Psoas Abscess: Difficulties Encountered John A. Procaccino, M.D., Ian C. Lavery, M.D., Victor W. Fazio, M.D., John R. Oakley, M.D. From The Cleveland Clinic Foundation, Department of Colorectal Surgery, Cleveland, Ohio From 1961 to 1989, 67 patients underwent various surgical procedures for psoas abscess. Retrospective analysis was undertaken in an effort to determine optimal surgical therapy. Forty patients were cured with one operation. Twenty-one patients required two operations, four patients required three operations, and two patients required more than three operations. The reason for failure of treatment was failure to resect the diseased bowel or to drain the psoas abscess adequately. A technique to recognize and treat the abscess definitively will be illustrated. The most common etiologies were Crohn's disease in 49 patients, postoperative sepsis in eight patients, and complications of renal disease in four patients. The length of hospital stay ranged from 5 to 392 days (mean, 26 days). There were two deaths. Failure to recognize and treat psoas abscess results in considerable morbidity. [Key words: Psoas abscess; Technique; Crohn's disease] Procaccino JA, Lavery IC, Fazio VW, Oakley JR. Psoas abscess: difficulties encountered. Dis Colon Rectum 1991 ; 3 4 : 7 8 4 - 7 8 9 .
A
half century ago, the most common etiology , of psoas abscess was tuberculosis of the spine. This entity has vanished with medical advances in the treatment of tuberculosis. The first description of Crohn's disease as the etiologic factor for a psoas abscess was reported by Van Patter e t a L 1 of the Mayo Clinic in 1954. The association of inflammatory bowel disease and psoas abscess has been reported more frequently. Kyle,2 in 1971, reported Crohn's disease as the most common cause ofpsoas abscess in northeast Scotland. Leu e t al. 3 from the Mayo Clinic reported on the changing patterns of diagnosis and etiology of psoas abscess. They concluded that psoas abscess was often a complication of Crohn's disease and was a significant problem. We reviewed the Cleveland Clinic experience with psoas abscess in an attempt to identify etiology and review therapeutic modalities. It is our intention to describe an adequate means of identifying the
Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, April 29 to May 4, 1990. Address reprint requests to Dr. Lavery: The Cleveland Clinic Foundation, One Clinic Center, 9500 Euclid Avenue, Cleveland, Ohio 44195-5044. 784
abscesses and to propose a surgical technique for their management.
PATIENTS AND METHODS Between 1962 and 1989, 67 patients with psoas abscess were treated at the Cleveland Clinic. Forty patients were male, and 27 patients were female. The mean age at the time of admission was 38 years (range, 3-77 years). The length of hospital stay ranged from 5 to 392 days (mean, 26 days) (Table 1). All patients received surgical treatment at the Cleveland Clinic. There were two deaths in the postoperative period. Abscess contents were sent for bacteriologic analysis, and each surgical specimen was analyzed by the Department of Pathology.
RESULTS Of the 67 patients in the study, 49 patients had Crohn's disease as the etiology of their psoas abscesses. Of the remaining patients, eight abscesses developed postoperatively, four had a renal origin, and six were from miscellaneous causes (Fig. 1). Thirty-nine patients had a right-sided abscess, and 28 patients had a left-sided abscess. The anatomic proximity of the diseased bowel to the psoas major muscle accounted for the development of the abscess on a given side. A posterior perforation in ileocolic disease may lead to a right-sided abscess. A left-sided abscess is usually from sigmoid colon disease. Classic physical findings, such as hip flexion or loin bulge (Figs. 2 and 3), were not seen in all patients. The most frequently encountered signs and symptoms were abdominal pain, pyrexia, hip pain, and chills or rigors (Table 2). The most helpful diagnostic modalities were CT scan and upper GI series (Figs. 4 and 5). Of the patients who had a CT scan, 88 percent of the scans
PSOAS ABSCESS: DIFFICULTIESENCOUNTERED
Vol. 34, No. 9
785
Table 1. Demographics Total number of patients: Male: Female: Age at admission (yr): Range: Mean:
67 40 27 3-77 38
RENAL 6% (4)
POST OF 12~ (8) CROHN'S DISEASE 73% (49)
Figure 1. Etiology: 39 patients had a right-sided abscess, and 28 patients had a left psoas abscess. (OTHER includes septic arthritis, carcinoma of the left colon, diverticulitis, and tuberculosis.)
