Radiologic Management of Infected Fluid Collections

Variant: 1 Patient with right lower quadrant abdominal pain, fever, and leukocytosis for 7 days. Physical examination shows no peritoneal signs. CT scan shows a thin-walled fluid collection, greater than 3 cm, adjacent to the cecum, nonvisualization of the appendix, and an appendicolith. Imaging findings are highly suspicious for appendicitis. Treatment includes antibiotics.

Procedure	Appropriateness Category
Percutaneous catheter drainage only	Usually Appropriate
Percutaneous catheter drainage followed by delayed surgery	Usually Appropriate
Needle aspiration	May Be Appropriate
Surgical drainage	May Be Appropriate
Conservative management only	Usually Not Appropriate

Variant: 2 Patient with a history of left hemicolectomy 2 months ago for colon carcinoma. Two weeks after placement of a drain into an abdominal abscess; the patient presents with abdominal pain and fever. Drain output is 25 cc per day and the collection is unchanged in size by CT. Treatment includes antibiotics.

Procedure	Appropriateness Category
Catheter upsizing	Usually Appropriate
Intracavitary thrombolytic therapy and drainage	Usually Appropriate
Laparoscopic drainage	May Be Appropriate
Open surgical drainage	May Be Appropriate
Continued antibiotics and drainage (no change in care)	May Be Appropriate
Continued antibiotics and drain removal	Usually Not Appropriate

Variant: 3 Patient who is an intravenous drug abuser presents with fever and tachycardia and on imaging is found to have 2 noncommunicating splenic abscesses accessible percutaneously through a 1 cm rim of normal splenic tissue. Treatment includes antibiotics.

Procedure	Appropriateness Category
Percutaneous catheter drainage only	Usually Appropriate
Splenectomy	Usually Appropriate
Needle aspiration	May Be Appropriate
Conservative management only	Usually Not Appropriate

Variant: 4 Patient with abdominal pain radiating to the back 5 weeks after hospitalization for acute pancreatitis. Afebrile. CT scan shows a walled-off collection in the body of the pancreas indenting a broad portion of the body of the stomach, affecting the gastric outlet. The collection is percutaneously accessible with a 3-cm window. MR cholangiopancreatography shows a patent pancreatic duct.

Procedure	Appropriateness Category
Endoscopic cystgastrostomy	Usually Appropriate
Percutaneous catheter drainage only	May Be Appropriate
Surgical cystenterostomy	May Be Appropriate
Percutaneous needle aspiration	May Be Appropriate
Conservative management only	Usually Not Appropriate

Variant: 5 Patient with a 2 week history of cough, fever, and foul-smelling sputum. Worsening condition despite a full course of broad-spectrum antibiotics. Sputum cultures negative. CT scan shows a right lower lobe abscess. Treatment includes antibiotics.

Procedure	Appropriateness Category
Percutaneous catheter drainage only	May Be Appropriate
Surgery	May Be Appropriate
Another course of antibiotics and postural drainage	May Be Appropriate (Disagreement)
Needle aspiration	Usually Not Appropriate

Variant: 6 Patient with a 3 week history of pneumonia, fever, dyspnea. Worsening condition despite a full course of broad-spectrum antibiotics. CT scan shows a loculated pleural collection with overlying pleural thickening (empyema). Treatment includes antibiotics.

Procedure	Appropriateness Category
Percutaneous catheter drainage with administration of thrombolytic therapy	Usually Appropriate
Video-assisted thoracic surgery decortication	Usually Appropriate
Open decortication	May Be Appropriate
Needle aspiration	Usually Not Appropriate
Another course of antibiotics and postural drainage	Usually Not Appropriate

Variant: 7 Woman of childbearing age with abdominal pain, fever, and leukocytosis. Marked tenderness on pelvic examination. CT scan shows a walled-off, probable tubo-ovarian abscess (TOA) greater than 3 cm. Treatment includes antibiotics.

Procedure	Appropriateness Category
Transabdominal percutaneous catheter drainage	Usually Appropriate
Transgluteal percutaneous catheter drainage	Usually Appropriate
Transrectal percutaneous catheter drainage	Usually Appropriate
Transvaginal percutaneous catheter drainage	Usually Appropriate
Transabdominal needle aspiration	May Be Appropriate
Transgluteal needle aspiration	May Be Appropriate
Transrectal needle aspiration	May Be Appropriate
Transvaginal needle aspiration	May Be Appropriate
Conservative management only	May Be Appropriate
Endoscopic US-guided drainage	May Be Appropriate
Surgical/laparoscopic drainage	May Be Appropriate

Variant: 8 Patient with recent endoscopic retrograde cholangiopancreatography and sphincterotomy now with 3 weeks of worsening right upper quadrant pain, fever, jaundice, and malaise. CT scan reveals 2 liver abscesses greater than 3 cm. MRCP demonstrates no biliary obstruction or stones. Treatment includes antibiotics.

