Journal Club Case Presentation

By: Areeb Siddiquie

SubjectiveA 35-year old male presents to the clinic complaining of anal pain. Patient states that 4 days ago he first felt a slightly tender pimple-like mass at the anus which has progressively gotten extremely painful and much larger in size. Pain is 8/10 and throbbing in nature. He complains that the pain prevents him from having any BM’s or being able to sit. He denies fever, N/V, abdominal pain, blood in stool, or history of trauma.

PMH is significant for DM II.

Vitals within normal rangePhysical examination shows a firm erythematous

mass near the anal orifice which is extremely tender to palpation (consistent with dx of abscess).

Diagnosis is primarily clinical; imaging studies are not necessary except in recurrent or complex cases:Pelvic CT is best to locate abscess if there is

suspicion based on history but negative findings on physical exam

Transrectal US best to evaluate depth or extent of abscess

MRI best for deep or extensive fistulas

Objective

Assessment/PlanAnorectal Abscess:

Perianal: Around the opening of the anus (most common; but usually an extension of a deeper abscess)

R/o: Perirectal (aka supralevator), ischiorectal, or intersphincteric abscesses extending to superficial skin

Treatment: Surgical I&DAntibiotic therapy has not been shown

to decrease healing time or reduce recurrence, therefore is not primary therapy

Surgical InterventionSurgical drainage under general anesthesia

in the OR is almost always required to evaluate the extent of the abscess and to find and treat any fistulasSuperficial perianal abscess seen in the clinic may

be the tip of a deeper perirectal or ischiorectal abscess

Delay in surgical intervention can lead to stricture formation which impairs anal continence, or systemic infection and death

Diabetics are especially prone to necrotizing anorectal infections if not treated in the OR immediately

Anorectal Abscesses: Classified by Location

Anorectal AbscessesUsually occur due to obstruction of

crypts/glands at the dentate line with fecal matter , edema from trauma, or foreign body

MC in middle aged malesDM, HIV, Crohn’s , and STDs are

predisposing conditionsSigns and symptoms may also include

pelvic pain, constipation, urinary retention, and fever

Surgical Technique1. Incision and pus collection for culture2. Blunt disruption of all loculations (with fingers)3. Irrigation of cavity4. Determine extent of abscess and look for fistula• Treatment of fistula depends on it’s tract and how much

sphincter muscle it penetrates or passes through5. Intersphincteric abscess is treated with internal

sphincterotomy which also destroys the crypt6. Perirectal and Ischiorectal abscesses are drained with a

cathether or a large excision to prevent premature skin closure and reaccmuluation of abscess (catheter preferred over large incision b/c less invasive to sensitive rectal skin and no surgical packing required)

Surgical Technique 1. If a superficial fistula tract identified, fistulotomy is performed

Incision of tract, ablation of gland (to eliminate source of obstruction), and saucerization of skin (opening at the exit)

2. If a high fistula or a deep tract penetrating the external sphincter or more is identified (determined by probing through internal opening) treat with:

Collagen fistula plug or Fibrin glue (best initial option because no risk of sphincter damage, but higher recurrence rates)

Core fistulectomy with mucosal advancement flap (in very complex rectal fistulas: allows small opening to drain and then covers w/ flap)

Seton stitch: Staged fistulotomy (since actual incision is difficult in deep penetrating fistulas)

Tight: Cuts through fistula over time: high rate of damage to sphincters Loose: Slow fibrosis, prevents sphincter muslces from being damaged, and

allows long term drainage (takes too long to treat)

Post OpAdvise patient to perform daily sitz bath (shown to

speed up healing)Antibiotics based on cultures, usually as

prophylaxis to prevent spread of infection, but not shown to prevent recurrenceMost commonly staph aureus, E.coli, and Bacteroides

Pain managementFollow up to check for recurrence and look for

fistula if it was not found during the procedureInternal opening of fistula is difficult to find during

procedure due to active inflammation and pus hence wound should always be left open to prevent recurrence and allow follow up evaluation of fistula

ReferenceAccessMedicine, Essentials of General

Surgery: anorectal disease: http://www.accessmedicine.com/content.aspx?aID=5310081&searchStr=anorectal+abscess

Medscape Perianal abscess and fistula treatment: http://emedicine.medscape.com/article/191975-treatment#a1132