Psoas abscesses complicating colonic disease: imaging and therapy
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1 Ann R Coll Surg Engl 1998; 80: Psoas abscesses complicating colonic disease: imaging and therapy D N Lobo MS FRCSEd(Gen Surg)' Specialist Surgical Registrar W K Dunn MB BS FRCR1 Consultant Radiologist S Y Iftikhar DM FRCSEd2 Consultant Surgeon J H Scholefield ChM FRCS' Reader in Surgery 1Departments of Surgery and Radiology, University Hospital, Nottingham 2Department of Surgery, Derbyshire Royal Infirmary, Derby Key words: Colonic diseases; Complications; Diagnosis; Psoas abscess; Treatment Most surgeons think of psoas abscesses as a very rare condition related to tuberculosis of the spine, but in contemporary surgical practice they are more usually a complication of gastrointestinal disease. A case note study was undertaken on all patients treated for psoas abscess at two large hospitals in the mid-trent region over a 2-year period. All seven patients presented with pyrexia, psoas spasm, a tender mass and leucocytosis. The diagnosis was made on abdominal radiographs in one patient, CT scan in three, MRI in two, and ultrasound in one. Aetiological factors included Crohn's disease in three, appendicitis in two, and sigmoid diverticulitis and metastatic colorectal carcinoma in one each. Six patients underwent transabdominal resection of the diseased bowel, retroperitoneal debridement and external drainage of the abscess cavity. Percutaneous drainage was performed in one. Two patients had more than one surgical exploration for complications. There were no deaths and the hospital stay ranged from days. Psoas abscess can be a difficult and protracted problem. Bowel resection, thorough debridement, external drainage and concomitant antibiotics are essential for psoas abscesses complicating gastrointestinal disease. Defunctioning stomas may be necessary. However, in some cases a multidisciplinary approach may be required, as psoas abscesses can involve bone and joints. Psoas abscess is a potentially fatal condition with a reported incidence of 0.4 cases per population per year (1). Most psoas abscesses are secondary to disease in anatomically related structures. Tuberculosis of the spine used to be the most common cause, and though the condition is still encountered in the Western world Correspondence to: Mr D N Lobo, Department of Surgery, E Floor, West Block, University Hospital, Nottingham NG7 2UH (1-4), a gastrointestinal source is the most common aetiological factor (1,2,4-8). Psoas abscesses may also occur as a primary event in intravenous drug abusers (2,4), patients with HIV (4) and other forms of immunological dysfunction (1). We present our experience of seven patients treated for psoas abscesses secondary to colonic disease over the last 2 years. Patients and methods A case note study was undertaken on all patients treated at University Hospital, Nottingham, and Derbyshire Royal Infirmary, Derby, for psoas abscesses between January 1996 and December Presenting features, radiological findings, aetiology, treatment and outcome were documented. Results Six ofthe seven patients were male. The median age was 35 years (range years) and the median duration of symptoms was 3 weeks (range 1-12 weeks). All patients presented with a temperature > 380C and a pulse rate ) 100 bpm. A tender right or left flank/iliac fossa mass and ipsilateral psoas spasm were noted in all seven. The mean white cell count at admission was 20.5 x 109 cells/l (range x 109 cells/l). Transabdominal bowel resection, retroperitoneal debridement and external drainage of the abscess cavity were performed in six patients. Percutaneous drainage of the abscess was performed in one patient who had metastatic colorectal carcinoma. A heavy mixed growth of coliforms and enterococci was cultured from the pus drained from four patients. E. coli was isolated from one and anaerobic streptococci and bacteroides from another. One patient was treated with a course of
