Tissue Plasminogen Activator for the Treatment of Intraabdominal
Abscesses in a Neonate
By Ivan R. Diamond, Paul W. Wales, Bairbre Connolly, and Ted Gerstle
Toronto, Ontario
Fibrinolytic agents have been used successfully in the man-
agement of loculated empyema; however, their use in the
treatment of intraabdominal abscesses is limited. The au-
thors describe the case of a 4-week-old girl with intraabdomi-
nal abscesses secondary to intestinal perforation that were
not amenable to percutaneous drainage, but were managed
successfully with intracavitary administration of tissue-plas-
minogen activator. This case represents the first report in a
human, in which tissue-plaminogen activator was used to
facilitate percutaneous drainage of an intraabdominal ab-
scess. It is also the first time a fibrinolytic agent has been
used for this purpose in a child.
J Pediatr Surg 38:1234-1236. © 2003 Elsevier Inc. All rights
reserved.
INDEX WORDS: Abscess, fibrinolysis, tissue plasminogen
activator.
F
IBRINOLYTIC AGENTS including streptokinase,
urokinase, and tissue-plasminogen activator (tPA)
have been used successfully in the management of loc-
ulated empyema in both adults and children.
1
Their use,
however, in the treatment of intraabdominal sepsis is
limited. We present a case describing the first use of tPA
in a child for the management of intraabdominal ab-
scesses secondary to peritonitis.
CASE REPORT
A 4-week-old full-term girl had a history of intermittent watery
diarrhea for 2 weeks. She presented to the hospital with an acute onset
of abdominal distension, lethargy, and respiratory distress. On exami-
nation, she was mottled, unresponsive, and had a grossly distended,
firm abdomen. Vital signs on admission showed a heart rate of 40 with
no palpable blood pressure, respiratory rate of 20, and a temperature of
38.8°C. The patient was intubated and resuscitated with 80 mL/kg of
crystalloid and started on a dopamine infusion. Initial laboratory results
showed white blood cell count (WBC) of 77 ϫ 10
9
/L, hemoglobin level
of 122 g/L, Plts of 576 ϫ 10
9
/L, pH of 6.52, P
CO
2
of 61 mm Hg, PO
2
of 85 mm Hg, HCO
3
of 5mmol/L, lactate value of 16 mmol/L, PTT of
18, and INR of 1.18. Abdominal radiographs showed dilated loops of
small bowel with thickened walls. Abdominal sonography showed
thickened bowel with no peristalsis. Empiric antibiotics were initiated
(ampicillin, gentamicin, and metronidazole), and the patient was taken
to the operating room for treatment of an acute abdomen.
At laparotomy, the patient had generalized bowel ischemia with a
frankly necrotic ileum. The findings were consistent with a “low-flow
state”; likely secondary to hypovolemia from diarrhea. There was no
evidence of necrotizing enterocolitis, volvulus, malrotation, or bowel
obstruction. The peritoneal fluid was purulent. Twenty-seven centime-
ters of ileum were resected, and an ileostomy with mucous fistula was
created. A second-look laparotomy was performed 36 hours later. An
additional 24 cm of ileum was removed, and the ileostomy with
mucous fistula was refashioned. The patient was left with 102 cm of
small bowel from the duodenojejunal flexure to the stoma and 60 cm
from the mucous fistula to the ileocecal valve.
The patient’s immediate postoperative course was complicated by a
left femoral vein clot secondary to a central line placed at the time of
resuscitation. Enoxoparin was initiated. Despite 2 days of modest
improvement, the patient showed signs of ongoing sepsis with fever
and leukocytosis (46 ϫ 10
9
/L). The peritoneal fluid cultures taken at
the time of the original laparotomy showed Escherichi coli, Klebsiella
pneumoniae, and Streptococcus viridans. The same antibiotics were
continued. The patient had persistent abdominal distension that was
tense on examination. The very distended abdomen resulted in elevated
peak inspiratory pressures that prevented weaning of the ventilator.
Abdominal radiographs showed a gasless abdomen. Abdominal
ultrasound scan and computed tomography (CT) scan on postoperative
day 14, showed multiple, complex fluid collections. There was a 5- ϫ
6 cm collection between the stomach and spleen (Fig 1A) that was
contiguous with a 6- ϫ 8-cm midline collection, and there also was a
6- ϫ 3-cm pelvic collection. Percutaneous 10F pigtail drainage cathe-
ters were inserted into the upper abdominal collections, and only 20 mL
of purulent fluid was produced. The drains were ineffective, because
the collections were septated and the fluid was very thick and tenacious.
The clinical situation was difficult, because we were faced with a
young patient who had persistent, intraabdominal abscesses that were
causing ongoing systemic sepsis and were preventing ventilatory wean-
ing. We wanted to avoid another laparotomy because the patient was a
poor surgical candidate as a result of the profound physiologic insult
she had recently endured. We decided to pursue fibrinolytic therapy in
a manner analogous to treatment of loculated empyema. We elected to
use tissue-plasminogen activator, because streptokinase and urokinase
are no longer used at our institution. We found no information in the
literature about intraperitoneal use of tPA in a neonate. To be cautious,
we used one half of the dose used for empyema treatment. The parents
were informed fully about the possible complications. Two milligrams
of tPA in 8 mL of normal saline were instilled into the drainage catheter
located in the left upper quadrant. The catheter was clamped, and the
From the Division of Pediatric General Surgery and Department of
Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario,
Canada.
Address reprint requests to Ted Gerstle, MD, Division of General
Surgery, Rm 1526, The Hospital for Sick Children, 555 University Ave,
Toronto, Ontario M5G 1X8, Canada.
© 2003 Elsevier Inc. All rights reserved.
0022-3468/03/3808-0021$30.00/0
doi:10.1016/S0022-3468(03)00275-6
1234 Journal of Pediatric Surgery, Vol 38, No 8 (August), 2003: pp 1234-1236