Crohn's Disease with Left Psoas Abscess : Report of a Case

Transcription

1 Show Univ J Med Sci 11(4), , December 1999 Cse Report Crohn's Disese with Left Psos Abscess : Report of Cse Mild SHIBUSAWA, Aklr TSUNODA, Tetsuo SAWATANI, Ktsuo YAMAZAKI, Goichl KAMIYAMA, Mnbu TAKATA Mitsuo KUSANO Abstrct : We report herein cse of Crohn's disese complicted with left psos muscle bscess. The ptient ws 23-yer-old mn who hd been undergoing tretment for Crohn's disese for bout 7 yers. He presented with bdominl extremity pins, norexi fever on dmission. A CT scn reveled left psos retroperitonel bscesses brium enem lso showed lrge extrluminl cvity. A prtil resection of descending colon, colostomy extrperitonel dringe were crried out. Although Crohn's disese is often complicted with bdominl bscesses, psos bscess is very rre. A preopertive dignosis of bscess cn be mde using rdiologicl studies without ny difficulty. However, dequte dringe of bscess must be chieved s soon s possible opertion my depend on site of involvement condition of ptient. Key words : Crohn's disese, psos bscess Introduction Crohn's disese frequently presents with intrbdominl bscess. However, psos bscess is rre serious compliction of Crohn's disese. Although tuberculosis of spine hs previously been most common cuse of psos bscess, with incresing incidence of Crohn's disese, psos bscess cn be expected to be found s compliction of Crohn's disese more frequently. Only 13 cses with psos bscess s compliction of Crohn's disese hve been reported in Jpn to dte. This rticle describes rre cse of Crohn's disese complicted with left psos bscess. This report focuses on incidence, symptoms, clinicl significnce of surgicl tretment. Cse Report A 23-yer-old mn ws dmitted to our hospitl on Februry 4, 1999, for tretment of left psos muscle bscess. The ptient hd undergone n opertion for n nl fistul in He hd been dmitted to nor hospitl with bloody stools in My, 1991, he ws dignosed s hving ulcertive colitis underwent medicl tretment. He ws dmitted to hospitl on August 15, 1998, with bdominl pin fever. Furr investigtions disclosed tht he hd ileocolic Crohn's disese. A computed tomogrphy (CT) scn confirmed presence of n inflmmtory chnge round cecum descending colon, but no fistul ws found. Three months lter, though he hd no Second Deprtment of Surgery, School of Medicine, Show University 1-5-8, Htnodi, Shingw-ku, Tokyo, , Jpn.

2 298 Miki Fig A brium towrd descending brium extrluminl gin 1, 2). dmitted On tenderness with his he norexi enem Feburry 4, Lbortory extremity lprotomy ws descending colon, pins count ws performed on lrge in dt Februry 8, psos stricture of lrge which bscess descending nutrition A grde Tble fever protein reveled retroperitonel colon rpy, CT scn left 1. cvity lower (38.8 Ž) stiffening ws (Figs. bdominl Four ws he showed extrluminl reveled in C-rective 1999, shown high lekge nrrowing exmintion is with tretment reveled physicl ssocited extrluminl Jnury lso 12,200/mm3 left tight steroid brium on shows spce reveled received distention. cell exmintion fever dmission blood enem retroperitonel colon. exmintion Although bscess bdominl white enem lekge. retroperitonel et l A CT scn of bdomen demonstrtes low density re in left psos muscle (rrow). There is some collection of brium round left descending colon. Fig. symptoms, SHIBUSAWA, dys lter, ppered, 12.3mg bscess / dl. A congested were found

3 Crohn's Tble Fig Disese Lbortory with Psos dt on Abscess 299 dmission. Mcroscopic picture of resected specimen shows longitudinl ulcers (white rrowhed) penetrting ulcer (blck rrowhed). below hrd edemtous retroperitoneum. A prtil resection of descending colon, colostomy extrperitonel dringe were crried out. The surgicl specimen showed longitudinl ulcers penetrting ulcers 0.5 X 2.0 cm 0.3 X 1.3 cm in size in middle of descending colon (Fig. 3). The postopertive course ws uneventful he ws dischrged 5 weeks fter opertion. Discussion Although intrbdominl bscesses occur in 10-28% 1,21of ptients with Crohn's disese, psos bscess is rre compliction. Agh et l.3) reported 2 cses ; 0.41% incidence of psos bscesses in ir 483 cses of Crohn's disese. Keighley et l.1) found 2 preopertive bscesses (1.6%) in totl of 124 resections for Crohn's disese. In Jpn, exct incidence of psos bscess formtion is difficult to determine. However, Funym4) found 2 in 78 ptients (2.6% ) surgiclly treted for Crohn's disese. According to our serch of Jpnese literture, 13 cses with psos bscess s compliction of Crohn's disese hve been reported (Tble 24-14)) our cse is 14th cse. There were twelve men two women, rnging in ge from 14 yers to 37 yers, with medin ge of 26 yers.

