A case report on delayed diagnosis of perforated Crohn's disease with recurrent intra-psoas abscess requiring omental patch

Polybacterial Iliopsoas Muscle Abscess as an Indication for Early Diagnosis of Crohn's Disease

BACKGROUND Crohn disease (CD) is a chronic, relapsing inflammatory bowel disease characterized by penetrations or fistulae in the gastrointestinal tract and abscesses in the surrounding tissues. Diagnosis of CD is difficult with an iliopsoas muscle abscess (IMA) as an initial presentation. CASE REPORT A 22-year-old Japanese man had right hip pain 17 days prior to admission. Because of worsening pain, he was admitted to our hospital. Physical examination revealed limitation of his right hip motion and a positive right psoas sign. Abdominal contrast-enhanced computed tomography (CT) revealed a large right IMA. Continuous drainage, which revealed polymicrobial pus, with intravenous administration of antibiotics dramatically decreased the size of the IMA. The drainage tube was removed on hospitalization day 9 because barium enema and contrast radiography of the abscess through the drainage tube showed no fistula. However, on day 19 of hospitalization, the IMA was redetected by abdominal CT. Continuous abscess drainage was resumed, and the third contrast radiograph of the abscess revealed contrast medium flow into the small intestine. Colonoscopy detected stenoses and circumferential ulceration of the terminal ileum. Histopathological examination of the ileum biopsy showed histocyte aggregation with lymphocyte or plasmacyte infiltration of the lamina propria, compatible with a CD diagnosis. Laparoscopic ileocecal resection was performed on day 64 of hospitalization. CONCLUSIONS Penetration of the intestinal tract caused by CD should be suspected in a patient with a polymicrobial IMA. It is essential to identify the fistula and subsequently perform surgical resection of the affected intestinal area.

Pilot Study on the Influence of Incentive Spirometry on Percutaneous Image-Guided Intra-Abdominal Drainage Catheter Pressure: A Potential Method to Enhance Drainage

Background

To report the evaluation of incentive spirometry (IS)-induced pressure changes in intra-abdominal drainage catheters and consider its use for maintaining catheter patency and enhancing drainage.

Methods

Prospective study of patients with indwelling intra-abdominal drainage catheters for abdominal fluid collections who had their intra-abdominal pressures measured while performing incentive spirometry. Patients were instructed in the use of an incentive spirometer. Within a week after initial drainage, pressure changes with IS were evaluated three times at 1500 cc and three times at maximum inspiratory effort. Intra-abdominal pressure (IAP) was measured using a pressure monitor connected to the drainage catheter.

Results

Twenty patients (men, 12; women, 8). Fluid collection locations were pelvis, Right-upper quadrant (RUQ), Left-upper quadrant (LUQ), Left-lower quadrant (LLQ), and Right-lower quadrant (RLQ). A total of 16 of 20 patients showed an elevation of IAP with IS. At 1500 cc, the pressure increased by an average of 41.24 mmH2O. At maximal inspiratory effort, the pressure increased by an average of 48.26 mmH2O. Pressure increase was greater in upper abdomen catheters. Four patients with lower abdominal and pelvic collections showed minimal pressure changes with IS.

Conclusion

IS increases IAP and fluid flow through abdominal drainage catheters. Future studies are warranted to determine whether the use of IS enhances catheter performance and facilitates drainage via its effect on IAP.

Prognostic nutritional index as outcome predictor in patients with iliopsoas abscess

Cases with iliopsoas abscess (IPA) in a single hospital-based cases were reviewed and compared with clinical profiles of published hospital-based IPA series. To verify usefulness of prognostic nutritional index (PNI) used to predict outcome and severity of IPA, this study was performed. This study consists of 2 parts: Study 1 - Case review of IPA series in a single hospital: 7 cases with IPA treated in a single hospital in sequential 5 years were collected (series 1) and their clinical profiles compared. Study 2 - Review of hospital-based literature: A search of the PubMed database from 1990 to the present was performed, using the Boolean expression ([Psoas OR iliopsoas] AND [abscess] AND [hospital-based]). Two hospital-based case series were collected. The clinical profiles of 2 series were compared with series 1 to draw predictive factors of outcome and deciding treatment modality, medical or surgical. Study 1 - Analyzing 7 IPA cases, average age was 76.7 years old (varying from 64 to 91) and the lifesaving rate was 86%. PNI < 45, calculated with serum albumin (Alb) and total lymphocyte count, and larger cumulative abscess volume (CAV) measured by computed tomography seem outcome predictors. Study 2 - Analyzing 2 hospital-based IPA series (series 2 and 3), series 2 reviewed isolated IPA cases without any comorbidities and series 3 reviewed IPA cases with cardiovascular disorders. Among 3 series including ours, series 1 showed oldest case and longer length of hospitalization. Series 3 showed the highest mortality among 3 because it collected IPA with cardiovascular comorbidities. PNI seems predictors of outcome and disease activity in patients with IPA and might indicate treated with surgical intervention.