一位72歲女性復發性腹膜後膿瘍併發結腸瘻管的治療：病例報告

李定廉¹、張議徽¹

中國醫藥大學附設醫院 泌尿部¹

Management of Recurrent Retroperitoneal Abscess in a 72-Year-Old Female: A Case Report

Ting-Lien Li¹, Yi-Hui Chang¹

Department of Urology China Medical University Hospital, Taichung, Taiwan¹

Introduction: Retroperitoneal abscesses are rare but serious complications that can arise from various etiologies, including infections, trauma, or postoperative complications. In elderly patients with comorbidities such as diabetes mellitus and hypertension, the management of such conditions becomes increasingly complex. This case study illustrates the clinical challenges and management strategies employed in treating a recurrent retroperitoneal abscess in an elderly female patient.

Case Presentation: The patient is a 72-year-old female with a significant medical history of diabetes mellitus (DM), hypertension (HTN), left renal stone with an infectious stone, and recurrent urinary tract infections (UTIs). She was initially admitted via the emergency department (ED) due to left flank pain and swelling for 10 days. A CT scan revealed abscess formation in the left psoas and iliacus muscles, extending to the left lower abdominal wall with an air-fluid level, as well as a left staghorn stone with atrophic kidney. A percutaneous abscess drain (PAD) was inserted. A left radical nephrectomy was planned during the admission, and she was discharged smoothly afterward. However, four months later, she returned to the ED with fever. A CT scan showed a left retroperitoneal abscess with gas formation extending into the psoas and peri-lumbar area. As a result, a PAD was inserted again. The PAD was removed after 1.5 months when the abscess improved. Unfortunately, she subsequently developed left flank pain after PAD removal for one month, prompting her to return to the ED for further evaluation. A CT scan of the abdomen revealed fluid accumulation in the left lower posterior abdominal wall, extending into the left psoas and iliacus muscles, with an air-fluid level, suggestive of a residual abscess. Recurrent left retroperitoneal abscess, likely caused by Enterobacteriaceae and possibly due to a fistula between the left retroperitoneum and descending colon, was suspected. A lower gastrointestinal (GI) series confirmed the presence of a fistula between the left retroperitoneum and descending colon. Given the identification of the fistula, the patient was referred to a colorectal surgery (CRS) specialist. Surgical intervention included laparoscopic left hemicolectomy, which was converted to open surgery, along with incision of the left retroperitoneal abscess.The patient was discharged in stable condition and scheduled for outpatient follow-up. No abscess formation has been noted since the operation.

Conclusion: The management of recurrent retroperitoneal abscesses, particularly in elderly patients with comorbidities, requires a multidisciplinary approach. In cases of recurrent retroperitoneal abscess, identifying the source of the infection is crucial, and bacteria from the gastrointestinal (GI) system are most likely the cause. Therefore, a low GI series plays an important role in diagnosis. This case underscores the importance of thorough diagnostic evaluation, including imaging studies, to guide treatment decisions. The successful resolution of the patient's symptoms and laboratory markers post-surgery highlights the effectiveness of timely surgical intervention in managing complex abscess formations.