S4150 EUS-Guided Drainage of a Perirectal Abscess: Expanding the Role of Endoscopic Ultrasound in Pelvic and Perirectal Infections

Introduction: Perirectal abscesses are common infections that may range from superficial to deep pelvic collections. Prompt drainage is often required to prevent complications such as fistula formation or sepsis. While surgical and percutaneous approaches are well-established treatments, they may be limited by anatomical constraints or patient comorbidities. Endoscopic ultrasound (EUS)-guided drainage has emerged as a minimally invasive alternative, offering direct visualization and precise access to deep or difficult-to-reach collections. We present a case of a rectal abscess managed successfully with EUS-guided transrectal drainage, in which interventional radiology (IR) and surgery were not an option. Case Description/Methods: A 68-year-old woman with a history of gastrointestinal stromal tumor (GIST) sigmoid colon, status post resection in the past, and recurrent diverticulitis, presented with a few weeks of worsening rectal pain and pressure and decreased stool caliber. Flexible sigmoidoscopy with EUS revealed mucosal thickening in the rectum extending into the rectosigmoid junction, without ulceration or signs of malignancy. The findings were consistent with edema, likely from extrinsic compression. A computed tomography (CT) abdomen/pelvis showed a complex fluid and gas collection between the rectum and uterus, measuring 4.6 × 3.9 × 4.4 cm, extending superiorly into a likely communicating cavity. This raised suspicion of a sigmoid-rectal fistula with surrounding inflammation. Because of prior surgeries, repeat surgery was deemed hazardous. IR did not have good access to the collection, therefore, the patient was referred for consideration for EUS-guided drainage. Flexible sigmoidoscopy with EUS was performed, and a 15 mm hot Axios stent was placed into the abscess for drainage, and a 7 Fr × 3 cm double pigtail stent was placed. Three weeks later, the stent was removed. The cavity lining appeared healthy and partially collapsed, without evidence of ongoing infection. Discussion: EUS-guided drainage is a promising minimally invasive approach for managing deep perirectal abscesses, particularly when traditional methods are deemed hazardous. With real-time imaging and Doppler capability, EUS allows for safe and effective drainage via the transrectal route. Literature supports high clinical success rates, reduced complications, and faster recovery compared to surgical drainage. While the technique requires specialized expertise and is currently limited to select centers, cases like ours highlight its growing role in managing complex pelvic infections. Watch the video: https://tinyurl.com/25ACGS4150