Abscess

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This article is about the medical condition. For the death metal band, see Abscess (band).
Abscess
Classification and external resources
Five day old Abscess.jpg
Five-day-old abscess. The black dot is a clogged hair follicle.
ICD-10 L02
ICD-9 682.9, 324.1
MedlinePlus 001353
MeSH D000038

An abscess (Latin: abscessus) is a collection of pus that has built up within the tissue of the body.[1] Signs and symptoms for those close to the skin include: redness, pain, warmth, and swelling that when pressed feels like it is fluid filled.[1] The area of redness often extends beyond the swelling.[2] Carbuncles and furuncles are types of abscess that often involves hair follicles with carbuncles being larger.[3]

They are usually caused by a bacterial infection.[4] Often many different types of bacteria are involved in a single infection.[2] In the United States and many other areas of the world the most common bacteria present is methicillin-resistant Staphylococcus aureus.[1] Rarely parasites can cause abscesses and this is more common in the developing world.[5] Diagnosis is usually made based on what it looks like and is confirmed by cutting it open.[1] Ultrasound imaging may be useful in cases in which the diagnosis is not clear.[1] In abscesses around the anus, computer tomography (CT) may be important to look for deeper infection.[5]

Standard treatment for most skin or soft tissue abscesses is cutting it open and drainage.[6] There does not appear to be any benefit from also using antibiotics in most people who are otherwise healthy.[1] A small amount of evidence supports not packing with gauze the cavity that remains after drainage.[1] Closing this cavity right after draining it rather than leaving it open may speed healing without increasing the risk of the abscess returning.[7] Sucking out the pus with a needle is often not sufficient.[1]

Skin abscesses are common and have become more common in recent years.[1] Risk factors include intravenous drug use with rates reported as high as 65% in this population.[8] In 2005 in the United States 3.2 million people went to the emergency department for an abscess.[9] In Australia around 13,000 people were hospitalized in 2008 for the disease.[10]

Signs and symptoms[edit]

An abscess

The main symptoms and signs of an abscess are redness, heat, swelling, pain and loss of function. Abscesses may occur in any kind of solid tissue but most frequently on skin surface (where they may be superficial pustules (boils) or deep skin abscesses), in the lungs, brain, teeth, kidneys and tonsils. Major complications are spreading of the abscess material to adjacent or remote tissues and extensive regional tissue death (gangrene). Abscesses in most parts of the body rarely heal themselves, so prompt medical attention is indicated at the first suspicion of an abscess. An abscess could potentially be fatal (although this is rare) if it compresses vital structures such as the trachea in the context of a deep neck abscess.[citation needed]

If superficial, abscesses may be fluctuant when palpated. This is a wave-like motion which is caused by movement of the pus inside the abscess.[11]

Causes[edit]

Risk factors for abscess formation include intravenous drug use.[12]

They are usually caused by a bacterial infection.[4] Often many different types of bacteria are involved in a single infection.[2] In the United States and many other areas of the world the most common bacteria present is methicillin-resistant Staphylococcus aureus.[1]

Rarely parasites can causes abscesses and this is more common in the developing world.[5] Specific parasites known to do this include: dracunculiasis and myiasis.[5]

Perianal abscess[edit]

Surgery of the anal fistula to drain an abscess treats the fistula and reduces likelihood of its recurrence and the need for repeated surgery.[13] There is no evidence that fecal incontinence is a consequence of this surgery for abscess drainage.[13]

Perianal abscesses can be seen in patients with for example inflammatory bowel disease (such as Crohn's disease) or diabetes. Often the abscess will start as an internal wound caused by ulceration, hard stool or penetrative objects with insufficient lubrication. This wound typically becomes infected as a result of the normal presence of feces in the rectal area, and then develops into an abscess. This often presents itself as a lump of tissue near the anus which grows larger and more painful with time. Like other abscesses, perianal abscesses may require prompt medical treatment, such as an incision and debridement or lancing.

Incisional abscess[edit]

An incisional abscess is one that develops as a complication secondary to a surgical incision. It presents as erythema and warmth at the margins of the incision with purulent drainage from it.[14] If the diagnosis is uncertain, the wound should be aspirated with a needle, with aspiration of pus confirming the diagnosis and availing for Gram stain and bacterial culture.[14]

Differential[edit]

Other conditions that can cause similar symptoms include: cellulitis, a sebaceous cyst and necrotising fasciitis.[5] Cellulitis typically also has an erythematous reaction, but does not confer any purulent drainage.[14]

Pathophysiology[edit]

An diagram of an abscess

An abscess is a defensive reaction of the tissue to prevent the spread of infectious materials to other parts of the body.

