INFLAMMATORY/ INFECTIVE

CONDITIONS
DCM 3 SURGERY
BY
WOLINGHA SAMSON
[email protected]
Surgical infection is major problem in surgical
practice. Asepsis (prevention of entry of
organisms) and antisepsis (killing of the
bacteria in the skin or tissues) has made a
difference in surgical practice.

Epithelial surfaces act as mechanical barrier and

phagocytes, antibodies; complements,
macrophages, leukocytes,
 Malnutrition (obesity, weight loss).
 Metabolic disease (diabetes, uraemia, jaundice).
 Immunosuppression (cancer, AIDS, steroids,
chemotherapy and radiotherapy).
 Colonization and translocation in the
gastrointestinal tract.
 Poor perfusion (systemic shock or local ischemia).
 Foreign body material.
 Poor surgical technique (dead space, haematoma).
 It is spreading inflammation of subcutaneous and
fascial planes.
 Infection may follow a small scratch or wound or
incision.
 Causative Agents
 Commonly due to Streptococcus pyogenes and
other Gram +ve organisms.
 Often Gram - ve organisms like Klebsiella,
Pseudomonas, E. coli are also involved (usually
Gram -ve organisms cause secondary infection).
 Fever, toxicity (tachycardia, hypotension).
 Swelling is diffuse and spreading in nature.
 Pain and tenderness, red, shiny area with stretched
warm skin.
 Cellulitis will progress rapidly in diabetic and
immunosuppressed individuals.
 Tender regional lymph nodes may be palpable
which signify severity of the infection.
 Elevation of limb or part to reduce oedema so as to
increase the circulation.
 Antibiotics.
 Dressing (often glycerine dressing is used as it
reduces the oedema because of its hygroscopic
action).
 Bandaging.
An abscess is a localized collection of pus, usually,
but not invariably, produced by pyogenic organisms.

An abscess commences as a hard, red, painful

swelling, which then softens and becomes fluctuant.
If not drained, it may discharge spontaneously
onto the surface or into an adjacent viscus
or body cavity.
 Staphylococcus aureus. Streptococcus pyogenes.

 Gram-negative bacteria (E. coli, Pseudomonas,

Klebsiella).

 Anaerobes.
 General condition of the patient: Nutrition,
anaemia, age of the patient.

 Associated diseases: Diabetes, HIV,

immunosuppression.

 Type and virulence of the organisms

 Trauma, haematoma, road traffic accidents.

 Fever often with chills and rigors.
 Localised swelling which is smooth, soft and
fluctuant.
 Visible (pointing) pus.
 Throbbing pain and pointing tenderness.
 Brawny induration around.
 Redness and warmth with restricted movement
around a joint.
External Sites
 Fingers and hand.
 Neck.
 Axilla.
 Breast.
 Foot, thigh-here it is deeply situated with brawny
induration.
 Ischiorectal and perianal region.
 Abdominal wall.
 Dental abscess, tonsillar abscess and other
abscesses in the oral cavity
Internal Abscess
 Abdominal: Subphrenic, pelvic, paracolic,
amoebic liver abscess, pyogenic abscess of liver,
splenic abscess, pancreatic abscess.
 Perinephric abscess.
 Retroperitoneal abscess.
 Lung abscess.
 Brain abscess.
 Retropharyngeal abscess.
 Total count is increased.
 Urine sugar and blood sugar is done to rule out
diabetes.
 USG of the part or abdomen or other region is
done when required.
 Chest X-ray in case of lung abscess.
 CT scan or MRl is done in cases of brain and
thoracic abscess.
 Investigations, relevant to specific types: Liver
function tests, blood culture.
 Bacteraemia, septicaemia, and pyaemia.
 Multiple abscess formation.
 Metastatic abscess.
 Destruction of tissues.
 Antibioma formation.
 Brain abscess can cause intracranial hypertension,
epilepsy, neurological deficit.
 Liver abscess can cause hepatic failure, rupture,
jaundice.
 Lung abscess can lead to bronchopleural fistula or
septicaemia or respiratory failure or ARDS.
Abscess should be formed before draining.
Exceptions for this rule are:
 Parotid abscess
 Breast abscess
 Axillary abscess
 Thigh abscess
 Ischiorectal abscess
 Visible pus
 Pointing tenderness
 Fluctuation
 Excruciating pain
Hilton's method of draining an abscess.
 Initially broad spectrum antibiotics are started
(depending on severity, extent and site of the
abscess).

