Absceso de psoas como complicación de la enfermedad de Crohn: presentación de 3 casos y revisión de la literatura médica

Efficacy of different therapeutic options for spontaneous abdominal abscesses in Crohn's disease: are antibiotics enough?

BACKGROUND

Management of abdominal abscesses (AA) in Crohn's disease (CD) always includes antibiotics, and some type of drainage is added according to the response and other considerations. Our aim was to assess the efficacy of different therapeutic approaches to spontaneous AA in CD.

METHODS

All cases of AA in CD were identified from the databases of five university hospitals. Postoperative cases were excluded. Therapeutic success was defined as abscess resolution and nonreappearance within 1 year of follow-up.

RESULTS

We identified 128 cases in 2236 patients (cumulative incidence 5.7%). Initial therapy included medical therapy with antibiotics alone (42.2%), antibiotics plus percutaneous drainage (23.4%), and antibiotics plus surgical drainage (34.4%). The highest final efficacy corresponded to surgery (91%) as compared with antibiotic therapy alone (63%) or percutaneous drainage (30%). Failure of initial therapy was predicted by immunomodulators at diagnosis (odds ratio [OR] 8.45; 95% confidence interval [CI] 1.16-61.5; P = 0.03), fistula detectable in imaging techniques (OR 5.43; 95% CI 1.18-24.8; P = 0.02), and abscess size (OR 1.65; 95% CI 1.07-2.54; P = 0.02) only for patients treated with antibiotic therapy alone. Percutaneous drainage was associated with 19% of complications (enterocutaneous fistulas 13%); surgery was associated with 13% of postoperative complications (enterocutaneous fistulas 7.7%). Following abscess resolution, 60% of patients were started on thiopurines, 9% on biologics, and in 31% baseline therapy was not modified.

CONCLUSIONS

Management of spontaneous AA in CD with antibiotics alone seems to be a good option for small abscesses, especially those without associated fistula and appearing in immunomodulator-naïve patients. Surgery offers better results in the remaining clinical settings, although percutaneous drainage can avoid operative treatment in some cases.

[Microbiological diagnosis of intra-abdominal infections]

Intra-abdominal infections represent a large and wide group of diseases which include intra- and retro-peritoneal infections. Some of them could be defined as uncomplicated, where the infectious process is limited to the organ or tissue of origin (appendicitis, diverticulitis, cholecystitis…). Complications occur when the infection spreads to the peritoneum, triggering localised peritonitis and abdominal abscesses. Most intra-abdominal infections are due to perforation or inflammation of the intestinal wall. The microorganisms that cause these infections come from the gastrointestinal flora, and therefore produce polymicrobial infections mixed with a predominance of anaerobic bacteria. Microbiological diagnosis is essential to determine the aetiology and the susceptibility of antimicrobial agents of the microorganism involved, especially in nosocomial infections or in community infections in predisposed patients due to increasing bacterial resistance to antimicrobial agents, multidrug resistance and fungal involvement. Despite the advances in microbiological diagnosis, in the case of intra-abdominal infections it still remains direct, being based on stains and cultures, the most notable progress is the introduction of mass spectrometry (MALDI-TOF) for the rapid identification of the pathogens involved. This review will provide recommendations on the collection, transport and microbiological processing of clinical specimens. Comments on the pathogenesis, clinical and microbiological diagnosis of peritonitis primary, secondary, tertiary and peritonitis (and other infections) associated with peritoneal dialysis, intra-abdominal abscesses (intraperitoneal, retroperitoneal and visceral), biliary tract infections, appendicitis and diverticulitis are also presented.

[Pyogenic and tuberculous abscesses of the psoas muscle]

OBJECTIVES

To describe the clinical characteristics of patients with abscess on the psoas muscle (PA) and to identify the possible differences existing between pyogenic and tuberculous etiologies.

PATIENTS AND METHODS

A retrospective review of patients diagnosed of PA in one hospital was conducted (1983-2009). Two groups were established, that is pyogenic and tuberculous, and the clinical findings, analyses and evolution were compared.

RESULTS

Thirty PA were included, 83% pyogenic and 17% tuberculous, average age 53 years. On 9 occasions, 30% were primary and on 21 occasions, 70% secondary (to skeletal pathology in 8, to urological in 8 and to gastrointestinal in 8). No clinical differences were observed between both groups. Pyogenic and tuberculous etiologies were differentiated analytically through leukocyte values (13,871 vs. 8,560/mm(3), p=0.018), hemoglobin (11 vs. 14 g/dL, p=0.008) and erythrocyte sedimentation rate (ESR) (108 vs. 17 mm/h, p<0.0001). Abscesses were diagnosed by computed tomography (CT) in 29 patients (97%) and by magnetic resonance in 1 (3%), both with a diagnostic sensitivity of 100%, as opposed to 50% for ultrasound scanning. Left laterality was less frequent in pyogenic abscesses (44% vs. 100%, p=0.031). The blood cultures were positive in 22% and abscess pus culture in 82%. Gram negative bacilli, Streptococcus spp. and S. aureus were the most frequent isolations. A total of 67% were drained: transcutaneously 50%, surgically 13% and both techniques 3%. Two patients died (7%), both with pyogenic abscess.

CONCLUSIONS

Secondary pyogenic abscesses constitute the most frequent PA group. CT is the diagnostic procedure of choice. Leukocytosis, anemia, raised ESR and right laterality suggest pyogenic etiology. Transcutaneous drainage is substituting surgical drainage and also makes it possible to obtain diagnostic samples.