2 406 D N Lobo et al. antibiotics before operation and no organisms were cultured. Intravenous antibiotics were administered to all patients. There were no deaths and the median hospital stay was 16 days (range days). Case 1 (M/38) A patient being treated with prednisolone and mesalazine for Crohn's disease had a large left retroperitoneal abscess involving the iliopsoas muscle on CT scan (Fig. 1). At laparotomy, there was a retroperitoneal perforation of a thickened and inflamed left colon which was in communication with the psoas abscess. A left hemi- Figure 1. Case 1. Contrast enhanced abdominal CT scan demonstrating a large abscess within the left iliopsoas muscle. Muscle enlargement, a low-density area, gas bubbles and contrast enhancing margins are all seen. colectomy was performed and an end colostomy and mucus fistula were fashioned. Histology confirmed Crohn's disease. There were no complications and bowel continuity was restored 3 months later. Case 2 (M/35) Abdominal CT scan findings of a caecal mass in association with a right psoas abscess were confirmed at laparotomy and a right hemicolectomy was performed. There were no complications and histology suggested acute appendicitis with paracaecal inflammatory change. Case 3 (M/58) Gas within the left psoas muscle indicative of abscess formation was noted on abdominal radiograph (Fig. 2) of a patient known to have sigmoid diverticular disease. The psoas abscess was in association with a sigmoid diverticular abscess and Hartmann's procedure was performed. The patient was reoperated 11 days later for adhesive obstruction and is presently awaiting reversal of Hartmann's procedure. Case 4 (M/33) The patient had undergone a right hemicolectomy 6 months previously for Crohn's disease and was on prednisolone and azathioprine. MRI demonstrated destruction of L4-5 vertebral bodies along with an extensive soft tissue collection ramifying through L4/5 and L5/S1 disc spaces, involving the left psoas muscle and extending into the presacral region down to the coccyx. There was a tract communicating between the sigmoid colon and the presacral collection (Fig. 3). At laparotomy the rectosigmoid was densely adherent to the abscess cavity anterior to the sacral promontory. Pus was present in the L5/SI disc space and within the left psoas muscle. Hartmann's procedure was performed and histology Figure 2. Case 3. Supine and left lateral abdominal radiographs showing gas within the left psoas muscle extending to its insertion in the lesser trochanter.
3 Psoas abscesses complicating colonic disease 407 Figure 4. Case 5. CT scan through upper thigh. Gas (arrow) is seen within the right psoas muscle near its insertion into the lesser trochanter. repeated debridement of the right iliacus, psoas and adductor canal muscles. The hospital stay was 152 days and bowel continuity was restored 6 months later. Figure 3. Case 4. Saggital Ti-weighted MRI scan demonstrating destruction of L4-5 vertebral bodies and involvement of the disc spaces. A presacral collection (arrowhead) extending to the coccyx is seen communicating with the sigmoid colon (arrow). Case 6 (M/31) Initial CT scan of a patient being treated with mesalazine for Crohn's disease demonstrated enlargement of the right psoas muscle with surrounding inflammatory change and thickened bowel loops. No fluid collection or abscess formation was noted. This was thought to be consistent with exacerbation of Crohn's disease and he was treated with mesalazine and antibiotics. MRI 6 weeks later displayed a right psoas abscess with possibility of a fistula between the ascending colon and abscess cavity (Fig. 5). confirmed Crohn's disease. The patient's postoperative recovery was complicated by systemic sepsis and prolonged ileus. There was evidence of vertebral regeneration on follow-up MRI and bowel continuity was restored 8 months later. Case 5 (F/26) A patient who had been extensively investigated for recurrent abdominal pain in the past had a large right psoas abscess extending to the lesser trochanter on CT scan (Fig. 4). Thickening of the caecum with retrocaecal abscess formation was also noted. A right hemicolectomy was performed. She then had a laparotomy and end ileostomy for anastomotic dehiscence on the 11th postoperative day. Two further laparotomies for drainage of intra-abdominal abscesses were performed. MRI 2 months after the initial operation demonstrated osteomyelitis of the right femoral head with septic arthritis and extension of the abscess to the right adductor canal. She then underwent excision of the right femoral head and Figure 5. Case 6. T2-weighted MR image of the abdomen demonstrating a right psoas abscess as an area of high signal (arrow). The right psoas muscle is generally of increased signal compared with the normal left psoas.
