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Reality or a selection bias?" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "259" "paginaFinal" => "260" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Vicente Navarro López" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Vicente" "apellidos" => "Navarro López" "email" => array:1 [ 0 => "vnavarro@vinaloposalud.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Enfermedades Infecciosas, Hospital Universitario del Vinalopó, Elche, Alicante, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Variabilidad en el origen del absceso del músculo iliopsoas a lo largo del tiempo. ¿Sesgo de publicación o una auténtica realidad?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Iliopsoas abscesses (IPA) are purulent collections located in the psoas major and/or iliacus of this digastric muscle.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">1</span></a> Most publications report abscesses in the psoas, and this is the reason why the term “psoas muscle abscess” has been generalised when referring to this disease. On occasion, however, said term has been erroneously employed when the abscess was located in the iliacus.<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">2,3</span></a> In order to avoid misunderstandings with the nomenclature, it seems reasonable to employ the term “iliopsoas abscess” if the affected muscle is not specified or if the collection affects both muscles. The term “psoas muscle abscess” should be relegated to those cases in which only the psoas is affected.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Nowadays, the most widely accepted classification for IPA divides them into 2 groups: primary abscesses, and abscesses secondary to an infection site located in the vicinity of the muscle, as this focal infection is considered the gateway for the infection.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">5</span></a> In primary IPA, there is no source of infection in the vicinity, and the accepted hypothesis about its origin is the previous existence of bacteraemia that caused the later infection of the muscle. The causes of secondary IPA are multiple, the most frequent being spondylodiscitis, severe urinary tract infection and inflammatory bowel disease.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The first IPA publications at the end of the <span class="elsevierStyleSmallCaps">19</span>th century and well into the 20th century featured frequent growth of <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> (<span class="elsevierStyleItalic">M. tuberculosis</span>) as the causal agent of the abscess.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">3</span></a> Later on and with more frequency, more cases caused by pyogenic bacteria such as <span class="elsevierStyleItalic">Staphylococcus aureus</span> and <span class="elsevierStyleItalic">Escherichia coli</span> were reported as the most common microbiological causal agents. Thus, by the second half of the 20th century, IPA caused by <span class="elsevierStyleItalic">M. tuberculosis</span> was mentioned much less frequently than abscesses caused by gram-positive and gram-negative pyogenic germs.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">4,7–9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In the initial descriptions of IPA cases, there was more primary than secondary IPA.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">4,10,11</span></a> However, said situation has changed with time, especially in most publications from the 1980s, when secondary IPA prevailed over primary IPA.<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">8,12–20</span></a> The most important bibliographical review of this disease was published by Ricci et al. in 1986.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">6</span></a> This document included an analysis of IPA cases until that moment and revealed that 367 cases were reported from 1881 to 1985. Among them, a total of 286 (76.1%) were primary IPA cases whereas 90 (23.9%) were secondary, featuring Crohn's disease as the main cause for the later.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Later, in 1992, another bibliographic review was published that included 67 new IPA reports between 1986 and 1992. This publication featured a description of these new cases, together with those which had been previously published by Ricci et al. in 1986.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">21</span></a> Again, this second document concluded that primary IPA was more frequent than the secondary type, which was most often caused by Crohn's disease. However, when the 67 new cases contributed by this paper were analysed alone, 2 facts stood out: first, in these 67 cases, secondary IPA was more frequent (38 cases) than primary IPA (29 cases); and secondly, Crohn's disease is not the most frequent cause among the cases of secondary IPA, since it was significantly surpassed in number by spondylodiscitis.</p><p id="par0030" class="elsevierStylePara elsevierViewall">From 1992 to date, most publications have reported a greater incidence of secondary IPA over the primary type. Furthermore, in cases from developed countries where computed tomography (CT) scans are available, most IPA are secondary to focal bone lesions and less frequently gastrointestinal and urinary foci.<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">8,9,12–18,20,22,23</span></a> Still more significant is that, since 1992, the number of abscesses secondary to Crohn's disease has dropped, and there has been a much greater incidence of bone foci caused by spondylodiscitis and even urinary foci.