Surgery Case 5

CHIEF COMPLAINT

VS: BP= 120/80; PR= 85/min; RR= 18/min; T- 37.8 0 C HEENT: anicteric sclera, pink palpebral

conjunctivae HEART & LUNGS: unremarkable ABDOMEN: flat, soft, non-tender w/

normoactive bowel sounds

DRE: erhythematous, warm and tender 5x4 cm mass at the perianal region; DRE cannot be tolerated by the patient

59 y/o maleDiabetic T- 37.8 0 CErythematous, warm and tender 5x4 cm mass on the R perianal region

DRE cannot be tolerated by the patient

RECTAL CA LYMPHOGRANULOMAVENEREUM

HSV

PERIANAL ABSCESS

Perianal Pain * Aggravated by sitting done

* Prior to bowel movement

(-)

(-) (-) ✔

Palpable mass

Present

(-) Genital ulcers

(-) Genital ulcer

✔

Fever and Chills

(-)

Present

(-)

✔

Rectal Discharge

(-)

Present (-) ✔

Constipation Present

(-)

(-) ✔

Perianal abscess Patient’s Symptoms

Perianal Pain * Aggravated by sitting done

* Prior to bowel movement

✔

Palpable mass ✔

Fever and Chills ✔

Rectal Discharge ✖

Constipation

DIAGNOSIS:

M > F (3:1) peak incidence: 3rd

to 5th decade of life. The disease is more

prevalent in immunocompromised patients such Diabetics hematologic disorders inflammatory bowel

disease (IBD) HIV positive These disorders should

be considered in patients with recurrent perianal infections.

HALLMARK: Perianal pain and fever

dull perianal discomfort and pruritus

perianal pain often is exacerbated by movement and increased perineal pressure from sitting or defecation.

PE: demonstrates a small, erythematous, well-defined, fluctuant, subcutaneous mass near the anal orifice.

LABORATORY EVALUATION: elevated WBC count

DIAGNOSTIC PROCEDURES are rarely necessary unless evaluating a recurrent abscess.

A CT scan or MRI has an accuracy of 80% in determining incomplete drainage.

Early surgical drainage of the purulent collection.

Primary antibiotic therapy alone is ineffective in resolving the underlying infection and simply postpones surgical intervention.

Any delay in surgical drainage of anorectal abscesses prolongs infection, augments tissue damage, and may impair sphincter continence function, as well as promote stricture and/or fistula formation.

The ability to drain an anorectal abscess depends on patient comfort and on the location and accessibility of the abscess.

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

The patient typically will follow up with his/her physician in 2-3 weeks for wound evaluation and inspection for possible fistula-in-ano.

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