Perforated jejunal diverticulum presenting with a psoas abscess.

CASE REPORT A 73 year old man presented with loss of mobility, anorexia, weight loss and pain in the left hip. Recent investigation of altered bowel habit had shown extensive diverticular disease of the sigmoid colon. On examination he was cachectic, dehydrated and pyrexic. There was redness, increased temperature, swelling and crepitus in the left groin with fixed flexion deformity and painful limitation of movement of the left hip. There were no abdominal signs. He had a leucocytosis and raised E.S.R. X-rays of his hips were normal. Coliforms, streptococcus faecalis and proteus were cultured and 1 ml of pus was aspirated from the left groin. Initial treatment was with metronidazole and cephazolin. Computerised tomography confirmed our clinical impression of a large left psoas abscess. Shortly afterwards he became septicaemic, necessitating urgent drainage of the abscess through the left groin. Initially his condition improved with the release of pus, but after two days small bowel content appeared in the discharge and he again became septicaemic. At laparotomy he was found to have multiple diverticula on the mesenteric border of the jejunum. One of these was adherent to the posterior abdominal wall and communicated via a psoas abscess with the left groin incision. The diverticular disease of the colon was not involved. Resection of 30 cm of jejunum was required. Post-operatively he recovered normal bowel activity and both wounds healed well. Unfortunately despite prophylactic heparinisation he died two weeks after laparotomy from a pulmonary embolus.