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
