The space between: a supralevator abscess caused by perforated diverticulitis
A 60-year-old male presented to our institution with a 4–6-week history of progressive constipation, painful defecation, urinary retention and increasing lower abdominal pain and pressure. He described some associated nausea, chills and tenesmus after small, frequent movements. Additionally, this patient relayed ∼8-lb weight loss over a 2-month period secondary to decreased oral intake and fear of painful and incomplete evacuation, and had begun experiencing pelvic and sacral pain when sitting. His past medical history included hypothyroidism, anxiety, hypercholesterolemia and smoking. On physical exam the patient demonstrated tenderness to palpation across the lower abdomen without evidence of peritonitis. Digital rectal examination revealed an enlarged prostate, good sphincter tone; significant tenderness upon palpation of the rectum was elicited, with no purulent drainage expressed.\nContrast-enhanced computed tomography (CT) scan revealed the presence of diverticulosis and perirectal mesenteric stranding concerning for diverticulitis (Fig. ); therefore, the patient was admitted and treated empirically for the same with i.v. antibiotics. He was discharged several days later with a 2-week course of amoxicillin clavulanate.\nIn the 6-week follow-up, repeat CT demonstrated eccentric thickening of the rectosigmoid with interval development of an adjacent complex pelvic fluid collection with supralevator extension measuring 3.5 × 2.5 cm (Fig. a and b). Percutaneous needle biopsy revealed pus, and a drainage catheter was left in place (Fig. a and b). The patient did not improve, was reimaged and was found to have collection extending into the ischiorectal fossa and supralevator space (Fig. ). Owing to refractory pain and persistent leukocytosis, the patient was taken to the operating room for examination under anesthesia. No fistulous tract or internal drainage was noted within the rectal vault; however, consistent with the imaging, external induration was observed along the right ischiorectal fossa, where, upon incision, a large purulent cavity was evacuated. On evening rounds, the patient was noted to have a marked leukocytosis and frank stool coming from the ischial wound, and he was taken emergently to the operating room for diagnostic laparotomy where a perforated diverticulum adherent to the pelvic sidewall was identified (Fig. ). Therefore, a Hartmann procedure, drainage of supralevator abscess, irrigation and debridement of the right ischiorectal wound, was performed.