straight arrow) through the greater sciatic foramen and into the abscess. A medial approach was used to avoid impingement on the sciatic nerve, which courses through the lateral aspect of the foramen (curved arrow). (c) Axial CT image shows a catheter (arrows) that has been inserted alongside the needle.

View larger version (113K): [in a new window]   Figure 6c.  Imaging-guided drainage of an appendiceal abscess with use of the tandem trocar technique and a transgluteal approach in a 6-year-old male patient. (a) Axial CT image shows an abscess (arrows) deep in the pelvic cavity, a location in which an anterior percutaneous approach is precluded because of proximity to the bowel. (b) Axial CT image obtained with the patient prone shows the placement of a guiding needle (straight arrow) through the greater sciatic foramen and into the abscess. A medial approach was used to avoid impingement on the sciatic nerve, which courses through the lateral aspect of the foramen (curved arrow). (c) Axial CT image shows a catheter (arrows) that has been inserted alongside the needle.

View larger version (128K): [in a new window]   Figure 7a.  Imaging-guided drainage of an abscess in a 14-year-old patient with fever after appendectomy at which diffuse peritoneal contamination was found. (a) Axial CT image shows a left subphrenic abscess (arrows) located above the spleen. (b) Axial CT image at a level inferior to a shows that the abscess extends lateral to the spleen. The CT findings did not clearly indicate whether one or two catheters would be needed for successful drainage. A first catheter was placed and drainage was performed with an intercostal approach by using US and fluoroscopic guidance. US images obtained after initial catheter placement showed a persistent fluid collection, and a second drainage procedure therefore was performed at a location slightly inferior to the first. (c) Fluoroscopic image shows the two catheters (arrows) used to drain the two loculated abscesses. Drainage was successful after the placement of the second catheter, and there were no pleural complications.

View larger version (127K): [in a new window]   Figure 7b.  Imaging-guided drainage of an abscess in a 14-year-old patient with fever after appendectomy at which diffuse peritoneal contamination was found. (a) Axial CT image shows a left subphrenic abscess (arrows) located above the spleen. (b) Axial CT image at a level inferior to a shows that the abscess extends lateral to the spleen. The CT findings did not clearly indicate whether one or two catheters would be needed for successful drainage. A first catheter was placed and drainage was performed with an intercostal approach by using US and fluoroscopic guidance. US images obtained after initial catheter placement showed a persistent fluid collection, and a second drainage procedure therefore was performed at a location slightly inferior to the first. (c) Fluoroscopic image shows the two catheters (arrows) used to drain the two loculated abscesses. Drainage was successful after the placement of the second catheter, and there were no pleural complications.

View larger version (154K): [in a new window]   Figure 7c.  Imaging-guided drainage of an abscess in a 14-year-old patient with fever after appendectomy at which diffuse peritoneal contamination was found. (a) Axial CT image shows a left subphrenic abscess (arrows) located above the spleen. (b) Axial CT image at a level inferior to a shows that the abscess extends lateral to the spleen. The CT findings did not clearly indicate whether one or two catheters would be needed for successful drainage. A first catheter was placed and drainage was performed with an intercostal approach by using US and fluoroscopic guidance. US images obtained after initial catheter placement showed a persistent fluid collection, and a second drainage procedure therefore was performed at a location slightly inferior to the first. (c) Fluoroscopic image shows the two catheters (arrows) used to drain the two loculated abscesses. Drainage was successful after the placement of the second catheter, and there were no pleural complications.

View larger version (148K): [in a new window]   Figure 8a.  Imaging-guided drainage of a pancreatic abscess in a 16-year-old male patient. (a) Axial CT image shows an abscess (curved arrows) anterior to the pancreas and posterior to the stomach (open arrow), with unopacified loops of small bowel located laterally (solid straight arrows). (b) Axial CT image shows the placement of a catheter (open arrow) via a percutaneous route (solid arrow).

View larger version (146K): [in a new window]   Figure 8b.  Imaging-guided drainage of a pancreatic abscess in a 16-year-old male patient. (a) Axial CT image shows an abscess (curved arrows) anterior to the pancreas and posterior to the stomach (open arrow), with unopacified loops of small bowel located laterally (solid straight arrows). (b) Axial CT image shows the placement of a catheter (open arrow) via a percutaneous route (solid arrow).

