Ischiorectal abscess with retro and intraperitoneal dissemination: a case report
Lahoucine Alzaz, Mohamed Lamribah, Hamza Mougib, Youssef Harrouni, Mehdi Soufi, Mohammed Ouazni
Received: 05 Jul 2023 - Accepted: 19 Aug 2023 - Published: 30 Aug 2023
Domain: Gastroenterology,Proctology,General surgery
Keywords: Ischiorectal abscess, pneumoperitoneum, pneumo-retroperitoneum, case report
©Lahoucine Alzaz et al. PAMJ - Clinical Medicine (ISSN: 2707-2797). This is an Open Access article distributed under the terms of the Creative Commons Attribution International 4.0 License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Cite this article: Lahoucine Alzaz et al. Ischiorectal abscess with retro and intraperitoneal dissemination: a case report. PAMJ - Clinical Medicine. 2023;12:49. [doi: 10.11604/pamj-cm.2023.12.49.40976]
Available online at: https://www.clinical-medicine.panafrican-med-journal.com/content/article/12/49/full
Ischiorectal abscess with retro and intraperitoneal dissemination: a case report
Anorectal abscess is a common condition in proctology emergencies. However, it does not present with peritoneal symptoms. A computerized tomography (CT) scan is not a routine examination in this condition, but remains necessary in case of peritoneal symptomatology, showing the presence of pneumo-retroperitoneum and multiple retro and intraperitoneal collections which is extremely rare. We present a rare case of ischiorectal abscess with retro and intraperitoneal dissemination in a patient who presented with perineal pain associated with diffuse abdominal pain.
Anorectal abscess is an infection of soft tissues caused by the obstruction and then infection of the crypts and anal glands due to chronic constipation, inflammatory bowel diseases (Crohn's), malignant tumors, foreign bodies, and sexually transmitted diseases . Parks et al.  are classified anorectal abscesses into perianal, ischiorectal, intersphincteric, and supralevator abscesses. Supralevator abscesses are the least frequent, with the maximum incidence of anorectal abscesses occurring in the third and fourth decade of life . Men are more frequently affected than women . CT scans are generally not deemed necessary, but they are discreetly useful in the case of a supralevator abscess. We present a rare case of an ischiorectal abscess in a patient who exhibited diffuse abdominal pain due to the significant extension of the abscess through the abdominal fascia and retroperitoneal region.
Patient information: a 65-year-old male patient presenting a medical history of uncontrolled diabetes has been admitted due to acute abdominal and perineal pain, accompanied by symptoms of constipation and abdominal distension.
Clinical findings: the clinical examination revealed a temperature of 39°, a distended abdomen with generalized abdominal defense, a perineal and digital rectal examination revealed a left peri-anal abscess that was indurated and not fistulized to the skin, with an internal opening located at 2 o'clock.
Diagnostic assessment: biological tests were requested, revealing a normal white blood cell count of 8720/mm³ and an increased C-Reactive Protein (CRP) of 249.9mg/l. Abdominal-pelvic CT scan revealed multiple retroperitoneal fluid collections, pneumo-retroperitoneum and an encapsulated intraperitoneal effusion in the peri-hepatic region accompanied by pneumoperitoneum (Figure 1).
Therapeutic interventions: given this clinical-scanographic picture, a perforative peritonitis was strongly suspected, and an emergency laparotomy was performed, revealing purulent effusion of the supra-mesocolic floor without any evident digestive perforation. Subsequently, a perineal incision and drainage of the anal abscess was performed with corrugated rubber drain.
Follow-up and outcome of interventions: in the postoperative period, the patient was admitted to the intensive care unit for 24 hours where he died from refractory septic shock.
Inform consent: an informed written consent was obtained from the patient to publish this work.
An ischiorectal abscess typically manifests as an acute condition and calls for prompt intervention in the form of incision and drainage, along with appropriate resuscitative measures and administration of effective antibiotics. A literature review indicates that while there have been a few reported cases of ischiorectal abscesses presenting with retro-pneumoperitoneum [5,6] but to the best of our knowledge, a single documented case in 2017 has been reported, indicating the occurrence of intraperitoneal dissemination of an ischiorectal abscess . In our case, due to the presence of free air in the peritoneal cavity, we expected to find a perforative peritonitis, but surgical inspection revealed no obvious etiology, leaving the hypothesis of dissemination from the affected retroperitoneum.
