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Indications / Contraindications
Indications — PCD First-Line
- Symptomatic abdominopelvic abscesses >5 cm (PCD superior to needle aspiration alone)
- Abscesses with enteric fistulas (first-line though expect ~40% failure)
- Postoperative abscesses (81% clinical success)
- Crohn's abscesses — bridge to reduce postop sepsis, enables primary anastomosis
- Diverticular abscesses — preop PCD reduces postoperative sepsis
- Infected cystic tumors unresponsive to antibiotics (sepsis and pain palliation)
- Hepatic abscesses — pyogenic; post-ablation/radioembolization
- Splenic abscesses — simple, uniloculated
Avoid / Not First-Line
- Grossly perforated viscus / free peritonitis (mortality up to 60%; PCD adds risk)
- Acute hematoma not yet liquefied
- Abscess without a mature wall
- Interloop abscesses — no safe access; treat with antibiotics ± aspiration or surgery
- Suspected malignant cystic mass — seeding risk; tissue diagnosis first
Antibiotics ± Aspiration Sufficient (no catheter needed)
- Collections <3–4 cm — >50–60% resolve with antibiotics alone
- Amebic abscesses — amebicidal agents ± aspiration
- Tubo-ovarian abscesses <5 cm — 2/3 resolve with antibiotics
- Echinococcal cysts — specialized PAIR technique (not standard PCD)
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Pre-Procedure Checklist
Review imaging. CT preferred — map collection size, location, loculations, fistulae, relationships to bowel/vessels/bladder. Identify safest access route. US acceptable for superficial/large collections.
Labs (SIR Category 2–3). Platelets ≥50K, INR <1.5, Hgb ≥9.0. Correct coagulopathy prior to procedure.
Anticoagulation holds. Aspirin — no hold. Clopidogrel: risk-based — often does not need to be held; hold 5 days only if procedural bleeding risk exceeds thrombotic risk. LMWH — hold 2–4 half-lives. Warfarin — hold 5 days (target INR <1.5). Discuss bridging with referring team for high-thrombotic-risk patients.
IV antibiotics. Administer broad-spectrum coverage ≥1 hour before procedure. 2nd/3rd-generation cephalosporin or ampicillin-sulbactam + aminoglycoside. Adjust per prior cultures/sensitivities if available.
Deep pelvic collections. Foley catheter for bladder decompression. Overnight oral or intraprocedural rectal contrast to distinguish bowel from collection on CT.
Sedation plan. IV access + moderate sedation (midazolam + fentanyl) for most cases. MAC for transrectal/transvaginal approaches. General anesthesia for pediatric patients.
Consent. Discuss: bleeding, sepsis/bacteremia, adjacent organ injury, fistula formation, drain dislodgement, incomplete drainage, need for repeat procedure or surgery.
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Relevant Anatomy
Approach Principles
- Safest, most direct, shortest percutaneous route
- Avoid vital structures — vessels, bowel, nerves
- No transcolonic access (exceptions: transgastric for pancreatic collections; transrectal/transvaginal for deep pelvic)
- Place catheter in most dependent portion of cavity — gravity is the primary drainage mechanism
- Angled approach facilitates wire coiling and catheter advancement
Subphrenic / Hepatic / Splenic
- Subphrenic: Angle cranially from anterior subcostal (<7th rib) or lateral (<10th rib). Fluoroscopic assessment at all respiratory phases — avoid pleural transgression.
- Hepatic: Subcostal preferred; include normal liver parenchyma in tract; avoid gallbladder and major bile ducts. Intercostal approach for dome collections (gantry tilt).
- Splenic: Lateral/posterolateral approach; include splenic parenchyma in tract; high pneumothorax risk — plan carefully.
Peripancreatic / Deep Pelvic
- Peripancreatic: CT required. Inferolateral approach posterior to stomach; avoid stomach and bowel. Pancreatic duct fistula expected — plan for prolonged drainage.
- Deep pelvic: Foley + rectal contrast before access. Three approaches: transgluteal (greater sciatic foramen — avoid sciatic nerve); transvaginal (posterior pelvic in non-menstruating women); transperineal.
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Technique
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Abscess/Fluid Collection Drainage Supplies
CT or US guidance system
21–22g micropuncture needle
0.035"–0.038" guidewire
Cope/Neff/AccuStick coaxial system
8–14Fr all-purpose drainage catheter (pigtail locking)
Trocar drainage catheter set (large/superficial alternative)
Sterile prep/drape
1% lidocaine
Drainage bag
Culture tubes (aerobic, anaerobic, AFB, fungal)
60 mL syringe for irrigation
Moderate sedation medications
Seldinger vs. Trocar — Choose Before You Start
Seldinger — 21–22g needle → wire → serial dilation → catheter
- Preferred for small, deep, or high-risk collections
- Less pain; allows small-needle confirmation before large catheter
- Use wire test for viscous collections
Trocar — combined catheter/cannula/stylet advanced directly
- Preferred for large, superficial collections
- Faster; more painful
- Do NOT use for deep pelvic or complex access
Steps (Seldinger Technique)
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Planning CT / US
Confirm collection size, location, and access window. Identify adjacent structures. Choose Seldinger vs. trocar approach. Mark skin entry site.