View larger version (99K): [in a new window]   Figure 9a.  Imaging-guided drainage of persistent abscess in a 13-year-old female patient after appendectomy (same patient as in Fig 4). Despite diminished catheter output and initial improvement in the patient’s condition after initial percutaneous drainage, a low-grade fever persisted at 10 days. (a) Axial CT image shows a persistent fluid collection (arrows) around the catheter, a finding that indicates an extension of the abscess into the psoas muscle. (b) Fluoroscopic image shows a fluid collection (arrows) with a complex shape; despite the near-optimal position of the catheter in the abscess, drainage was incomplete. The 8-F catheter was exchanged for a 12-F catheter, and, after 5 more days of drainage, the abscess and clinical symptoms resolved.

View larger version (140K): [in a new window]   Figure 9b.  Imaging-guided drainage of persistent abscess in a 13-year-old female patient after appendectomy (same patient as in Fig 4). Despite diminished catheter output and initial improvement in the patient’s condition after initial percutaneous drainage, a low-grade fever persisted at 10 days. (a) Axial CT image shows a persistent fluid collection (arrows) around the catheter, a finding that indicates an extension of the abscess into the psoas muscle. (b) Fluoroscopic image shows a fluid collection (arrows) with a complex shape; despite the near-optimal position of the catheter in the abscess, drainage was incomplete. The 8-F catheter was exchanged for a 12-F catheter, and, after 5 more days of drainage, the abscess and clinical symptoms resolved.

View larger version (118K): [in a new window]   Figure 10a.  Unsuccessful drainage of multiple abscesses in a 15-year-old female patient with Crohn disease after sigmoid colon resection and anastomosis creation. (a, b) Axial CT images obtained to determine the source of postoperative fever show fluid collections (straight arrows in a) just above and posterior to the bladder (curved arrow in a) and in the paracolic gutters (arrows in b). Because the enhanced peritoneum indicated inflammation, the fluid had to be sampled for testing or drained. (c-e) Axial CT images show the insertion of a needle (arrows in c), guide wire (arrows in d), and 10-F catheter (arrows in e) for drainage of the fluid near the bladder with the Seldinger technique. (Fluid in the paracolic gutters was drained with the trocar technique.) Despite triple antibiotic therapy and drainage of all fluid collections, the fever did not resolve. (f-h) Axial CT images obtained with instillation of rectal contrast material show enhancement and distention of the cavities that contain the two most caudal catheters (straight arrows in f and g), as well as contrast material flowing into the peritoneum (curved arrows in g) and extending cephalad to the subhepatic space (curved arrows in h). Massive anastomotic leak was diagnosed, and the patient underwent anastomotic revision.

View larger version (121K): [in a new window]   Figure 10b.  Unsuccessful drainage of multiple abscesses in a 15-year-old female patient with Crohn disease after sigmoid colon resection and anastomosis creation. (a, b) Axial CT images obtained to determine the source of postoperative fever show fluid collections (straight arrows in a) just above and posterior to the bladder (curved arrow in a) and in the paracolic gutters (arrows in b). Because the enhanced peritoneum indicated inflammation, the fluid had to be sampled for testing or drained. (c-e) Axial CT images show the insertion of a needle (arrows in c), guide wire (arrows in d), and 10-F catheter (arrows in e) for drainage of the fluid near the bladder with the Seldinger technique. (Fluid in the paracolic gutters was drained with the trocar technique.) Despite triple antibiotic therapy and drainage of all fluid collections, the fever did not resolve. (f-h) Axial CT images obtained with instillation of rectal contrast material show enhancement and distention of the cavities that contain the two most caudal catheters (straight arrows in f and g), as well as contrast material flowing into the peritoneum (curved arrows in g) and extending cephalad to the subhepatic space (curved arrows in h). Massive anastomotic leak was diagnosed, and the patient underwent anastomotic revision.

View larger version (121K): [in a new window]   Figure 10c.  Unsuccessful drainage of multiple abscesses in a 15-year-old female patient with Crohn disease after sigmoid colon resection and anastomosis creation. (a, b) Axial CT images obtained to determine the source of postoperative fever show fluid collections (straight arrows in a) just above and posterior to the bladder (curved arrow in a) and in the paracolic gutters (arrows in b). Because the enhanced peritoneum indicated inflammation, the fluid had to be sampled for testing or drained. (c-e) Axial CT images show the insertion of a needle (arrows in c), guide wire (arrows in d), and 10-F catheter (arrows in e) for drainage of the fluid near the bladder with the Seldinger technique. (Fluid in the paracolic gutters was drained with the trocar technique.) Despite triple antibiotic therapy and drainage of all fluid collections, the fever did not resolve. (f-h) Axial CT images obtained with instillation of rectal contrast material show enhancement and distention of the cavities that contain the two most caudal catheters (straight arrows in f and g), as well as contrast material flowing into the peritoneum (curved arrows in g) and extending cephalad to the subhepatic space (curved arrows in h). Massive anastomotic leak was diagnosed, and the patient underwent anastomotic revision.

