Aust. N.Z . J . Surg. 1992,62, 662-664

PSOAS ABSCESS FOLLOWING INGESTION OF PSOAS

BRETT D. ARCHER AND IAN A. CAMPBELL Wimmera Base Hospital, Horsham, Victoria, Australia

A case of right psoas abscess that was caused by duodenal perforation following the ingestion of a wooden skewer from a filet mignon is presented. Surgical repair of the perforation, drainage of the abscess and 5 days of intravenous antibiotics resulted in prompt recovery.

Key words: abscess, foreign body, gastrointestinal perforation.

Introduction

Foreign body perforation of the gastrointestinal tract is well documented, particularly when it in- volves sharp objects swallowed by mentally deranged or interned individuals. ',* In a 'mentally stable' patient, the diagnosis may be difficult because the patient usually has no recollection of ingesting the foreign body. A recent article describing a series of five cases of toothpick perforation of the gastroin- testinal tract highlighted the difficulty in diagnosis and the significance of wearing dentures as a risk factor.

A unique case of perforation of the duodenum by a blunt ended wooden skewer, which resulted in a right psoas abscess is presented.

Case report

A 59 year old male presented to the Wimmera Base Hospital with a 10 day history of right iliac fossa (RIF) pain and fever. Initially he saw his local medical officer complaining of generalized myal- gia, malaise and right groin pain which was worse on flexing the right hip. His temperature was 37.5"C, and he was treated for a viral infection. He returned to his local medical officer 1 week later complaining that the pain in the RIF now radiated down the thigh as far as the patella and he was unable to extend the right hip. His temperature was 37.4"C. Past medical history was of a duodenal ulcer. He was referred with possible septic arthritis, at which time he complained of several rigors. He did not complain of any bowel symptoms.

On examination he was sweaty, his temperature was 38.5"C. and his pulse was 84 beatslmin. He was tender in the RIF, with no guarding or rebound.

Correspondence: Mr. I . A Campbell, Wimmera Base Hospital, Baillie Street, Horsham, Vic. 3400, Australia.

Accepted for publication 12 June 1991

No mass was palpable and bowel sounds were nor- mal. He lay with the right hip flexed - 30" and right hip extension was very painful.

A provisional diagnosis was made of paracaecal pathology involving the right psoas major muscle; either an invasive caecal carcinoma, or appendicitis with abscess.

Pre-operative investigations included white cell count of 15.1 x 109/L (80% neutrophils, 11% lymphocytes). Pelvic X-ray showed minor osteo- arthritic changes that were more marked in the right hip. Some well corticated, clearly demarcated cystic changes in the neck of the right femur were thought not to be significant.

At Iaparotomy, through a midline incision, a 58 mm long wooden skewer (Fig. 1) was found to have perforated the second part of the duodenum and embedded in the right psoas major muscle, creating a psoas abscess. The skewer was removed, the duodenum repaired and the abscess drained. Mass closure with a Yeates drain to the abscess cavity was performed and intra-operative cefoxitin and metronidazole were administered.

The patient was given intravenous amoxyciIlin, gentamicin and metronidazole for 2 days postopera- tively until cultures of the pus grew Streptococcus milleri and Streptococcus morbillorum. Amoxy- cillin and metronidazole were continued for a fur- ther 3 days. The patient made a rapid recovery and was discharged on the ninth postoperative day.

On questioning, the patient recalled eating a filet mignon that contained wooden meat skewers, ap- proximately 2 weeks before admission. He had no recollection of swallowing anything unusual at the time.

Discussion

While ingested foreign bodies are one of the more common causes of bowel perforation, most are either arrested in the upper gastrointestinal tract and

663 PSOAS ABSCESS

Fig. 1. Wooden skewer removed from right psoas abscess.

removed, or pass spontaneously without further p r ~ b l e m . ~

Two broad patient groups are recognized: first the ‘accidental swallowers’, usually children but also adults who have upper dentures that impair the sensation of swallowing a foreign body; and second the ‘deliberate swallowers’, either mentally de- ranged, professionally deranged (circus performers etc.), or interned individuals. ’ Of these two groups, the latter tends to provide the more bizarre reports, in particular a case described by Chalk and Foucar of a manic-depressive patient from whom 2533 for- eign bodies were removed at laparotomy.5

Factors influencing the fate of an ingested for- eign body are the shape and sharpness of the object. Smooth, rounded objects, such as coins, marbles, and buttons will tend to pass. Many sharp objects may also pass. Sterry-Ashby and Hunter-Craig reported a series of 18 sharp foreign objects that reached the small intestine; of these 12 continued through the gut harmlessly and six caused a per- foration. Their conclusion was that sharp metallic foreign bodies are easily diagnosed and detected, and seldom cause complications, whereas sharp nonmetallic foreign bodies (such as fish and chicken bones) may cause complications in the in- testine, and are difficult to diagnose.’ More recent series have reported the toothpick as a commonly ingested foreign body that tends to perforate the gastrointestinal tract with varied sequelae. 3x-8

Sites of perforation distal to the stomach are usu- ally the duodenum, ileo-caecal region, or diver- ticulae (small or large b o ~ e l ) . ~ . ~ Variations described in the presentation of foreign body perforation of the gastrointestinal tract fall into five groups: peri- tonitis, intra-abdominal mass/abscess, abdominal wall mass/abscess, mass in a hernial sac, or uncom-

monly as migration to a distal site via duodeno- caval fistulae.’.’’

