Showa Univ J Med Sci 15(4), 351•`356, December 2003

Case Report Crohn's Disease with a Left Psoas Muscle and an Abdominal Wall Abscess: a Case Report

Naokuni YASUDA1), Makoto WATANABE1), Tomokazu KUSANO1), Akira TSUNODA2) and Mitsuo KUSANO2)

Abstract : A male aged 37 complained of a lower abdominal lump with pain. He had been diagnosed with Crohn's disease at our hospital in September 1995. He was referred to our department because the lump had ruptured releasing pus. The abscess formation persisted despite percutanous drainage. The inflamed descending colon was resected. A fistula had formed between an abdominal wall abscess and a left psoas muscle abscess. These fistulas were then enlarged to facilitate drainage. The patient was discharged on the 54th postoperative day. Eleven months later, he was admitted again due to slight pain around the previous drainage scar. As computed tomography findings revealed recurrent , percutaneous ultrasound-guided drainage was performed. His symptoms disappeared, and he was discharged on the 21st day of admission. Taking individual nutrition status and the cause of abscesses into account, an appropriate surgical plan for Crohn's disease patients with primary and/or recurrent left psoas muscle abscess may include percutaneous ultrasound or computed tomography-guided drainage.

Key words : Crohn's disease, left psoas muscle abscess, abdominal wall abscess

Introduction

Fistula and/or abdominal abscess formation in Crohn's disease is common. The disease, however, rarely extends into the retroperitoneum or pelvis. In this Crohn's disease case, a left psoas muscle abscess and an abdominal wall abscess merged.

Case Report

A 37-year-old man complained of a lower abdominal lump with pain which had been present since September 2001, and was referred to our department because the lump had ruptured releasing pus on September 15, 2001 (Fig. 1). In September 1995, he had been

diagnosed with Crohn's disease ( and large bowel type) at the Department of

Medicine in our hospital. Prednisolone (5 mg) and/or mesalazine (1500 mg) have been taken daily since then. At the time of admission, height and weight were 166 cm and 48

kg, respectively, temperature was 37.5•Ž, pulse was 120 beats per minute and respiration

were 16 breaths per minute. Blood pressure was 120/78 mmHg. A physical examination

showed a lower abdominal ruptured lump with tenderness and (five times per day).

Abnormal laboratory values were: hemoglobin 6.9 g/dl, hematocrit 23%, white blood cell

1) Department of Surgery, Isesaki Municipal Hospital, 12-1 Tsunatorihonmachi, Isesaki, Gunma, 372-0817, Japan. 2) Second Department of Surgery, Showa University School of Medicine. 352 Naokuni YASUDA, et al

Fig. 1. Pus from the ruptured lump

Fig. 2. Computed tomography examination revealed large abscesses in the left psoas muscle and the abdominal wall (arrows)

count 14 000/ƒÊl, total protein 5 g/dl, CRP 6.35 mg/dl. A drain tube was inserted through the wound of the ruptured lump, and a blood transfusion and total parental nutrition were begun. Cultures of the abscesses grew Enterococcus faecium and Candida albicans. The general condition improved gradually, but tenderness of left lower quadrant continued, and complete amelioration of a left psoas muscle abscess and an abdominal wall abscess was not

recognized in computed tomography findings (Fig. 2). Gastrographin enema examination revealed penetration and abscess formation on the descending colon (Fig. 3). He was

diagnosed with abscesses resulting in penetration associated with Crohn's disease and on November 15, 2001, an operation was performed. Via a laparotomy, it could be seen that the descending colon was strongly adhered to the latus, forming an abscess

against the abdominal wall. Therefore the descending colon was resected. A fistula was present between the abdominal wall abscess and the left psoas muscle abscess, and the fistula was enlarged to facilitate drainage. Macroscopically, the resected specimen demonstrated an inflamed mucosa and thickened colonic wall (Fig. 4). Histopathology findings showed Crohn's Disease with a Left Psoas Muscle Abscess 353

Fig. 3. Gastrographin enema examination revealed a penetration on the descending colon

Fig. 4. Resected specimen. Thickened colonic wall, longitudinal ulcers and inflamed mucosa are evident transmural inflammation and granulomas (Fig. 5). A fluid diet was started on the 16th postoperative day. The inserted drain tube was washed with isotonic sodium chloride solution and removed on the 42nd postoperative day. Sudden deafness developed, and steroid therapy (total dosage of prednisolone over 16 days was 550 mg) was needed, but his condition afterwards was good. He was discharged on the 54th postoperative day without any evidence of inflammation due to abscesses. Eleven months later, he was readmitted due to mild pain around the previous drainage scar. Computed tomography findings revealed an extra-abdominal abscess and an abdominal wall abscess (Fig. 6). Gastrographin enema examination revealed that there was no fistula formation between the abscesses and the colon. Under local anesthesia, percutaneous 354 Naokuni YASUDA, et al

Fig. 5. Granulomas in the resected colon (H&E staining, •~40)

Fig. 6. Computed tomography examination showed recurrent abscesses in the extra-peritoneal space and the abdominal wall (arrows)

ultrasound guided drainage was performed. His symptoms disappeared gradually with total parental nutrition. The drain tube was removed on the 13th day, and he was discharged after 21 days.