View larger version (123K): [in a new window]   Figure 10d.  Unsuccessful drainage of multiple abscesses in a 15-year-old female patient with Crohn disease after sigmoid colon resection and anastomosis creation. (a, b) Axial CT images obtained to determine the source of postoperative fever show fluid collections (straight arrows in a) just above and posterior to the bladder (curved arrow in a) and in the paracolic gutters (arrows in b). Because the enhanced peritoneum indicated inflammation, the fluid had to be sampled for testing or drained. (c-e) Axial CT images show the insertion of a needle (arrows in c), guide wire (arrows in d), and 10-F catheter (arrows in e) for drainage of the fluid near the bladder with the Seldinger technique. (Fluid in the paracolic gutters was drained with the trocar technique.) Despite triple antibiotic therapy and drainage of all fluid collections, the fever did not resolve. (f-h) Axial CT images obtained with instillation of rectal contrast material show enhancement and distention of the cavities that contain the two most caudal catheters (straight arrows in f and g), as well as contrast material flowing into the peritoneum (curved arrows in g) and extending cephalad to the subhepatic space (curved arrows in h). Massive anastomotic leak was diagnosed, and the patient underwent anastomotic revision.

View larger version (124K): [in a new window]   Figure 10e.  Unsuccessful drainage of multiple abscesses in a 15-year-old female patient with Crohn disease after sigmoid colon resection and anastomosis creation. (a, b) Axial CT images obtained to determine the source of postoperative fever show fluid collections (straight arrows in a) just above and posterior to the bladder (curved arrow in a) and in the paracolic gutters (arrows in b). Because the enhanced peritoneum indicated inflammation, the fluid had to be sampled for testing or drained. (c-e) Axial CT images show the insertion of a needle (arrows in c), guide wire (arrows in d), and 10-F catheter (arrows in e) for drainage of the fluid near the bladder with the Seldinger technique. (Fluid in the paracolic gutters was drained with the trocar technique.) Despite triple antibiotic therapy and drainage of all fluid collections, the fever did not resolve. (f-h) Axial CT images obtained with instillation of rectal contrast material show enhancement and distention of the cavities that contain the two most caudal catheters (straight arrows in f and g), as well as contrast material flowing into the peritoneum (curved arrows in g) and extending cephalad to the subhepatic space (curved arrows in h). Massive anastomotic leak was diagnosed, and the patient underwent anastomotic revision.

View larger version (128K): [in a new window]   Figure 10f.  Unsuccessful drainage of multiple abscesses in a 15-year-old female patient with Crohn disease after sigmoid colon resection and anastomosis creation. (a, b) Axial CT images obtained to determine the source of postoperative fever show fluid collections (straight arrows in a) just above and posterior to the bladder (curved arrow in a) and in the paracolic gutters (arrows in b). Because the enhanced peritoneum indicated inflammation, the fluid had to be sampled for testing or drained. (c-e) Axial CT images show the insertion of a needle (arrows in c), guide wire (arrows in d), and 10-F catheter (arrows in e) for drainage of the fluid near the bladder with the Seldinger technique. (Fluid in the paracolic gutters was drained with the trocar technique.) Despite triple antibiotic therapy and drainage of all fluid collections, the fever did not resolve. (f-h) Axial CT images obtained with instillation of rectal contrast material show enhancement and distention of the cavities that contain the two most caudal catheters (straight arrows in f and g), as well as contrast material flowing into the peritoneum (curved arrows in g) and extending cephalad to the subhepatic space (curved arrows in h). Massive anastomotic leak was diagnosed, and the patient underwent anastomotic revision.

View larger version (121K): [in a new window]   Figure 10g.  Unsuccessful drainage of multiple abscesses in a 15-year-old female patient with Crohn disease after sigmoid colon resection and anastomosis creation. (a, b) Axial CT images obtained to determine the source of postoperative fever show fluid collections (straight arrows in a) just above and posterior to the bladder (curved arrow in a) and in the paracolic gutters (arrows in b). Because the enhanced peritoneum indicated inflammation, the fluid had to be sampled for testing or drained. (c-e) Axial CT images show the insertion of a needle (arrows in c), guide wire (arrows in d), and 10-F catheter (arrows in e) for drainage of the fluid near the bladder with the Seldinger technique. (Fluid in the paracolic gutters was drained with the trocar technique.) Despite triple antibiotic therapy and drainage of all fluid collections, the fever did not resolve. (f-h) Axial CT images obtained with instillation of rectal contrast material show enhancement and distention of the cavities that contain the two most caudal catheters (straight arrows in f and g), as well as contrast material flowing into the peritoneum (curved arrows in g) and extending cephalad to the subhepatic space (curved arrows in h). Massive anastomotic leak was diagnosed, and the patient underwent anastomotic revision.

