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ANATOMY
 Extraperitoneal space Psoas major and iliacus Psoas major – fusiform muscle from  lower border of T12 to upper border ...
 Lies in close proximity to organs such as  the sigmoid  colon, appendix, jejunum, ureters, abdomin  al aorta, kidneys, p...
Psoas abscess Iliopsoas abscess is a collection of pus  in the iliopsoas compartment. First described by Mynter in 1881 ...
Aetiology   Primary psoas abscess :     Hematogenous spread from an occult      source of infection     Occurs in patie...
   Secondary abscess :     Due to infection from an adjacent organ     Can be pyogenic or tuberculous     Tuberculosis...
SECONDARY PSOASABSCESS   Gastrointestinal - Crohn’s disease, diverticulitis,    appendicitis, colorectal cancer   Genito...
BACTERIOLOGY   Related to cause   Mycobacterium tuberculosis   Primary (hematogenous) – usually Staphylococcus aureus ...
 Common in males than females Right > left ; bilateral (3%) Mortality     Secondary > primary     Untreated – 100%
CLINICAL FEATURES   Classical triad ( 30% )     Fever     Back pain     Limp    Variable and non-specific features    ...
 Position of comfort – supine with knee  moderately flexed, hip mildly externally  rotated Spine – gibbus, tenderness, p...
DIFFERENTIALDIAGNOSIS Femoral hernia Enlarged inguinal nodes Tumors arising from the pelvis or lumbar  area Iliac arte...
Complications Intra peritoneal rupture Hydroureteronephrosis Deep venous thrombosis Septicemia
Investigations CBC - Raised white cell count, Anaemia ↑ ESR ↑CRP Blood culture, urine culture Radiography of abdomen,...
Investigations   CT abdomen – ‘gold standard’; low density    mass in retroperitoneum; info on location    and relation w...
Management Appropriate antibiotics and adequate  drainage Antibiotics :     Culture specific     Primary : empirical a...
 Relatively uncommon condition Vague clinical features Insiduous onset and occult nature –  diagnostic delays High mor...
Psoas abscess
Psoas abscess
Psoas abscess
Psoas abscess
Psoas abscess
Psoas abscess
Psoas abscess
Psoas abscess
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Psoas abscess

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Psoas abscess

  1. 1. ANATOMY
  2. 2.  Extraperitoneal space Psoas major and iliacus Psoas major – fusiform muscle from lower border of T12 to upper border or L5 Passes along pelvic brim and beneath inguinal ligament into thigh Attached to lesser trochanter of femur L2 , L3, L4
  3. 3.  Lies in close proximity to organs such as the sigmoid colon, appendix, jejunum, ureters, abdomin al aorta, kidneys, pancreas, spine, and iliac lymph nodes Psoas fascia ( part of iliac fascia) invests the surface of the muscle Attached to vertebral bodies, fibrous arches and transverse processes and to iliopubic eminence Retains the pus of psoas abscess
  4. 4. Psoas abscess Iliopsoas abscess is a collection of pus in the iliopsoas compartment. First described by Mynter in 1881 who referred it as ‘psoitis’ Classification  Primary and secondary
  5. 5. Aetiology Primary psoas abscess :  Hematogenous spread from an occult source of infection  Occurs in patients with immunocompromised state  Diabetes mellitus, AIDS, IV drug abusers, renal failure
  6. 6.  Secondary abscess :  Due to infection from an adjacent organ  Can be pyogenic or tuberculous  Tuberculosis of the spine  Crohn’s disease
  7. 7. SECONDARY PSOASABSCESS Gastrointestinal - Crohn’s disease, diverticulitis, appendicitis, colorectal cancer Genitourinary - Urinary tract infection, cancer, extracorporeal shock wave lithotripsy Musculoskeletal - Vertebral osteomyelitis, septic arthritis, infectious sacroiliitis Vascular - Infected abdominal aortic aneurysm, femoral vessel catheterisation Miscellaneous - Endocarditis, intrauterine contraceptive device, suppurative lymphadenitis
  8. 8. BACTERIOLOGY Related to cause Mycobacterium tuberculosis Primary (hematogenous) – usually Staphylococcus aureus Renal source – usually monomicrobial ; E. coli, Proteus mirabilis Gastrointestinal – polymicrobial; E. coli, Enterobacter spp., enterococci and anaerobes such as bactroides; Salmonella, Mycobacterium kansasii and Mycobacterium xenopi are other rare causative organisms
  9. 9.  Common in males than females Right > left ; bilateral (3%) Mortality  Secondary > primary  Untreated – 100%
  10. 10. CLINICAL FEATURES Classical triad ( 30% )  Fever  Back pain  Limp Variable and non-specific features  Abdominal or flank pain  Malaise  Weight loss  Nausea  Referred pain to the groin or knee  Painless swelling in the inguinal region  Duration – usually longer than one week
  11. 11.  Position of comfort – supine with knee moderately flexed, hip mildly externally rotated Spine – gibbus, tenderness, paraspinal spasm Clinical tests – non specific  Place the hand proximal to ipsilateral knee and ask the patient to lift the leg  pain  Patient lying on normal side, hyperextension of affected hip  pain
  12. 12. DIFFERENTIALDIAGNOSIS Femoral hernia Enlarged inguinal nodes Tumors arising from the pelvis or lumbar area Iliac artery aneurysm
  13. 13. Complications Intra peritoneal rupture Hydroureteronephrosis Deep venous thrombosis Septicemia
  14. 14. Investigations CBC - Raised white cell count, Anaemia ↑ ESR ↑CRP Blood culture, urine culture Radiography of abdomen, kidney, spine X ray abdomen erect – bulge in psoas shadow USG – operator dependant; gas shadows obscure retoperitoneum
  15. 15. Investigations CT abdomen – ‘gold standard’; low density mass in retroperitoneum; info on location and relation with adjacent organs MRI IVP Mantoux Screening for diabetes, HIV, kidney disorders Pus culture and sensitivity Pus for AFB and Gram staining
  16. 16. Management Appropriate antibiotics and adequate drainage Antibiotics :  Culture specific  Primary : empirical anti-staphylococcal Anti tuberculous drugs Drainage :  Image guided ( CT ) percutaneous drainage  Open extraperitoneal drainage: ○ Through lateral loin incision ○ Psoas region reached extraperitoneally ○ Pus drained – drainage tube kept
  17. 17.  Relatively uncommon condition Vague clinical features Insiduous onset and occult nature – diagnostic delays High mortality and morbidity High index of suspicion required

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