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|Year : 1987 | Volume
| Issue : 2 | Page : 97-8
Ano-rectal abscess with retro-peritoneal spread (a case report).
Zaveri JP, Nathani RR, Mathure AB
|How to cite this article:|
Zaveri J P, Nathani R R, Mathure A B. Ano-rectal abscess with retro-peritoneal spread (a case report). J Postgrad Med 1987;33:97
Anorectal abscesses resulting from anal gland infection, are located between the internal sphincter and longitudinal muscle of the rectum as emphasized by Parks. Various forms of the disease i.e. peri-anal, intersphincteric, ischiorectal, submucous and supralevatores are well known. The supralevator abscess is reportedly the least common and most serious. This report deals with a case of anorectal abscess with spread to the retroperitoneal space.
A 35 year old male patient was admitted with two days' history of progressive pain and swelling in the peri-anal region. On examination, he had local tenderness, erythema and swelling. Temperature was 101°F and white blood cells count was 11,300 per cubic mm. The patient had no history of diabetes, blood dyscrasias or any local anorectal pathology in the past. The patient was administered penicillin and chloremphenicol and the abscess was drained under general anaesthesia. Post-operatively, the patient was maintained on antibiotics, packing and irrigation. He remained septic and the infection spread within 12 hours of drainage. The patient complained of vomiting, abdominal distension and pain. X-ray abdomen showed air in the retro-peritoneal space on the left side [Fig. 1] with paralytic ileus. Keeping in mind retroperitoneal spread of anorectal abscess, the retroperitoneum was explored by a lumbar incision. On exploration, there was foul smelling purulent discharge with extensive necrosis of the retroperitoneal tissues. After extensive debridement and local irrigation, the abdomen was closed with a corrugated drain in place. Pus swabs demonstrated E. coli, Pseudomonas and Gram positive spore bearing rods. The patient was given metronidazole arid repeated sittings of hyperbaric oxygen, besides antibiotics. Blood culture in this critically ill patient showed growth of E. coli and Proteus. Antibiotic therapy was modified depending on antibiotic sensitivity report. But the patient had persistent high fever, pancytopenia and sepsis, despite wound care and supportive treatment. Twenty days after the original operation, the patient expired.
Suppurative disease of the rectum and peri-rectum is a common clinical problem. Suppuration is usually located below the level of the pubo-rectalis muscle. If not treated during this stage, more than 90% will rupture through the longitudinal muscle and extend trans-sphincterically into one of the infralevator anorectal spaces as the pubo-rectalis sling exerts a strong pressure on the posterior rectal wall at the anorectal ring preventing supralevator extension of abscess. Rarely, a low intermuscular abscess may extend above the level of the pubo-rectalis muscle to form a high intermuscular abscess, which may rupture into one of the supralevator spaces.
The incidence of supralevator abscess varies from zero in Golighers' series of 200 cases to 1.5% in Bevans' series of 184 cases and to 2.45% in Hills' series of 626 cases of anorectal abscesses. However, Goldenberg recently reported an incidence of 7.5% in his series of 400 cases of ano-rectal abscesses attributing low socio-economical status of the patients in the series as the causative factor. Spread of anorectal abscess to the retro-peritoneum is very rare. Lindell et al and Goldenberg in their series of 58 cases and 400 cases respectively have not reported a single case of retroperitoneal extension. Hanley has described one such case in his series of 33 patients of anorectal supralevator abscess. An anorectal abscess with spread restricted to the supralevator spaces in the pelvis, can be drained through the levator muscle, by making an incision through one or both of the fossa ischiorectalis. For potentially lethal spread into the retroperitoneum lumbar incision is required to achieve adequate drainage and irrigation.
The authors wish to thank the Dean, Dr. (Mrs.) P. M. Pai for granting permission to publish this case.
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