Q.how will you manage a TOA 9cm, with fever ,SIRS ?

Introduction

Complication of untreated PID (15% to 35%)

• Delay in treatment
• Virulent organism

Most common in women of reproductive age

Nulliparous 60%

Definition

1. Inflammatory mass
2. involving the tube and/or ovary
3. Occasionally involve bowel bladder
4. characterized by the presence of pus

Mortality (in severe sepsis) 5-10%

Aetiology

Polymicrobial 30-40%

1. Ascending/upper genital tract infection →pus discharge in to peritoneal cavity through tubes →PID →TOA
2. 2ry to other intra-abdominal pathology-Appendicitis , Diverticulitis ,Pyelonephritis
3. Direct spread,
4. Hematogenous spread

• STD-GC, Chlamydia, BV( GV,Pepto strepto coccus),
• E.coli, Hib
• TB-Mycoplasma tuberculosis, genitalium
• IUCD-Actinomyces
• Anaerobes-bacteroids
• GAS-Strep Pyo
• GBS-Strep Agalacties-GBS

Risk factors

1. Age:>45 years more severe,
   1. Paradoxically Risk factors more in younger age
2. Previous episode of PID –delay in treatment, virulence of the organism IUCD
3. Sex
   1. Early onset
   1. Non-use of barrier contraception Earlier age at first sexual intercourse
   1. Multiple sexual partners
4. Immune
   1. Diabetes
   1. Immunocompromised states
5. Co-existing endometriosis ( eg more risk after OR for IVF: however routine Ab prophylaxis not indicated):theories Immune dysfunction. walls of endometriomas more susceptible for bac invasion than ovary cortex, blood act as good culture media
6. OR  in IVF introduce infection

Diagnosis

Clinical+ inflammatory +radiological markers

DD

Gyn	Non Gyn
Endometrioma or other ovarian cyst malignancy Ectopic pregnancy	Appendicular massDiverticulitis

Hx

1. Fever +Diarrhea( TOA suggestive than PID)
2. Abdominal/pelvic pain
3. LOA
   Vaginal discharge

• Presence/absence of risk factors
• Fertility wish

In severe cases

Tachycardia ,RR increases ,Low BP, High lactate So

— TOA more likely than PID

Ex

1. Pyrexia
2. Adnexal tenderness (bilateral or unilateral)
3. Adnexal mass on abdominal palpation/bimanual examination

SE/VE

• Cervical discharge
• Cervical excitation

Ix

In all	Ill patients
HCG in all reproductive age
Blood WBC Elevated WBC >15( higher than PID)Elevated ESR ( higher than PID)Elevated CRP( with clinical signs :most sensitive predictor TOA) Swabs– vaginal , rectal, urethral Positive Neisseria gonorrhoeae and/or Chlamydia trachomatis testsConsider HIV and other STI testing	Consider blood culture,CVS-lactate ,MAPRS- SpO2Coag- INR

TOA more suggestive than PID- diarhrhea, Mass, CRP,  WBC, ESR, USS cog wheel

 

Imaging

USS

First line imaging to guide diagnosis and treatment

Mass	complex /solid and cystic adnexal mass ( when withour pyrexia consider CA)
Tube:	Pyosalpinx-elongated, dilated, fluid filled mass with partial septae and thick walls
	Cogwheel sign( tube)-sensitive marker of TOA: pathognomonic of acute tubal inflammation
Ovary	Tubovarian complex ovary  =PCO appearance with adhered tube
Uterus	Enlarged uterus with ill defined margins and endometrium
FF	Echogenic complex FF

“Cogwheel sign”- thickened endosalpingeal folds (pathognomonic of acute tubal inflammation)

Tubo-ovarian complex-inflammed ovary can acquire a reactive polycystic appearance because of oedema and adhere to tube to ovary. Lies in the D VS tumors which lie anterior superior to uterus

CT

• Adv:
• If USS is inconclusive or symptoms suggest other pathology
• Can see
  • Details
  • anteriorly displaced mesosalphinx
  • septated tubal mass,
  • thick peritoneum,
  • thick uterosacrals( DD-endometriosis),
  • hazy pelvic fat
• rectosigmoid involvement, ureter involvement( HU/HN)
• Help to refine the diagnosis
  • Origin: Can see GI origin ,
  • ovarian vein entering TOA sensitivity 94%, sp 100%( VS appendicular abcess),
  •  gas inside suggest bowel pathology eg.appendicular abcess,
• Disadv: delay in treatment

MRI

• Adv: Less radiation, higher sen 95%  spe 89% than USS, good for pregß
• Diadv: More limited resource/not readily available/accessible

Management

MDT-CA, micro, radiology, venerology

HDU if ill

Initial management

• Admit and commence IV antibiotics
• Exclude systemic sepsis
• If +, “Sepsis Six” protocol