Procedure	Appropriateness Category
Percutaneous catheter drainage only	Usually Appropriate
Needle aspiration	May Be Appropriate
Percutaneous catheter drainage with conversion to percutaneous biliary drain	May Be Appropriate
Surgical management	May Be Appropriate
Continued conservative management	May Be Appropriate

Variant: 9 Patient presents to the emergency department with 5 days of progressive ankle swelling and 2 days of fever. An ultrasound was obtained given the diffuse soft-tissue swelling around the ankle which revealed a subperiosteal abscess. Treatment includes antibiotics.

Procedure	Appropriateness Category
Surgical drainage	Usually Appropriate
Needle aspiration	May Be Appropriate
Percutaneous catheter drainage only	May Be Appropriate
Continued conservative management	Usually Not Appropriate

Panel Members

Clifford R. Weiss, MD^a; Christopher R. Bailey, MD^b; Eric J. Hohenwalter, MD^c; Jason W. Pinchot, MD^d; Osmanuddin Ahmed, MD^e; Aaron R. Braun, MD^f; Brooks D. Cash, MD^g; Samir Gupta, MD^h; Charles Y. Kim, MDⁱ; Erica M. Knavel Koepsel, MD^j; Matthew J. Scheidt, MD^k; Kristofer Schramm, MD^l; David M. Sella, MD^m; Jonathan M. Lorenz, MDⁿ.

Summary of Literature Review

Introduction/Background

Overview of Diagnostic Imaging Options

Overview of Therapeutic Options

Discussion of Procedures by Variant

Variant 1: Patient with right lower quadrant abdominal pain, fever, and leukocytosis for 7 days. Physical examination shows no peritoneal signs. CT scan shows a thin-walled fluid collection, greater than 3 cm, adjacent to the cecum, nonvisualization of the appendix, and an appendicolith. Imaging findings are highly suspicious for appendicitis. Treatment includes antibiotics.

Variant 2: Patient with a history of left hemicolectomy 2 months ago for colon carcinoma. Two weeks after placement of a drain into an abdominal abscess; the patient presents with abdominal pain and fever. Drain output is 25 cc per day and the collection is unchanged in size by CT. Treatment includes antibiotics.

Variant 3: Patient who is an intravenous drug abuser presents with fever and tachycardia and on imaging is found to have 2 noncommunicating splenic abscesses accessible percutaneously through a 1 cm rim of normal splenic tissue. Treatment includes antibiotics.

Variant 4: Patient with abdominal pain radiating to the back 5 weeks after hospitalization for acute pancreatitis. Afebrile. CT scan shows a walled-off collection in the body of the pancreas indenting a broad portion of the body of the stomach, affecting the gastric outlet. The collection is percutaneously accessible with a 3-cm window. MR cholangiopancreatography shows a patent pancreatic duct.

Variant 5: Patient with a 2 week history of cough, fever, and foul-smelling sputum. Worsening condition despite a full course of broad-spectrum antibiotics. Sputum cultures negative. CT scan shows a right lower lobe abscess. Treatment includes antibiotics.

Variant 6: Patient with a 3 week history of pneumonia, fever, dyspnea. Worsening condition despite a full course of broad-spectrum antibiotics. CT scan shows a loculated pleural collection with overlying pleural thickening (empyema). Treatment includes antibiotics.

Variant 7: Woman of childbearing age with abdominal pain, fever, and leukocytosis. Marked tenderness on pelvic examination. CT scan shows a walled-off, probable tubo-ovarian abscess (TOA) greater than 3 cm. Treatment includes antibiotics.

Variant 8: Patient with recent endoscopic retrograde cholangiopancreatography and sphincterotomy now with 3 weeks of worsening right upper quadrant pain, fever, jaundice, and malaise. CT scan reveals 2 liver abscesses greater than 3 cm. MRCP demonstrates no biliary obstruction or stones. Treatment includes antibiotics.

Variant 9: Patient presents to the emergency department with 5 days of progressive ankle swelling and 2 days of fever. An ultrasound was obtained given the diffuse soft-tissue swelling around the ankle which revealed a subperiosteal abscess. Treatment includes antibiotics.

Summary of Highlights

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

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The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.