4 300 Miki SHIBUSAWA, et ltble 2. Summry of 14 Ptients of Crohn's disese with Psos bscess.*tpn : t

5 Crohn's Disese with Psos Abscess 301 Mycobcterium tuberculosis ws previously most common cuse of psos bscess. With decline of spinl tuberclosis in developed countries, psos bscess is most commonly due to direct extension from djcent bowel. 15) Therefore, most common pthogens re grm-negtive bcillus like Escherichi coli, nerobic bcteri. Diseses of gstrointestinl trct tht cn secondrily cuse psos bscess include diverticulitis, crcinom of colon, ppendicitis, pncretitis Crohn's disese. With incresing incidence of Crohn's disese, psos bscess cn be expected to be found complicting Crohn's disese more frequently. Wlsh et l15 reported 11 ptients with psos bscess, in 6 of ptients source of ir bscess ws gstrointestinl. In 3 of se ptients, bscess ws cused by perfortion from bowel with Crohn's disese. A psos bscess due to Crohn's disese is result of direct contct of ny fissure in n ulcerted bowel penetrting bckwrds. In 14 ptients who hve been reported in Jpn including ours, eight of bscesses (57.1%) occurded on right, six (32.9%) on left. Ricci Meyer 16 reported 41 ptients in literture : 34 (82.9%) were on right, seven (17.1%) were on left. It hs been noted tht psos bscess is more common in ptients with terminl ilel /or right colonic disese thn those with only left colonic involvement by Crohn's disese. A psos bscess my be expected to occur in ptient with Crohn's disese, especilly with long durtion of disese. In nine ptients durtion of Crohn's disese ws known : n verge of 5 yers (rnge 1 month to 14 yers) hd elpsed from time of dignosis to presenttion with psos bscess. In our cse, durtion of disese ws bout 7 yers. The dignosis of psos bscess is most efficiently ccurtely mde using CT scn mgnetic resonnce imging. A CT hd been performed in 13 of 14 cses tht we studied. Keighley et l.1) stted tht ptients with n bdominl pelvic bscess hd rised serum lkline phosphtse hd decresed serum lbumin levels. A fll in serum lbumin often occurs in ctive phse of disese. Dew et l. 17) in n nlysis of heptic dysfunction in Crohn's disese found tht rised levels of lkline phosphtse in periopertive period were usully due to intrbdominl sepsis. But we could not confirm ny bnormlity in lkline phosphtse in our ptient. Ptients with psos bscess complin of following chrcteristic symptoms: flexion contrcture of thigh, limp, limb bck pin, generl symptoms of ctive Crohn's disese. In presented cses, none hd previously hd history of bdominl surgery. At time of detection of psos bscess, three ptients were receiving prednisolone ( PDL ), three were receiving PDL in combintion with slzosulfpyridine (SASP) or 5-minoslicylic cid (5-ASA ), three took SASP lone. Most ptients hd underwent dringe of bscess bowel resection. Twelve ptients received surgicl rpy two ptients continued medicl tretment. Where percutneous dringe ws n initil rpy, resolution of bscess ws seen in two of four ptients. One of two ptients who received only medicl tretment did not require n opertion, but or twelve ptients underwent resection rpy. In our cse, removl of disesed bowel dringe were initil rpies, becuse bscess hd been present for long time, re ws mrked stenotic chnge of descending colon. According to report by Ricci Meyer16), when incision dringe lone ws initil surgicl procedure, resolution of bscess occurred in only 26.9% of cses. However, development of ultrsonogrphy CT scn hs been