The organisms or foreign materials kill the local cells, resulting in the release of cytokines. The cytokines trigger an inflammatory response, which draws large numbers of white blood cells to the area and increases the regional blood flow.

The final structure of the abscess is an abscess wall, or capsule, that is formed by the adjacent healthy cells in an attempt to keep the pus from infecting neighboring structures. However, such encapsulation tends to prevent immune cells from attacking bacteria in the pus, or from reaching the causative organism or foreign object.

Diagnosis[edit]

Ultrasound image of breast abscess, appearing as a mushroom-shaped dark (hypoechoic) area

Abscesses must be differentiated from empyemas, which are accumulations of pus in a preexisting rather than a newly formed anatomical cavity.

For those with a history of intravenous drug use, an X-ray is recommended before treatment to verify that no needle fragments are present.[12] In this population if there is also a fever present infectious endocarditis should be considered.[12]

Treatment[edit]

The standard treatment for an uncomplicated skin or soft tissue abscess is opening and draining.[6] There does not appear to be any benefit from also using antibiotics in most cases.[1] A small amount of evidence did not find benefit from packing the abscess with gauze.[1]

Incision and drainage[edit]

Main article: Incision and drainage
Abscess five days after incision and drainage.
Abscess following curettage.

The abscess should be inspected to identify if foreign objects are a cause, which may require their removal. If foreign objects are not the cause, a doctor will incise and drain the abscess and prescribe painkillers and possibly antibiotics.[15]

Surgical drainage of the abscess (e.g., lancing) is usually indicated once the abscess has developed from a harder serous inflammation to a softer pus stage.

In critical areas where surgery presents a high risk, it may be delayed or used as a last resort. The drainage of a lung abscess may be performed by positioning the patient in a way that enables the contents to be discharged via the respiratory tract. Warm compresses and elevation of the limb may be beneficial for a skin abscess.

Antibiotics[edit]

Most people who have an uncomplicated skin abscess should not use antibiotics.[6] Antibiotics in addition to standard incision and drainage is recommended in persons with severe abscesses, many sites of infection, rapid disease progression, the presence of cellulitis, symptoms indicating bacterial illness throughout the body, or a health condition causing immunosuppression.[1] People who are very young or very old may also need antibiotics.[1] If the abscess does not heal only with incision and drainage, or if the abscess is in a place that is difficult to drain such as the face, hands, or genitals, then antibiotics may be indicated.[1]

In those cases of abscess which do require antibiotic treatment, Staphylococcus aureus bacteria is a common cause and an anti-staphylococcus antibiotic such as flucloxacillin or dicloxacillin is used. The Infectious Diseases Society of America advises that the draining of an abscess is not enough to address community-acquired methicillin-resistant Staphylococcus aureus (MRSA), and in those cases, traditional antibiotics may be ineffective.[1] Alternative antibiotics effective against community-acquired MRSA often include clindamycin, doxycycline, minocycline, and trimethoprim-sulfamethoxazole.[1] The American College of Emergency Physicians advises that typical cases of abscess from MRSA get no benefit from having antibiotic treatment in addition to the standard treatment.[6] If the condition is thought to be cellulitis rather than abscess, consideration should be given to possibility of strep species as cause that are still sensitive to traditional anti-staphylococcus agents such as dicloxacillin or cephalexin in patients able to tolerate penicillin. Antibiotic therapy alone without surgical drainage of the abscess is seldom effective due to antibiotics often being unable to get into the abscess and their ineffectiveness at low pH levels.

Culturing the wound is not needed if standard followup care can be provided after the incision and drainage.[6] Performing a wound culture is unnecessary because it rarely gives information which can be used to guide treatment.[6]

Packing[edit]

In North America, after drainage, an abscess cavity is often packed, perhaps with cloth, in an attempt to protect the healing wound. However, evidence from emergency medicine literature reports that packing wounds after draining causes pain to the person and does not decrease the rate of recurrence, bring more rapid healing, or lead to fewer physician visits.[16]

Primary closure[edit]

Closing an abscess right after draining it rather than leaving it open appears to speed healing without increase the risk of the abscess returning.[7] This may not apply to anorectal abscesses. While they heal faster there may be a higher rate of recurrence than those left open.[17]

Prognosis[edit]

Even without treatment they rarely result in death as they will naturally burst through the skin.[5]

Epidemiology[edit]

Skin abscesses are common and have become more common in recent years.[1] Risk factors include intravenous drug use with rates reported as high as 65% in this population.[8] In 2005 in the United States 3.2 million people went to the emergency department for an abscess.[9] In Australia around 13,000 people were hospitalized in 2008 for the disease.[10]

Society and culture[edit]

The Latin medical aphorism "ubi pus, ibi evacua" expresses "where there is pus, there evacuate it" and is classical advice in the culture of Western medicine.

