Pyogenic illiopsoas abscessa diagnostic and therapeutic challenge :Pyogenic illiopsoas abscessa diagnostic and therapeutic challenge Zahid M Bahli S.H.O surgery


Historical background :Historical background Herman Mynter 1881 first described as psoitis More than 500 cases have been reported in world literature Current standard dictionary defines illiopsoas abscesses “an abscess usually tuberculous originating in tuberculous spondylitis and extending through illiopsoas to inguinal region”. 70% were diagnosed on autopsy before the invention of CT scan


Illustrative case history :Illustrative case history Previously healthy48 yrs male smoker 2 wks hx of back pain,malaise,weakness,unresponsive to conventional NSAIDS O/E ill looking,flushed,tachycardia(115/min) pyrexic(38.5c),BP115/80mmHg, tender renal angle. Rest of examination was unremarkable.


Labs :Labs Urine (proteins,RBC,leucocytes) Blood (wbc 39000,CRP375,ESR72,rest of blood unremarkable). PFA revealed no significant finding Blood cultures and urine cultures sent to lab. A USG abdomen and IVU booked for next day.


Probable cause :Probable cause Pyelonephritis as probable cause of the condition was made and patient commenced on iv ciprofloxacillin. No improvement ????????????? USG normal After 24 hrs redness and swelling noticed in rt flank.


Next :Next An urgent ct scan of abdomen was carried out which revealed a huge psoas abscess. CT guided drainage was performed and drain catheter was kept in. Subsequently conditions of the patient improved. Continuous flushing of drain and repeated tub grams(wkly)to see progress .


CT picture of the abscess :CT picture of the abscess


CT picture 2 :CT picture 2


Percutaneous drainage :Percutaneous drainage


Drainage catheter :Drainage catheter


anatomy :anatomy


anatomy :anatomy Henry Gray  (1825-1861).


Relations :Relations Left side


Relations :Relations Left side (lower pole)


Yes its true! :Yes its true! 3.9 cases per year before 1985 12 cases per year in 1992(Taiwoo et al 2001) Incomplete reporting from developing world….may be lowered incidence. Upto1985 all case reported from developing world were primary in origin( Asia /Africa)99% (Ricci et al 367 case review). Eurup17% and America 61% are primary. M>FM, Young>Old,rt>lt (Breese 142 paed pts)


Primary or secondary psoas abscess :Primary or secondary psoas abscess Primary is mostly haematogenous in origin Secondary abscess usually as a consequence of spread from an adjacent organ. Controversy as which one is more common Failure to investigate primary abscess. Primary and secondary relatively rare in older population. However recent study from John Hopkins School of medicine revealed that secondary psoas abscess is more prevalent than primary (61% 2-78 yrs) as compared primary(28-81 yrs). 3% are bilateral Mortality in untreated case is 100%


Primary psoas abscess :Primary psoas abscess Common in young (83% in <30 yrs). 54% <10 yrs 3M:1FM Rt=Lt Mean hospital stay 38.8 days 86% IVDA & 56% HIV infected. Immonocompromised,DM,steroids,elderly,renal failure 86% staph. aureus 15-20% hx of trauma. even microscopic…sequence Mortality 2.5%.


Secondary psoas abscess :Secondary psoas abscess 78% between 10 and 50 yrs M=FM ,RT>LT (58-68%)...reason?? Mean hospital stay 33.2 days 80% GIT (23-73% crohn’s) 26% osteomylitis A recent review from UK revealed 25% are due to tuberculosis. table


Table1 :Table1 GIT crohn,s,UC,appendicitis,colorectal ca,diverticulitis GUT UTI,ca,ECSWL Musculoskeletal vertebral osteomylitis,septic arthritis , infectious sacroillitis. Vascular infected abdominal aortic aneurysm, femoral vessel catheterisation Miscellaneous endocarditis,IUCD,suppurative lymphadenitis


Common pathogens :Common pathogens 88% staph. aureus in primary abscess However presence of staph does not rule out primary abscess(Satoshi h et al). Secondary psoas abscess is mostly due to strep 4.9%.E.coli 2.8%. Mycobacterium is a common cause in developing countries but uncommon in west. Others proteus,Yesinia,klebsiella,becteroides,clostridia We had strep constallateue and


Remember! :Remember! 70% were diagnosed on autopsy before widespread use of ct scan. Preoperative diagnosis is correct in 50% cases. High degree of suspicion and knowledge of anatomy of retroperitoneal space is very important. Most of times classical picture is absent and non specific features predominate. Only 30 % exhibit classical tirade


Common presentations :Common presentations Fever >38c (94%) (satoshi h et al) Back/flank/abd pain (88%) Limited hip movements (82%) non in one study (T lee et al) Classical tirade(fever,pain,hip flexion contracture) only in 30%/70% in one study Chills(45%) Mass(27%) Abd. tenderness (1%) Associated features. septic shock53%,DIC29%, ARDS 12% (Japan)


Labs :Labs Leucocytes >10000/mm (35000/mm) Raised ESR (375) in our patient 100% case in J H study showed above features. Haematuria & pyouria >10 RBC/WBC per high power field 59% & 71% (satoshi h et al). Other baseline (U&E,LFTs,amylase,coag) Cultures (blood,urine,pus)


Imaging studies :Imaging studies Specificity/sensitivity PFA USG (37% negative USG (satoshi et al), 100% negative (Pan fu et al) in diabetics…adv/disadv CT considered as standard up till now. diagnostic &therapeutic. CT????????or USG MRI …need more evaluation Others (Tc-scan,gallium,ivu,barium studies.) Ga-67 in FUO 80% successful in detecting lesion, 75% positive in picking concomitant lesion…often not seen by CT.


Treatment :Treatment Appropriate antimicrobial therapy Drainage PCD vs. Surgical drainage PCD successful in80%/66.7% in two studies. (Santaella et al)surgery (100%) vs. PCD 57% while Ricci et al.97.3% vs. 49%. PCD was reported in 1984 by Muller et al 20/22 treated pcd,(Contasdaemer et al 21/22) (Orv Hetil. 1994 Nov 20;135(47):2597-602, Urology. 1987 Apr;29(4):450-3. Ind J Radiol Image 2001 11:1:13-16 86% success 24 patients,Radiology 2002;225:353-358.) 26 patients, We achieved success with CT guided pcd ,and repeated tub grams ,and accordingly flushing of drain with saline.


Indications :Indications Surgery failure of pcd, relative contraindications of pcd,presence of another intrabdominal pathology, in Crohn,s performing a single operation to drain the abscess and resect diseased segment is desirable. PCD pcd under image guidance should be first step especially in very sick and septic patient to control sepsis, useful to undertake before surgery to improve conditions of patient.


Conclusion :Conclusion Disease changes its pattern. Psoas abscess should be kept in mind while making a diagnosis of pyelonephritis. CT is regarded as a standard way of diagnosing Psoas abscess up till now. PCD is a successful way of treating abdominal abscesses especially Psoas abscess.


Questions??????? :Questions??????? Thank you