6 302 Miki SHIBUSAWA, et l remrkble, percutneous dringe using se methods my be more efficient. Percutneous dringe should refore initilly be ttempted, but opertive dringe is ultimtely required. In conclusion, lthough Crohn's disese is often complicted with bdominl bscesses, psos bscess is rre compliction. However, with incresing incidence of Crohn's disese, psos bscess cn be expected to complicte disese more frequently. Preopertive dignosis of bscess cn be esily mde by rdiologicl study. Adequte dringe of bscess must be chieved s soon s possible opertion my depend on site of involvement condition of ptient. References 1) Keighley MRB, Estwood D, Ambrose NS, Alln RN Burdon DW : Incidence microbiology of bdominl pelvic bscess in Crohn's disese. Gstroenterology 83 : (1982) 2) Greenstein AJ, Krk AE Dreiling DA : Crohn's disese of colon. Am J Gstroenterol 62 : (1974) 3) Agh FP, Woosley EJ Amendol MA : Psos bscess in inflmmtory bowel disese. Am J Gstroenterol 80 : (1985) 4) Funym Y, Sski I, Nito H, Tsuchiy T, Tkhshi M, Koym K, Msuko T, Tkhshi K, Hiwtshi N Mtsuno S : Psos bscess complicting Crohn's disese : report of two cses. Surg Tody 26 : (1996) 5) Ymmoto T, Moriski H, Kitno K, Fukud R, Nkjim K, Izukur T, Uemtsu K, Ohnishi S Kikui M : A cse of Crohn's disese, complicted by psos bscess formtion. Kyosi Iho 25 : (1974) (in Jpnese) 6) Umemoto Y, Tnimur H, Tniguchi K Ymgmi Y : A cse of Crohn 's disese with psos bscess. Nippon Shokkibyo Gkki Zsshi 89: 905 (1992) (in Jpnese) 7) Ngsw Y, Nknishi K, Murym Y, Kondo S, Okuno M, Shinomur Y, Mtsuzw Y, Nezu R, Tkgi Y Okd A : A cse of Crohn's disese with psos bscess. Nippon Shokkibyo Gkki Zsshi 91 : (1994) (in Jpnese) 8) Akiym M, Mizushim Y, Ued R Mtsuno T : A cse of Crohn's disese with psos bscess. Nippon Dicho Komonbyo Gkki Zsshi 47 : (1994) (in Jpnese) 9) Ymguchi T, Ymzki Y, Kuwt K, Iizuk T, Oowd T, Ookouchi T, Hidhr I Ymmoto Y : A cse of psos bscess due to Crohn's disese. Chubu Nippon Seikeigek Sigigek Gkki Zsshi 37 : 1601 (1994) (in Jpnese) 10) Ooy M, Ako S, Hirysu Y, Tkizw A, Fujit M, Terd H, Sski K, Ishikw H Yoshimur S : A cse of colonic Crohn's disese with psos bscess. Nippon Rinsho Geki Gkki Zsshi 56 : 322 (1995) (in Jpnese) 11) Tsuzuki H, Tmuchi T, Okmoto T, Ymmur H, Shoji T Koym Y : A cse of Crohn's disese complicted by psos bscess. Nippon Rinsho Geki Gkki Zsshi 57 : (1996) (in Jpnese) 12) Wtnbe F, Hond S, Kubot H, Yoshii S, Higuchi R, Sugimoto K, Iwski H, Hni H Kneko E : A cse of Crohn's disese with left iliopsos bscess. Nippon Shokkibyo Gkki Zsshi 94 : (1997) (in Jpnese) 13) Hshimoto Y, Sugihr S, Inoue K, Iwgki S, Hshimoto Y, Fukuym G Sito Y : A cse of Crohn's disese with right psos bscess. Nippon Dicho Komonbyo Gkki Zsshi 51 : 706 (1998) (in Jpnese) 14) Sugimori S, Fujii H, Ymmoto K, Ishikw H, Morit T, Ht M, Koym F, Teruchi S, Kobyshi T, Enomoto T, Nkno H, Yoshikw S Inji N : Two cses of psos bscess complicted with Crohn's disese. Nippon Dicho Komonbyo Gkki Zsshi 51 : 706 (1998) (in Jpnese) 15) Wlsh TR, Reilly JR, Edwrd H, Webster M, Peitzmn A Steed DL : Chnging etiology of iliopsos bscess. Am J Surg 163 : (1992) 16) Ricci MA Meyer KK : Psos bscess complicting Crohn's disese. Am J Gstroenterol 80 : (1985) 17) Dew MJ, Thompson H Alln RN : The spectrum of heptic dysfunction in inflmmtory bowel disese. Q J Med 48 : (1979) [Received August 19, 1999: Accepted September 29, 1999]