4 408 D N Lobo et al. The terminal ileum, caecum and ascending colon were thickened and inflamed and the posterior wall of the ascending colon was communicating with the psoas abscess. Crohn's disease was confirmed on histological examination of the right hemicolectomy specimen. There were no complications. Case 7 (M/75) The patient had an anterior resection for a rectal carcinoma 1 year before presentation. A large right psoas abscess and multiple liver metastases were seen on abdominal ultrasound scan. No colonic lesion was demonstrated on barium enema. Liver biopsy confirmed metastatic adenocarcinoma and ultrasound-guided percutaneous drainage of the abscess was performed. Symptomatic relief was obtained on non-operative management. The patient died from metastatic disease 3 months after discharge. Discussion Psoas abscesses complicating gastrointestinal disease are not as uncommon as surgeons may think. The onset is usually insidious and diagnosis may be delayed. The primary gastrointestinal inflammatory process must be adequately treated in order to gain control of the abscess. Morbidity is high and occasionally these abscesses may involve adjacent bones and joints, at which point a multidisciplinary therapeutic approach is needed. More than 40% of all psoas abscesses treated in the West are secondary to gastrointestinal disease (1,2,4,8). Crohn's disease is the most common cause in many studies (1,2,8) and could be present in up to 73% of patients (8). Other gastrointestinal conditions implicated are diverticulitis (1,3,5,7), appendicitis (1,5), colonic carcinoma (1,7) and pancreatitis (2). Three of our patients had Crohn's disease, two had appendicitis, and one each sigmoid diverticulitis and metastatic colorectal carcinoma. Psoas abscesses are also known to be a sequel to gastrointestinal anastomotic dehiscence (7,8) and infection of the rectal stump after Hartmann's procedure (5,6). Fever is the most frequent symptom in patients with psoas abscess, but the classic features of abdominal pain, hip flexion and an abdominal, flank or groin mass may be present in under 50% of patients (1,2,8). It is unusual that all our patients presented with the characteristic features of the disease. In a large review of patients with psoas abscesses, an accurate diagnosis was made in only 53% of 178 patients in whom a preoperative diagnosis was recorded (6). Insidious onset of the disease and inconsistent clinical findings result in a delay in diagnosis and increased morbidity (1). Antibiotic therapy initiated by primary care practitioners may result in patients presenting late and a high index of suspicion is obligatory. Striking findings on abdominal radiographs as seen in Fig. 2 (Case 3) are exceptional, and plain radiographs have a low diagnostic accuracy (3). Ultrasound is accurate in only 70% of cases and small psoas abscesses are usually missed (3). Therefore, CT scanning, which is widely available, is the current diagnostic gold standard. The most commonly seen features of a psoas abscess on CT scan are a focal low-density area within an enlarged psoas muscle (Fig. 1 and Fig. 4, Case 1 and Case 5). In addition, the edge of the abscess typically enhances with intravenous contrast. Other features that may be present include gas within the lesion and infiltration of surrounding fat (3). Bowel, pancreatic, renal and vertebral abnormalities may also be noted on CT scan. CT scan also helps predict suitability for percutaneous drainage. Unilocular primary psoas abscesses usually respond well to percutaneous drainage (4,6). Patients with multilocular abscesses and concurrent retroperitoneal and intraperitoneal abnormalities tend to need surgical intervention (4,6). Psoas abscesses appear on MRI as areas of increased intensity on T2-weighted images (3,9) (Fig. 5, Case 6). Abscesses are shown as lesions with signal-void centres and intense peripheral enhancement on gadolinium-enhanced images. MRI may be superior to CT in the diagnosis of psoas abscess, but case numbers in comparative studies have been too small to establish the benefit (10,11). Advantages of MRI over CT include better delineation of the extent of infiammatory change in surrounding tissues and the ability of MRI to demonstrate abscesses as a distinct collection separate from adjacent soft tissue without the necessity of intravenous contrast (3,9,10). Bone marrow infiltration, which is an indicator of early osteomyelitis (Case 5), is much better seen on MRI. Intervertebral disc space involvement (Fig. 3, Case 4), which is more typical of infection than malignancy, is also better demonstrated on MRI (3). MRI provided excellent definition of the disease process in our series. Surgical intervention is the treatment of choice for psoas abscesses known to be secondary to gastrointestinal pathology (1,2,4-8), as this permits treatment of the underlying disease, which may include resection of the diseased bowel, adequate debridement of the necrotic psoas muscle, external drainage of the abscess cavity and concomitant antibiotic therapy. Defunctioning of the bowel may be necessary on some occasions. The transabdominal route is preferred for surgical exploration. Incisions in the groin, thigh and back are not recommended initially as the primary pathology is usually overlooked, resulting in a high failure rate (6). Extension of the abscess into the thigh and communication with muscle compartments, as in Case 5, requires a multidisciplinary approach for local exploration and debridement. Surgical intervention is not without significant morbidity and mortality. One of the largest series has shown that 27 of 67 patients (40%) treated for psoas abscess required more than one surgical procedure (8). Mortality in the range of 18-25% has been described (1,2,4). Reasons for the high morbidity and mortality include delayed diagnosis and intervention, poor nutritional status, inadequate drainage of the abscess and failure to resect diseased bowel (1,2,4-8). Percutaneous drainage may be valuable before definitive surgery in unstable, septic patients (2-4). Non-operative manage-
5 ment may also be considered in patients with advanced malignancy. It has been shown, though not in a randomised study, that patients undergoing surgical drainage have a significantly shorter hospital stay than those treated by percutaneous drainage (4). Paucity of gastrointestinal symptoms and absence of previous history of gastrointestinal disease may pose a diagnostic and therapeutic dilemma in some patients. Involvement of the gastrointestinal tract in the inflammatory process may be demonstrated on MR and CT scans. Bowel pathology must be suspected in patients not improving after percutaneous drainage of psoas abscesses. Upper and lower gastrointestinal contrast radiology is helpful in the management of such patients, but there remains a group of patients in whom gastrointestinal involvement is first diagnosed at laparotomy. In conclusion, psoas abscesses secondary to gastrointestinal disease are a complex clinical problem. An early diagnosis is seldom made and percutaneous drainage is rarely definitive treatment. The recommended therapy of transabdominal resection of the involved bowel, debridement of the necrotic retroperitoneum and external drainage of the abscess cavity may not always be adequate. Repeated exploration, defunctioning of the affected bowel and nutritional support may be required in complex cases. References 1 Bartolo DCC, Ebbs SR, Cooper MJ. Psoas abscess in Bristol: a 10-year review. Int J Colorectal Dis 1987; 2: Psoas abscesses complicating colonic disease Walsh TR, Reilly JR, Hanley E, Webster M, Peitzman A, Steed DL. Changing etiology of iliopsoas abscess. Am J Surg 1992; 163: Paley M, Sidhu PS, Evans RA, Karani JB. Retroperitoneal collections-aetiology and radiological implications. Clin Radiol 1997; 52: Santaella RO, Fishman EK, Lipsett PA. Primary vs secondary iliopsoas abscess: presentation, microbiology, and treatment. Arch Surg 1995; 130: Hardcastle JD. Acute non-tuberculous psoas abscess: report of 10 cases and review of the literature. Br J Surg 1970; 57: Ricci MA, Rose FB, Meyer KK. Pyogenic psoas abscess: worldwide variations in etiology. World J Surg 1986; 10: Leu S-Y, Leonard MB, Beart RW Jr, Dozois RR. Psoas abscess: changing patterns of diagnosis and etiology. Dis Colon Rectum 1986; 29: Procaccino JA, Lavery IC, Fazio VW, Oakley JR. Psoas abscess: difficulties encountered. Dis Colon Rectum 1991; 34: Weinreb JC, Cohen JM, Maravilla KR. Iliopsoas muscles: MR study of normal anatomy and disease. Radiology 1985; 156: Wall SD, Fisher MR, Amparo EG, Hricak H, Higgins CB. Magnetic resonance imaging in the evaluation of abscesses. AJR 1985; 144: Lee JKT, Glazer HS. Psoas muscle disorders: MR imaging. Radiology 1986; 160: Received 27 May 1998
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