Peri-rectal Abscess Snehalata Topgi, M4 January 2014

19 yr old female w/ pmh Type1DM (dx 2006) presents to ED with L gluteal pain Pt noticed small, tender lump on L buttock 2.5 wks prior, which became enlarged and tender Saw PCP 5 days prior, dx with perirectal abscess and given PO Keflex course; I&D not performed 3 days prior had brown, malodorous drainage and returned to clinic; Bactrim added 1 day prior, having fever, chills, worsening pain; decided to come to ED Brief Clinical Hx

Hypotensive SBP 80-90s, tachycardic 128, RR 18-20s, initially afebrile then spiked to 100.6, breathing well on room air. Blood glucose 400s, POC ketones negative. Lactate 2.6. Blood and urine cultures obtained. CT A/P ordered. Patient started on IVF, Ertrapenem. General surgery was consulted to evaluate abscess; performed I&D with drain placed at bedside. Patient was then transferred to MICU

CONSTITUTIONAL: Awake, alert, cooperative LUNGS: No increased work of breathing, good air exchange, cta bilaterally, no crackles or wheezing CV: regular rate and rhythm, normal S1 and S2, no murmur noted and no edema ABDOMEN: normal bowel sounds, soft, non-distended, non-tender and no masses palpated MSK: there is no redness, warmth, or swelling of the joints NEUROLOGIC: AOx3, no focal deficits SKIN: L medial gluteal: large area of erythema that is warm, tender to palpation, firm; drain in place with no active draining at time of exam Significant Physical Exam

Septic shock Perirectal abscess Fistula Perforation Nectrotizing fasciitis Differential Diagnosis

Transperineal Ultrasound – Detection of fistulous tracts and fluid collections in preoperative planning, with high sensitivities of 85%. Xray, KUB CT with contrast – In one retrospective study, CT scanning for perirectal abscesses confirmed by surgical drainage yielded a sensitivity of 77%, with the false-negative patients being significantly more likely to be immunocompromised. ( Caliste X, Nazir S, Goode T, et al. Sensitivity of computed tomography in detection of perirectal abscess. Am Surg. Feb 2011;77(2): ) MRI Options for Diagnostic Imaging

Perirectal abscess extending to retroperitoneum Diagnosis from CT

Normal Abdomen, Sagittal Anatomy

Hypodense fluid collection with multiple gas foci in the left perianal region. Abscess extends into the retroperitoneum, adjacent to the left perirectal Region. Case Patient Air is visualized tracking from this the abscess into the retroperitoneum, encasing the IVC and the left renal hila, to the level of the diaphragmatic hiatus. Acc:

Lower Abdomen, Coronal Anatomy Concern for a fistulous connection with the rectum and the sigmoid colon. Cannot be confirmed because oral contrast has not advanced to the level of the rectum. Normal >>> <<< Case Patient

Other Example Cases ^^^Posterior perirectal abscess^^^Posterior perirectal abscess with extension into Ischeiorectal region

Repeat CT obtained 3 days later – New bilateral pleural effusion – Reduction in azygoesophageal, retroperitoneal, and peroneal gas – Left gluteal abscess drain in place Plans for better DM control Repeat CT in 2 weeks Patient Follow-up

That’s it. Questions?