| Abstract: | 目的：本研究回顧台中榮總急診部，在六年期間(從民國85年6月至91年6月止)，腸腰肌膿瘍的系列報告並討論處置和預後，訂出腸腰肌膿瘍臨床診斷、治療、預後和追蹤之臨床路徑。
病患和方法：依照ICD No.(728.9)，查詢腸腰肌膿瘍診斷，紀錄其基本資料、臨床表現、致病菌、實驗室檢查、影像學檢查、處置和預後，在六年期間，共有51位病患確定為腸腰肌膿瘍之臨床診斷。
結果：總共有51位病患收錄於本研究分析中，有30位(58.8%)男性，21位(41.2%)女性。年齡從35至87歲(62.9±12.7)。住院日數從1天至79天(25.9±17.1)。最主要的主訴是疼痛和(或)下肢無力及變形，有38位(74.5%)病患。同時具有腸腰肌膿瘍的臨床三特徵，疼痛和(或)下肢無力及變形併不明原因發燒者，只有16位(31.4%)病患。實驗室檢查顯示白血球增生(70.6%)合併左偏現象(75.0%)和帶狀白血球血症(11.8%)、貧血(66.7%)、尿素氮上升(34.8%)、肌胺酸酐上升(30.0%)及鹼性磷酸?上升(62.5%)。膿瘍組織培養最常見的致病菌是格蘭氏陽性球菌(50.0%)而金黃色葡萄球菌是主要的病菌(32.1%)；格蘭氏陰性菌是第二常見的病菌(39.3%)。40位接受血液培養，呈現陽性報告者有20例(50.0%)。有37位(72.5%)病患，接受剖腹手術外科介入治療和經超音波和(或)電腦斷層引導下的經皮導管引流治療。其餘14位(27.5%)病患只接受抗生素的保守治療。本研究有45位(88.2%)患者存活，另外6位(11.8%)患者死亡，包含保守治療組3位(21.4%)死亡，外科引流治療組也有3位(8.1%)死亡，因此保守治療組死亡率高於外科引流治療組。
結論：本研究顯示符合腸腰肌膿瘍的臨床三特徵只佔31.4%，和之前報告30%?50%相近。膿瘍組織培養最常見的致病菌是金黃色葡萄球菌(32.1%)，比文獻報告44.4%?95%低。40位接受血液培養，呈現陽性報告者有20例(50.0%)，比文獻報告42%高。處置的方式有外科清創引流、經皮的導管引流，併用抗生素，或僅使用抗生素的內科保守治療。本研究死亡率11.8%，和之前報告2.5?25%接近。本研究發現高齡、低血紅素、高尿素氮和高肌胺酸酐是腸腰肌膿瘍預後不良的因子且保守治療死亡率偏高。
建議：如果一個病患有疑似的腸腰肌膿瘍，在腸腰肌攝影若有顯示不正常的內容物，一定要考慮膿瘍。對於腸腰肌膿瘍應該要強調和重視早期診斷和立即治療來降低住院日數和死亡率。根據主要主訴、過去病史、潛在疾病、理學檢查、實驗室檢查、影像學檢查、細菌培養和病理結果做腸腰肌膿瘍之診斷治療和追蹤的臨床路徑流程圖表。
Subject:
We reviewed the serial cases of the iliopsoas muscle abscess (IPA) and discuss the management and prognosis of the IPA during the last 6 years at the emergency department of Veterans General Hospital in Taichung.
Patients and methods:
According the ICD No. (728.9), there were 51 patients diagnosed to have the IPA by clinical manifestations, laboratory studies and imaging survey during the last 6 years (from June, 1996 to June, 2002).
Results:
There were 51 patients enrolled in our analysis by clinical manifestations, laboratory studies and imaging survey. 30 patients (58.8%) were male and 21 patients (41.2%) were female. The age ranged from 35 to 87 (62.9+/-12.7) years. The admission length of stay was from 1 to 79 (25.9+/-17.1) days. The most common chief complaint was pain or weakness of lower limbs found in 38 patients (74.5%). The clinical classic triad of IPA, pain, lower limb weakness and/or deformity combined with fever of unknown origin, was found in 16 patients (31.4%). Laboratory data revealed leukocytosis (70.6%) with left shift (75.0%) and bandemia (11.8%), anemia (66.7%), increased blood urea nitrogen (BUN) (34.8%), increased creatinine (Cr) (30.0%) and elevated alkaline phosphatase (62.5%). The most common microorganisms in pus tissue cultures were Gram-positive cocci found in 14 patients (50.0%) of 28 patients with positive findings of pus/tissue cultures. The Gram-positive coccus included 9 patients (32.1%) with the infection of Staphylococcus. The second most common microorganisms were Gram-negative bacilli found in 11 patients (39.3%) of 28 patients with positive findings of pus tissue cultures. The positive rate of blood culture was 50%, found in 20 of 40 patients who had blood cultures. 37 patients (72.5%) received management via surgical intervention by laparotomy and/or PCD under US-/CT-guidance, plus the treatment with intravenous antibiotics, according to the culture data of blood and/or pus tissue. The remaining 14 patients (27.5%) received conservative medical treatment with intravenous antibiotics only, according to the culture data of blood and/or pus tissue. There were 45 patients (88.2%) who survived after treatment and 6 patients (11.8%) expired. The mortality rate in the group of medical treatment (21.4%) was significant higher than that in the group of surgical intervention (8.1%).
Conclusion:
Our report revealed that there were only 31.4% demonstrating the clinical triad of IPA, including fever, limping and pain, similar to previous reports of 30%~50%. The most common microorganism of pus/tissue culture was Gram-positive coccus (50.0%), and Staphylococcus is the leading microorganism (32.1%), which is lower than previous reports of 44.4%~95%. The positive rate of blood culture was 50%, found in 20 of 40 patients receiving blood cultures, which is higher than previous reports of 42%. The management included surgical debridement, US-/CT-guidance PCD, plus intravenous antibiotics, or conservative medical treatment with intravenous antibiotics only. The survival rate was 88.2% and 6 patients (11.8%) expired. The mortality rate was similar to previous reports of 2.5~25%. We find that old age, anemia, high BUN and Cr were poor prognostic factors for the IPA and the mortality rate is higher in the conservative group in this study.
Suggestion:
In a patient with a suspected IPA who reveals abnormal content on the iliopsoas muscle imaging, abscess should be considered. Early diagnosis and prompt aggressive treatment for reducing the mortality rate should be informative, especially for the primary care physician in the emergency department. According to the chief complaint, past history, underlying disease, physical examination, laboratory data, imaging survey and the result of bacterial culture, we build up the clinical pathway of diagnosis, management and follow-up for the IPA. |
