ABSCESS (Latin abscessus — abscess; synonym: abscess, apostema) — the delimited accumulation of pus in various fabrics and bodies. Abscess should be distinguished from empyemas (see) — accumulations of pus in perigastriums and hollow bodies — and phlegmons (see) — a diffuse purulent inflammation of fabrics.
The etiology and a pathogeny
the Main causative agent of a purulent infection is staphylococcus in the form of a monoculture or in association with other microbes (colibacillus, proteas, a streptococcus and dr).
Most often the contagium gets from the outside (an exogenous infection) though take place and cases of an endogenous infection. The drift of an infection from the next or remote bodies is possible: dontogenous And.; couple - and peritonsillar And.; subphrenic And. — in the presence of the centers of a purulent inflammation in bodies of a chest cavity; metastatic And. lungs, brain, kidneys and some other. Hit of some chemicals (e.g., kerosene) in fabric leads to development so-called aseptic And., if the infection is not implemented into a zone of the arisen necrosis. Reason And. there can be an introduction to fabrics of strong solutions of medicinal substances — 25% of solution of magnesium sulfate, Cordiaminum etc.
Vaccines of poliomyelitis and even antibiotics are known a case of development of Abscess in children after administration of diphtheritic, scarlatinal anatoxins. Pathogenetic factor of development And. various localizations, as a rule, is purulent inflammation (see), a cut leads to fusion of fabrics and sometimes to a necrosis and rejection of devitalized fabrics — sequestration. The formed fabric sequesters are in a cavity And. also can be exposed further to enzymatic fusion (see. Sequester, sequestration ).
Feature of Abscess as the delimited purulent process is existence of a piogenic membrane — the internal wall of an abscess covered by granulyatsionny fabric. The piogenic cover delimits is purulent - necrotic process and produces exudate. Ability of surrounding fabrics to create a granulyatsionny cover is manifestation of the normal defense reaction of an organism directed to isolation of purulent process. This manifestation of nonspecific reactivity, edge is defined by a normality of physiological systems of a healthy organism. In the presence of a serious illness (a nutritional dystrophy, avitaminosis, a diabetes mellitus, malignant tumors, etc.) ability of an organism to delimit a purulent inflammation by creation of a granulyatsionny shaft is broken and the piogenic membrane has discontinuous character or is not formed at all (I. V. Davydovsky, 1969). In these cases of a full otgranicheniye of process does not occur, and it accepts diffuse character.
The pathological anatomy
Abscess always arises or in already died fabrics in which microbic chemical processes of an autolysis (e.g. accrue, at an injury), or in the living tissues which are exposed to strong microbic influence (e.g., at infections). On character of a current And. can be acute and chronic.
In an initial stage of formation Abscess infiltrirutsya by inflammatory exudate and leukocytes the limited site of fabric. Gradually under the influence of enzymes of leukocytes fabric is exposed to fusion, and the cavity filled with purulent exudate is formed. The shape of a cavity can be both simple roundish, and difficult, with numerous pockets.
Walls And. in an early stage of its formation are covered it is purulent - fibrinous imposings and scraps of nekrotizirovanny fabrics. Further on the periphery And. the zone of a demarcation inflammation develops, the infiltrate making it forms a basis for formation of the piogenic membrane forming a wall of a cavity (fig. 1). The piogenic membrane represents a layer of granulyatsionny fabric rich with vessels. Gradually in that its part, edges it is turned towards people around And. fabrics, there is a maturing of granulations. Thus, if And. gets a chronic current, in a piogenic membrane two layers are formed: internal, turned into a cavity and consisting of granulations, and outside, formed by mature connecting fabric (fig. 2).
In various bodies Abscesses have the nek-ry features reflecting an originality of a structure and function of these bodies. So, at And. a liver in its contents there is an impurity of bile; there are sites of epithelization of a piogenic membrane.
And., as a rule, comes to an end with spontaneous emptying and an exit of pus to a body surface, in hollow bodies or in a perigastrium. Break And. on a body surface or in hollow body on condition of good drainage of a purulent cavity and lack of the cicatricial capsule quite often leads to elimination of a cavity And. by scarring. Rather seldom And. is exposed to encapsulation. At the same time pus is condensed, crystals of cholesterol, drop out around And. the thick cicatricial capsule containing ksantomny cells is formed. Sometimes And., arising around zooparasites, petrifications are exposed.
If the message of Ampere-second a body surface is not enough or there are other reasons interfering fall of walls of a cavity And., after its emptying forms fistula (see) — the narrow channel covered by granulyatsionny fabric or an epithelium which connects a cavity of Ampere-second a body surface or to a gleam of hollow body. Fistula often arises when in a cavity And. foreign bodys or sequesters contain.
