How to manage a patient with a history of previous abdominal surgery presenting with an indentation on the anterior rectal wall?

From the Guidelines

For a patient with a history of previous abdominal surgery who presents with an indentation on the anterior rectal wall, the recommended management would be option C: Transrectal incision and drainage. This approach is most appropriate because the indentation likely represents a pelvic abscess or collection that has developed as a complication of the previous surgery. Transrectal drainage is the preferred method when an abscess is palpable and fluctuant on rectal examination, as it provides direct access to the collection with minimal risk of contaminating the peritoneal cavity. The procedure involves making an incision through the rectal wall at the point of maximal fluctuance, followed by drainage of purulent material and placement of a drain if necessary. This approach allows for immediate decompression of the abscess, relief of symptoms, and collection of specimens for culture. While CT or ultrasound-guided approaches (options A and B) may be useful for deeper or less accessible collections, the transrectal approach is more direct and effective when the abscess is clearly palpable on rectal examination. Following drainage, the patient should receive appropriate antibiotics based on culture results and require close follow-up to ensure complete resolution of the collection, as suggested by the guidelines for anorectal emergencies 1. It is also important to consider the patient's overall clinical condition, including the presence of sepsis or hemodynamic instability, when deciding on the timing and approach for surgical intervention, as outlined in the guidelines for complicated rectal prolapse 1. In general, the management of anorectal abscesses involves a surgical approach with incision and drainage, with the timing based on the presence and severity of sepsis 1. The use of wound packing after drainage is not universally recommended and should be based on individual patient factors and clinical judgment, as there is limited evidence to support its routine use 1. Ultimately, the goal of management is to provide effective drainage, relieve symptoms, and prevent complications, while also considering the patient's overall health status and risk factors for recurrence or other conditions, such as Crohn's disease 1.

Some key points to consider in the management of this patient include:

• The importance of a thorough medical history and physical examination, including a digital rectal examination, to diagnose and assess the extent of the abscess or collection.
• The need for prompt surgical intervention in the presence of sepsis or hemodynamic instability.
• The consideration of individual patient factors, such as age, comorbidities, and surgeon expertise, when deciding on the approach for surgical intervention.
• The importance of close follow-up and monitoring after drainage to ensure complete resolution of the collection and prevent complications. The guidelines for anorectal emergencies provide a framework for managing patients with anorectal abscesses, including the use of surgical drainage and the consideration of individual patient factors 1. In the context of complicated rectal prolapse, the guidelines suggest a more nuanced approach, considering the presence of peritonitis, hemodynamic instability, and other factors when deciding on the surgical approach 1. Overall, the management of this patient requires a careful consideration of the clinical presentation, individual patient factors, and the available evidence-based guidelines.

From the Research

Management of Abscess

• The patient's history of previous abdominal surgery and the presence of an indentation on the anterior rectal wall suggest a possible abscess formation.
• According to 2, most simple abscesses can be diagnosed upon clinical examination and safely managed in the ambulatory office with incision and drainage.
• However, the use of imaging-guided aspiration, such as CT or US guided aspiration, may be considered for abscesses that are not easily accessible or for patients with a high risk of complications.
• 3 suggests that ultrasound is valuable in diagnosing abscesses that are not clinically evident and in guiding incision and drainage (I&D) procedures.
• The management of the abscess should be individualized, taking into account the patient's medical history, the size and location of the abscess, and the presence of any underlying conditions.

Treatment Options

• Incision and drainage (I&D) is a common treatment option for abscesses, as mentioned in 2 and 3.
• Transrectal incision and drainage may be considered for abscesses located in the rectal area, but this approach may carry a higher risk of complications.
• CT or US guided aspiration may be a suitable alternative to I&D for abscesses that are not easily accessible or for patients with a high risk of complications.
• Antibiotics may be prescribed in addition to I&D, but the evidence suggests that they may not significantly improve the percentage of patients with complete resolution of their abscesses, as mentioned in 4 and 5.

Preoperative Care

• If surgery is planned, preoperative care should be provided to prepare the patient for the procedure, as discussed in 6.
• This includes physical and psychosocial care, as well as preoperative tests and clinical assessments.
• Patient information and education should also be provided during the preoperative period.