Figure 3. A loin bulge seen in this patient with a psoas abscess secondary to Crohn's disease.
Table 2. Signs and Symptoms Abdominal pain Hip pain Chills/rigors Abdominal mass Temperature >38~ Groin mass Flank mass Cutaneous fistula Diarrhea Weight loss >10 Ib
Figure 2. Hip flexion in a patient with a right-sided psoas abscess.
were abnormal and aided in the diagnosis of psoas abscess. Similarly, 76 percent of those having an upper gastrointestinal series (UGI) showed abnormalities aiding in the diagnosis of the underlying etiology of their psoas abscess. In the surgical management of these patients, 25
Frequency
Percent
43 35 27 22 36 9 8 10 11 20
73 59 46 37 61 15 14 17 19 34
underwent abscess drainage alone as the initial operation. Abscesses which developed after operation or were missed at operation and were identified in the postoperative period were treated by incision and drainage alone or by laparotomy and drainage through the flank. These included one CT-guided percutaneous drainage. Twelve underwent laparotomy and open drainage, and 12 had a flank or groin incision and drainage. Fifteen patients underwent laparotomy, abscess drainage, resection of diseased bowel with stoma formation or
786
Dis Colon Rectum, September 1991
PROCACCINO ETAZ
anastomosis, and proximal diversion. A third group of 27 patients had laparotomy, abscess drainage, resection of diseased bowel, and primary anastomosis as their initial surgical treatment. These patients were in good general condition. The anastomosis lay away from the site of sepsis in the region of the abscess. Patients who were debilitated, because of the underlying disease and the abscess, had invariably been on high doses of steroids. In this circumstance, a staged operation was performed. An anastomosis is performed with proximal diversion to minimize complications from failure to heal satisfactorily. If the anastomosis would be in or near the location of the abscess, only a stoma is constructed after the resection. Extraperitoneal drainage alone is performed in patients with a large abscess. This is followed by laparotomy and resection within a few days after Figure 5, Upper GI series illustrating perforative ileocolic Crohn's disease resulting in a psoas abscess.
40
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35
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Ii
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O
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,,=, 15-
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==
::::iiii!ii
z=
1 2 3 >3 NUMBER OF OPERATIONS 15 patients Mad a planned, staged procsdure 1or their abscess (22%) 12 patients had more procedures than planned due to failure of the initial operation to eradicate their abscess (18=/o) 40 patients had one operation to eradicate their abscess
Figure 4. CT scan demonstrating a large right psoas ab-
Figure 6. Number of operations required to eradicate ab-
scess.
scess. T a b l e 3.
Initial Operation Performed No. of Patients Type
Crohn's/ GI Source
Renal/Postop./ Other
Laparotomy, abscess drainage, resection of diseased bowel, and primary anastomosis
27
0
Laparotomy, abscess drainage, resection of diseased bowel with stoma or anastomosis, and proximal diversion
14
Simple abscess drainage: Percutaneous Laparotomy open drainage Flank/groin I & D
0
1
4
8
7
5
Vol. 34, NO. 9
PSOAS ABSCESS: DIFFICULTIES ENCOUNTERED
detoxification has taken place. These results are further stratified according to etiology (Table 3). Forty patients required only one operation to eradicate their abscesses (Fig. 6). Fifteen patients had a planned, staged procedure for their abscess. Twelve patients had more procedures than planned owing to failure of the initial operation to eradicate their abscess. Forty percent of the patients required more than one operation for cure.
