Abscess

Overview of Abscess

• Abscess is a buildup of a pus that can affect any part of your body.
• They can occur on your skin, in your mouth or around your organs.
• Skin may look red and swollen.
• Bacterial infections usually cause pus formation in that area.
• Treatment often includes surgical intervention or Incision and drainage (I&D). (1) 

Causes 

• When our normal skin barrier is broken, even from minor trauma, or small tears, or inflammation, bacteria can enter the skin. An abscess can form as your body’s defences try to kill these germs with your inflammatory response (white blood cells = pus). Obstruction in a sweat or oil (sebaceous) gland, or a hair follicle or a pre-existing cyst can also trigger an abscess.  Chronic steroid therapy 
• Chemotherapy 
• Diabetes 
• Cancer 
• AIDS 
• Sickle cell disease 
• Peripheral vascular disorders 
• Crohn’s disease 
• Ulcerative colitis 
• Severe burns 
• Severe trauma (3)

Types of Abscess

1. Pyogenic: Commonest form of an abscess. It can be subcutaneous, deep or can occur within the viscera such as liver or kidney. In this chapter, pyogenic abscess refers to soft tissue abscess.
2. Pyaemic: Occurs due to circulation of pyaemic emboli in the blood (pyaemia).
3. Cold: Usually refers to tubercular abscess due to involvement of either lymph nodes or spine. (2)

Risk Factors of Abscess

• Diabetes Mellitus 
• Chemotherapy 
• Alcohol abuse 
• Poor hygiene habits 
• Poor blood circulation (6)

Pathogenesis of Abscess

Abscesses are localized collections of pus caused by suppuration buried in a tissue, an organ, or a confined space. They are produced by seeding of pyogenic bacteria into a tissue. Abscesses have a central region that appears as a mass of necrotic leukocytes and tissue cells.

There is usually a zone of preserved neutrophils around this necrotic focus, and outside this region there may be vascular dilation and parenchymal and fibroblastic proliferation, indicating chronic inflammation and repair.

In time, the abscess may become walled off by fibrous tissue. [9]

Pathophysiology of Abscess

• Pyogenic organisms, predominantly Staphylococcus aureus, cause tissue necrosis and suppuration.  
• Pus is composed of dead and dying white blood cells that release damaging cytokines, oxygen free radicals and other molecules.  
• It is surrounded by an acute inflammatory response and a pyogenic membrane composed of a fibrinous exudate and oedema and the cells of acute inflammation.  
• Granulation tissue (macrophages, angiogenesis and fibroblasts) forms later around the suppurative process and leads to collagen deposition.  
• If it is not drained or resorbed completely, a chronic abscess may result. If it is partly sterilised with antibiotics, an antibioma may form. (4)  

Clinical Features of Abscess

• Abscesses cause pain, fever, swelling, and erythema.
• The pain is often throbbing and tends to worsen until the abscess either ruptures or is drained.
• Cutaneous abscesses are fluctuant, tender, and often surrounded by a ring of cellulitis…
• Fever is almost always present with deeper abscesses, and rigors may occur. (10)

Sign and Symptoms  

• The patient feels ill and complains of throbbing pain at the site.  
• Throbbing pain is indicative of pus and is due to pressure on the nerve endings by the pus.  
• Fever, with or without chills and rigors, can be present. (2) 

Signs  

1. Calor-heat: The affected part is warmer due to local rise in temperature.
2. Rubor-redness: It is due to inflammation resulting in hyperaemia.
3. Dolor-pain: An abscess is extremely tender.
4. Tumour-swelling: It consists of pus. It is tensely cystic with surrounding brawny oedema.
5. Loss of function: The function of the part is impaired, due to pain.
6. Fluctuation: It can be elicited. However, in a deep-seated abscess it may be negative, as in breast . (2)

Clinical Examination

• When examined, Redness present over affected part with Swelling. 
• On touch there is sensation on heat present with pain. 

Diagnosis  of Abscess is Made upon:

• History 
• Signs & Symptoms 
• Clinical Examination 
• And Blood Culture. 