Needle exchange programmes often administer or provide referrals for abscess treatment to injection drug users as part of a harm reduction public health strategy.[18][19]

Etymology[edit]

The word is believed to have originated from the Latin: carbunculus, originally a small coal; diminutive of carbon-, carbo: charcoal or ember, but also a carbuncle stone, "precious stones of a red or fiery colour", usually garnets.[20]

Monstrous carbuncle[edit]

In 1984 Charles, Prince of Wales famously described the proposed Sainsbury Wing extension to the National Gallery in London as a "monstrous carbuncle on the face of a much-loved and elegant friend",[21] a term now widely used to describe architecture, particularly modernist architecture, unsympathetic to its surroundings.[22][23]

Other types[edit]

The following types of abscess are listed in the medical dictionary:[24]

  • acute abscess
  • alveolar abscess
  • amebic abscess
  • apical abscess
  • apical periodontal abscess
  • appendiceal abscess
  • Bartholin abscess
  • Bezold abscess
  • bicameral abscess
  • bone abscess
  • Brain abscess
  • Brodie abscess
  • bursal abscess
  • caseous abscess
  • Caseous lymphadenitis
  • cheesy abscess
  • cholangitic abscess
  • chronic abscess
  • cold abscess
  • crypt abscesses
  • dental abscess
  • diffuse abscess
  • Douglas abscess
  • dry abscess
  • Dubois abscesses
  • embolic abscess
  • fecal abscess
  • follicular abscess
  • gas abscess
  • gingival abscess
  • gravitation abscess
  • gummatous abscess
  • Hidradenitis suppurativa
  • hematogenous abscess
  • hot abscess
  • hypostatic abscess
  • ischiorectal abscess
  • lateral alveolar abscess
  • lateral periodontal abscess
  • mastoid abscess
  • metastatic abscess
  • migrating abscess
  • miliary abscess
  • Munro abscess
  • orbital abscess
  • otitic abscess
  • palatal abscess
  • pancreatic abscess
  • parafrenal abscess
  • parametric abscess
  • paranephric abscess
  • parapharyngeal abscess
  • parotid
  • Pautrier
  • pelvic
  • perforating
  • periapical
  • periappendiceal
  • periarticular
  • pericemental
  • pericoronal abscess
  • perinephric
  • periodontal abscess
  • perirectal
  • peritonsillar abscess
  • periureteral abscess
  • periurethral abscess
  • phlegmonous abscess
  • Pott abscess
  • premammary abscess (including subareolar abscess)
  • psoas abscess
  • pulp abscess
  • pyemic abscess
  • radicular abscess
  • residual abscess
  • retrobulbar abscess
  • retrocecal abscess
  • retropharyngeal abscess
  • ring abscess
  • root abscess
  • satellite abscess
  • septicemic abscess
  • stellate abscess
  • stercoral abscess
  • sterile abscess
  • stitch abscess
  • subdiaphragmatic abscess
  • subepidermal abscess
  • subhepatic abscess
  • subperiosteal abscess
  • subphrenic abscess
  • subungual abscess
  • sudoriferous abscess
  • suture abscess
  • thymic abscesses
  • Tornwaldt abscess
  • tropical abscess
  • tuboovarian abscess
  • verminous abscess
  • wandering abscess
  • worm abscess

References[edit]

