A 31-year-old woman with asthma presented with 1 week of lower abdominal pain and fevers after a recent emergency room discharge for appendicitis that had been managed conservatively with antibiotics. Upon presentation, she underwent a computed tomography (CT) scan of the abdomen and pelvis, which revealed a multiloculated pelvic abscess measuring approximately 7.3 × 4.7 × 7.0 cm ([Fig. 1]). The collection was thought to be unamenable to drainage by interventional radiology.
Fig. 1 Computed tomography scan of the abdomen and pelvis showing a multiloculated pelvic abscess measuring approximately 7.3 × 4.7 × 7.0 cm.
The patient underwent a lower gastrointestinal endoscopic ultrasound (EUS), which identified the pelvic abscess from the rectosigmoid colon. After color flow Doppler had been used to ensure there was no intervening vasculature, a cautery-enhanced delivery system was used to deploy a 10-mm lumen-apposing metal stent (LAMS; Axios; Boston Scientific, Marlborough, Massachusetts, USA) into the collection, with the distal flange in the collection and the proximal end in the sigmoid colon. This process was visualized under fluoroscopic, endosonographic, and endoscopic guidance. Copious amounts of purulent material were seen draining from the stent. The stent was then dilated and two double-pigtail plastic stents (10 Fr × 7 cm) were deployed into the metal stent to prevent migration ([Video 1]).
Video 1 Endoscopic ultrasound-guided transrectal abscess drainage using a lumen-apposing metal stent (LAMS).
The patient was discharged on hospital day 4 after an uncomplicated post-operative course. A repeat CT scan of the abdomen and pelvis was performed nearly 3 weeks later and revealed resolution of the multiloculated pelvic abscess; the LAMS was endoscopically removed a few days later. The patient was subsequently seen in follow-up and has continued to remain asymptomatic.
The use of LAMSs has revolutionized EUS as it creates a large conduit for drainage, as well as for passage of both the endoscope and a variety of endoscopic accessories [1]. While surgical resection has been the main approach to drainage of intra-abdominal and pelvic collections, EUS can be a useful modality to aid in the diagnosis and for therapeutic drainage of pelvic collections [2]
[3]
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[5].
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