Clinically diagnosing an abscess typically involves a combination of: 

Medical history:

• Onset and duration of symptoms: Sudden and rapid progression of symptoms suggest a more acute infection. 
• Pain characteristics: Localized pain, tenderness, throbbing, or warmth are common. 
• There is Fever and chills: These may be present, especially with deeper abscesses. 
• Check for Drainage: Any history of pus drainage from the affected area is significant. 

Predisposing factors: Recent surgery, skin injuries, indwelling catheters, or weakened immune system increase the risk of abscess formation. 

Physical examination:

• Inspection: Look for swelling, redness, warmth, and tenderness in the suspected area. 
• Palpation: Gently feel for fluctuance, a collection of fluid that moves under pressure, which suggests an abscess. 
• Drainage: If it is pointing (nearing the surface) or fluctuant, gentle drainage with a sterile needle and syringe may be performed to obtain pus for culture and sensitivity testing. 

Imaging studies:

• Ultrasound is often the first choice for superficial abscesses due to its portability and lack of radiation. 
• CT scan: More detailed imaging for deeper abscesses or complex locations. 
• MRI scan: May be used in specific cases, like abscesses near the brain or spinal cord. 

Here are some additional points to consider: 

• The specific symptoms and presentation of an abscess can vary depending on its location and underlying cause. 
• Early diagnosis and treatment are important to prevent complications like cellulitis, sepsis, or spread of the infection. 
• Treatment typically involves drainage of the abscess and antibiotics to target the specific bacteria causing the infection. 

Differential Diagnosis of Abscess

• Ruptured aneurysm can present as subcutaneous abscess with pain, redness and local rise of temperature. There may be leukocytosis also. Ruptured vertebral artery aneurysm in the posterior triangle and popliteal artery aneurysm in the popliteal fossa have been incised, mistaking them for an abscess.
  • Caution: When in doubt, aspirate with a wide bore needle before incising an abscess.
• Soft tissue sarcoma in the thigh can be confused for a deep-seated abscess. However, throbbing pain, high grade fever with chills and rigors and short duration of the swelling clinches the diagnosis of an abscess. (2)

Complications of an abscess include

• Spread of infection to adjacent tissues, hematogenous dissemination to distant sites (e.g., brain, lung, liver, kidney), rupture, development of bacteremia and sepsis, and rarely, squamous cell carcinoma within a chronic abscess cavity. (11)

Investigations of Abscess

• Total count is increased.
• Urine sugar and blood sugar for rule out diabetes.
• USG of the part or abdomen or other region is done when required.
• Chest X-ray in case of lung it.
• Gallium isotope scan is very useful.
• CT scan or MRI is done in cases of brain and thoracic abscess.
• Investigations, relevant to specific types: Liver function tests, PO2 and PCO2 estimation, blood (7)

Treatment of Abscess

• Untreated abscess tends to point spontaneously along the area of least resistance to the nearest epithelial surface, e.g. skin, gut, oral cavity. However, deep-seated abscess such as breast abscess may cause much tissue destruction before pointing. 
• Incision and drainage (I&D) under general anaesthesia. General anaesthesia is preferred because in the presence of infection, local anaesthesia may not act and it is difficult to break all the loculi of an abscess without causing pain. (2)

Prevention of Abscess

• Control Blood Sugar Leval  
• Maintain hygiene habits 
• Take Proper Treatments

Homeopathic Treatment of Abscess 

Homeopathy treats the person as a whole. It means that homeopathic treatment focuses on the patient as a person, as well as his pathological condition. The homeopathic medicines selected after a full individualizing examination and case-analysis. 

Which includes 

• The medical history of the patient, 
• Physical and mental constitution, 
• Family history, 
• Presenting symptoms, 
• Underlying pathology, 
• Possible causative factors etc. 

A miasmatic tendency (predisposition/susceptibility) also often taken into account for the treatment of chronic conditions. 

What Homoeopathic doctors do? 