BUFALO

1. Blood cultures
2. Monitor UOP
3. IV fluids
4. IV broad spectrum antibiotics
5. Measure serum Lactate
6. High flow O2

If acute abdomen :may need immediate surgery

Do Quick assestment AMPLE FS, RF

Definitive management :

depends on stability, fertility wish, prev surgery, size of abcess, expertise

1. Medical
2. USS/CT guided drainage
3. Surgical -salphigo oophorectomy

1.Medical

• IV broad spectrum antibiotics
• Ability to penetrate the abscess cavity
• Remain active within the abscess
• Be active against commonest pathogens

(IV clindamycin, metronidazole ,cefoxitin penetrate, active in abcess and reduce size)

Regimes

Duration

• Evidence is lacking
• Wait for 24 -48 hours to respond
• With Clinical improvement (70%), settling of pyrexiaàchange to oral and continue for 14 days , modify according to cultures
• Longer course needed- large abscess, after a gynecological intervention

Predictors of lack of response to medical therapy

1. Size of abscess (>5cm)
2. Age>40years
3. Higher initial white cell count
4. Smoking

2.USS/CT guided drainage

1. Rapid symptom improvement,
2. resolution of pyrexia,
3. decreased length of hospital stay
4. Minimally invasive and well tolerated
5. Avoids risks associated with surgery and anaesthesia resolution with aspiration alone 88%
6. Specimen for culture
7. Disadv: High recurrence rate

Routes

1. Transabdominal
2. Transvaginal
3. Transrectal
4. Trans gluteal

USS guided aspiration	Catheter placement  Indications
Small, single abscess with clear fluids	Larger, bilateral, multiloculated abscess with thick viscous material

3.Surgical

Indications

1. Failure to respond to antibiotics 24 to 48 hours
2. Acute abdomen with rupture of abscess is suspected
3. Rapid clinical deterioration
4. Chronic Abcess , >8cm
5. Consider at low threshold for post menopausal due to risk of malignancy 47%( TOA in PM is rare 1.7%)

Role of diagnostic laparoscopy:

• Mild PID endometritis, salpingitis: subtle changes may miss on laparoscopy.
• If patient stable no need to do diagnostic laparoscopy on all PID. Medical Rx will suffice

Options

1. Unilateral or bilateral Salpingo-oophorectomy ( no fertility wish)- Best
2. Drainage
3. Pelvic clearance ( more morbidity)

Routes (size of abscess, previous surgical history, fertility wishes, skills)

• Laparotomy
• Laparoscopy

	Laparotomy	Laparoscopy
indication	Previous significant abdominal surgery Large abscess Co-existing eg. IBD	Fertility wishes
Adv	thorough exploration of pelvis and bowelsThorough wash out of pelvis and abdomen with possible reduction in pus remnants Advances laparoscopic skills not required	Quicker recoverySmaller incisionsLess postoperative painMore fertility
concerns	Intra op AbPus swabPut a large drain: drain forming pusTechnical difficult: morbidity	No routine diagnostic laparoscopy

Technical difficulty

1. Fragile necrotic tissue –difficult to handle result in tissues collapsing and haemorrhaging
2. distorted anatomy :Oedema, thickened peritoneium- difficult to visualize and
3. adherent ureter, bladder, bowel àdamage, internal iliac arteryà lacerations

• Consider

1. Detailed consent
2. interval surgery after 6 weeks of acute episode eg, persistant adenexial mass

Post op-

1. Continue IV antibiotics and refine with the pus culture + ABST report
2. Look for ileus and manage ( irritation, catheter tip)
3. Monitoring
   1. 4 hourly observation,
   1. daily FBC and CRP,
   1. daily senior clinician review
   1. MEWS-vitals ,UOP
4. Drain :monitor
5. Counselling? Fertility à may need IVF
6. Treat partners to prevent reinfection
7. optimize nutrition: N/V/Appetite low
8. DVT prophylaxis( stockings, LMWH if repeat Surgery unlikely)
9. Fluctuating pyrexia –further imaging ( subphrenic, thoracic abcess)

Long term complications

Tissue damage, adhesions, scarring ,fistulae è SF, CPP, Ectopic

1. Chronic pelvic pain
2. One third of women with TOA
3. Related to severity and number of episodes
4. No change in medical or Sx Mx

• Subfertility

Laparoscopy and drainage ( better)	Medicle Antibiotics alone
Fertility 32-63%Laparoscopy should be considered for all who wish fertilityConsider salpingectomy or occlusion at surgery in preparation for IVF( liase with fertility team)	Fertility 4-15%

• Ectopic pregnancy

Special Circumstances-

Intrauterine devices

1. Relationship between IUCD and Actinomyces israelii ( multi abcess ,granulation tissue and fibrosis)
2. Well respond to penicillin
3. Removal is associated with better short-term clinical outcomes
4. Risk of pregnancy –need EC

Pregnancy TOA-

Fetal risk	Maternal
MiscarriagePreterm labour ChorioamnionitisIUD	Death

• Optimal treatment depends on severity of infection and gestational age
• Appendix abcess more common
• Ix-MRI to establish the diagnosis safe in pregnancy

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