While the notions of abscess formation and spread to contiguous structures are recognized, the authors can find no reported case of a psoas abscess resulting from this mechanism.

In common with other cases of foreign body per- foration of the gastrointestinal tract, this patient wore upper dentures, which seemed to impair his palatal sensation considerably. He shared no other ‘risk factors,’ in particular he was not mentally deranged, interned, intoxicated, nor had he had any previous abdominal surgery.

Although the wooden skewer shared the prop- erties of length and slenderness with toothpicks, fish bones and chicken bones, it was unusual in that it was blunt ended.

This is the first reported case of psoas abscess secondary to foreign body perforation of the gastro- intestinal tract. It reaffirms previous statements that, given the protean presentations of foreign body per- foration of the gastrointestinal tract, pre-operative diagnosis is difficult. However management of the patient according to basic surgical principles result- ed in a good recovery.

References STERRY-ASHBY B . & HUNTER-CRAIG I . D. (1967) For- eign body perforations of the gut. Br. J . Surg. 54, 382-4. SCHWARZ S. 1. (1988) Principles of Surgery, 5th edn, Chapter 27. McGraw-Hill, Singapore. HEWEIT P. J . & YOUNG J . F. (1991) Toothpick inju- ries to the gastrointestinal tract. Aust. N . Z . J . Surg. 61, 35-7. DEBAKEY M. E. & CWLEY D. A. (1961) Foreign bodies in the stomach and duodenum. In Abdominal

664 ARCHER AND CAMPBELL

Operations, 4th edn. (Ed. R. I. Maingot), Chapter 4. Appleton, New York. CHALK S. G. & FOUCAR H. 0. (1928) Foreign bodies in stomach; report of case in which more than 2500 foreign bodies were found. Arch. Surg. 16, 494-500. CALLON R. A. & BRADY P. G. (1990) Toothpick per- foration of the sigrnoid colon: an unusual case associ- ated with Erysipelothrix rhusoparhiae septicaemia. Gastrointest. Endosc. 36, 141-3. BLANKFIELD R. P. & KELLY R. B. (1989) Toothpick perforation mimicking jejunal lymphoma. Postgrad. Med. 86, 265-6.

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PETERS T. G., LWKE J. R. & WEIGHT G. R. (1988) Suppurative pylephlebitis caused by toothpick per- foration. South M e d . J . 81, (3) 414-15. MACMANUS J. E. (1941) Perforations of the intestine by ingested foreign bodies; report of two cases and review of the literature. Am. J . Surg. 53, 393-400. JUSTWIANI F., WIGODA L. & ORTEGA R. (1974) Duo- denocaval fistula due to toothpick perforation JAMA 227,788-9.

Aust. N . Z . J . Surg. 1992, 62, 664-665

SPONTANEOUS RUPTURE OF A SPLENIC ARTERY ANEURYSM

GEORGE H. C. EVANS, JOHN GUNN AND WILLIAM M. CASTLEDEN Department of Surgery, Fremantle Hospital, Fremuntle, Western Australia, Austrulia

A case of a splenic artery aneurysm occurring in a 37 year old man is reported.

Key words: aneurysm, splenic artery, spontaneous rupture.

Introduction

Spontaneous intra-abdominal catastrophes are un- common and may prove difficult to diagnose. Such a case is reported and its surgical management is discussed.

Case report

A 37 year old man was helping a friend with some landscape gardening that involved moving some very large rocks. After lifting the largest of these be- tween them they both sat down. The patient then developed severe abdominal pain and became un- well. He reported to the emergency department where he was noted to be in pain, with a tachycardia of 132 beats/min and a blood pressure of 1 10/70 mmHg. His abdomen was diffusely tender with guarding. A diagnosis of intraperitoneal bleed or ruptured vis- cus was made. The haemoglobin at that stage was 13.2g/dL with a white cell count of 24.9 X IO’/L. A little free intraperitoneal blood and a large haema- toma filling the left upper quadrant were found at laparotomy. The bleeding was thought to be due to rupture of a retroperitoneal vein. The abdomen was closed when the bleeding had stopped and the patient was transferred to intensive care for observation.

Correspondence: Mr George H. C. Evans, Senior Registrar in Sur&ery, Royal Free Hospital, Hampstead, London NW3 2QG.

Accepted for publication 12 June 1991

Overnight it became apparent that he was bleeding intermittently, his blood pressure and urine output were maintained by intravenous fluids and blood transfusion. A selective coeliac axis arteriogram was performed as an emergency because of the un- certainty about the bleeding site. This clearly demonstrated a 2 cm splenic artery aneurysm that was not actively bleeding (Fig. I ) . He was returned to theatre 18 h after his initial presentation. The splenic artery aneurysm was easily located in the lesser sac above the body of the pancreas. There was no active bleeding until the clot directly over

Fig. 1. Coeliac artery angiugraphy