Hameed, K

Maniar, R

English

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eCommons@AKUDepartment of Surgery Department of SurgeryMarch 1992An unusual presentation of ischiorectal abscessK HameedR ManiarFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_surgPart of the Surgery CommonsRecommended CitationHameed, K., Maniar, R. (1992). An unusual presentation of ischiorectal abscess. Journal of Pakistan Medical Association, 42(3), 76-77.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_surg/690AN UNUSUAL PRESENTATION OF ISCHIORECTALABSCESSPages with reference to book, From 76 To 77 Khalid Hameed, Rizwan Maniar ( Department of Surgery, The Aga Khan University Hospital, Karachi. ) INTRODUCTION Neglected ischiorectal abscess can result in spread of infection in various anatomical planes andmislead the attending physician. In such complicated cases CT scan can be very helpful.CASE REPORT A 49 year old male patient was admitted with a seven day history of fever and incontinence of fluidfaeces and painful swelling of the left thigh. He had schizophrenia and had been on stelazine for 10years. During the present illness he had received treatment for malaria and typhoid. He was referred toAga Khan University Hospital with a possible diagnosis of femoral vein thrombosis. On examination,he looked toxic, temperature was 104°C, pulse 120/minute, abdomen slighily distended, fluid thrill waspresent and bowel sounds were normal. The left thigh was warm and its circumference increasecompared to the right. All peripheral pulses were palpable. Rectal examination showed an ischio-rectalabscess of horseshoe variety with multiple sinuses discharging pus. Plain films of the abdomen showedsome distended loops of small bowel suggesting ileus and the possibility of a soft tissue mass in the leftside of the pelvis. The white cell count was 30.2x101 dl, routine hematological and biochemicalinvestigations including random blood sugar were normal. U-scan of the abdomen was unrewarding;doppler studies showed a patent left femoral vein. The patient was examined under anaesthesia and alarge ischiorectal abscess was drained. A thorough search was made for an internal opening, which wasnot found1. The organisms cultured from the pus were E. coli and klebsiella. Following this procedurethe patient did not improve, continued to be toxic and the white cell count remained elevated. CAT scanof the abdomen and pelvis showed a large abscess cavity starting at the lower pole of the left kidneyand extendingdown to the retroperitoneal space lateral and posterior to the psoas muscle then findingits way anterior to the left iiacus muscle. The abscess further tracked down into the anterior thigh tillthe level of the greater trochanter. Medially it tracked along the left lateral wall of the pelvis andappeared to be continuous with the apex of the ischiorectal fossa. There was large amount of gas in theabscess cavity at various sites. Under CT guidance a size 20 Pr drain was inserted into the abscesscavity, from an extra peritoneal posterior approach2, 900cc of pus was drained. With this valuableinformation a further EUA was performed. The retroperitoneal abscess was drained extraperitoneallyand the thigh was drained by means of a separate vertical incision. The ischiorectal cavities were re-explored and communication with retroperitoneal space was confirmed. Thereafter there wasremarkable improvement in the patient’s condition. Two further dressings under anaesthesia wererequired for residual debris3. He was discharged after 19 days hospital stay.DISCUSSION This case report highlights two important aspects of patient management, (i) patients who havepsychiatric disorders are poor historians and their illness may progress to an advanced stage beforeappropriate medical attention is sought. This is partly the result of a disturbed mental status and failureto appreciate the gravity of their problems, (ii) anatomical planes of an ischiorectal abscess and role ofCT scan in complicated cases. Pus may track up from the ischiorectal fossa to the lateral pelvic spaceand extend in the retroperitoneal space as high as the lower pole of kidney and may further track downto the anterior thigh behind faciailiacüs. CT scan is a useful method to detect these ramifications of acomplicated ischiorectal abscess and has both diagnostic and therapeutic implications.REFERENCES 1. Ramanujam, P.S., Prasad, M.L., Herand, Abcarian, H. and Tan, AR. Perianalabscesses and fustulas. Astudyof 1023 patients. Dis. Colon. Rectum, 1984; 27:593-7.2. Robert, A., Clark, R.A. and Towbin, R., Abscess drainage with CT and ultrasound guidance. RadioLdin. North Am., 1983; 21:445- 59.3. Abcarian, H. Acute suppurationsof the anorectum. 5urg. Annu., 1976; 8:305-33.

An unusual presentation of ischiorectal abscess

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An unusual presentation of ischiorectal abscess

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