DISCUSSION The most common etiology of psoas abscess is Crohn's disease. Seventy-three percent of our patients (49 of 67) had regional enteritis. The most common presenting signs and symptoms include abdominal pain, ipsilateral hip pain, and pyrexia. The diagnosis was made clinically and confirmed with the aid of barium studies of the intestine and/
787
or CT scanning. CT-guided drainage was performed in only one abscess. This is not technically desirable to attempt in all patients because of the location of the abscess. A posterior approach is anatomically difficult, and an anterior or lateral approach is often limited by overlying intestine. Where it is possible, this technique should be employed. Twenty-seven patients required more than one operation. Most commonly, reoperation was required when psoas abscesses were not recognized or not adequately drained. If a staged procedure had been planned and the diseased bowel not resected, further surgery was necessary. Failure to recognize a psoas abscess is due to the collarbutton configuration with only a small opening in the psoas fascia (Fig. 7). This opening may be missed unless specifically looked for when a posterior perforation of the bowel is present. One
Figure 7. Typical intraoperative appearance of diseased bowel and small opening in the psoas fascia communicating with the abscess cavity (collar-button opening evident after removal of the diseased bowel).
788
PROCACCINO E T A L
Dis Colon Rectum, September 1991
Figure 8. Resection of the diseased bowel, curettage, and drainage of the abscess are prerequisites for proper treatment.
should be alert to the possibility of a psoas abscess if a segment of diseased bowel is adherent to the anterior psoas fascia, suggesting a posterior perforation and abscess. After pinching the bowel off, any area of granulation tissue should be examined carefully. Direct pressure on the psoas muscle may produce a bead of pus, which identifies the opening to the deeper abscess cavity. The granulation tissue should be explored with the tip of a finetipped clamp such as a tonsil or Moynihan clamp. The opening is typically only a few millimeters in size. When identified, the anterior psoas fascia is divided longitudinally in a cephalad and caudad direction to open the entire length of the abscess. Insufficient antibiotic coverage for the chronically infected muscle may result in incomplete resolution, with recrudescence at a later time. Antibiotic coverage is based on culture and sensitivity and Gram's stain from the pus. The bacteria are usually Gram-negative and may be aerobic or anaerobic. Metronidazole and ceftizoxime sodium is an appropriate combination to initiate treatment. The final
antibiotic coverage is determined by culture and sensitivity and continued for approximately 2 weeks. If a patient with Crohn's disease has a segment of diseased bowel which is adherent to the fascia of the psoas muscle, even the smallest area of induration on the anterior surface of the muscle should prompt exploration of this area to exclude the presence of a psoas abscess. Curettage and drainage of the abscess with concomitant resection of the diseased segment of bowel is the proper treatment regimen (Fig. 8). Curettage or probing of the abscess is done gently, only to provide adequate drainage and explore the psoas muscle for not immediately apparent loculi. Vigorous curettage will lead to bleeding and damage to the muscle, which is markedly inflamed, friable, and easily damaged. The abscess within the muscle typically does not have well-defined margins or a pyogenic membrane but is within the bundles of the psoas muscles confined by its strong fascial covering. Prolonged drainage of the abscess is pro-
Vol. 34, No. 9
PSOAS ABSCESS: DIFFICULTIES ENCOUNTERED
vided by laying Penrose drains along the length of the abscess cavity. These are brought out through a generous lateral incision which does not inhibit egress of the pus. In particularly chronic abscesses, a mushroom catheter is also placed to remain for a period after removal of the Penrose drains. This ensures complete drainage and collapse of the cavity. Premature removal may allow reaccumulation of the pus. Such is the nature of the abscess and the inability to mechanically remove a pyogenic membrane as in well-localized abscesses. This may span 2 or 3 weeks. If there is any doubt that the cavity has been obliterated, a sinogram can be performed through the mushroom catheter. Only a high index of suspicion and aggressive surgical intervention will decrease the morbidity associated with an unrecognized or inadequately treated psoas abscess. CONCLUSION Psoas abscess is an uncommon and challenging entity. The most common etiology is Crohn's dis-
789
ease. Forty percent of our patients required more than one operation for cure. We believe that the following five points are the salient features in the proper management of psoas abscess: 1. 2. 3. 4. 5.
High index of suspicion. Resection of concomitantly diseased bowel. Adequate unroofing of the abscess. Prolonged abscess drainage. Adequate and sometimes prolonged antibiotic coverage.
