A RARE CASE OF PREPERITONEAL ABSCESS IN A NIGERIAN FEMALE: ULTRASOUND DIAGNOSIS AND PERCUTANEOUS CATHETER DRAINAGE

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A.O. Adeyinka¹ , P.T. Adenigba² , A.J. Adekanmi¹ , A.T. Adeniji-Sofoluwe¹ , B.E. Osobu² , and T.O. Oke³

1. Department of Radiology, College of Medicine University of Ibadan, Ibadan, Nigeria. 
2. Department of Radiology, University College Hospital, Ibadan, Nigeria.
3. Hepatobiliary division, Department of Medicine, University College Hospital, Ibadan

Abstract

A preperitoneal abscess is an uncommon manifestation of extraperitoneal collection. We present a case of an anterior abdominal wall preperitoneal abscess in a 30-year-old Nigerian female with abdominal pain and purulent abdominal wall discharge ten days after an initial admission for spontaneous bacterial peritonitis. This report underscores the role of ultrasound in diagnosis and follow-up and percutaneous ultrasound-guided continuous percutaneous catheter drainage and management of an extraperitoneal abscess.

Keywords: Pre-peritoneal abscess, Ultrasound-guided, Continuous drainage.

Introduction

Preperitoneal space is an uncommon site in the extraperitoneal space for an abscess to develop. Abscess in the extraperitoneal space can result from an infectious, inflammatory, traumatic, or neoplastic process^{1, 2} .

While contrast-enhanced computed tomographic examination with gastrointestinal tract contrast administration will depict excellently intraabdominal abscess in any abdominal compartment³ , ultrasonography has evolved as an ionizing radiation-free, accurate, cheap, and repeatable imaging modality in intraabdominal abscess management.³ We reported this case to emphasize the need to have a high index of suspicion for the diagnosis of preperitoneal abscess using an ultrasound scan and emphasize the benefit of ultrasound-guided percutaneous catheter drainage of the abscess using the Seldinger technique

CASE REPORT

A 30-year-old Nigerian female initially presented with progressive abdominal swelling and pain of a one month duration with associated intermittent high-grade fever and yellowness of eyes of 5 days before presentation. Abdominal pain was insidious in onset, dull, and generalized but worse at the right upper quadrant of the abdomen, non-radiating, and no aggravating or relieving factor was noted by the patient. There were associated episodes of vomiting and loose stools three days before presentation. She had scarification marks on her abdomen and visited a private hospital from where she was referred to our hospital for expert management. Past medical history was insignificant; she was not a known hypertensive, diabetic, asthmatic, or peptic ulcer patient. She was admitted and managed for spontaneous bacteria peritonitis with background chronic liver disease. She was also transfused with two units of blood due to severe anaemia (Haematocrit then was 16%). She had intravenous rocephin. metronidazole, omeprazole, ringers’ lactate, intravenous febramol, intramuscular pentazocine, and significantly improved, and she was discharged home in a stable condition. She was readmitted during her first follow-up visit at the medical outpatient clinic, ten days after being discharged from the hospital, because of a 2-day history of abdominal pain with associated purulent discharge from the anterior abdominal wall. The purulent discharge was from her supraumbilical region. There was no associated fever, vomiting, or constipation.

Clinical examination at the follow-up visit revealed a chronically ill-looking, pale, febrile (Temperature = 390C), and an anicteric young woman with tachycardia. The abdomen was full, moved with respiration but had a supraumbilical sinus draining foul-smelling purulent fluid. There was generalized abdominal tenderness and hepatomegaly. The respiratory and central nervous system examination findings were not contributory. Some laboratory tests were not done due to a lack of funds, and social workers were called in to help out. A clinical diagnosis of the intraabdominal abscess was made, she was referred to the interventional radiology unit to confirm the diagnosis and possible imageguided drainage of the suspected intra- abdominal abscess. Abdomino-pelvic ultrasound scan, however, revealed extensive low-level echo collections with internal echogenic foci in the preperitoneal layer of the abdominal wall, worse in the left quadrants, in keeping with gas-forming infection of this abdominal wall layer [Figure 1]. Furthermore, the abscess’s maximum depth (anteroposterior) was measured at 14.3 mm in the left lumbar region [Figure 1], and the collection extends inferiorly over the dome of the distended urinary bladder and the retroverted uterus. Besides, an infra umbilical herniation of small bowel loops into the transversalis fascial plane of the abdominal wall was noted in the suprapubic region. The visualized bowel loops, however, showed normal caliber and peristalsis.