 Under general anaesthesia or regional block

anesthesia,* after cleaning and draping, abscess is
aspirated and presence of pus is confirmed.
• Skin is incised adequately, in the line parallel to
the neurovascular bundle in the most dependent
position.
• Next, pyogenic membrane is opened using Sinus
forceps* and all loculi are broken up. Abscess cavity
is cleared of pus and washed with saline.
• A drain (either gauze drain or corrugated rubber
drain) is placed.
• Wound is not closed. Wound is allowed to granulate
and heal. Sometimes secondary suturing or skin grafting
is required.
• Pus is sent for culture and sensitivity.
• Antibiotics are continued.
• Treating the cause is important.
 It is an acute staphylococcal infection of a hair
follicle with perifolliculitis which usually proceeds
to suppuration and central necrosis. Often boil
opens on its own and subsides (S. aureus
infection).

 Furuncle in external auditary canal is very painful

because of rich cutaneous nerves. Here skin is
adherent to perichondrium
Treatment
 Antibiotics.
 Drainage of boil.

Complications
 Cellulitis.
 Lymphadenitis.
 Hidradenitis (Infection of group of hair follicles) .
 Boil in dangerous zone can cause cavernous sinus
thrombosis.
 It is an infective gangrene of skin and
subcutaneous tissue.
 Staphylococcus aureus is the main culprit.
 Common site of occurrence is nape of the neck and
back.
 It is common in diabetics and after forty years of
age.
 It is common in males.
 Urine sugar and urine ketone bodies.
 Blood sugar.
 Discharge for C/S.
 Control of diabetes is essential using insulin.
 Antibiotics like penicillins, cephalosporins or
depending on C/S is given.
 Drainage is done by a cruciate incision and
debridement of all dead tissues is done. Excision is
done later.
 Once wound granulates well, skin grafting may be
required.
 It is spreading inflammation of the skin, deep fascia
and soft tissues with extensive destruction, toxaemia
commonly due to Streoften due to mixed infections
like coliforms, Gram-negative organisms.
 It is common in old age, smoking, diabetics,
immunosuppressed, malnourished, obesity, steroid
therapy and HIV patients. Trauma is a common
precipitating factor I cause - 80%.
 It can occur in limbs, lower abdomen (Meleney's
infection), groin, perineum. There is acute
inflammatory response, oedema, extensive necrosis
and cutaneous microvasculature thrombosis.
 Muscle is usually not involved in necrotising
fasciitisptococcus pyogenes infection.
 Sudden swelling and pain in the part with oedema,
discoloration, necrotic areas, ulceration.
 Foul smelled discharge.
 Features of toxaemia with high-grade fever and chills,
hypotension.
 Oliguria often with acute renal failure due to acute
tubular necrosis.
 Jaundice.
 Rapid spread in short period (in few hours).
 Features of SIRS, MODS with drowsy, ill-patient.
 Condition if not treated properly may be life
threatening.
Management
• N fluids, fresh blood transfusion.
• Antibiotics depend on CIS or broad-spectrum antibiotics.
High dose penicillins are very effective. Clindamycin, third
generation cephalosporins, arninoglycosides are also often
needed.
• Catheterisation and monitoring of hourly urine output.
• Haematocrit, serum creatinine assessment.
• Pus culture, blood culture.
• Electrolyte management and monitoring.
• Control of diabetes, if patient is diabetic
• Oxygen, ventilator support, dopamine, dobutamine
supplements whenever required.
• Radical wound excision of gangrenous skin and necrosed
tissues at repeated intervals.
 It is the most common hand infection.
 It occurs in subcuticular area under the
eponychium.
 Minor injury to finger is the common cause.
 Suppuration occurs very rapidly.
 It tracks around the skin margin and spreads under
the nail causing hang nail or floating nail.
 Organisms are Staphylococcus aureus and
Streptococcus pyogenes.
CHRONIC PARONYCHIA
It is commonly due to fungal infection.
Clinical Features
• Itching in the nail bed.
• Recurrent pain.
• Discharge.
• Secondary bacterial infection may supervene.
Investigation
Culture of scrapings for fungus and oth er causative
agents.
Treatment
• Long term antifungal therapy.
• Antibiotics for secondary infection.
• In severe cases removal of nail is required.
Surgical Anatomy
 There are three triangular web spaces filled with
fat between the dorsal and volar skin. When the
space is filled with pus it straddles the deep
transverse ligament.
 Even though pus is volar, it points out dorsally.
It originates from-
 Abrasion.
 Infection of proximal volar space of finger.
 Callosities.
 Infection of proximal spaces.
 Staphylococcus.
 Streptococcus.
 Gram-negative organisms.
 Fever.
 Pain and tenderness.
 Oedema of dorsum of hand.
 Maximum tenderness is on the volar aspect.
 'V' sign- Separation of fingers.
 If untreated, infection may spread into other web
spaces and hand spaces.
Treatment