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Prep, drape, and local anesthesia
Sterile prep. Mark access site. Track 1% lidocaine from skin to collection wall under CT/US guidance. Do not enter the collection with the anesthesia needle.
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Access needle + aspiration
Advance 21g access needle to collection under CT/US. Aspirate 5 mL — note appearance (pus, bile, blood, serous) and send for culture. If too viscous to aspirate: wire test — advance wire into cavity; wire assuming cavity shape confirms correct position.
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Wire and dilation
Advance 0.038" Amplatz wire into cavity with a generous loop. Remove needle. Make skin incision. Serially dilate over wire in 2–3Fr steps to desired catheter size.
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Catheter placement
Advance drainage catheter to most dependent portion of cavity. Release lock (pigtail). Confirm position with 1–2 mL dilute contrast — confirms catheter in collection, excludes fistulae, and sizes collection.
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Drainage and specimen collection
Connect to drainage bag. Aspirate maximum fluid. Send fluid for: culture/Gram stain, cell count, pH, amylase (if peripancreatic), bilirubin (if biliary). Document fluid character.
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Secure catheter
Secure catheter with suture and locking loop suture. Apply sterile dressing. Confirm output in drainage bag. Prescribe BID 10 mL NS flush nursing orders before leaving suite.
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Troubleshooting
Problem
Can't aspirate despite correct position (viscous pus)
Likely cause: Contents too thick to aspirate through needle. Does not mean wrong position.
Next step: Wire test — advance wire; cavity shape confirms correct position. Use biliary dilator with side holes to initiate drainage. Upsize catheter if viscous output continues to be problematic.
Problem
Collection not fully draining (loculated)
Likely cause: Fibrinous septations preventing free drainage between locules.
Next step: Gentle irrigation 10–20 mL NS BID. Intracavitary tPA (4 mg/30 mL saline, dwell 1h, daily ×3–5 days) for persistent loculations. Catheter repositioning or additional catheter placement for multilocular disease.
Problem
Drain output suddenly stops
Likely cause: Catheter kinked, debris/clot in catheter, or collection resolved.
Next step: Flush 10 mL saline. If still no output — CT to confirm catheter position and collection status. Reposition or upsize catheter as needed. Do not assume collection has resolved without imaging.
Problem
Drain appears to be pulling out
Likely cause: Suture failure, inadequate initial securing, or patient activity.
Next step: Do not force reinsertion blindly. CT to confirm collection status and catheter position. IR re-access under imaging if catheter has fully dislodged and collection persists.
Problem
Enteric fistula suspected (enteric contents in drain)
Likely cause: Adjacent bowel fistula into collection or drainage catheter erosion into bowel.
Next step: Contrast injection through drain to confirm. Low-output fistula — drainage + NPO/bowel rest; often closes with prolonged drainage. High-output fistula — surgical consult. Set expectations with clinical team: weeks of drainage are normal.
Problem
Patient deteriorates after drainage
Likely cause: Bacteremia/sepsis from bacterial release during collection decompression (5–10% incidence within hours).
Next step: Blood cultures. Escalate antibiotics. Ensure drain is patent and draining freely. Supportive care usually sufficient if drain is working.
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Complications
Major Complications
- Hemorrhage 1–4% (highest hepatic, splenic) — observation for minor; angiography/embolization for active arterial bleed
- Bacteremia/Sepsis 5–10% — transient within hours of drainage; prevention with pre-procedure antibiotics + hydration; usually supportive care sufficient
- Bowel injury <1% with CT/US guidance — depends on extent; surgical consult if full-thickness
- Pleural transgression (subphrenic) — empyema or pneumothorax; careful respiratory-phase planning; pleural tube if large
Other Complications
- Fistula formation 10–20% with enteric-adjacent collections — most resolve with prolonged drainage + bowel rest; surgery for persistent/high-output
- Drain dislodgement (common) — prevention with secure suture lock; reimaging and IR re-access
- Incomplete drainage / treatment failure 15–25% — risk factors: multiloculation, enteric fistula, immunosuppression; fibrinolytics, additional catheters, or open surgery
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Post-Procedure Care
Monitoring & Labs
- Document drain output every 8 hours; note character (purulent, serous, bloody, bilious, enteric)
- Send fluid cultures at placement and at 48h if inadequate clinical response
- Serial clinical assessment: fever curve, WBC trend, abdominal pain
- CRP/WBC at 48–72h as response markers
Drain Patency
- Flush drain BID with 10 mL NS to maintain patency (nursing orders)
- Upsize catheter criteria: output <30 mL/24h with evidence of remaining collection — upgrade 2Fr over wire
- Discharge with drain: patient/caregiver education; home nursing setup; follow-up imaging at 2 weeks
Criteria for Catheter Removal
- Output <10 mL/24h ×2 consecutive days
- Imaging confirms resolved collection (or residual <2 cm)
- No enteric or biliary fistula demonstrated
- Do NOT remove based on low output alone — always confirm with imaging before removal
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Critical Pearls
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CT for planning; US for real-time guidance. CT preferred for most abdominal/pelvic drainage planning — superior visualization of anatomy and relationships. US for real-time guidance of superficial or large collections.
