The space between: a supralevator abscess caused by perforated diverticulitis

Abstract

Supralevator abscesses are the rarest manifestation of anorectal suppurative disease. We report a supralevator abscess in a 60-year-old male whose earliest presentation included poorly localized abdominal and pelvic pain, tenesmus, urinary retention and weight loss, initially treated as diverticular disease based upon imaging and presentation. Progressive symptoms led to the discovery of a pelvic abscess with subsequent percutaneous drainage, later followed by emergent laparotomy, where a single perforated diverticulum was revealed to be the source fistulization. He underwent a Hartmann procedure with concomitant drainage of supralevator and ischiorectal collections. Perirectal pain with neurological involvement is part of a constellation of signs and symptoms that should invoke a high index of clinical suspicion for supralevator abscess formation. Percutaneous attempts at drainage are often inadequate; definitive surgical therapy is the best approach to prevent recurrence and associated morbidity.

Supralevator Abscess - A Diagnostic Dilemma

“…Co-morbidities such as infl ammatory bowel disease, obesity, malnutrition, immunocompromised state, and diabetes, increases the risk of complications. Th e clinical course, complicated by the absence of typical signs and presence of lower abdominal pain, may confuse clinicians to search for abdominal pathology [6].…”

“…It is diffi cult to access supralevator abscess rectally and drain it adequately [4]. If drained through levator ani muscle through ischiorectal fossa a complex fi stula can result, and recurrences are common [6]. Th is leaves percutaneous drainage or open transabdominal drainage.…”