REFERENCES 1. Van Patter WN, Bargen JA, Dockerty MB, Feldman WH, Mayo CW, Waugh JM. Regional enteritis. Gastroenterology 1954;26:347-50. 2. Kyle J. Psoas abscess in Crohn's disease. Gastroenterology 1971;61:149-55. 3. Leu S-Y, Leonard MB, Beart RWJr, Dozois RR. Psoas abscess: changing patterns of diagnosis and etiology. Dis Colon Rectum 1986;29:694-8.
A
half century ago, the most common etiology , of psoas abscess was tuberculosis of the spine. This entity has vanished with medical advances in the treatment of tuberculosis. The first description of Crohn's disease as the etiologic factor for a psoas abscess was reported by Van Patter e t a L 1 of the Mayo Clinic in 1954. The association of inflammatory bowel disease and psoas abscess has been reported more frequently. Kyle,2 in 1971, reported Crohn's disease as the most common cause ofpsoas abscess in northeast Scotland. Leu e t al. 3 from the Mayo Clinic reported on the changing patterns of diagnosis and etiology of psoas abscess. They concluded that psoas abscess was often a complication of Crohn's disease and was a significant problem. We reviewed the Cleveland Clinic experience with psoas abscess in an attempt to identify etiology and review therapeutic modalities. It is our intention to describe an adequate means of identifying the
Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, April 29 to May 4, 1990. Address reprint requests to Dr. Lavery: The Cleveland Clinic Foundation, One Clinic Center, 9500 Euclid Avenue, Cleveland, Ohio 44195-5044. 784
abscesses and to propose a surgical technique for their management.
PATIENTS AND METHODS Between 1962 and 1989, 67 patients with psoas abscess were treated at the Cleveland Clinic. Forty patients were male, and 27 patients were female. The mean age at the time of admission was 38 years (range, 3-77 years). The length of hospital stay ranged from 5 to 392 days (mean, 26 days) (Table 1). All patients received surgical treatment at the Cleveland Clinic. There were two deaths in the postoperative period. Abscess contents were sent for bacteriologic analysis, and each surgical specimen was analyzed by the Department of Pathology.
RESULTS Of the 67 patients in the study, 49 patients had Crohn's disease as the etiology of their psoas abscesses. Of the remaining patients, eight abscesses developed postoperatively, four had a renal origin, and six were from miscellaneous causes (Fig. 1). Thirty-nine patients had a right-sided abscess, and 28 patients had a left-sided abscess. The anatomic proximity of the diseased bowel to the psoas major muscle accounted for the development of the abscess on a given side. A posterior perforation in ileocolic disease may lead to a right-sided abscess. A left-sided abscess is usually from sigmoid colon disease. Classic physical findings, such as hip flexion or loin bulge (Figs. 2 and 3), were not seen in all patients. The most frequently encountered signs and symptoms were abdominal pain, pyrexia, hip pain, and chills or rigors (Table 2). The most helpful diagnostic modalities were CT scan and upper GI series (Figs. 4 and 5). Of the patients who had a CT scan, 88 percent of the scans
PSOAS ABSCESS: DIFFICULTIESENCOUNTERED
Vol. 34, No. 9
785
Table 1. Demographics Total number of patients: Male: Female: Age at admission (yr): Range: Mean:
67 40 27 3-77 38
RENAL 6% (4)
POST OF 12~ (8) CROHN'S DISEASE 73% (49)
Figure 1. Etiology: 39 patients had a right-sided abscess, and 28 patients had a left psoas abscess. (OTHER includes septic arthritis, carcinoma of the left colon, diverticulitis, and tuberculosis.)
Figure 3. A loin bulge seen in this patient with a psoas abscess secondary to Crohn's disease.