View larger version (124K): [in a new window]   Figure 10h.  Unsuccessful drainage of multiple abscesses in a 15-year-old female patient with Crohn disease after sigmoid colon resection and anastomosis creation. (a, b) Axial CT images obtained to determine the source of postoperative fever show fluid collections (straight arrows in a) just above and posterior to the bladder (curved arrow in a) and in the paracolic gutters (arrows in b). Because the enhanced peritoneum indicated inflammation, the fluid had to be sampled for testing or drained. (c-e) Axial CT images show the insertion of a needle (arrows in c), guide wire (arrows in d), and 10-F catheter (arrows in e) for drainage of the fluid near the bladder with the Seldinger technique. (Fluid in the paracolic gutters was drained with the trocar technique.) Despite triple antibiotic therapy and drainage of all fluid collections, the fever did not resolve. (f-h) Axial CT images obtained with instillation of rectal contrast material show enhancement and distention of the cavities that contain the two most caudal catheters (straight arrows in f and g), as well as contrast material flowing into the peritoneum (curved arrows in g) and extending cephalad to the subhepatic space (curved arrows in h). Massive anastomotic leak was diagnosed, and the patient underwent anastomotic revision.

View larger version (116K): [in a new window]   Figure 11a.  Recurrent abscess in a 6-year-old female patient with appendicolith. (a) Axial CT image obtained 1 week after initial transrectal drainage shows only the catheter (arrow) and no residual fluid, a finding that, with the patient’s improved clinical status and low catheter output, led to the removal of the catheter. (b) Axial CT image at a level more cephalad than a shows an appendicolith (arrow). (c) Axial CT image, obtained when the patient returned with fever and pain 2 weeks after catheter removal, shows a recurrent abscess (arrows) that may be secondary to the appendicolith.

View larger version (120K): [in a new window]   Figure 11b.  Recurrent abscess in a 6-year-old female patient with appendicolith. (a) Axial CT image obtained 1 week after initial transrectal drainage shows only the catheter (arrow) and no residual fluid, a finding that, with the patient’s improved clinical status and low catheter output, led to the removal of the catheter. (b) Axial CT image at a level more cephalad than a shows an appendicolith (arrow). (c) Axial CT image, obtained when the patient returned with fever and pain 2 weeks after catheter removal, shows a recurrent abscess (arrows) that may be secondary to the appendicolith.

View larger version (117K): [in a new window]   Figure 11c.  Recurrent abscess in a 6-year-old female patient with appendicolith. (a) Axial CT image obtained 1 week after initial transrectal drainage shows only the catheter (arrow) and no residual fluid, a finding that, with the patient’s improved clinical status and low catheter output, led to the removal of the catheter. (b) Axial CT image at a level more cephalad than a shows an appendicolith (arrow). (c) Axial CT image, obtained when the patient returned with fever and pain 2 weeks after catheter removal, shows a recurrent abscess (arrows) that may be secondary to the appendicolith.

View larger version (116K): [in a new window]   Figure 12a.  Drainage failure due to misdiagnosis of a pelvic lesion in a 6-year-old female patient transferred from an outside hospital for treatment. (a) Axial CT image from the outside hospital shows an apparent pelvic abscess (arrows), in which transrectal drainage was subsequently performed. (b) Axial contrast-enhanced CT image obtained because of scant drainage 4 days after the procedure shows irregularly enhanced contents and no change in the size of the apparent abscess, which was subsequently diagnosed as a dysgerminoma.

View larger version (123K): [in a new window]   Figure 12b.  Drainage failure due to misdiagnosis of a pelvic lesion in a 6-year-old female patient transferred from an outside hospital for treatment. (a) Axial CT image from the outside hospital shows an apparent pelvic abscess (arrows), in which transrectal drainage was subsequently performed. (b) Axial contrast-enhanced CT image obtained because of scant drainage 4 days after the procedure shows irregularly enhanced contents and no change in the size of the apparent abscess, which was subsequently diagnosed as a dysgerminoma.