  1. ^ a b c d e f g h i j k l m n o p q r Singer, Adam J.; Talan, David A. (Mar 13, 2014). "Management of skin abscesses in the era of methicillin-resistant Staphylococcus aureus". The New England Journal of Medicine 370 (11): 1039–47. doi:10.1056/NEJMra1212788. PMID 24620867. 
  2. ^ a b c Elston, Dirk M. (2009). Infectious Diseases of the Skin.. London: Manson Pub. p. 12. ISBN 9781840765144. 
  3. ^ Marx, John A. Marx (2014). "Dermatologic Presentations". Rosen's emergency medicine : concepts and clinical practice (8th ed. ed.). Philadelphia, PA: Elsevier/Saunders. pp. Chapter 120. ISBN 1455706051. 
  4. ^ a b Cox, Carol Turkington, Jeffrey S. Dover ; medical illustrations, Birck (2007). The encyclopedia of skin and skin disorders (3rd ed. ed.). New York, NY: Facts on File. p. 1. ISBN 9780816075096. 
  5. ^ a b c d e f Marx, John A. Marx (2014). "Skin and Soft Tissue Infections". Rosen's emergency medicine : concepts and clinical practice (8th ed. ed.). Philadelphia, PA: Elsevier/Saunders. pp. Chapter 137. ISBN 1455706051. 
  6. ^ a b c d e f American College of Emergency Physicians, Five Things Physicians and Patients Should Question, Choosing Wisely: an initiative of the ABIM Foundation (American College of Emergency Physicians), retrieved January 24, 2014 
  7. ^ a b Singer, Adam J.; Thode, Henry C., Jr; Chale, Stuart; Taira, Breena R.; Lee, Christopher (May 2011). "Primary closure of cutaneous abscesses: a systematic review". The American Journal of Emergency Medicine 29 (4): 361–6. doi:10.1016/j.ajem.2009.10.004. PMID 20825801. 
  8. ^ a b Langrod, Pedro Ruiz, Eric C. Strain, John G. (2007). The substance abuse handbook. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. p. 373. ISBN 9780781760454. 
  9. ^ a b Taira, BR; Singer, AJ; Thode HC, Jr; Lee, CC (Mar 2009). "National epidemiology of cutaneous abscesses: 1996 to 2005.". The American journal of emergency medicine 27 (3): 289–92. doi:10.1016/j.ajem.2008.02.027. PMID 19328372. 
  10. ^ a b Vaska, VL; Nimmo, GR; Jones, M; Grimwood, K; Paterson, DL (Jan 2012). "Increases in Australian cutaneous abscess hospitalisations: 1999-2008.". European journal of clinical microbiology & infectious diseases : official publication of the European Society of Clinical Microbiology 31 (1): 93–6. doi:10.1007/s10096-011-1281-3. PMID 21553298. 
  11. ^ Churchill Livingstone medical dictionary. (16th ed.). Edinburgh: Churchill Livingstone. 2008. ISBN 9780080982458. 
  12. ^ a b c Khalil, PN; Huber-Wagner, S; Altheim, S; Bürklein, D; Siebeck, M; Hallfeldt, K; Mutschler, W; Kanz, GG (Sep 22, 2008). "Diagnostic and treatment options for skin and soft tissue abscesses in injecting drug users with consideration of the natural history and concomitant risk factors.". European journal of medical research 13 (9): 415–24. PMID 18948233. 
  13. ^ a b Malik, Ali Irqam; Nelson, Richard L; Tou, Samson; Malik, Ali Irqam (2010). "Incision and drainage of perianal abscess with or without treatment of anal fistula". doi:10.1002/14651858.CD006827.pub2. 
  14. ^ a b c Duff, Patrick (2009). "Diagnosis and Management of Postoperative Infection". The Global Library of Women's Medicine. doi:10.3843/GLOWM.10032. ISSN 1756-2228. 
  15. ^ Green, James; Saj Wajed (2000). Surgery: Facts and Figures. Cambridge University Press. ISBN 1-900151-96-0. 
  16. ^ Bergstrom, KG (Jan 2014). "News, views, and reviews. Less may be more for MRSA: the latest on antibiotics, the utility of packing an abscess, and decolonization strategies.". Journal of drugs in dermatology : JDD 13 (1): 89–92. PMID 24385125. 
  17. ^ Kronborg O, Olsen H (1984). "Incision and drainage v. incision, curettage and suture under antibiotic cover in anorectal abscess. A randomized study with 4-year follow-up". Acta Chirurgica Scandinavica 150 (8): 689–92. PMID 6397949. 
  18. ^ Tomolillo, CM; Crothers, LJ; Aberson, CL (2007). "The damage done: a study of injection drug use, injection related abscesses and needle exchange regulation.". Substance Use & Misuse 42 (10): 1603–11. doi:10.1080/10826080701204763. PMID 17918030. 
  19. ^ Fink, DS; Lindsay, SP; Slymen, DJ; Kral, AH; Bluthenthal, RN (May 2013). "Abscess and self-treatment among injection drug users at four California syringe exchanges and their surrounding communities.". Substance Use & Misuse 48 (7): 523–31. doi:10.3109/10826084.2013.787094. PMID 23581506. 
  20. ^ OED, "Carbuncle": 1) stone, 3) medical
  21. ^ "A speech by HRH The Prince of Wales at the 150th anniversary of the Royal Institute of British Architects (RIBA), Royal Gala Evening at Hampton Court Palace". Retrieved 2007-06-16. 
  22. ^ "Prince's new architecture blast". BBC News. 2005-02-21. Retrieved 2007-06-16. 
  23. ^ "No cash for 'highest slum'". BBC News. 2001-02-09. Retrieved 2007-06-16. 
  24. ^ "Abscess". Medical Dictionary - Dictionary of Medicine and Human Biology. Retrieved 2013-01-24. 

External links[edit]