Table 2. Signs and Symptoms Abdominal pain Hip pain Chills/rigors Abdominal mass Temperature >38~ Groin mass Flank mass Cutaneous fistula Diarrhea Weight loss >10 Ib
Figure 2. Hip flexion in a patient with a right-sided psoas abscess.
were abnormal and aided in the diagnosis of psoas abscess. Similarly, 76 percent of those having an upper gastrointestinal series (UGI) showed abnormalities aiding in the diagnosis of the underlying etiology of their psoas abscess. In the surgical management of these patients, 25
Frequency
Percent
43 35 27 22 36 9 8 10 11 20
73 59 46 37 61 15 14 17 19 34
underwent abscess drainage alone as the initial operation. Abscesses which developed after operation or were missed at operation and were identified in the postoperative period were treated by incision and drainage alone or by laparotomy and drainage through the flank. These included one CT-guided percutaneous drainage. Twelve underwent laparotomy and open drainage, and 12 had a flank or groin incision and drainage. Fifteen patients underwent laparotomy, abscess drainage, resection of diseased bowel with stoma formation or
786
Dis Colon Rectum, September 1991
PROCACCINO ETAZ
anastomosis, and proximal diversion. A third group of 27 patients had laparotomy, abscess drainage, resection of diseased bowel, and primary anastomosis as their initial surgical treatment. These patients were in good general condition. The anastomosis lay away from the site of sepsis in the region of the abscess. Patients who were debilitated, because of the underlying disease and the abscess, had invariably been on high doses of steroids. In this circumstance, a staged operation was performed. An anastomosis is performed with proximal diversion to minimize complications from failure to heal satisfactorily. If the anastomosis would be in or near the location of the abscess, only a stoma is constructed after the resection. Extraperitoneal drainage alone is performed in patients with a large abscess. This is followed by laparotomy and resection within a few days after Figure 5, Upper GI series illustrating perforative ileocolic Crohn's disease resulting in a psoas abscess.
40
,....%.~ ,.......-
35
.... ..;.:.:.:--
,,=, a0m I-.< PI
:.-:':':.-...... ".'.'.'.--
Ii
.','.'.'.
O
-'"'""~
,,=, 15-
I:i:i:i:
==
::::iiii!ii
z=
1 2 3 >3 NUMBER OF OPERATIONS 15 patients Mad a planned, staged procsdure 1or their abscess (22%) 12 patients had more procedures than planned due to failure of the initial operation to eradicate their abscess (18=/o) 40 patients had one operation to eradicate their abscess
Figure 4. CT scan demonstrating a large right psoas ab-
Figure 6. Number of operations required to eradicate ab-
scess.
scess. T a b l e 3.
Initial Operation Performed No. of Patients Type
Crohn's/ GI Source
Renal/Postop./ Other
Laparotomy, abscess drainage, resection of diseased bowel, and primary anastomosis
27
0
Laparotomy, abscess drainage, resection of diseased bowel with stoma or anastomosis, and proximal diversion
14
Simple abscess drainage: Percutaneous Laparotomy open drainage Flank/groin I & D
0
1
4
8
7
5
Vol. 34, NO. 9
PSOAS ABSCESS: DIFFICULTIES ENCOUNTERED
detoxification has taken place. These results are further stratified according to etiology (Table 3). Forty patients required only one operation to eradicate their abscesses (Fig. 6). Fifteen patients had a planned, staged procedure for their abscess. Twelve patients had more procedures than planned owing to failure of the initial operation to eradicate their abscess. Forty percent of the patients required more than one operation for cure.
DISCUSSION The most common etiology of psoas abscess is Crohn's disease. Seventy-three percent of our patients (49 of 67) had regional enteritis. The most common presenting signs and symptoms include abdominal pain, ipsilateral hip pain, and pyrexia. The diagnosis was made clinically and confirmed with the aid of barium studies of the intestine and/
787
or CT scanning. CT-guided drainage was performed in only one abscess. This is not technically desirable to attempt in all patients because of the location of the abscess. A posterior approach is anatomically difficult, and an anterior or lateral approach is often limited by overlying intestine. Where it is possible, this technique should be employed. Twenty-seven patients required more than one operation. Most commonly, reoperation was required when psoas abscesses were not recognized or not adequately drained. If a staged procedure had been planned and the diseased bowel not resected, further surgery was necessary. Failure to recognize a psoas abscess is due to the collarbutton configuration with only a small opening in the psoas fascia (Fig. 7). This opening may be missed unless specifically looked for when a posterior perforation of the bowel is present. One
Figure 7. Typical intraoperative appearance of diseased bowel and small opening in the psoas fascia communicating with the abscess cavity (collar-button opening evident after removal of the diseased bowel).
