Presentation Topic : Anorectal abscess

Department of surgerySwornim Gyawali

Intern GMC

Todays objective

• Patient complaint and clinical finding • Differential diagnosis • Workup • Ano-rectal anatomy review• Topic discussion • Management

Patient complaints of :• dull perianal discomfort and pruritus

• exacerbated by movement and increased perineal pressure from sitting or defecation

• present with swelling around the rectum

• perirectal drainage that may be bloody, purulent, or mucoid

( note: ischiorectal abscess often present with systemic fevers, chills, and severe perirectal pain)

On examination:

• normal vital signs on initial evaluation

• Physical examination: a small, erythematous, well-defined, fluctuant, subcutaneous mass near the anal orifice

• DRE: a fluctuant, indurated mass may be encountered

Likely Diagnosis of Anorectal Pain

Pain Alone Pain and Lump Pain and Bleeding Pain with Lump and Bleeding

• Anal Fissure• Anusitis• Ulcerative Proctitis• Proctalgia Fugax

• Perianal Hematoma• Strangulated Internal Hemorrhoid• Abscess• Pilonidal Sinus

• Anal Fissure• Proctitis

• Hemorrhoids• Ulcerated Perianal Hematoma

Pain, bleeding, with/without Pus Draining

Pain with Lump, Pus Draining, with/without Bleeding

Pain with Lump, Pus Draining, and Bleeding

Pain with Lump, Pus Draining, Bleeding, and NecroticTissue

Perianal Crohn’s Disease

Hidradenitis Suppurativa

Fistula-in-AnoPerianal Tumors

Fournier’s Gangrene

Differential diagnosis

Workup/Investigations :

• CBC with differential : may show leukocytosis• Pus cultures• Blood cultures • confirmation by means of anal

ultrasonography, CT or MRI• Plain x-rays little clinical significance

Anorectal Abscess infection arising in the cryptoglandular epithelium lining the anal canal

Anatomy review

Types /classification1. Perianal (60%) :of suppuration in an anal

gland2. Ischorectal (30%): extension laterally through

the external sphincter3. Submucous4. Pelvirectal : situated between the upper

surface of the levator ani and the pelvic penitoneum

5. Fissure abscess

Classification

Etiology

• Non specific :Cryptoglandular in origin.

• Specific : 1. Infection : E.coli , Staph. , strep. , Bacteroids2. Irritation : Crohn’s disease, ulcerative colitis, FB3. Immune compromised state : DM,AIDS,malignancy4. Others : TB, STDs, Radiation therapy,

PATHOPHYSIOLOGY

Originates from an infection arising in the crypto glandular epithelium lining the anal canal

The internal anal sphincter normally serves as a barrier to infection passing from the gut lumen to the deep perirectal tissues.

This barrier can be breached through the crypts of Morgagni, which can penetrate through the internal sphincter into the intersphincteric space

PATHOPHYSIOLOGY

Once infection gains access to the intersphincteric space, it has easy access to the adjacent perirectal spaces

Extension of the infection can involve the intersphincteric space 2–5%, ischiorectal space 20-25% , or even the supralevator space 2.5%.

Epidemology

• May resolve itself • third and fourth decades of life• quite common in infants too• Men are affected more frequently than

women 2:1 – 3:1• relation between the formation of ano-rectal

abscesses and bowel habits

Management • Early surgical drainage of the purulent

collection• Primary antibiotic therapy alone is ineffective• Any delay : augments tissue damage, may

impair sphincter continence function, promote stricture and/or fistula formation

• Ability to drain an anorectal abscess depends on patient comfort and on the location and accessibility of abscess.

Drainage of perianal or superficial abscesses

The gauze is removed after 24 hours, and the patient is instructed to take sitz baths 3 times a day and after bowel movements.

Pus is collected and sent for culture. Hemostasis is achieved with manual pressure, and the wound is packed with iodophor gauze.

A small cruciate incision is made over the area of fluctuancy in close proximity to the anal verge.

Post operative

• analgesics and stool softeners are prescribed to relieve pain and prevent constipation.

• Antibiotic therapy when indicated– to cover aerobes and anaerobes e.g. ciprofloxacin 500 mg PO 2x daily for 5 days

• follow up: 2-3 weeks for wound evaluation and inspection for possible fistula-in-ano.

COMPLICATIONS

Fistula-in-AnoFournier’s Gangrene

CarcinomaDeath

Fecal Incontinence

PROGNOSIS

Drainage alone results in cure for50%.

50% will have recurrences and develop an anal fistula.

Thank you !!!

• Refrences Bailey & Love's Short Practice of Surgery 25th

edition Manipal manual of surgery 3rd editionSRB’s manual of surgery 4th edition