EP230 - A Rare Case of a Supralevator Abscess from Perforated Diverticulitis

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Purpose/Background: Supralevator abscesses are the least common type of anorectal abscesses, occurring in 1-9% of patients, and account for only 3-4% of total incidences of suppurative disease of the anorectum. We present the case of an 80 year old female who was found to have a perirectal abscess while under the care of vascular surgery for treatment of left lower extremity cellulitis following a left fem-peroneal artery bypass. The perirectal abscess was incidentally noted on a CT angiogram of the left lower extremity. She recalled several months of left lower quadrant abdominal pain when straining with bowel movements and an episode of constipation immediately following her LLE bypass. Three years prior, she had a positive Cologuard and subsequent colonoscopy. She reported ‘colon inflammation’ was noted which she attributed to diclofenac use that caused her to have frequent diarrhea. Past medical history was significant for breast cancer and no history of diverticulosis. Physical exam demonstrated moderate tenderness with deep palpation of the abdomen LLQ. Significant labs included a WBC of 18.

Methods/Interventions: As the abscess was noted high in the pelvis on CT imaging with no evidence of superficial extension on exam, the patient’s Xarelto was held, and she underwent transgluteal IR drain placement. Purulent fluid and blood was obtained, and culture grew: Escherichia Coli, Klebsiella Oxytoca, and Streptococcus Constellatus. Infectious disease was consulted and managed IV antibiotics while inpatient, and recommended Augmentin twice daily for 2 weeks on discharge. While at home, the IR drain began putting out feculent fluid. Approximately 5 weeks following IR drain placement, she underwent colonoscopy for evaluation of colo-cutaneous fistula. Severe sigmoid diverticulosis was noted with multiple diverticuli and tortuosity, preventing advancement of the scope proximally.

Results/Outcomes: The patient underwent an elective robotic low anterior resection with colorectal anastomosis, drainage of pelvic abscess secondary to diverticulitis, IR drain removal, takedown of entero-colic fistula (between the terminal ileum and inflamed portion of sigmoid colon), and creation of diverting loop ileostomy. Two months later she underwent a completion colonoscopy showing an intact colorectal anastomosis without stricture and her ileostomy was subsequently reversed without issue.

Conclusion/Discussion: While a rare occurrence, surgeons and clinicians should be aware of the potential for a supralevator abscess to originate from perforated diverticulitis.