EUS-Guided Drainage of Pelvic Abscess Shyam Varadarajulu, MD Pelvic abscesses are most commonly encountered in the setting of postoperative compli- cations. Traditionally, these were drained by surgery or under radiological guidance. Although limited, there is growing evidence that under the guidance of endoscopic ultra- sound pelvic abscesses can be drained with successful outcomes. This review describes the technical details and outcomes associated with this procedure. Tech Gastrointest Endosc 9:51-54 © 2007 Elsevier Inc. All rights reserved. KEYWORDS endoscopic ultrasound, pelvic abscess, drainage D evelopment of pelvic abscess is a well-recognized post- operative complication in patients undergoing low an- terior resection for rectal cancer or following obstetrical sur- gery. 1 Rupture of pelvic abscess is a life-threatening emergency, and every attempt should be made to avoid this complication. Traditionally, these abscesses are drained via the percutaneous, transrectal, or transvaginal route under ultrasound or computed tomogram (CT)-guidance with suc- cessful outcomes. 1-4 The transvaginal route is ideally suited to drain pelvic abscesses because of the proximity of the vaginal fornices to the pelvic fluid collections. However, the trans- vaginal route has the disadvantage of being only semisterile. Hence, due to the risk of introducing infection into a previ- ously sterile region, the transvaginal approach is generally used only for biopsy of solid lesions or for draining cystic lesions that can be completely aspirated. In a recent study, the feasibility of ultrasound-guided transrectal aspiration of pelvic abscesses was assessed in 15 women in whom intrave- nous antibiotic therapy had failed and whose abscesses were not suitable for colpotomy drainage or transabdominal or transvaginal ultrasound-guided aspiration. 4 Purulent mate- rial was aspirated from the abscesses in 14 of the 15 women. These 14 women were successfully treated with real-time ultrasound-guided transrectal drainage, and only 4 required placement of an indwelling catheter. This report generated interest that led to the evolution of EUS-guided drainage of pelvic abscesses. This review details the technical aspects and outcomes of endoscopic ultrasound (EUS) in the management of patients with pelvic abscesses. Instruments and Materials A clear understanding of the anatomy of the pelvis and the location of the abscess is important before proceeding with pelvic drainage. In all patients, a dedicated pelvic MRI or CT imaging should be initially performed to ascertain their un- derlying nature and confirm that these abscesses cannot be drained by well-proven alternate techniques. The most com- mon reason to undergo EUS-guided drainage is due to the lack of an adequate window to drain the lesion percutane- ously or if the patient is a high-risk candidate for surgical drainage. Patients should be administered prophylactic anti- biotics (amoxicillin plus clavulinic acid, 2 g) before the inter- vention and continued on oral antibiotics for 4 to 5 days. A preparation in the form of an enema and/or polyethylene glycol is mandatory to minimize the chances of contamina- tion and for adequate visualization. Also, the procedure is best performed in a unit with fluoroscopy set up to enable Division of Gastroenterology-Hepatology, University of Alabama at Birming- ham School of Medicine, Birmingham, AL. Address reprint requests to Shyam Varadarajulu, MD, Division of Gastroen- terology-Hepatology, University of Alabama at Birmingham Medical Center, 410 LHRB, 1530 3rd Ave S, Birmingham, AL 35294. E-mail: svaradarajulu@yahoo.com Figure 1 CT of the pelvis revealing an 8-  7-cm abscess cavity. 51 1096-2883/07/$-see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.tgie.2006.11.016