Discussion

In recent years, the number of Crohn's disease patients in Japan has increased. With this disease, a fistula and/or an intra-peritoneal abscess often occur. There are around 20 case reports of a merged psoas muscle abscess in Japan1) suggesting that it is a rare occurrence as compared to the 2.7-5 % incidence rate observed in Europe and American2,3). The transmural inflammation in Crohn's disease causes deep fissuring ulceration which may result in perforation. Free perforation in Crohn's disease is rare4), but fistulas and abscesses develop frequently between the leaves of the mesentery, and between the bowel wall and the adjacent organs5). As the ileocecal region is at risk in Crohn's disease, many authors suggest that a right psoas muscle abscess occurs more commonly1,5). A left-sided Crohn's Disease with a Left Psoas Muscle Abscess 355 abscess usually results from sigmoid colon disease5-7). In this case, gastrographin enema examination revealed that a left psoas muscle abscess and an abdominal wall abscess had developed from the lesion in the descending colon. It has been suggested that there is a relationship between abscess formation, and steroid history, but this connection has not been observed in Japan1). As it is important to make an early diagnosis, a psoas muscle abscess should be considered when a Crohn's disease patient presents with a dilatation disorder of the lower extremites and/or pain in the inguinal area along with typical symptoms such as pyrexia and abdominal pain. Computed tomography and ultrasound were suggested to be the diagnostic tests of choice7,8). In the present case, computed tomography was useful for diagnosis and follow-up. Broad-spectrum antibiotics are important adjunctive therapy for a psoas muscle abscess. Ricci and Meyer7) reported that seventy percent of the abscesses contain Escherichia coli, 29% a Proteus species, and 26% Streptcoccus faecalis. Steroid therapy should be avoided if possible. Some authors reported that percutaneous ultrasound- or computed tomography- guided drainage might offer an alternative in selected cases5). Antibiotics are administerd following percutaneous drainage, and then surgery is desirable after the inflammation has reduced. On the other hand, most agree that incision and drainage alone almost always lead to a fecal fistula or recurrent abscesses7). As for the operative approach, complete excision of the diseased bowel and fistula should be planned rather than a bypass because of higher recurrence rates and the risk of malignancy in the bypassed segment3,7). There is much discussion as to the benefits of resection with immediate anastomosis versus resection with diversion. There is a case report of an anastomosis leakage involving an artificial anus9). More patients who had their small intestine resected were cured, compared to those who had only their colon resected7). In this case, resection and immediate anastomosis was performed because the inflammation was reduced after drainage, and the general condition of the patient was stabilized. Though resection and immediate anastomosis may increase the risk of anastomotic leakage, there are some advantages in avoiding diversion colostomy or ileostomy in terms of QOL and cost effectiveness. The postoperative abscess recurrence rate reported was approximately 40% 5,7). The cause of recurrent abscesses may be due to inadequate drainage, formation of another fistula due to the association with Crohn's disease, immunocompromised condition and anastomotic leakage. In this case, percutaneous ultrasound-guided drainage worked well as treatment for the recurrent abscesses as there was no evidence of connection between the colon and the abscesses by gastrographin enema examination. Short-term steroid therapy for sudden post-operative deafness might be one of the causes of recurrent abscesses. As highlighted by this case, computed tomography is also useful in making an early diagnosis of recurrent abscesses when they are suspected. Taking individual nutrition status and the cause of abscesses into account, an appropriate surgical plan including percutaneous ultrasound- or computed tomography-guided drainage should be evaluated carefully in a Crohn's disease patient with a primary and/or recurrent left psoas muscle abscess.

Conclusion

We report here a patient with Crohn's disease who needed surgical treatment for a left psoas muscle abscess and an abdominal wall abscess, and local treatment for recurrent 356 Naokuni YASUDA, et al abscesses. Discussion of the pertinent literature was included.

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[Received June 13, 2003 : Accepted July 24, 2003]