<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">9,13,18,20,22–25</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The differences found between the results from most of the publications from the last 3 decades and the reports by Ricci et al. in 1986 have several causes. The generalised use of CT scans starting in the 1980s is probably the determining factor for the identification of the causal focus of these abscesses as well as for the increase in the number of secondary IPA diagnoses and decrease in primary IPA diagnoses. This technique, which makes it possible to identify the lesion adjacent to the iliopsoas muscle in most cases, was not available at the time when the first IPA cases were published.<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">11,18,19,25–30</span></a> If said technique and/or nuclear magnetic resonance imaging (MRI) had been available, in many cases then classified as primary IPA, a focus near the muscle (spondylodiscitis, for example) could have been demonstrated, and such cases would have been classified as secondary IPA. In contrast, cases secondary to Crohn's disease do not need imaging techniques for diagnosis, which is usually based on symptoms or surgical findings. Therefore, the number of secondary diagnoses would not be as underestimated in the absence of a CT scan or MRI as in cases with bone lesions.<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">31,32</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Currently, antibiotic treatment together with percutaneous drainage is the procedure of choice for IPA, whereas surgical drainage was more frequently used in initial reports of this disease.<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">5,6</span></a> Some authors have reported shorter hospitalisations when drainage is performed during major surgery in lieu of percutaneous drainage.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">24</span></a> This datum has been the main argument on which some manuscripts base their recommendations for using major surgery as the primary therapeutic alternative in cases of IPA.<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">10,24</span></a> In spite of said recommendations, the greater convenience and less aggressiveness of percutaneous drainage (PD) has made this technique the procedure of choice, thus replacing the surgical drainage in most cases and showing comparable recovery rates.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">4,27</span></a> Cases of IPA due to Crohn's disease are the only exception in which a major surgical approach is preferable. In said cases, a fistula communicating the intestine with the IPA is generally identified. This indicates the need for surgical intervention in order to resolve the abscess, in addition to bowel resection and the closure of the fistulous tract.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">4,10,19</span></a> In those cases of IPA with multiple septa within the abscess, PD may not be enough and may need many punctures to completely drain the abscess. When complete drainage is not achieved through this technique, major surgery will also be needed.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">4,24,27</span></a> Finally, in cases of small abscesses that are technically impossible to drain percutaneously, treatment may be approached exclusively with antibiotics, which achieves recovery rates similar to those obtained by through PD and major surgery.<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">5,15,33</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In conclusion, the future of the IPA involves accurate identification of the cases in which both the psoas major and iliacus of this digastric muscle are affected, together with a search for those specific causes which are the source of infection in each situation. Unlike the reports published decades ago, nowadays most IPA cases are due to spondylodiscitis, whereas Crohn's disease is an exception. In fact, reports in which Crohn's disease is reported to prevail are few and correspond to publications from general surgery units specifically specialised in the treatment of inflammatory bowel disease.<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">31,34</span></a> This fact caused an important selection bias, which was accepted by the authors of these manuscripts and has induced the erroneous affirmation that Crohn's disease is the main cause of secondary IPA. Finally, regarding the treatment of choice, PD should be considered the first alternative. Only when the abscess is caused by Crohn's disease would a surgical approach be considered to drain the abscess together with a probable fistulous tract between the abscess and the affected bowel.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Navarro López V. Variabilidad en el origen del absceso del músculo iliopsoas a lo largo del tiempo. ¿Sesgo de publicación o una auténtica realidad? 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Journal Information
Vol. 144. Issue 6.
Pages 259-260 (March 2015)
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Vol. 144. Issue 6.
Pages 259-260 (March 2015)
Editorial
Worldwide variations over the years in etiology of iliopsoas abscess. Reality or a selection bias?
Variabilidad en el origen del absceso del músculo iliopsoas a lo largo del tiempo. ¿Sesgo de publicación o una auténtica realidad?
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Vicente Navarro López
Unidad de Enfermedades Infecciosas, Hospital Universitario del Vinalopó, Elche, Alicante, Spain
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