CASE 10072 Published on 18.07.2012

Trans-rectal sonographic guided catheter drainage of pelvic collection – technique and limitations

Section

Interventional radiology

Case Type

Clinical Cases

Authors

Thakral A,Sundareyan R,Kumar Sheo,Sharma P

Sanjay Gandhi Post Graduate Institute of Medical Sciences
Patient

23 years, female

Categories
Area of Interest Pelvis, Interventional non-vascular ; Imaging Technique Ultrasound, Ultrasound-Colour Doppler, CT
Clinical History
23-year-old unmarried female patient presented with fever, following open cholecystectomy for symptomatic cholelithiasis. Haematological profile showed raised total leukocyte count (20,000/cu.mm). Transabdominal sonography and CECT abdomen were performed to localise the source of pyrexia. Interventional ultrasonography allowed management for the same which helped in achieving clinical improvement and normalisation of TLC.
Imaging Findings
USG and CECT abdomen revealed a collection suggestive of abscess in the pouch of Douglas. No safe access for trans-abdominal needle placement was present and the patient was an unmarried, virgin girl hence excluding transvaginal approach. So trans-rectal approach was selected.
Procedure: She received intravenous antibiotics and rectal enema pre procedure. A 8-4 MHz end-fire probe covered with condom and attached biopsy guide was used for trans rectal sonographic guidance. The collection was localised and an 18 gauge Chiba needle (Cook Inc., Bloomington, USA) was advanced into it. Samples for culture were obtained. A 0.9 mm (0.035 in.) Amplatz ultra-stiff guidewire (Cook Inc., Bloomington, USA) was inserted through the needle and coiled within the abscess cavity. After serial dilatations with Coons dilator, a 12F self-retaining locking loop catheter (Cook Inc., Bloomington, USA) was inserted into the collection. Catheter was secured to the buttocks and connected to a leg bag. Catheter patency was assessed daily.
Discussion
Percutaneous catheter drainage for intraabdominal collections is the standard of care in absence of indications for immediate surgery .[1] Intraabdominal collections generally occur in post operative setting, due to infective and inflammatory aetiology secondary to various bowel components and gynaecological conditions. Problems encountered in percutaneous trans-abdominal drainage of pelvic (especially deep seated) collections are risk of injury to intervening bowel and neurovascular structures. [2] To overcome these, alternative approaches like 1. Trans-rectal, 2. Trans-vaginal 3. Trans-gluteal routes can be used. Major drawbacks of transgluteal approach include possible injury to neurovascular structures in the greater sciatic notch and catheter kinking. Trans-vaginal approach is possible only in sexually active females- This method provides limited accessibility to presacral region with poor patient compliance. [3] Hence, trans-rectal route is preferred for being less painful and better tolerated with higher clinical cure rates and fewer complications. [4]
Trocar technique of catheter placement is simpler and less time consuming. [2, 5] But associated tissue drag increases chance of injury to adjacent organs while catheter repositioning after inaccurate placement may not be possible. [5] Seldinger technique is preferred for being less traumatic with accurate catheter placement. Better sonographic visibility of newer guidewires obviates need for additional flouroscopic guidance and allows manipulations under sonographic guidance itself.
Local anaethesia ± mild sedation prove sufficient for this procedure. But children and uncooperative patients may require general anaesthesia. Minimum size of initial catheter for proper drainage should be 10F (especially for infected collection). Locking loop catheters are available to 14 F.
Catheter patency, amount of drainage and patient’s condition should be assessed daily. Catheters need 8 hourly flushing with 5-10 ml of normal saline to maintain patency. Catheter removal can be planned when daily output falls below 10 ml and patient improves clinically. When signs of infection persist with reduced catheter output, clogging, displacement, or kinking should be looked for. Further imaging, especially CT, helps confirm catheter position and amount of residual collection. Repositioning or replacement with larger bore catheter is required. A fistulous communication to the intestine should be suspected and confirmed by contrast study when catheter output continues to remain high with change in character from pus to bowel contents. In these instances, catheter should be left in place until definitive surgery is performed or repeated catheter injection confirms resolution of fistula. [2, 4, 5]
Our patient improved with abscess resolution after 8 days. Catheter was then removed and patient discharged uneventfully.
Differential Diagnosis List
Trans-rectal sonographic guided catheter drainage of pelvic collection
Ovarian cyst
Rectal duplication cyst
Final Diagnosis
Trans-rectal sonographic guided catheter drainage of pelvic collection
Case information
URL: https://www.eurorad.org/case/10072
DOI: 10.1594/EURORAD/CASE.10072
ISSN: 1563-4086