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Man With History of Multiple Abscesses
IMAGES IN EMERGENCY MEDICINE Daniel Joseph, MD; Kristin Berona, MD; Tarina Kang, MD 0196-0644/$-see front matter Copyright © 2015 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2014.10.015
Figure 3. Sagittal CT image showing the posterolateral right perianal fistula (arrow).
Figure 1. External tract of the spontaneously draining wound.
Figure 4. Axial CT image showing the fistula extending posterolaterally and interiorly from the anal canal to the inferomedial right buttock (arrow). Figure 2. Ultrasonographic image showing the tract (arrow) adjacent to the rectum.
[Ann Emerg Med. 2015;66:239.] A 35-year-old man with a history of multiple abscesses presented to the emergency department with a painful mass to his right buttock. Physical examination revealed multiple wounds to his gluteus that were draining pus (Figure 1). Given the spontaneous drainage, conservative management was initially elected; however, the patient complained of rectal pain, so point-of-care ultrasonography was performed (Figure 2). Deep tracts were visualized, so a follow-up computed tomography (CT) scan (Figures 3 and 4) was performed and surgery was consulted. For further discussion on this case, see page 240. For the diagnosis and teaching points, see page 242. To view the entire collection of Images in Emergency Medicine, visit www.annemergmed.com Volume 66, no. 3 : September 2015
Annals of Emergency Medicine 239
EM:RAP Commentary in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org).The authors have stated that no such relationships exist and provided the following details: Dr. Jhun reports other from Hippo Education, Inc., outside of the submitted work. Dr. Aguilera reports other from EM:RAP, outside of the submitted work. Dr. Bright reports other from Hippo Education, Inc., outside of the submitted work. Dr. Herbert reports other from EM:RAP and Hippo Education, Inc., outside of the submitted work. REFERENCES 1. Joseph D, Berona K, Kang T. Man With History of Multiple Abscesses. Ann Emerg Med. 2015;66:239. 2. Coates W. Disorders of the anorectum. In: Marx JA, Hockberger R, Walls R, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 8th ed. Philadelphia, PA: Elsevier Saunders; 2013; p. 1276-1289. 3. Steele SR, Kumar R, Feingold DL, et al; Standards Practice Task Force of the American Society of Colon and Rectal Surgeons. Practice parameters for the management of perianal abscess and fistula-inano. Dis Colon Rectum. 2011;54:1465-1474.
242 Annals of Emergency Medicine
Jhun et al 4. Abcarian H. Anorectal infection: abscess-fistula. Clin Colon Rectal Surg. 2011;24:14-21. 5. Poggio JL. Fistula-in-Ano. eMedicine. Available at: http://emedicine. medscape.com/article/190234-overview#showall. Published September 9, 2013. Accessed July 15, 2015. 6. Tabry H, Farrands PA. Update on anal fistulae: surgical perspectives for the gastroenterologist. Can J Gastroenterol. 2011;25:675-680. 7. Schwartz DA, Loftus EV Jr, Tremaine WJ, et al. The natural history of fistulizing Crohn’s disease in Olmsted County, Minnesota. Gastroenterology. 2002;122:875-880. 8. Holtzman LC, Hitti E, Harrow J. Incision and drainage. In: Roberts J, ed. Roberts and Hedges’ Clinical Procedures of Emergency Medicine. 6th ed. Philadelphia, PA: Elsevier Saunders; 2013. 9. Wedemeyer J, Kirchhoff T, Sellge G, et al. Transcutaneous perianal sonography: a sensitive method for the detection of perianal inflammatory lesions in Crohn’s disease. World J Gastroenterol. 2004;10:2859-2863. 10. Maconi G, Tonolini M, Monteleone M, et al. Transperineal perineal ultrasound versus magnetic resonance imaging in the assessment of perianal Crohn’s disease. Inflamm Bowel Dis. 2013;19: 2737-2743.
Volume 66, no. 3 : September 2015
Figure 3. Sagittal CT image showing the posterolateral right perianal fistula (arrow).
Figure 1. External tract of the spontaneously draining wound.
Figure 4. Axial CT image showing the fistula extending posterolaterally and interiorly from the anal canal to the inferomedial right buttock (arrow). Figure 2. Ultrasonographic image showing the tract (arrow) adjacent to the rectum.
[Ann Emerg Med. 2015;66:239.] A 35-year-old man with a history of multiple abscesses presented to the emergency department with a painful mass to his right buttock. Physical examination revealed multiple wounds to his gluteus that were draining pus (Figure 1). Given the spontaneous drainage, conservative management was initially elected; however, the patient complained of rectal pain, so point-of-care ultrasonography was performed (Figure 2). Deep tracts were visualized, so a follow-up computed tomography (CT) scan (Figures 3 and 4) was performed and surgery was consulted. For further discussion on this case, see page 240. For the diagnosis and teaching points, see page 242. To view the entire collection of Images in Emergency Medicine, visit www.annemergmed.com Volume 66, no. 3 : September 2015
Annals of Emergency Medicine 239
EM:RAP Commentary in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org).The authors have stated that no such relationships exist and provided the following details: Dr. Jhun reports other from Hippo Education, Inc., outside of the submitted work. Dr. Aguilera reports other from EM:RAP, outside of the submitted work. Dr. Bright reports other from Hippo Education, Inc., outside of the submitted work. Dr. Herbert reports other from EM:RAP and Hippo Education, Inc., outside of the submitted work. REFERENCES 1. Joseph D, Berona K, Kang T. Man With History of Multiple Abscesses. Ann Emerg Med. 2015;66:239. 2. Coates W. Disorders of the anorectum. In: Marx JA, Hockberger R, Walls R, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 8th ed. Philadelphia, PA: Elsevier Saunders; 2013; p. 1276-1289. 3. Steele SR, Kumar R, Feingold DL, et al; Standards Practice Task Force of the American Society of Colon and Rectal Surgeons. Practice parameters for the management of perianal abscess and fistula-inano. Dis Colon Rectum. 2011;54:1465-1474.
242 Annals of Emergency Medicine
Jhun et al 4. Abcarian H. Anorectal infection: abscess-fistula. Clin Colon Rectal Surg. 2011;24:14-21. 5. Poggio JL. Fistula-in-Ano. eMedicine. Available at: http://emedicine. medscape.com/article/190234-overview#showall. Published September 9, 2013. Accessed July 15, 2015. 6. Tabry H, Farrands PA. Update on anal fistulae: surgical perspectives for the gastroenterologist. Can J Gastroenterol. 2011;25:675-680. 7. Schwartz DA, Loftus EV Jr, Tremaine WJ, et al. The natural history of fistulizing Crohn’s disease in Olmsted County, Minnesota. Gastroenterology. 2002;122:875-880. 8. Holtzman LC, Hitti E, Harrow J. Incision and drainage. In: Roberts J, ed. Roberts and Hedges’ Clinical Procedures of Emergency Medicine. 6th ed. Philadelphia, PA: Elsevier Saunders; 2013. 9. Wedemeyer J, Kirchhoff T, Sellge G, et al. Transcutaneous perianal sonography: a sensitive method for the detection of perianal inflammatory lesions in Crohn’s disease. World J Gastroenterol. 2004;10:2859-2863. 10. Maconi G, Tonolini M, Monteleone M, et al. Transperineal perineal ultrasound versus magnetic resonance imaging in the assessment of perianal Crohn’s disease. Inflamm Bowel Dis. 2013;19: 2737-2743.
Volume 66, no. 3 : September 2015