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Antibiotics ≥1h before — bacteremia in 5–10% within hours of drainage. Broad-spectrum coverage is mandatory before manipulating an infected collection. Pre-treat, don't post-treat.
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Seldinger for deep/high-risk; trocar for large/superficial/simple. Never use trocar technique for deep pelvic collections — risk of uncontrolled injury to neurovascular structures.
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Wire test for viscous collections. If you can't aspirate but the position looks correct — advance a wire. Wire taking the shape of the cavity = correct position. Proceed with dilation and catheter.
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Catheter in most dependent portion. Gravity is the primary drainage mechanism. Position matters more than catheter size for adequate drainage of a simple collection.
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Inject 1–2 mL contrast through catheter after placement. Confirms intracavitary position, reveals unexpected fistulae to bowel/biliary/urinary tract, and helps size the collection for response assessment.
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Intracavitary tPA (4 mg dwell) for loculated collections at 48h. If collection is not resolving at 48h and loculations are suspected, intracavitary fibrinolytics change management and frequently avoid surgery. Don't wait too long to escalate.
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Low daily output ≠ collection resolved. Always image before removing catheter. A plugged drain with residual collection is the most common cause of clinical failure.
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Enteric fistula = prolonged dwell (often weeks). Set expectations early with the clinical team. Early surgery is rarely indicated. Document output character daily — feculent output is diagnostic.
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Pelvic collections: Foley + rectal contrast before procedure. Bladder decompression is essential. Rectal contrast distinguishes sigmoid/rectum from collection — prevents catastrophic misidentification on CT.
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Drain Management
Daily Protocol
- Document exact output (mL/24h) and character: purulent, serous, bloody, bilious, or enteric
- Flush 10 mL NS BID; note flush return vs. net output
- Check skin entry site — leak, skin erosion, infection, suture integrity
- Assess patient clinically: fever curve, WBC trend, pain at drain site
Output Thresholds
- >50 mL/day — draining well; continue; upsize if output is thick or declining despite residual collection
- 10–50 mL/day — decreasing output; image at 48–72h to assess residual
- <10 mL/day ×2 days + resolved on imaging — remove catheter
Sudden Output Change — Investigate
- Sudden increase — new fistula? Bilious = biliary; feculent = bowel; cloudy = new infection
- Bloody output — vessel erosion; hold flushes; CT angiography if active bleed suspected
- Complete stop — catheter obstruction or malposition; flush then CT
Catheter Exchange / Upsizing
- Exchange over wire via fluoroscopy — never pull old catheter until new one is in position
- Upsize in 2Fr steps (e.g., 10Fr → 12Fr)
- Consider exchange when: inadequate drainage of known residual collection, persistent thick/viscous output, suspected catheter malposition
Intracavitary Fibrinolytics (tPA Protocol)
- Indication: Loculated or non-resolving collections at 48h with catheter in good position
- Protocol: tPA 4 mg/30 mL normal saline; instill into collection, clamp 1 hour, then open to drain
- Frequency: Daily ×3–5 days
- Expect increased output volume and change in character after treatment
- Repeat CT after 3–5 days to assess response before continuing or escalating
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References & Resources
Primary sources · Key data · Related procedures
Key Guidelines
- SIR quality improvement guidelines for percutaneous abscess drainage
- IDSA guidelines: Diagnosis and Management of Complicated Intra-abdominal Infection
Primary References
- Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the IDSA. Clin Infect Dis. 2010;50(2):133–164.
- vanSonnenberg E, Wittich GR, Goodacre BW, Casola G, D'Agostino HB. Percutaneous abscess drainage: update. World J Surg. 2001;25(3):362–369.
- Gervais DA, Ho CH, O'Neill MJ, Arellano RS, Hahn PF, Mueller PR. Recurrent abdominal and pelvic abscesses: incidence, results of repeated percutaneous drainage, and underlying causes in 956 drainages. AJR Am J Roentgenol. 2004;182(2):463–466.