Indian Journal of Radiology and Imaging Indian Journal of Radiology and Imaging

MUSCULOSKELETAL RADIOLOGY
Year
: 2001  |  Volume : 11  |  Issue : 1  |  Page : 13--16

Percutaneous drainage of tuberculous abcesses


SK Puri1, H Panicker1, P Narang1, N Kumar2, A Dhall3, SB Gupta1,  
1 Department of Radiodiagnosis, G B Pant Hospital, New Delhi-110 002, India
2 Department of Gastroenterology, G B Pant Hospital, New Delhi-110 002, India
3 Department of Orthopaedics, Lok Nayak Hospital, New Delhi-110 002, India

Correspondence Address:
S K Puri
Radiodiagnosis, 15A/14, East Patel Nagar, New Delhi 110008
India

Abstract

Objectives: To assess the role of percutaneous catheter drainage (PCD) in the management of tuberculous ilio-psoas abscesses. Materials and methods: Twenty-two patients with 26 tuberculous ilio-psoas abscesses were subjected to PCD under real _time US guidance taking help of a pre-procedure CT for planning the route of catheter insertion. Results: Complete cure of the ilio-psoas abscesses could be achieved in 22 of 26 abscesses (84.6%). Average duration of drainage was 10 days. US / CT follow-up ranged from 3-24 months. PCD was a failure in four abscesses (15.4%). Two patients, one with bilateral abscesses, had recurrent abscesses while one patient had an abscess associated with extensive spondylo-discitis. No significant complication was encountered in the study. Conclusions: PCD is a simple, safe and very effective (success rate 84.6%) alternative to surgical drainage in the management of tuberculous ilio-psoas abscesses.



How to cite this article:
Puri S K, Panicker H, Narang P, Kumar N, Dhall A, Gupta S B. Percutaneous drainage of tuberculous abcesses.Indian J Radiol Imaging 2001;11:13-16


How to cite this URL:
Puri S K, Panicker H, Narang P, Kumar N, Dhall A, Gupta S B. Percutaneous drainage of tuberculous abcesses. Indian J Radiol Imaging [serial online] 2001 [cited 2019 Sep 17 ];11:13-16
Available from: http://www.ijri.org/text.asp?2001/11/1/13/28302


Full Text

Percutaneous catheter drainage (PCD) of abscesses adheres to the basic principles of surgical management by providing decompression, evacuation and continuous drainage without dissemination of sepsis [1]. Its safety, simplicity and excellent cure rates in drainage of abdominal abscesses/collections have established it as an alternative to surgical drainage [2],[3],[4]. However, only limited literature is available, regarding PCD in tuberculous ilio-psoas abscesses [5],[6],[7],[8]. The present study was undertaken to find out the efficacy of PCD in such abscesses.

 Materials and Methods



During the last three years, 22 patients with 26 tuberculous ilio-psoas abscesses were subjected to PCD. Their ages ranged from 10 to 46 years. There were 12 men and 10 women. All the patients had abscesses larger than 4cm and were symptomatic in the form of fever, back pain, leg pain or flexion deformity of leg. In cases of acutely sick patients with very large abscesses, PCD was performed immediately while in cases of less symptomatic patients anti-tuberculous treatment for 3-4 weeks was given prior to PCD. Subsequently all patients were given a full course of anti-tuberculous treatment.

Diagnosis of tuberculosis was made by the following investigations: blood examination, Mantoux test, pus culture, typical radiological features in chest and spine, as seen on radiographs, CT or MR.

Chest radiographs showed active lesions of tuberculosis in eight patients, fibro-calcific lesions in five patients, pleural effusion in one patient and mediastinal and hilar lymphadenopathy in one patient each. No abnormality was seen in six patients (27.3%). Vertebral lesions with or without discitis were noticed in 21 of 22 patients (95.5%). The dorso-lumbar spine was involved in three patients and the lumbar spine in 12 patients while six patients had lumbo-sacral lesions. One patient had no spinal lesion. Pus culture for mycobacterium tuberculosis was positive only in nine patients (40.9%) and was sterile in the rest of the patients.

Eighteen patients had unilateral abscesses, while four patients had bilateral abscesses. Ten abscesses were confined to the psoas muscle, four to the iliacus muscle and twelve were ilio-psoas abscesses. In one patient, the psoas abscess extended into the posterior mediastinum till the level of carina, in two patients the ilio-psoas abscesses extended into the groin anteriorly and in two patients, the psoas abscesses extended into the posterior abdominal wall muscles.

US could demonstrate the abscess in all patients. However, a pre-procedure CT was always done for exact localization of the abscess.

 Procedure



Catheter insertion was performed using local anesthesia and real-time US guidance, taking the help of a pre-procedure CT for planning the route of catheter insertion. For abscesses confined to the psoas compartment only, a postero-lateral approach was adopted while for ilio-psoas abscesses with a larger iliacus component or abscesses confined only to the iliacus muscle, an antero-lateral extra-peritoneal approach was chosen. Care was always taken to avoid intervening bowel loops. For large easily accessible abscesses, a trocar catheter (12 F _14 F) was inserted directly while for the rest of the abscesses, a Malecot's catheter or pigtail catheter (8 F- 14F) was inserted using the Seldinger technique.

After completely evacuating the cavity, it was flushed with normal saline or Cipro floxacillin solution and the catheters were routinely connected to a drainage bag capable of maintaining continuous suction. Daily or alternate day irrigations were performed. Blocked catheters were re-opened using saline or by introducing a stiffener. At least twice during the entire drainage period, after irrigating the cavity, 1 gm streptomycin was instilled into the cavity.

