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Case 99: Fever and abdominal pain

This 34 year old alcoholic man presented with 2 weeks of left sided abdominal pain, fever and anorexia. On examination he has tenderness and a mass in the left iliac fossa

1. What does the CT show?

The CT shows a grossly expanded left psoas muscle containing possible fluid density material and several locules of gas. There is inflammatory stranding in the adcent retroperitoneal and mesenteric fat.

2. What is the likely underlying diagnosis and differentials?

The most likely diagnosis is complicated and neglected diverticulitis with localised perforation and abscess formation.
Complicated Crohn's disease should be considered particularly if there has been a history of gastro-intestinal upset. Foriegn body perforation or a complicated carcinoma are less likely.

3. Outline your management of this man?

Thorough history, examination and investigation to assess degree of sepsis and organ dysfunction. The primary treatment for this condition is resection of the diseased segment of bowel. The potential risks with this approach include the necessity for a major laparotomy and colonic resection with stoma. In view of this there is a role for non-operative management in selected stable patients.
Non-operative mangement includes broad spectrum intravenous antibiotics, bowel rest and IV fluid resuscitation. The patient then requires ongoing regular review to confirm clinical improvement and detect failure to improve or deterioration at an early stage. This would then be an indication for operative management.
The key to non-operative management is drainage of the abscess. This may be achieved by an extraperitoneal left iliac fossa surgical approach. Alternatively, percuatenous drainage can be achieved under image guidance but may be inadequate.
Note that a psoas abscess may track along the muscle and therefore present in the groin below the inguinal ligament.