At some diseases owing to features of pus it can actively melt surrounding fabrics, extend on interfabric cracks and accumulate in the places remote from primary localization And., e.g. so-called cold And. (natechnik) characteristic of tuberculosis who can be also emptied through the fistular courses.
A clinical picture
the Abscesses Formed as a result of a purulent or aseptic inflammation have various outcome: spontaneous opening with break outside (And. hypodermic cellulose, muscular And., mastitis, paraproctitis, etc.); break and emptying in the closed cavities (belly, pleural, in a cavity of joints etc.); break of an abscess in a cavity of the bodies which are reported with external environment (in a cavity of a gut, a stomach, a bladder, bronchial tubes, etc.). The emptied cavity And. under favorable conditions decreases in sizes, it is fallen down and thanks to the active proliferative phenomena is exposed to scarring. At incomplete emptying and bad drainage of a cavity of L. process can pass in chronic with education is long not healing fistula on site of A. Proryv's breakthrough of pus in the closed cavities leads to development of widespread purulent processes (peritonitis, pleurisy, a pericardis, meningitis, arthritis etc.) with a heavy current and the forecast.
At superficially located acute Abscesses local manifestations are characterized by classical signs of an inflammation (redness, a swelling, pain, local temperature increase, dysfunction), it is possible to define zybleniye (see). The inflammatory phenomena can occupy various space and depth depending on the size A. and its localizations. Character pus (see), contained in a cavity And. (a consistence, color, a smell), is defined by a type of an infection: the fetid smell, dirty-gray color of pus are characteristic of putrefactive flora; dense flavovirent pus — for staphylococcus; blue-green color and a sweetish smell — for a stick of blue-green pus etc. At chronic And. the general and local symptoms are a little expressed. And. a tubercular etiology are characterized by a stertost of the general manifestations and small expressiveness of local fabric reaction (cold And.). At And. a tubercular origin pus quite often spreads on interfabric cracks far from the place of initial emergence (e.g., to retroperitoneal cellulose and to the medial surface of a hip at a tubercular spondylitis), forming congestive And. (see. Natechnik ).
The general clinical displays of Abscess have no specific characters and are typical for pyoinflammatory processes of any localization. Expressiveness of the general symptoms is defined by a condition of a macroorganism, virulence of microflora, extensiveness of the local inflammatory phenomena, depth and prevalence of necrotic changes in the center of an inflammation. They come down to fervescence from subfebrile figures to 41 ° in hard cases, to a febricula, weakness, loss of appetite, a headache.
In peripheral blood the leukocytosis - to 20 000 and more with a neutrocytosis and a deviation to the left is noted. ROE is, as a rule, accelerated. Extent of these changes depends on weight of a course of pathological process.
At a heavy current of Ampere-second difficulties in clarification of the reasons defining weight of a condition of the patient arise dominance of the phenomena of intoxication sometimes. Such state can be caused as absorption of toxic products from the center of defeat (see. Is purulent - resorptive fever ), and generalization of an infection. The issue is usually resolved by comparison of the local and general phenomena. Compliance of temperature reaction and hematologic shifts of expressiveness of local is purulent - necrotic process specifies on is purulent - resorptive fever; in these cases the general frustration disappear with elimination of the center of an infection. At sepsis heavy intoxication and changes from internals are usually not adequate to local changes, and symptoms of heavy intoxication do not disappear with elimination of the center.
Clinical displays of Abscesses of various bodies have the, caused by localization, specific characters (And. lung, liver, postpharyngeal, subphrenic, interintestinal, etc.). And. it is necessary to differentiate from hematomas (see), cysts (see), the breaking-up tumors. The diagnostic puncture is of great importance. Receiving pus at a puncture, in addition to establishment of the diagnosis in doubtful cases, allows to conduct a bacteriological research — allocation of the activator and definition of its sensitivity to antibiotics. It is especially important in modern conditions with a big frequency of antibiotikorezistentny forms of microflora since rational causal treatment is impossible without knowledge of a type of the activator and its sensitivity to antibiotics.
In the presence of gas-forming flora in a cavity And. gas — gas can be formed and accumulate And. Availability of gas facilitates as clinical diagnosis — emergence of a tympanic sound at percussion over area A. (tympanitis apostematica), and radiological; in pictures in a cavity And. the vial of gas and horizontal level of pus under it is defined (it is the most frequent in And. around foreign bodys and in the bullet wounds complicated by a putrefactive infection). Other radiological signs And. — pathological blackout and shift or deformation of the next anatomic educations.
Diagnosis And. is the indication for an operative measure, the purpose to-rogo irrespective of localization of process is opening of an abscess, emptying and drainage of his cavity.
