Thursday, August 12, 2010

Horseshoe Abscess

These cases are sometimes a little tricky. The patient had been suffering from severe butt pain for over a week. He couldn't even sit upright in a chair. He was feverish and had an elevated WBC count upon arrival in the ER. But on exam, you couldn't actually see any of the typical findings of perianal sepsis---no erythema, induration, or fluctuance. But it hurt him like hell when you tried to do a rectal exam. So we got the pelvic scan as seen above to help clarify the diagnosis.

What you see is a circumferential abscess/phlegmon, ringing the low rectum. You can't just lance these things at bedside like you can most abscesses. So I took him to the OR and made a couple of counter incisions to help effectuate complete drainage of the deeper pelvic sepsis. Then I like to leave a Penrose drain in situ, connecting the two incisions. It comes out in the office usually in a week.


Sarada Kakinada said...

nice one! it took me a few seconds to find, because somehow I assumed that "horseshoe abscess" meant an abscess in a horseshoe kidney (which I obviously couldn't locate).

hope your patient's sitting a little prettier now =P

Anonymous said...

You left out the best part of the case...
the Smell.
Its sort of like when I forgot about that 2lb of Corned Beef in the trunk of my car, didn't find it till 3 months later when we got a flat.
in Internship there was this Japanese Radiology Resident who couldn't pronouce "Phlegmon" to save his life.
Whenever we needed a laugh we'd take him a scan like that just to here him say
"whats a "Fregmon"??

it was like an Abbot & Costello routine.
guess you had to be there.


Anonymous said...

did you drain the posterior midline source of the infection by dividing the internal sphincter? look for internal opening to identify a fistula?

Jeffrey Parks MD FACS said...

there was a posterior midline fistula. it was a deeper transphincteric one, so I did partial fistulotomy and left a soft seton. will bring him back in a few weeks.