• Elevation of hand.
• Antibiotics and analgesics.
• Drainage under regional or general anaesthesia.
A horizontal incision is placed on volar skin of
the web and deepened to reach the space by
dividing fibres of palmar fascia. Pus is drained
and sent for culture and sensitivity.
Causes
 Trauma.
 Spread from infection of finger spaces and web
spaces.
 Haematogenous spread.
 Spread from tenosynovitis.
 Pain and tenderness in the palm.
 Oedema of dorsum of hand (frog hand).
 Loss of concavity of palm.
 Painful movement of metacarpophalangeal joint (but
interphalangeal joint movements are normal and
 Pain free).
 Fever.
 Palpable tender axillary lymph nodes.
 Eventually pus may come out of palmar aponeurosis
forming collar stud abscess and later sinus formation.
 X-ray of the part is required.
 Elevation of the affected limb.
 Antibiotics and analgesics.
 Drainage under general anaesthesia. A horizontal
incision is placed on the volar aspect without
crossing the palmar creases and should be
extended deep to palmar aponeurosis. A drain is
placed. Pus is sent for culture and sensitivity and
appropriate antibiotics are continued.
 Osteomyelitis of metacarpals
 Stiffness of hand
 Suppurative arthritis
 Extension of infection into other spaces
 Common bacteria: Staphylococcus aureus,
Streptococcus pyogenes.
Clinical Features
 Symmetrical swelling of entire finger.
 Flexion of finger-Hook sign.
 Severe pain on extension.
 Tenderness over the sheath.
 Oedema of whole hand, both palm and dorsum (due
to lymphatic spread).
 As ulnar bursa extends into the little finger its
infection results in pain and tenderness extending up
to little finger but not much to other fingers.
 Elevation of the affected limb.
 Antibiotics and analgesics.
 Position of rest.
 Drainage under general anaesthesia. Incisions are
placed over the site of maximum tenderness and
flexor sheath should be opened up. Many a times
multiple incisions are required.
 Spread of infection proximally into forearm
 Stiffness of fingers and hand
 Suppurative arthritis
 Osteomyelitis
 Median nerve palsy
 Bacteraemia and septicaemia
Types
 1. Subareolar.
 2. Intramammary.
 3. Retromammary (submammary).
1. Subareolar mastitis
• It is the infection under the areola due to cracks in
the nipple or areola. It results from an infected gland
of Montgomery or a furuncle of the areola.
• Often it is associated with duct ectasia - causing
formation of abscess, sinus and fistula.

Clinical Features
• Red, inflamed, edematous areola with a tender
swelling underneath.

Treatment
• Under cover of antibiotics pus is drained by making
a subareolar incision.
SUBAREOLAR ABSCESS.
2. lntramammary mastitis (Breast
abscess)
a. Lactational abscess of the breast:
Commonly seen in lactating women.

Precipitating factors
• Cracked nipple
• Retracted nipple
• Improper cleaning of the nipple
• Inadequate milk sucking by baby or milk
expression causing stasis
• Infection from the mouth of the baby
• Haematoma getting infected
Mode of infection:
Bacteria (Staph. aureus-commenest) enters the breast
during sucking through the cracked nipple. Occasionally
it can be from haematogenous spread. Gram negative
and other bacterial infections can supervene later.
Staphylococcus aureus causes clotting of milk in the
blocked duct and multiply.

Duct initially gets blocked by epithelial debris or by

retracted nipple. Initially it begins in one quadrant but
later involves entire breast.
Clinical features:
• Continuous throbbing pain in the breast and fever.
• Diffuse redness, tenderness and brawny
induration in the breast.
• Purulent discharge from the nipple.
• Entire breast may get involved eventually.
• It is difficult to differentiate initial stage of
mastitis (stage of cellulitis) from stage of breast
abscess formation. When it is treated by antibiotics
without incision and drainage eventually it may get
organised to form a non tender, hard breast lump
with sterile pus inside - stage of antibioma
formation.
TYPICAL BREAST ABSCESS WITH
FEATURES OF ACUTE
INFLAMMATION
b. Non-lactational abscess of the breast:

It commonly occurs in duct ectasia and periareolar

infections. Common organisms are bacteroides,
anaerobic streptococci, enterococci and gram negative
organisms.
It is commonly recurrent with tender swelling under
the areola.

Treatment:
• Antibiotics.
• Repeated aspirations.
• Drainage and later cone excision of the duct is done.
3. Retromammary mastitis
• It is due to tuberculosis of the intercostal lymph
nodes or ribs beneath or suppuration of the
intercostal lymph nodes.
• Breast is normal.

