UNIT 1: ABSCESS AND PHLEGMOM
Key Unit competence
Take appropriate decision on abscess and phlegmon conditions
Introductory activity 1.0
Observe skin structure displayed on image A, B and C below and answer to the questions below.
1. Reference to what you learned in anatomy and physiology, which one of the three images would reflect the normal structure of the skin in the human body?
2. What characteristics/elements would indicate the abnormalities in the structure of the skin? Describe the abnormalities that you have observed if any.
3. What do you think can cause the abnormalities that you have observed?
4. What are the manifestations of the observed abnormalities in the human body?
5. How can health personnel identify these abnormalities?
6. How can these abnormal structures be collected?
1.1. Description of Abscess and phlegmon
Learning Activity 1.1
K.A, a previously healthy 18-year-old young man presents with history of pain and swelling on his right thigh and in the left arm pit since 4 days. K.A reported that he was injured by his colleagues when playing football last month. K.A also reports that he normally has excessive sweat in the arm pit and has been shaving his axillary hair with same disposable razor for long time. Last night K.A had headache and fever.
After taking his vital signs, the nurse found that all vital signs are within normal limits, except the slight increase of the body temperature (37.8C). On examination, the health care provider found that there is a 3 x 3 cm confined fluctuant, warm, tender, and erythematous mass. There is no drainage or associated open wound. In addition to that another one unbounded small (1 x 2 cm) mass in the left arm pit was diagnosed. The health care provider requested to take blood sample of FBC that showed a slight increase of WBC.
The medical doctor concluded that the mass on the right leg was an abscess and that the one on the left arm pit is the phlegmon.
Questions related to the case study.
1. From the case study above, identify the risk factors that can be associated with abscess and phlegmon
2. Explain the pathophysiological mechanisms behind swelling, tenderness and local heat
3. Describe the signs and symptoms of K.A described in the case study.
4. From the signs described in the case study, what is the key characteristic that differentiates abscess from phlegmon?
1.1. 1. Definition of abscess and phlegmon
An abscess is accumulation of pus in soft tissues. It may be difficult to differentiate abscess from phlegmon but abscess is confined to the area of infection (image B, introductory activity 1.0) and phlegmon is unbounded and can keep spreading out along connective tissue and muscle fibre (image C introductory activity 1.0). Abscess and phlegmon can be internal or external. The most common site of external abscess and phlegmon include inguinal and axillary areas, anus, vaginal (Bartholin gland) and neck.
1.1.2. Causes and Pathophysiology of abscess and phlegmon
Abscess and Phlegmon are frequently caused by bacteria; most often group A streptococcus or Staphylococcus aureus. People with compromised immune system may be vulnerable to abscess and phlegm on formation. Bacteria may enter via a scratch, insect bite, or injury. It kills the local cell, resulting in the release of cytokines. Cytokines trigger an inflammatory response (figure 1.1); a large numbers of white blood cells migrates to the area then increases the regional blood flow.
Figure 1.1. Pathophysiology of abscess
The increased blood supply leads to increased temperature of the area, pain, swelling and redness. The final structure of the abscess consists of the central cavity with pus and a surrounding wall, which is the pyogenic membrane. If the natural and acquired resistance of the host is adequate, the pyogenic membrane is rapidly replaced by granulation tissue which prevents the systemic invasion of bacteria (figure 1.2).
Pus is a viscous liquid that consists mostly of dead and dying neutrophils and bacteria, cellular debris, and fluid leaked from blood vessels. Because an abscess is virtually inaccessible to antibodies and antibiotics, it is very difficult to treat. Sometimes a surgical incision is necessary to drain and eliminate it. Some abscesses, can burst of their own accord. The abscess cavity then collapses, and the tissue is replaced through the process of repair.
1.1.3. Signs and symptoms of abscess and phlegmon
Signs and Symptoms of skin abscess and phlegmon vary, depending on the location and severity of the infection. If not treated, an infection can spread to deeper tissue and disable the limb or area involved. Local signs of skin abscess and phlegmon can be: heat, redness, sore, swelling and pain. A patient may also have systemic signs of a bacterial infection, such as swollen lymph glands, fatigue, fever and headache.
1.1.4. Diagnostic measures
Skin abscess and phlegmon are visible and can easily be diagnosed through inspection. Palpation on the area of pain can reveal lumps or tenderness. For internal abscess different laboratory and radiology tests can be ordered, which may include Full blood count (FBC), ultrasound, X-ray, MRI and CT scan. The results of FBC may show elevated WBCs mainly neutrophils.
Self-assessment activity 1.1
The following are the causes and risk factors of abscess and phlegmon, use them to complete the table below:
Staphylococcus area, injury, bite, scratch, excessive sweat, low immune system
1.2. The management of abscess and phlegmon
Learning Activity 1.2
After different investigations the health care provider decided to do the incision and drainage to evacuate pus and debris. In the post-incision report, the health care provider noted that
K.A will receive oral antibiotics and painkiller medications. K.A received his medications and was discharged home and given appointment after 3 days for wound dressing change.
Questions related to the case study.
1. What is the surgical treatment plan adopted by the health care provider for KA?
2. Discuss in group, different medical treatment prescribed to this patient and give an example of appropriate drug on each group of medication (antibiotics and painkiller).
1.2.1. The treatment plan of Abscess and phlegmon
The treatment of Abscess and phlegmon is oriented by the level of severity. Minor phlegmon may be treated with oral antibiotics. But incision and drainage may be performed to clean dead tissues and prevent the spread of infection. Incision and drainage is the treatment of choice of abscess (figure 1.3). The site of incision and drainage is performed to evacuate pus and debris.
Antibiotics and pain killer medications are also prescribed to subside infection and relieve pain. The appropriate duration of antibiotics for treatment of skin and soft tissue infection depends on the nature of the clinical presentation, and the clinical response should guide duration of therapy.
! Consideration for practice
Antibiotics are not mandatory in the post abscess incision and drainage. Other clinical considerations may guide the decision of antibiotics such immune status, living conditions, size (≥2 cm), multiple lesions, systemic signs such as fever, inadequate response of incision and location of the abscess and phlegmon.
1.2.2. Evolution and complications of abscess and phlegmon
The untreated abscess and phlegmon can spread infection to the surrounding tissues and even into the bloodstream causing an infective endocarditis and a systemic infection (septicaemia). The reoccurrence of abscess and phlegmon may be possible.
Self-assessment activity 1.2
1. Do patients with abscess always receive antibiotics during post-incision and drainage? Justify your answer.
2. How can external and skin abscess and phlegmon be diagnosed?
1.3. End of unit assessment
End of unit assessment
1. Identify the common sites of abscess and phlegmon
2. Which one of the following is not a sign and symptom of an abscess and phlegmon (choose the best answer)?
a) Redness
b) Swelling
c) Nausea
d) Local heat
3. Incision and drainage is the best option for the treatment of abscess and phlegm. What are the pathophysiological reasons justifying this best option?
4. A forty-year-old woman presented with the chief complaint of redness, pain, swelling of left groin. She was previously treated with oral pain killer without improvement. The physical examination showed that there is a fluctuant, tender, and erythematous mass, and warm on touch on the left groin. The Health Care Provider (HCP) suspected an abscess.
a) What are the questions with regard to abscess, the HCP will ask to complete the history of this woman?
b) What are the disturbed needs of this patient?
c) Draw a teaching plan that will help this woman to prevent the complications of the abscess