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.
4 comments:
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
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
"AHHHSOOOOO COULD BE FREGMON!!!"
"whats a "Fregmon"??
"YOU NOT KNOW WHAT FREGMON IS??"
it was like an Abbot & Costello routine.
guess you had to be there.
Frank
did you drain the posterior midline source of the infection by dividing the internal sphincter? look for internal opening to identify a fistula?
anon-
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.
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