Keywords
endoscopic ultrasonography guided drainage - intraperitoneal abscess cavity - perforated
peptic ulcer
Introduction
Perforated peptic ulcer (PPU) is an acute abdominal condition that usually gets complicated
by intraperitoneal abscess. Such a situation usually requires a surgical treatment.[1] Recently reported literature suggests that an application of endoscopic ultrasonography
(EUS) guided drainage is feasible for the treatment of intraperitoneal abscess adjacent
to the digestive tract.[2]
[3] EUS-guided drainage is a well-established treatment of pancreatic pseudocysts.[4] Here, we report a case in which EUS-guided drainage was successfully implemented
to drain an intraperitoneal abscess following sealed-off peptic perforation.
Case Report
A 74-year-old female presented with a 7-day history of burning epigastric pain, low-grade
fever, generalized myalgia, and anorexia. She was on nonsteroidal anti-inflammatory
drugs for osteoarthritis, which she was taking on her own. Abdominal ultrasonography
showed coagulated fluid collection, with air near the posterior part of the stomach
body. A plain computed tomography (CT) scan of the abdomen revealed multiple communicating
pockets of collection and air in the lesser sac. The patient was hospitalized for
further work-up and treatment. Her laboratory examination revealed leukocyte count
of 18,400/mm3, platelet count of 355,000 /mm3, total protein level of 5.8 mg/dL, serum albumin level of 3.4 mg/dl, prothrombin
time of 12.9 seconds, and international normalized ratio of 1.14. The patient underwent
diagnostic upper gastrointestinal (GI) endoscopy and EUS, which revealed lesser sac
abscess ([Fig. 1a]) and multiple deep peptic ulcers of the greater and lesser curvature in the stomach
([Fig. 1b]), with one large healing ulcer in the duodenum ([Fig. 1c]). Clinical diagnosis of sealed-off peptic perforation was made in view of the current
findings. There was no active perforation of any ulcer; hence, endoscopic ultrasound
was used to locate and drain the abscess. EUS-guided drainage was performed under
sedation using intravenous midazolam and fentanyl. The large lesser sac abscess cavity
was visualized using a therapeutic endoscope and punctured by a 19-gauge needle. A
guidewire was introduced through the needle and coiled within the large lesser sac
abscess ([Fig. 2a]). The punctured tract was dilated with a 6-Fr cystotome catheter using the Hurricane
balloon to allow stent placement. A 20-mm-long “Nagi” stent was inserted under combined
endoscopic and fluoroscopic guidance ([Fig. 2b]). A short-term nasocystic drainage catheter was used for lavage. At the end of the
procedure, a 7-Fr double-pigtail (DTP) stent was also kept through “Nagi” stent ([Fig. 2c]). The pus was sent for culture and sensitivity. Klebsiella pneumoniae and Streptococcus gallolyticus species were detected in the culture report. She received intravenous antibiotic
therapy of cefoperazone and sulbactam (3,000 mg/day) and proton pump inhibitors before
and after drainage. On the third day of the procedure, abdominal ultrasonography was
performed, which revealed a 23-mL residual collection in relation to fundus and 2-mL
collection in the posterior aspect of the stomach. EUS-guided single-shot drainage
was performed for retrofundic collection; the “Nagi” stent was removed, and a DPT
stent was kept in situ through the same opening. On the seventh day of admission,
the patient was discharged after removal of the DPT stent and resumed oral diet. The
patient was on clinical follow-up thereafter and oral proton pump inhibitors. On the
45th day of follow-up, GI endoscopy with EUS was performed, which revealed no evidence
of any ulcer or collection ([Fig. 3]).
Fig. 1 Endoscopic and endoscopic ultrasonography examination of ulcer and abscess on the
day of presentation. (a) Endoscopic ultrasonography showing lesser sac abscess. (b) Endoscopy showing sealed-off peptic perforation. (c) Duodenal ulcers.
Fig. 2 Endoscopic ultrasonography-guided drainage technique. (a) Guidewire placement under endoscopic ultrasonography guidance. (b) Placement of “Nagi” stent for the drainage of pus. (c) Double-pigtail stent through Nagi stent.
Fig. 3 Endoscopic examination on the 45th day, showing no evidence of any ulcer or perforation.
Discussion
The therapeutic value of EUS-guided drainage was first recognized in 1992 for the
treatment of pancreatic pseudocyst.[4] Currently, EUS-guided drainage usage for an intraperitoneal abscess resulting from
PPU is still in inception. The literature search revealed only one published case
report, which revealed EUS-guided fine-needle aspiration for the treatment of complication
of PPU.[3] This case report demonstrates our experience of treating intraperitoneal abscess
resulting from PPU with EUS-guided drainage.
Usually, an intraperitoneal abscess formed after PPU is treated by surgery/laparoscopy
with lavage and drainage along with suture repair of perforation.[1] The surgical treatment does carry morbidity.[1]
[3] In this case, the collection was situated only in lesser sac without contaminating
the greater sac. Hence, therapeutic treatment with the help of EUS was decided as
a modality. The abscess was then treated successfully with EUS-guided drainage. In
addition, a complete general anesthesia was also avoided in this patient. Surgical
complications can be minimized when elderly patients are treated with the lesser invasive
method of EUS-guided drainage whenever feasible. The procedure’s safety and efficacy
need to be confirmed by larger clinical trials.
Conclusion
EUS-guided drainage is a lesser invasive and useful technique in the treatment of
intraperitoneal (lesser sac) abscess cavity formed after PPU. In future, the indications
for EUS-guided drainage will be established by the accumulation of further clinical
experience.
