Endoscopic ultrasound-guided drainage of a pelvic abscess via a J-pouch

Table of Contents

While prior reports have demonstrated the usefulness of endoscopic ultrasound (EUS) for transrectal drainage of pelvic abscesses, its utility for performing drainage via an ileoanal reservoir (J-pouch) has not been reported before.

A 28-year-old patient with a history of total colectomy and a J-pouch for ulcerative colitis presented with persistent fever and rectal pain. Computed tomography (CT) of the pelvis revealed an abscess measuring 5 × 3 cm adjacent to the J-pouch ([Fig. 1]).

EUS-guided drainage of the abscess was requested because of the lack of an adequate window for percutaneous drainage. At EUS, the pelvic abscess was punctured ([Fig. 2]) using a 19-gauge needle (Expect; Boston Scientific, Natick, Massachusetts, USA), and a 0.035-inch guide wire was then coiled into the abscess ([Fig. 3]) under fluoroscopic guidance. The transmural tract was sequentially dilated using a 5-Fr endoscopic retrograde cholangiopancreatography cannula and a 6-mm balloon dilator ([Fig. 4]). A 7-Fr double pigtail stent was then deployed into the abscess cavity ([Fig. 5]).

Fig. 1 Computed tomography (CT) of the pelvis, revealing a 5 × 3-cm pelvic abscess in a patient with J-pouch anatomy.

Fig. 2 Endoscopic ultrasound (EUS) image: the abscess cavity was punctured using a 19-gauge fine needle aspiration needle via the J-pouch under EUS guidance.

Fig. 3 a A 0.035-inch guidewire coiled within the abscess cavity under fluoroscopic guidance to facilitate sequential dilation. b Endoscopic view of the guidewire passed into the abscess cavity via the J-pouch.

Fig. 4 Dilation of the transmural tract using a 6-mm over-the-wire balloon.

Fig. 5 Placement of a double pigtail stent into the abscess cavity via the J-pouch.

Postprocedure, the patient was afebrile and had no rectal pain. Follow-up CT revealed complete resolution of the abscess, and so the transrectal stent was retrieved by sigmoidoscopy.

Fitting a J-pouch, sometimes referred to as ileoanal reservoir, involves colectomy with mucosal proctectomy and the creation of an ileal reservoir which is anastomosed to the anal canal [1]. In a meta-analysis, 9.5 % of patients with a J-pouch developed pelvic abscess from anastomotic dehiscence [2]. Initial management often includes percutaneous drainage; a persistent abscess may require surgery [3]. In a prior study by myself and a co-author, we have shown that EUS is a minimally invasive alternative for drainage of pelvic abscesses [4]. However, patients with a J-pouch were excluded because of concerns of perforation in a surgically constructed anatomy. Given the inability to treat the pelvic abscess by percutaneous means, we attempted drainage via the J-pouch in this patient, with good clinical outcomes.

Endoscopy_UCTN_Code_TTT_1AS_2AZ

Competing interests: None

References

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