Are not subject to opening cold And. a tubercular etiology owing to the superinfection which is inevitably arising at the same time pyogenic flora. The applied earlier puncture method of treatment of a row superficially located And. (e.g., mastitis) was not repaid since this method leads to massive development of cicatricial fabric and encapsulation of the infected contents.
A puncture of Abscess with aspiration of pus and the subsequent introduction to a cavity And. antibiotics, fermental drugs it can be applied only according to strict indications, at certain localizations And. (e.g., transparietal punctures nedropiruyemy through a bronchial tube And. lung).
Resection of body (e.g., a lung) together with And. as the radical method of treatment is applied only at chronic And.
At created And. a brain with the well-marked capsule removal can be applied And. together with its capsule.
Operation of the opening which is superficially located And. it is carried out under a local infiltration anesthesia of 0,25% or 0,5% solution of novocaine or a short-term intravenous anesthesia (Sombrevinum, Epontolum, thiopental of sodium). Freezing by Aether chloratus, as a rule, shall not be applied. During the opening And. internals the endotracheal anesthesia is shown.
For opening of Abscess choose the shortest quick access taking into account anatomic features and topography of body. For this purpose quite often apply a method of opening And. on a needle. Originally punktirut And., then on a needle cut fabrics. During the opening of an abscess whenever possible approach its lower pole to create good conditions for drainage.
For the purpose of reduction of infection of a surgery field carefully isolate gauze napkins the site of body where it is supposed to open an abscess, and, having made a small opening in a wall And., delete pus with a suction machine. Aspirirovav pus, a section expand, the remained pus and necrotic fabrics delete. If the abscess cavity is extensive, it is inspected a finger, dividing the available crossing points, delete sequesters of fabrics. It is necessary to avoid the rough manipulations breaking a piogenic membrane, the Cavity And. wash out antiseptic solution. As a rule, pt need for a stop of bleeding since the vessels located in a zone of an inflammation are thrombosed. Cavity And. drain one or several rubber or polyethylene tubes and enter into it the gauze tampons moistened with solution of proteolytic enzymes, solutions of purposeful antibiotics. At insufficiency of emptying through the main section do counteropening (see). Technology of opening And. internals — see articles about appropriate authorities.
Treatment of Abscesses after their opening is carried out by the principle of treatment of purulent wounds taking into account staging of a current of a wound process (see. Wounds, wounds ). As soon as the wound is cleared of pus and necrotic fabrics and there will be granulations, pass to seldom changed salve dressings.
Topical administration of antibiotics at postoperative treatment And. it is inexpedient; their efficiency considerably decreases availability of necrotic fabrics and pus in a wound.
Use of means of physical antiseptics promotes only removal of the melted necrotic fabrics and the liquefied pus, fusion is made under the influence of the proteolytic enzymes which are formed in a wound. Therefore use of proteolytic enzymes in postoperative treatment And. various localization or in treatment And., drained in natural ways (e.g., acute And. a lung, drained through a bronchial tube), is effective. Use of an enzymatic necrolysis by the developed techniques (V. I. Struchkov, And. V. Grigoryan, etc., 1970) by 1,5 — 2 times reduces terms of treatment of patients, and at chronic And. a lung increases efficiency of preoperative preparation. Enzymotherapy creates favorable conditions for use of early secondary seams on the granulating wounds, including and the openings formed later And.
The general treatment includes the strengthening therapy, hemotransfusions, plasmas etc., use of antibiotics taking into account sensitivity of microbic flora, use of means of specific therapy (immunization by staphylococcal anatoxin, use of specific gamma-globulin). At the Abscesses which developed against the background of a diabetes mellitus it is necessary for correction of the broken metabolism. Treatment of Abscesses of interiors and Abscesses of various areas of a body — see the relevant articles (e.g., Brain , Douglas abscess , Retropharyngeal abscess , Subphrenic abscess , Kidneys etc.).
Bibliography: Davydovsky I. V. General pathology of the person, M., 1969, bibliogr.; Strukov A. I. and Kodolova I. M. Chronic nonspecific diseases of lungs. M. 1970; V. I Pods. Purulent surgery, M., 1067; V. I. Pods of ides of river. Proteolytic enzymes in purulent surgery, M., 1970, bibliogr.; F. G., Pugleev V. P. and Yakovlev A. M. corners. Complications at intrathoracic operations, L., 1966, bibliogr.; General pathology. ed. by L. Florey, p. 151, L., 1970; Handbuch der speziellen pathologlechcn Anatomie und Histologic, hrsg. v. F. Henke u. O. Lubarach, Bd 3, T. 1. S. 67 u. a., B., 1928.
V. K. Goyetshtsev; B.C. Spiders (stalemate. An.)