Anorectal abscesses

1. Anorectal abscess
By
Vivek Ghosh
Intern
Dept. of General Surgery, GMCTH
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2. Presentation outline
• Case presentation
• Introduction & Etiology
• Classification
• Clinical features
• Investigations
• Treatment
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3. Case
• 28 yrs./Male with swelling in the right buttock for 8 days, which
gradually increased in size
• Pain over the area, throbbing type, continous, non-radiating,
associated with local rise of temperature
• No h/o local trauma, discharge from the swelling
• No h/o fever or vomiting
• Past History: No h/o similar episodes in the past
No known h/o any chronic illness till date
On Examination:
GC: fair
Vitals: Stable
Systemic Examination: Normal
Local examination:
Swelling about 3x2 cm. in size on right buttock, lateral to anal opening
Local temperature raized
Tenderness +
Erythematous
Induration +
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4. Case(contd…)
• Investigations: Blood parameters all within
normal limits
Serology: negative
• Provisional Diagnosis: Perianal abscess (Rt)
• Treatment: Incision & Drainage under IVA
• Operative findings: Ischiorectal abscess-
about 10 ml of pus was drained
• Final diagnosis: Ischiorectal abscess(Rt)
• Patient discharged on 2nd POD
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5. Anorectal abscess
• Acute anorectal suppuration
• Etiology:
 Cryptoglandular (95%)
 Infection : E.coli(60%) , Staph., Strep. , Bacteroides
 Irritation : Crohn’s disease, ulcerative colitis, FB
 Immune compromised state : DM,AIDS,malignancy
 Others : TB, STDs, Radiation therapy,
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6. Classification
1. Perianal (60%)
2. Ischiorectal (30%):
extension laterally
through the external
sphincter
3. Submucous(5%)
4. Pelvirectal : situated
between the upper
surface of the levator ani
and the pelvic
peritoneum
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7. Epidemiology
• Peak incidence: 3rd and 4th decades of life
• Men are affected more frequently than
women are, with a male-to-female
predominance of 2:1 to 3:1
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8. Clinical features
• Perianal discomfort/ pain- throbbing/ aching
• exacerbated by movement and increased
perineal pressure from sitting or defecation
• Perianal swelling
• Perianal abscess usu. presents early(2-3 days)
whereas ischiorectal abscess usu. presents later
• Ischiorectal abscess often presents with high
grade fever with chills and rigor
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9. On examination
• Perianal swelling: Tender, erythematous,
fluctuant, warm
• DRE: a fluctuant, indurated mass may be
encountered
• Fluctuation may not be present in ischiorectal
abscess (late feature)
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10. Investigations
• Clinical diagnosis
• Investigations relevant to specific causes
• When abscess is not obviously apparent but a
high degree of clinical suspicion exists
Ultrasound, CT scan and MRI may be helpful
• Pus culture
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11. Treatment
• 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
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12. The gauze is removed after 24 hours, and the
patient is instructed to take sitz baths
Pus is collected and sent for culture. Hemostasis
is achieved with manual pressure, and the
wound is packed with iodophor gauze.
A cruciate incision is made over the most
fluctuant point, with excision of skin edges to
deroof the abscess
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13. Post operative
• Analgesics
• Stool softners
• Antibiotics
• follow up: 2-3 weeks for wound evaluation
and inspection for possible fistula-in-ano.
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14. • Pelvirectal abscess:
 Diagnosis and treatment of underlying pelvic
pathology
Drainage of pus through the rectum or
through posterior fornix in females
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15. Take home message
• Anorectal abscess usually produce throbbing
pain, swelling in the anal region.
• Anatomically classified as perianal, ischiorectal,
submucous and pelvirectal abscess.
• Primary modality of treatment is drainage of pus
with analgesics and appropriate antibiotics
• Underlying problem should be looked for and
adequately treated
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16. References
1. Bailey & Love’s Short Practice of Surgery, 26th Edition
2. Manipal Manual of Surgery, K.R. Shenoy et al, 4th Edition
3. SRB’s Manual of Surgery, S. Bhat M, 4th Edition
4. Beard JM, Osborn J. Anorectal Abscess. Rakel RE, Rakel DP,
Textbook of Family Medicine. 8th ed. Philadelphia, Pa:
Saunders; 2011
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