The supra-levatorian space is a pelvic compartment located above the levator ani muscle that communicates anteriorly with the retzius space, laterally with the retro-inguinal spaces, and posteriorly with the retroperitoneum . The pubo-rectal muscle acts as a barrier against abscess expansion. However, abscesses can rarely spread above or within the muscle, usually with a fistula, allowing the spread of inflammation into extraperitoneal anterior and posterior abdominal compartments . The intra-peritoneal dissemination can be explained by the Interfascial Diffusion Theory . In the case of rapid development of large fluid volumes, the storage capacities of retro-peritoneal spaces can be exceeded, causing the fluids to seek decompression routes within these sliding spaces.
The classic distinction between intraperitoneal and extraperitoneal compartments remains a daily clinical application. However, it is important to understand that the abdomen, pelvis, and retroperitoneum constitute an anatomical continuum through subserosal fat tissue and its expansions in mesenteric ligaments and folds . The perirenal space communicates with the retro hepatic space at the area nuda. Communication between these two spaces occurs through the kneeland canal . It is crucial to be aware of the different manifestations of ischiorectal abscesses and the risk of their dissemination, particularly in the presence of atypical symptoms. Prompt resuscitation and appropriate imaging should be conducted prior to any intervention as the progression of inflammation can be unpredictable and can extend in various anatomical planes, both within the peritoneal cavity and beyond it into the retroperitoneal space.
The diagnosis of ischiorectal abscess presenting with abdominal symptoms, particularly in immunocompromised and elderly patients, strongly suggests extensive fasciitis which can rapidly compromise vital prognosis. Aggressive treatment is often necessary to ensure a good outcome for this potentially fatal condition, even with specialized care.
The authors declare no competing interests.
All authors contributed to this work and read and agreed to the final manuscript.
Figure 1: axial view of computed tomography (CT): scan showing: A) perirectal pneumo-retroperitoneum (red arrow); B) pneumo-retroperitoneum in pararenal space, retro duodenal, and peri vena cava, (VCI); C) pneumo-retroperitoneum in retro pancreas (red arrow); D) pneumoperitoneum (red arrow) and peri hepatic effusion (blue arrow)
- Abcarian H. Anorectal infection: abscess-fistula. Clin Colon Rectal Surg. 2011 Mar;24(1):14-21. PubMed | Google Scholar
- Parks AG, Gordon PH, Hardcastle JD. A classification of fistula-in-ano. Br J Surg. 1976 Jan;63(1):1-12. PubMed | Google Scholar
- Pfenninger JL, Zainea GG. Common anorectal conditions: Part II. Lesions. Am Fam Physician. 2001 Jul 1;64(1):77-88. PubMed | Google Scholar
- Butt UI, Bhatti S, Wadood A, Rehman UA, Changazi SH, Malik K et al. A case report of pneumo-retro-peritoneum: An unusual presentation of ischio-rectal abscess. Ann Med Surg (Lond). 2017 Jun 26;20:66-68. PubMed | Google Scholar
- Weizberg M, Gillett BP, Sinert RH. Penile discharge as a presentation of perirectal abscess. J Emerg Med. 2008 Jan;34(1):45-7. PubMed | Google Scholar
- Rodríguez López N, Paulos Gómez AM, Lesquereux Martínez L, Bustamante Montalvo M. Isquiorectal abscess with intra and preperitoneal dissemination. Cir Esp. 2017 May;95(5):295. PubMed
- Coffin A, Boulay-Coletta I, Sebbag-Sfez D, Zins M. Radio anatomie du rétro-péritoine. J Radiol Diagn Interv. 2015;96(1):44-59. Google Scholar
- Mindell HJ, Mastromatteo JF, Dickey KW, Sturtevant NV, Shuman WP, Oliver CL et al. Anatomic communications between the three retroperitoneal spaces: determination by CT-guided injections of contrast material in cadavers. AJR Am J Roentgenol. 1995 May;164(5):1173-8. PubMed | Google Scholar
- Gore RM, Balfe DM, Aizenstein RI, Silverman PM. The great escape: interfascial decompression planes of the retroperitoneum. AJR Am J Roentgenol. 2000 Aug;175(2):363-70. PubMed | Google Scholar
- Tirkes T, Sandrasegaran K, Patel AA, Hollar MA, Tejada JG, Tann M et al. Peritoneal and retroperitoneal anatomy and its relevance for cross-sectional imaging. Radiographics. 2012 Mar-Apr;32(2):437-51. PubMed | Google Scholar