A homeopathy doctor tries to treat more than just the presenting symptoms. The focus is usually on what caused the disease condition? Why ‘this patient’ is sick ‘this way’?  The disease diagnosis is important but in homeopathy, the cause of disease not just probed to the level of bacteria and viruses. Other factors like mental, emotional and physical stress that could predispose a person to illness also looked for. Now a days, even modern medicine also considers a large number of diseases as psychosomatic. The correct homeopathy remedy tries to correct this disease predisposition.  The focus is not on curing the disease but to cure the person who is sick, to restore the health. If a disease pathology not very advanced, homeopathy remedies do give a hope for cure but even in incurable cases, the quality of life can greatly improve with homeopathic medicines. 

Homeopathic Medicines for Abscess: 

The homeopathic remedies (medicines) given below indicate the therapeutic affinity but this is not a complete and definite guide to the homeopathy treatment of this condition. The symptoms listed against each homeopathic remedy may not be directly related to this disease because in homeopathy general symptoms and constitutional indications also taken into account for selecting a remedy, potency and repetition of dose by Homeopathic doctor.  So, here we describe homeopathic medicine only for reference and education purpose. Do not take medicines without consulting registered homeopathic doctor (BHMS or M.D. Homeopath).  

Abscess: 

Apis Mel  

• Diffuse inflammation of the cellular tissues, ending in their destruction: stinging, burning pains in incipient abscesses  

Arnica   

• Hot, hard shining swelling; pricking pains and dull stitches in the part; general sinking of strength.    

Arsenic Alb  

• Intolerable burning pains during the fever or when the abscess threatens to become gangrenous; pus copious, bloody, corroding, ichorous, watery, and of a putrid smell; great debility, muscular prostration, sleeplessness and restlessness.    

Baryta Carb  

• Inflammation of the cellular tissue, passing over into suppuration; incipient suppuration of glands; boils and furuncles.    

Bryonia Alba  

• The tumor is either very red and shining or very pale; pains tensive, sharp, sticking, lancinating; throbbings in the part, worse towards evening and at night; heaviness and hardness of abscess.  

Belladonna  

• Pressure, burning and stinging in abscess; scarlet redness and hot swelling; pus scanty, cheesy and flocculent; great sensitiveness to cold air. Hepatic abscess or other glandular abscesses.    

Hepar Sulph  

• Lacerating and pricking pains in the tumors; throbbing and beating in the abscess, the skin over the abscess is highly inflamed, hard, hot and swelling; pus scanty, bloody, corroding smelling like old cheese; pains worse at night and by exposure to cold.    

Mercurius  

• SLOWLY SUPPURATING ABSCESSES. Burning redness of the skin, with prickling and tingling sensation; hard, hot, inflammatory swelling, pressing from within outward; pulsating pains; pus copious, bloody, corroding, thin and watery; or all these characters, but scanty.  

Phosphorus  

• Lymphatic abscesses, full of fistulae; callous feeling; hectic fever; pus copious and yellow.  

Pulsatilla  

• The abscess bleeds readily with stinging and cutting pains; bluish-red swelling (varices) in the suppurating parts, with itching, stinging and burning pains; abscesses after violent and long-continued inflammations; pus bloody or copious, greenish or yellow.    

Rhus Tox  

• ABSCESSES OF AXILLARY OR PAROTID GLANDS, swelling painful to touch, and discharging a bloody-serous pus, with stinging and gnawing pains. Smooth, red and shining swellings, the inflamed skin being covered with little painful white vesicles    

Silicea  

• It controls the suppurative process; seeming to mature processes when desired, and certainly reducing excessive suppuration to moderate limits. Pains of abscess are either burning, cutting, itching, prickling or pulsative. PUs copious or scanty, bloody brownish, corroding, gelatinous, gray or greenish, putrid, thin and watery, or yellow. After matter has been discharged, it promotes granulation and cicatrization.   

