From the Guidelines
The management of a patient with a history of previous abdominal surgery who presents with an indentation on the anterior rectal wall should be transrectal incision and drainage (option C). This approach is preferred because the indentation likely represents an anorectal abscess that has developed as a complication of the previous surgery. According to the guidelines from the World Journal of Emergency Surgery 1, a surgical approach with incision and drainage is recommended for patients with an anorectal abscess. The guidelines suggest that the timing of surgery should be based on the presence and severity of sepsis, and that fit, immunocompetent patients with a small perianal abscess and without systemic signs of sepsis may be considered for outpatient management.
In this case, transrectal incision and drainage is the most direct and effective approach, as it provides immediate decompression and allows for complete evacuation of purulent material. This procedure can be performed under local anesthesia with minimal morbidity and often results in rapid symptom relief. While CT-guided or ultrasound-guided aspiration (options A and B) are valid minimally invasive approaches for many intra-abdominal collections, they may not be as effective for a collection that is already bulging into the rectal lumen. The transrectal approach avoids traversing the peritoneal cavity, reducing the risk of spreading infection.
Key considerations in the management of this patient include:
- Performing a complete physical examination, including a digital rectal examination, to assess the extent of the abscess and guide treatment 1
- Checking for signs of systemic infection or sepsis, and requesting complete blood count, serum creatinine, and inflammatory markers as needed 1
- Considering antibiotic administration in the presence of sepsis and/or surrounding soft tissue infection or in case of disturbances of the immune response 1
- Sampling of drained pus in high-risk patients and/or in the presence of risk factors for multidrug-resistant organism infection 1
From the Research
Management of Abscess
- The patient has a history of previous abdominal surgery and an indentation on the anterior rectal wall, which may indicate an abscess.
- According to the study 2, most simple abscesses can be diagnosed upon clinical examination and safely managed in the ambulatory office with incision and drainage.
- The study 3 compared incision and drainage with ultrasonographically guided needle aspiration for skin abscesses and found that incision and drainage had a higher success rate (80% vs 26%).
- The study 4 provides an evidence-based review for emergency medicine clinicians and suggests that ultrasound is valuable in diagnosing abscesses and guiding I&D procedures.
- For the management of the patient's abscess, the options are:
- A. CT guided aspiration: There is no direct evidence to support the use of CT guided aspiration for this type of abscess.
- B. US guided aspiration: The study 3 found that ultrasonographically guided needle aspiration had a lower success rate compared to incision and drainage.
- C. Trans rectal incision and drainage: This option may be considered based on the location of the abscess, but the studies provided do not specifically address trans rectal incision and drainage.
- The use of antibiotics in the treatment of skin abscesses is still a topic of debate, with some studies 5, 6 suggesting that they may not be necessary for simple abscesses, while others may provide a positive effect in certain cases.