CASE REPORT CASE REPORT

24         SA JOURNAL OF RADIOLOGY • March 2007

Although there are a number of reports of successful drainage of deep 

pelvic collections using transrectal, transvaginal, transgluteal and other 

routes,1,2 some collections remain difficult to access.

An elderly female patient with renal failure presented with features 

of sepsis following a partial sigmoid colectomy for diverticular disease, 

with a left iliac fossa colostomy in place. A left pelvic sidewall collection 

was demonstrated by CT scanning (Fig. 1), but was not felt to be acces-

sible by the usual routes. A standard lower abdominal or pelvic approach 

was not possible because of overlying loops of bowel. The collection was 

too high and small for transgluteal or anterolateral approaches, added 

to which, the left iliac fossa colostomy further limited any approaches. 

Following a suggestion by one of the authors (PG), an attempt was 

made to drain the collection under fluoroscopy, using a transcolonic 

access route.

The patient was sedated and laid left side down in a left decubitus 

position, and the catheter was introduced per rectum with the aid 

of lubricating gel and a guiding finger. An initial attempted passage 

through the rectosigmoid with a headhunter catheter and hydrophilic 

guidewire was complicated by the somewhat tortuous sigmoid colon 

and the residual diverticulae. The catheter was very inclined to enter the 

diverticulae and stretch them, but by retraction and rotation, the main 

lumen could be re-entered. Some diverticulae were noted to contain 

concretions, presumably faecoliths. Gentle rotation, supplemented by 

intermittent contrast injections, hydrophilic guidewires and cobra cath-

eters eventually allowed entry into the pelvic sidewall collection (Fig. 2), 

presumably through a previously perforated diverticulum that may have 

led to the abscess in the first place. Using an exchange wire, a standard 

8F locking pigtail catheter was placed in the collection, with withdrawal 

of approximately 200 ml of pus. The hub of the catheter was secured in 

the gluteal cleft, and the patient’s features of sepsis improved over subse-

quent days. The catheter appeared well tolerated by the patient.

After a few weeks, the pigtail was accidentally dislodged. This was 

replaced with a longer internal-external drainage catheter which was 

again retained by locking the pigtail. Again purulent material was 

obtained from the collection, with clinical improvement.

This technique provides an alternative method for draining deep 

pelvic sidewall collections, but is probably only applicable where there is 

a breach in the colonic wall, as when the source of sepsis is the sigmoid 

colon, or the sepsis erodes into the colon.

1.  Loren I, Lasson A, Lundagards J, Nilsson A, Nilsson PE. Transrectal catheter drainage of deep abdominal 

and pelvic abscesses using combined ultrasonography and fluoroscopy. Eur J Surg 2001; 167: 535-539.

2. Gupta S, Madoff DC, Ahrar K, et al. CT-guided needle biopsy of deep pelvic lesions by extraperitoneal 

approach through iliopsoas muscle. Cardiovasc Intervent Radiol 2003; 26: 534-538.

Transcolonic pelvic abscess drainage  

S Beningfield, MB ChB, FFRad (D)

Department of Radiology, University of Cape Town

P Goldberg, MB ChB, FCS (SA), MMed

Division of Surgery, Groote Schuur Hospital, Cape Town

Figs. 1. CT scan showing the pelvic sidewall collection containing gas 
(arrow). Note left colostomy site (open arrow) blocking anterolateral 
access.

Fig. 2 a and b. Fluoroscopic image (a) during catheter (black arrow) 
manipulation showing pelvic sidewall collection (open arrow) apparently 
arising from diverticulum (white arrow) and (b) after placement of the 
drainage catheter (arrow).

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