788
PROCACCINO E T A L
Dis Colon Rectum, September 1991
Figure 8. Resection of the diseased bowel, curettage, and drainage of the abscess are prerequisites for proper treatment.
should be alert to the possibility of a psoas abscess if a segment of diseased bowel is adherent to the anterior psoas fascia, suggesting a posterior perforation and abscess. After pinching the bowel off, any area of granulation tissue should be examined carefully. Direct pressure on the psoas muscle may produce a bead of pus, which identifies the opening to the deeper abscess cavity. The granulation tissue should be explored with the tip of a finetipped clamp such as a tonsil or Moynihan clamp. The opening is typically only a few millimeters in size. When identified, the anterior psoas fascia is divided longitudinally in a cephalad and caudad direction to open the entire length of the abscess. Insufficient antibiotic coverage for the chronically infected muscle may result in incomplete resolution, with recrudescence at a later time. Antibiotic coverage is based on culture and sensitivity and Gram's stain from the pus. The bacteria are usually Gram-negative and may be aerobic or anaerobic. Metronidazole and ceftizoxime sodium is an appropriate combination to initiate treatment. The final
antibiotic coverage is determined by culture and sensitivity and continued for approximately 2 weeks. If a patient with Crohn's disease has a segment of diseased bowel which is adherent to the fascia of the psoas muscle, even the smallest area of induration on the anterior surface of the muscle should prompt exploration of this area to exclude the presence of a psoas abscess. Curettage and drainage of the abscess with concomitant resection of the diseased segment of bowel is the proper treatment regimen (Fig. 8). Curettage or probing of the abscess is done gently, only to provide adequate drainage and explore the psoas muscle for not immediately apparent loculi. Vigorous curettage will lead to bleeding and damage to the muscle, which is markedly inflamed, friable, and easily damaged. The abscess within the muscle typically does not have well-defined margins or a pyogenic membrane but is within the bundles of the psoas muscles confined by its strong fascial covering. Prolonged drainage of the abscess is pro-
Vol. 34, No. 9
PSOAS ABSCESS: DIFFICULTIES ENCOUNTERED
vided by laying Penrose drains along the length of the abscess cavity. These are brought out through a generous lateral incision which does not inhibit egress of the pus. In particularly chronic abscesses, a mushroom catheter is also placed to remain for a period after removal of the Penrose drains. This ensures complete drainage and collapse of the cavity. Premature removal may allow reaccumulation of the pus. Such is the nature of the abscess and the inability to mechanically remove a pyogenic membrane as in well-localized abscesses. This may span 2 or 3 weeks. If there is any doubt that the cavity has been obliterated, a sinogram can be performed through the mushroom catheter. Only a high index of suspicion and aggressive surgical intervention will decrease the morbidity associated with an unrecognized or inadequately treated psoas abscess. CONCLUSION Psoas abscess is an uncommon and challenging entity. The most common etiology is Crohn's dis-
789
ease. Forty percent of our patients required more than one operation for cure. We believe that the following five points are the salient features in the proper management of psoas abscess: 1. 2. 3. 4. 5.
High index of suspicion. Resection of concomitantly diseased bowel. Adequate unroofing of the abscess. Prolonged abscess drainage. Adequate and sometimes prolonged antibiotic coverage.
REFERENCES 1. Van Patter WN, Bargen JA, Dockerty MB, Feldman WH, Mayo CW, Waugh JM. Regional enteritis. Gastroenterology 1954;26:347-50. 2. Kyle J. Psoas abscess in Crohn's disease. Gastroenterology 1971;61:149-55. 3. Leu S-Y, Leonard MB, Beart RWJr, Dozois RR. Psoas abscess: changing patterns of diagnosis and etiology. Dis Colon Rectum 1986;29:694-8.
