Ultrasound-Guided Internal Drainage of a Large Intraabdominal Abscess Using a Double J-Stent at a Small Community Hospital--A Case Report

Abscesses, a common complication of diverticulitis, are frequently treated with conservative management, such as bowel rest and antibiotics. However, interventional radiology (IR) often performs percutaneous-catheter drainage (PCD) when medical management fails. PCD causes post-incisional pain in approximately 20% of patients¹. PCD may also be limited by the anatomical location of an abscess, particularly those situated near organs or unable to be reached from the skin without injury to nearby structures². Additionally, patients who require external collection bags may express embarrassment from having to manage an unsightly bag ³. 

To address the drawbacks of PCD, clinicians have begun performing CT- and ultrasound-guided internal drainage (USG-ID) utilizing plastic or lumen-posing metal stents (LAMS)^4,5. We report a case of complicated diverticulitis with a rectovesical abscess that, due to its location, was drained by USG-ID. However, since LAMS was not readily available at our facility, we elected to use a standard 8-French double J-stent. Our approach is the first to our knowledge that utilizes equipment universally available to institutions with standard IR access.

Methods or Case Description:

A 45-year-old male with a medical history significant for complicated diverticulitis requiring sigmoidectomy presented to the emergency department (ED) complaining of chills, nausea, and vomiting. One month earlier, he underwent a robotic-assisted sigmoidectomy with end-to-end low primary colorectal anastomosis with cystoscopy and bilateral lighted ureteral stent placement, which was uneventful and uncomplicated. In the ED, a CT scan of the abdomen/pelvis with IV and rectal contrast was completed. Imaging showed a 7 cm segment of thickened sigmoid colon proximal to the anastomosis with an adjacent 6.3 cm peripheral enhancing fluid collection abutting the bladder wall without evidence of contrast extravasation. Due to the proximity to the bladder and initial concern for bladder involvement, IR was consulted. The team deemed PCD of the rectovesical abscess too risky because the anatomic location, and thus IR decided to attempt USG-ID with stents available at the hospital.

The patient underwent transrectal ultrasound (US) guided drainage with double J-stent placement. This was performed by first inserting a transrectal US probe that demonstrated a fluid collection measuring approximately 2.9 cm by 4.6 cm, with an associated mass effect on the urinary bladder (Fig. 1). Then, under direct visualization, a needle was inserted into the fluid collection via the rectum and a wire was placed using Seldinger technique. The tract was dilated with sheath placement, and contrast was used to ensure that only the abscess cavity was entered. There was no contrast extravasation or extension into the urinary bladder. After bladder involvement was successfully ruled out, the abscess was drained and expressed approximately 150 mL of feculent, purulent material. A transrectal 8 French double J-stent was placed, with one side within the abscess cavity and the other side within the rectum to provide internal drainage (Fig. 2).

 
The patient tolerated the procedure well. By hospital day three, his symptoms and leukocytosis resolved so he was discharged home. While at home, on postoperative day 6, the stent inadvertently dislodged during a routine bowel movement without pain or difficulty. The patient denied any subsequent symptoms. The patient completed his course of antibiotics and underwent a follow-up CT scan two days post-stent removal (postoperative day 8), which demonstrated abscess resolution. He had a colonoscopy several months after USG-ID which demonstrated a normal anastomotic site from his previous colon resection.

Outcomes:

Most USG-ID procedures have occurred in large healthcare systems that have numerous subspecialties and resources readily available. Overall, studies suggest that USG-ID is less painful for patients while equally efficacious and safe relative to PCD in appropriately selected patients. Moreover, patients undergoing USG-ID do not require external bags, which may cause psychological distress for patients. Studies conducted by Donatelli et al. (2021) suggest that USG-ID is particularly useful for abscesses larger than 3 cm, well-encapsulated, and near the colonic wall. The primary limitation of draining abscesses by this technique is resources; small and/or resource-poor hospitals may lack the required materials needed to perform USG-ID as currently outlined in the literature. 

By using stents available in standard IR suites, our case demonstrates that internal drainage does not need to be limited to large hospitals but can also be a safe option within small community hospitals. Thus, cases like ours are vital to demonstrating that additional methods–such as USG-ID versus the standard, possibly more painful PCD option–are available and possible to all patient populations regardless of hospital resources and size. By writing this case, we hope to inspire similar hospitals with limited resources to investigate their capabilities to perform USG-ID of abscesses caused by diverticulitis. Although our case continues to build on the literature regarding USG-ID while also expanding the patient population that can receive this treatment method, more research should be done to determine the capability of this method in smaller abscesses as well. 

 
Post-operatively, the patient passed the drain without pain during a normal bowel movement. Although this was not the intended plan for drain removal, it ultimately eliminated the need for a second procedure which offered multiple patient benefits.  Most notably, fewer procedures innately reduce the risk of surgical complications, such as postoperative infection and injury to vital structures, or endoscopic complications, such as perforation. Additional research with larger sample sizes should be conducted to determine if catheter removal via bowel movement is a viable option for other patients. This would be especially beneficial for patients with a history of poor follow-up as fewer appointments would be required. Of note, the abscess will still need to be monitored for resolution with follow-up imaging, however, this is required in all cases regardless of the drain removal method.

Conclusion: Our case expands upon the existing literature surrounding the safety and efficacy of USG-ID for intra-abdominal abscesses that typically require PCD by demonstrating successful drainage with a transrectal 8 French double J-stent. We also demonstrate the capability of performing USG-ID at a small community hospital that provides care to an inner-city population–a location that is unequipped for multi-staged interventions that require significant resources from the patient and hospital. Additionally, our case suggests the possibility that patients can safely pass stents during bowel movements, which would eliminate the need for additional interventions for removal. We suggest additional studies be undertaken to investigate this relatively novel treatment modality more thoroughly.