Causes
• Tuberculosis of intercostal lymph nodes
• Tuberculosis of ribs beneath
• Suppuration of intercostal lymph nodes
• Empyema necessitans
• Infected haematoma.
Investigations:
• Chest X-ray.
• FNAC.
• ESR.
• Peripheral smear.
• U /S of breast and chest wall.
• Often CT scan chest may be needed.

Treatment:
• Cause has to be treated.
• Drainage through submammary /retromammary
incision.
 It is infection and suppuration with destruction of the
skeletal muscle, commonly due to Staphylococcus
aureus (90%) and Streptococcus pyogenes,
occasionally due to Gram-negative organisms.
 It is common in muscles of thigh, gluteal region,
shoulder and arm.
 Precipitating factors are similar to necrotising
fasciitis—trauma, malnutrition, anaemia, and
immunosuppression.
 Pain, oedema, tenderness over the site with apparently
normal overlying skin.
 Induration and muscle spasm is typical.
 Fever, jaundice, uraemia (acute renal failure) are
common.
 It is an acute nonsuppurative infection and
spreading inflammation of lymphatics of skin and
subcutaneous tissues due to beta haemolytic
streptococci, staphylococci, clostridial organisms.
 It is commonly associated with cellulitis.
 Streaky redness which is spreading is typical. On pressure
area blanches; on release redness reappears.
 Oedema of the part, palpable tender regional lymph nodes
are obvious.
 Fever, tachycardia, features of toxaemia.
 Groin lymph nodes are enlarged and tender in lower limb
lymphangitis.
 Regional lymph nodes (only) may eventually suppurate to
form
an abscess.
 Toxaemia, septicaemia may occur. Rapidity may be more in
 diabetics and immunosuppressed.
 Chronic lymphangitis occurs due to repeated attacks of
acute recurrent ymphangitis leading into acquired
lymphoedema.
 Blood count, platelet count, renal and liver
function tests, peripheral smear and blood
culture—are needed investigations.
 Antibiotics like penicillin, cloxacillin.
 Elevation, rest, glycerine magnesium sulphate
dressing.
It is an infective gangrene caused by clostridial
organisms involving mainly skeletal muscle.
Earlier it was called as malignant oedema.
Organisms
 Clostridium welchii (perfringens): Gram positive,
central spore bearing, nonmotile, capsulated
organisms.
 Clostridium oedematiens.
 Clostridium septicum.
 Clostridium histolyticus.
Incubation period is 1-2 days.
 Features of toxaemia, fever, tachycardia, pallor.
 Wound is under tension with foul smelling
discharge (sicklysweetyodour).
 Khaki brown coloured skin due to haemolysis.
 Crepitus can be felt.
 Jaundice may be ominous sign and also oliguria
signifies renal failure.
 Fulminant type causes rapid progress and often
death due to toxaemia, renal failure or liver failure
or MODS or ARDS.
 Massive type involving whole of one limb
containing fully dark coloured gas filled areas.
 Group type: Infection of one group of muscles,
extensors of thigh, flexors of leg.
 Single muscle type affecting one single muscle.
 Subcutaneous type of gas gangrene involves only
subcutaneous tissue (i.e. superficial involvement).
 X-ray shows gas in muscle plane or under the skin.
 Liver function tests, blood urea, serum creatinine,
total count, P021 PC02.
 CT scan of the part may be useful especially in
chest or abdominal wounds.
 Proper debridement of devitalised crushed
wounds.
 Devitalised wounds should not be sutured.
 Adequate cleaning of the wounds with H20 2
and normal saline.
 Penicillin as prophylactic antibiotic.
 Inj. Benzyl penicillin 20 lacs 4th hourly. + Inj.
metronidazole 500 mg 8th hourly + Inj. aminoglycosides
(if blood urea is normal) or third generation
cephalosporins.
 Fresh blood transfusion.
 Polyvalent antiserum25,000 units given intravenously
after a test dose and repeated after 6 hours.
 Hyperbaric oxygen is very useful.
 Liberal incisions are given. All dead tissues are
excised and debridement is done until healthy tissue
bleeds.
• Rehydration and maintaining optimum urine output
(30 ml/ hour) (0.5 ml/ kg/ hour).
• Electrolyte management.
• In severe cases amputation has to be done as a
lifesaving procedure - stump should never be closed.
• Often ventilator support is required.
• Once a ward or operation theatre is used for a
patient with gas gangrene, it should be fumigated for
24-48 hours properly to prevent the risk of spread of
infection to other patients especially with open
wounds.
• Hypotension in gas gangrene is treated with whole
blood transfusion.
1. Bailey and Love Short Practice of Surgery
2. Lecture Notes_ General Surgery - Ellis, Harold,
Calne, Roy, Wats
3. SRB Manual of Surgery 5th Edition
THE END