View larger version (142K): [in a new window]   Figure 13a.  Fluid collection in a 6-year-old female patient with pancreatitis. (a) Axial CT image shows a peripancreatic fluid collection (arrows) that extends caudad in the abdomen and pelvis, in a location in which percutaneous drainage is indicated only for an infected abscess. Because pancreatitis may cause fever, leukocytosis, and peripancreatic fluid accumulation even without the presence of infection, needle aspiration was performed and Gram stains were analyzed to determine whether complete drainage was necessary. (b) CT fluoroscopic image shows needle placement (arrows) in a retroperitoneal fluid collection in the paranephric space. Three other fluid collections (not shown) also were aspirated. Gram stains showed no white blood cells or organisms, and drainage therefore was unnecessary.

View larger version (139K): [in a new window]   Figure 13b.  Fluid collection in a 6-year-old female patient with pancreatitis. (a) Axial CT image shows a peripancreatic fluid collection (arrows) that extends caudad in the abdomen and pelvis, in a location in which percutaneous drainage is indicated only for an infected abscess. Because pancreatitis may cause fever, leukocytosis, and peripancreatic fluid accumulation even without the presence of infection, needle aspiration was performed and Gram stains were analyzed to determine whether complete drainage was necessary. (b) CT fluoroscopic image shows needle placement (arrows) in a retroperitoneal fluid collection in the paranephric space. Three other fluid collections (not shown) also were aspirated. Gram stains showed no white blood cells or organisms, and drainage therefore was unnecessary.

View larger version (140K): [in a new window]   Figure 14a.  Imaging-guidance drainage of multiple abscesses in a 10-year-old renal transplant patient with pancreatitis and bowel fistula. (a) Axial CT image shows two catheters placed in partially drained abscesses (arrows). (b) Axial CT image at a level caudad to a shows a third abscess that contains oral contrast material (arrows), a finding that signifies a bowel leak. (c) Sinogram helps confirm the communication of the abscess with the bowel and depicts a fistula (arrows) that is probably secondary to bowel wall digestion by pancreatic enzymes. Although pancreatic abscesses often communicate with the pancreatic duct, no contrast enhancement of the duct is evident in this case. The fistula healed after prolonged drainage (2 months), and surgery was avoided.

View larger version (146K): [in a new window]   Figure 14b.  Imaging-guidance drainage of multiple abscesses in a 10-year-old renal transplant patient with pancreatitis and bowel fistula. (a) Axial CT image shows two catheters placed in partially drained abscesses (arrows). (b) Axial CT image at a level caudad to a shows a third abscess that contains oral contrast material (arrows), a finding that signifies a bowel leak. (c) Sinogram helps confirm the communication of the abscess with the bowel and depicts a fistula (arrows) that is probably secondary to bowel wall digestion by pancreatic enzymes. Although pancreatic abscesses often communicate with the pancreatic duct, no contrast enhancement of the duct is evident in this case. The fistula healed after prolonged drainage (2 months), and surgery was avoided.

View larger version (146K): [in a new window]   Figure 14c.  Imaging-guidance drainage of multiple abscesses in a 10-year-old renal transplant patient with pancreatitis and bowel fistula. (a) Axial CT image shows two catheters placed in partially drained abscesses (arrows). (b) Axial CT image at a level caudad to a shows a third abscess that contains oral contrast material (arrows), a finding that signifies a bowel leak. (c) Sinogram helps confirm the communication of the abscess with the bowel and depicts a fistula (arrows) that is probably secondary to bowel wall digestion by pancreatic enzymes. Although pancreatic abscesses often communicate with the pancreatic duct, no contrast enhancement of the duct is evident in this case. The fistula healed after prolonged drainage (2 months), and surgery was avoided.

View larger version (116K): [in a new window]   Figure 15a.  Splenic abscesses in a 3-year-old female patient. (a) Axial T1-weighted MR image shows a large fluid collection (straight arrows) with a small satellite abscess (curved arrows) anterior to it. (b) Axial T1-weighted MR image shows the positions of two catheters during drainage. Drained pus was found at laboratory analysis to contain Bartonella henselae, the organism associated with catscratch disease.

View larger version (108K): [in a new window]   Figure 15b.  Splenic abscesses in a 3-year-old female patient. (a) Axial T1-weighted MR image shows a large fluid collection (straight arrows) with a small satellite abscess (curved arrows) anterior to it. (b) Axial T1-weighted MR image shows the positions of two catheters during drainage. Drained pus was found at laboratory analysis to contain Bartonella henselae, the organism associated with catscratch disease.