Ruptured Obturator Internus Muscle Abscess Causing Extensive Retroperitoneal Necrosis

Obturator internus muscle (OIM) abscess occurs rarely in adults. Accurate diagnosis is often hindered and delayed due to the deep location of the abscess and the nonspecific clinical features. Even of rarer occurrence is rupture of the obturator internus muscle abscess into the perirectal space and retroperitoneum causing extensive retroperitoneal necrotizing soft tissue infection. We present a case of ruptured left OIM abscess, which initially presented with clinical features, which were suspected as acute pancreatitis. Contrast-enhanced multidetector computed tomography (MDCT) of the abdomen and pelvis revealed ruptured left OIM abscess with extensive fat stranding, fluid collections, and pockets of gas throughout the perirectal space, perisigmoid space, and bilateral posterior pararenal and anterior pararenal spaces as well as thickening of bilateral anterior renal fascia, posterior renal fascia, and lateral conal fascia. These CT findings were consistent with extensive retroperitoneal necrotizing soft tissue infection secondary to ruptured left obturator internus muscle abscess. Broad-spectrum antibiotics were instituted immediately, and the patient was urgently worked up for drainage of the abscess and debridement of the necrotic material. However, the patient’s condition deteriorated quickly before the surgical interventions were performed and slipped into septic shock. Emergency resuscitative measures were unsuccessful, and unfortunately, the patient died. The case represents a rare pathology with an unusual presentation, which can be fatal if diagnosis and treatment is delayed.

Bilateral adrenal-renal fusion: A radiological diagnosis

In normal anatomy, the kidneys and adrenal glands are contained within the renal fascia and separated by a connective tissue capsule derived from mesenchymal tissue. Incomplete encapsulation can occur during embryonic development, resulting in adrenal-renal fusion. The true incidence of this developmental anomaly is unknown, as it has primarily been described in the literature following incidental detection on surgical or histological examination. We report the first documented case of bilateral adrenal-renal fusion, diagnosed radiologically.

Assessment of Thickened Renal Fascia as a Finding at Computed Tomography in the Diagnosis of Acute Pancreatitis

This cross sectional study was carried out in the department of Radiology & Imaging, BIRDEM, Dhaka, from January 2012 to December 2012 to find out the sensitivity of thickened renal fascia in diagnosis of acute pancreatitis at CT. Total 50 patients (mean age was 41.64 years with range from 18 to 65 years, 34M/ 16F) with clinical suspicion of acute pancreatitis included in this study after analyzing selection criteria. Total 32(64%) of the 50 clinically suspected cases were diagnosed as acute pancreatitis according to the criteria mentioned in material and methods. The mean thickness of renal fascia in acute pancreatitis was 7.20 ± 3.32 mm (mean±SD) with range from 1 to 13 mm and maximum 18(40%) patients were found having thickened fascia within 4.0 to 6.9 mm. The extension of acute panceatitis only in left side was 71.8%. In 21.8%, the extension was bilateral. In 3.1% the renal fascial thickening was present on right side only .In the remaining 3.1%, renal fascia was not thickened.In 31 (96.8%) patients, the process extended into the anterior pararenal space. Both anterior and posterior renal fascia thickening was observed in 2(6.2%) patients. Normal thickness of renal fascia was found in 1(3.1%) patient. Sensitivity of thickened renal fascia in diagnosis of acute pancreatitis at CT was found 97%, specificity 50%, accuracy 80%, positive predictive value77%, negative predictive value 90%.It can be concluded that renal fascia thickening is an important as well as sensitive (97%) CT feature in the diagnosis of acute pancreatitis.Medicine Today 2015 Vol.27(1): 4-7

The renal system

The focus of this chapter is the renal system and the clinical skills that are associated with renal dysfunction. By the end of this chapter you will be knowledgeable in relation to these skills and your new knowledge will be underpinned by up-to-date evidence-based best practice. It is anticipated that you will be able to do the following once you have read and studied this chapter: ● Understand urine sampling techniques and urine testing methods and their significance in clinical practice. ● Understand the various procedures and investigations that the infant, child, or young person may have to endure for renal system evaluation. The urinary system is important in maintaining the correct water and electrolyte concentrations in the body. Waste products and excess water and ions are eliminated from the body in the urine. The kidneys are situated on either side of the vertebral column in the abdomen. The ureter, renal blood vessels, nerves, and lymphatics enter the kidney at a cleft on the medial side called the hilum. The adrenal gland lies on top of the kidney. The outside of each kidney is lined by: ● The renal capsule—a layer of collagen fibres. ● The adipose capsule—a layer of fat. ● The renal fascia—a layer of dense connective tissue. These three layers of tissue protect and support the kidney. The inside of each kidney contains an outer area (the cortex) and an inner area (the medulla). The cortex is lighter in colour compared to the dark reddish-brown medulla. The medulla contains cone-shaped areas of tissue called the medullary pyramids, which point towards the hilum. The cortex extends in between the medullary pyramids forming the renal columns. Urine forms at the tip of the pyramids (papillae) and drains into the minor calyx, then into a larger major calyx. Two or three major calyces join together to form the renal pelvis, a funnel-shaped chamber that leads into the ureter. Nephrons are the functional units of the kidney, the structures where urine is formed.

Surgical Anatomy of the Retroperitoneal Spaces Part II: The Architecture of the Retroperitoneal Space

The extraperitoneal space extends between peritoneum and investing fascia of muscles of anterior, lateral and posterior abdominal and pelvic walls, and circumferentially surrounds the abdominal cavity. The retroperitoneum, which is confined to the posterior and lateral abdominal and pelvic wall, may be divided into three surgicoanatomic zones: centromedial, lateral (right and left), and pelvic. The preperitoneal space is confined to the anterior abdominal wall and the subperitoneal extraperitoneal space to the pelvis. In the extraperitoneal tissue, condensation fascias delineate peri- and parasplanchnic spaces. The former are between organs and condensation fasciae, the latter between this fascia and investing fascia of neighboring muscles of the wall. Thus, perirenal space is encircled by renal fascia, and pararenal is exterior to renal fascia. Similarly for the urinary bladder, paravesical space is between the umbilical prevesical fascia and fascia of the pelvic wall muscles—the prevesical space is its anterior part, between transversalis and umbilical prevesical fascia. For the rectum, the “mesorectum” describes the extraperitoneal tissue bound by the mesorectal condensation fascia, and the pararectal space is between the latter and the muscles of the pelvic wall. Perisplanchnic spaces are closed, except for neurovascular pedicles. Prevesical and pararectal (presacral) and posterior pararenal spaces are in the same anatomical level and communicate. Anterior to the anterior layer of the renal fascia, the anterior interfascial plane (superimposed and fused mesenteries of pancreas, duodenum, and colon) permits communication across the midline. Thus parasplanchnic extraperitoneal spaces of abdomen and pelvis communicate with each other and across the midline.