The catheters were pulled out once the daily drainage diminished to less than 10 ml for two consecutive days and a check US examination showed no significant residual collection. Follow-up was done by US / CT at fortnightly intervals for one month and then once every three months for at least six months.

 Results



Complete resolution of 22 of 26 (84.6%) abscesses could be achieved by PCD [Figure 1]. US /CT follow-up ranged from 3-24 months. All patients, particularly those having flexor spasm, showed immediate improvement as soon as the abscess was emptied. Other symptoms took a few days to a week for improvement. Volume of pus drained varied from 60 ml to 500 ml. Duration of drainage ranged from 7 to 28 days with an average of 10 days. No procedure related complication was encountered in any of the patients except a cutaneous fistula in a single patient. However, it healed with conservative management in two weeks time. In all patients with bilateral abscesses, separate catheters were inserted in the same sitting. In abscesses extending into the mediastinum, groin and posterior abdominal wall muscles a single catheter was found sufficient as these were communicating with the main abscess. Four patients had abscesses with multiple loculi and septae. In two of these, different loculi were communicating with each other and a single catheter could empty all the loculi. However, in the other two, after the larger loculus was emptied, other loculi could be entered by simple repositioning of the catheter. Small residual collections, immediately after catheter pull-out were frequently seen, in 12 of 26 abscesses (46.2%). However these resolved on their own without any further intervention.

Two patients, one with bilateral abscesses, had large recurrent abscesses in the same location within two weeks of catheter pull-out [Figure 2]. Both these patients were taking regular anti-tuberculous treatment. Both of these patients could be managed successfully by repeat PCD and needle aspiration. One patient continued to remain symptomatic even after two weeks of catheter drainage. This patient had extensive spondylodiscitis and was subjected to surgery.

 Discussion



Tuberculous ilio-psoas abscesses are usually secondary to vertebral or sacro-iliac involvement. Rarely, the muscle compartments are affected by direct spread from adjacent lymphadenopathy or even hematogenous spread from a distant focus [9,[10].

Chemotherapy alone is generally sufficient for smaller abscesses. However, larger abscesses require some sort of adjuvant drainage [10]. Needle aspiration is frequently not successful [5] and such cases are traditionally subjected to surgical drainage.

PCD in abdominal abscesses is now a firmly established initial mode of treatment. However, only a few studies and isolated case reports describing catheter drainage in tuberculous ilio-psoas abscesses and tuberculous abscesses in other sites are available in literature [5],[11].

Pombo et al [6] has reported CT guided PCD in six patients with seven psoas / ilio-psoas abscesses, which showed complete resolution in all cases with a single recurrent abscess in a patient who had stopped taking anti-tuberculous treatment. Duration of drainage reported was 5-11 days (mean 7 days).

Gupta et al [5] performed catheter drainage in 27 patients under real_time US guidance and had shown initial success in all 27 patients (100%). However, eight patients presented with recurrence (28.1%) requiring repeat interventions. Average duration of drainage was 11 days. A recurrence rate of 66.6% was reported with needle aspiration only. Causes of recurrence were thought to be either due to irregular/ incomplete anti-tuberculous treatment or due to the chronic nature of the disease process and persistence of an active tuberculous focus in the neighboring spine. All cases of recurrence could be managed successfully by repeat PCD or needle aspiration.

The results of our study also indicate a high success rate (84.6%) of PCD in the treatment of tuberculous ilio-psoas abscesses. We feel that if one can get a pre-procedure CT, real-time US guidance is a better and simpler way of inserting the catheter into the abscess, without any complications. A pre-procedure CT, in addition to providing accurate information about the location of the abscess and its relationship with surrounding viscera, can demonstrate pathology in the surrounding organs and is most useful for planning the route for catheter insertion, particularly in the pelvic abscesses [5],[7].

Most of the abscesses with multiple loculi or abscesses extending into the groin, mediastinum or posterior abdominal muscles could be managed with a single catheter alone. Streptomycin was instilled locally into the cavity believing that it could cause fibrosis of the abscess cavity in addition to its bactericidal action.

Among the four abscesses with failed PCD, one was associated with extensive spondylodiscitis and the symptoms were more because of the disease process extending into the spinal canal rather than the psoas abscess. Hence, PCD of psoas abscess alone was not found helpful and the patient was subjected to surgery of the spine.

Two patients, one with bilateral abscesses, had recurrence of abscesses within two weeks of catheter pull-out. Both these patients were taking regular anti-tuberculous treatment and had large abscesses for which urgent PCDs were performed, as they were severely symptomatic. Neither of the patients had received any anti-tuberculous treatment prior to PCD. Drainage period was 13 and 16 days in these patients. Hence, by the time the catheter was pulled out, these patients had received only 13 and 16 days of anti-tuberculous treatment. Probably such short duration of anti-tuberculous treatment was not enough to control the chronic tuberculous infection and hence lead to recurrence of abscesses. Success with repeat interventions further corroborates this fact. Hence, if possible, all patients should be given at-least 3-4 weeks of anti-tuberculous treatment prior to PCD. In patients where PCD is performed on urgent basis, one should try to keep the catheter in the abscess cavity for a longer time, even if daily drainage is less than 10 ml. This might reduce the incidence of recurrence in such patients. However, incomplete or irregular anti-tuberculous treatment, though not encountered in our study, should always be ruled out in cases of recurrent abscesses after PCD [5,[6].

Hence, we conclude that PCD is a very safe, simple and effective (success rate 84.6%) way of managing tuberculous ilio-psoas abscesses. One should not drain abscesses associated with extensive vertebral and spinal canal lesions. Early pull-out of catheters in patients who have had less than four weeks of anti-tuberculous treatment prior to PCD should be avoided.

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