85 year old man presented at the ER with progressive deterioration of general health,inability to walk in the past few months, mostly confined to bed in last few weeks. He has severe lower back pain, no radiation to the leg. He was incontinent of stools at presentation. He vomited once prior to presentation, has no appetite
Surgical history:
2011 : Diagnosed of prostate cancer and put on hormonal therapy
2012 : Diagnosed of rectal carcinoma T2N0M0 low anterior resection + radiotherapy
Examination :
T36.1, sat 99%, BP 125/75, HR 65/min
Not acutely ill. pale, low skin turgor.
Heart: S1S2 regular, no murmur.
Pulm: mild expiratory rhonchi on the left.
Abdomen: reduced peristalsis,mass, renal angles normal
Extremities: no edema, no arterial pulsations at the feet. Painful swelling of the right knee
Digital rectal examination :perianal mucous discharge . Absent anal sphincter tone, enlarged hard prostate.
Investigations :
Hemoglobine 7.2g/dl MCV 84 fL; MCH 1.7 fmol; MCHC 20.2 mmol/l; Leukocyten 9.1 x10^9/L; platelet 595 x10^9/L;
Na 136 mmol/l; K 4.0 mmol/l; Urea 7.9 mmol/l; Creatinine 83 µmol/L; GFR 76 ml/min; Calcium 2.48 mmol/l; Alkphos 118 U/l; ASAT 22 U/l; CK 39 U/l; Albumin 28 g/l
Glucose 8.6 mmol/l;
CRP 120 mg/l;
TSH 3.87 mU/l;
Urine sediment: some leukocytes.
X-ray of chest : normal.
X-ray of thorax and lumbar spine: normal.
X-ray of pelvis: normal.
Differential diagnosis:
- Cancer of the prostate with spinal metastasis
- Cord compression
- Pelvic abscess
MRI spine: Presacral abscess, with vertebral involvement.
Abdominal CT-scan: Large horseshoe shaped presacral abscess,and posterior to site of previous bowel anastomosis
Diagnosis : Presacral abcess
Treatment plan : Laparotomy to drain abscess plus faecal diversion if necessary if coexisting with colonic perforation. Preoperative assessment concluded that patient was unfit for surgery
Credits : Notes kindly offered by Dr Lotte, Holland.