Sulphur 

• CHRONIC ABSCESS, tendency to suppuration, dependent upon a psoric or scrofulous diathesis; pains throbbing or stinging, and after evacuation of the pus there is a tendency to ulceration. (8)   

Diet and Regimen for Abscess

• Protein rich foods, vegetables, dairy and grains. 
• Adeuate Hydration. 
• Fruits rich in vitamin C 
• Control Blood Sugar Leval (5)

 Do’s & Don’ts :

The Do’s

• Do consider drainage as the primary treatment for most abscesses. (4)(11)
• Do obtain cultures before initiating antibiotic therapy. (15)
• Do use appropriate antibiotics based on culture results and local susceptibility patterns. This is crucial for effective treatment and preventing antibiotic resistance.
• Do consider imaging studies (e.g., ultrasound, CT) to evaluate the extent of the abscess, especially if it is deep-seated or not readily visible.
• Do consider underlying predisposing factors (e.g., diabetes, immunosuppression) and address them appropriately to prevent recurrence.

The Don’ts:

• Don’t rely solely on antibiotics for the treatment of most abscesses. While antibiotics may be used as an adjunct to drainage, they are usually not sufficient on their own.
• Don’t delay drainage of an abscess, as this can lead to complications such as spread of infection, sepsis, and fistula formation.
• Don’t underestimate the potential for complications, especially in deep-seated or large abscesses.
• Don’t neglect to investigate and address underlying predisposing factors that may have contributed to abscess formation.
• Don’t forget to follow up with the patient to ensure complete resolution and monitor for recurrence. (12)(13)(14)

References of Abscess

1. Abscess: Types, Symptoms, Causes & Treatment (clevelandclinic.org) 
2. Manipal Manual Of Surgery Fourth Edition Chapter 2 
3. Abscess: Causes, Symptoms, Tests, and Treatment (webmd.com) 

4. Bailey & Love’s Short Practice Of Surgery 25th  Edition Chapter 4 

5. Nutrition Tips to Promote Wound Healing (eatright.org) 
6. Skin Abscess | Bon Secours 
7. SRB’S Manual Of Surgery 3rd Edition 
8. Lilienthal Homeopathic Therapeutics  
9. Robbins Basic Pathology (10th Edition), Kumar V., Abbas A.K., Aster J.C. (2017) Elsevier.
10. Schwartz’s Principles of Surgery (11th Edition), Brunicardi F.C., Andersen D.K., Billiar T.R., Dunn D.L., Hunter J.G., Matthews J.B., Pollock R.E. (2019), McGraw Hill Professional.
11. Sabiston Textbook of Surgery (21st Edition), Townsend C.M., Beauchamp R.D., Evers B.M., Mattox K.L. (2022), Elsevier.
12. Brunicardi F.C., Andersen D.K., Billiar T.R., Dunn D.L., Hunter J.G., Matthews J.B., Pollock R.E. (2019). Schwartz’s Principles of Surgery (11th Edition). McGraw Hill Professional.
13. Bennett J.E., Dolin R., Blaser M.J. (2020). Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases (9th Edition). Elsevier.

14. Williams N.S., Bulstrode C.J.K., O’Connell P.R. (2018). Bailey & Love’s Short Practice of Surgery (27th Edition). CRC Press.

15. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases (9th Edition)

16. A prospective study on skin and soft tissue infections: a fact-finding mission from a tertiary centre in north India (PubMed, 2023): This study found that abscesses accounted for 26% of SSTIs in their sample, with a mortality rate of 11.5%.

17. Management of acute bacterial skin and skin structure infections in India (International Surgery Journal, 2018): While not solely focused on abscesses, this paper discusses the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in India, a common cause of abscesses. It notes that MRSA is endemic in the country, with incidence ranging from 30% to 70%.

18. Skin and Soft Tissue Infections: Current Advancement in Epidemiology, Pathogenesis and Management (Journal of Pure and Applied Microbiology, 2023): This review article provides an overview of SSTIs, including their epidemiology, pathogenesis, and management. While it doesn’t specifically address India, it offers insights into the broader context of these infections.

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