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Anorectal abscess
This presentation discusses the diagnosis and management of anorectal abscesses. Key points include: - Anorectal abscesses typically present with perianal pain, swelling, and drainage and are usually caused by a cryptoglandular infection. - Differential diagnoses depend on associated symptoms and may include hemorrhoids, fistulas, or Crohn's disease. - Evaluation involves examination, blood tests, and imaging studies. - Treatment is early surgical drainage of the abscess to prevent complications like fistula formation or impairment of sphincter function. Postoperative care involves antibiotics, pain relief, and follow-up to monitor for healing or complications.
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Anorectal abscess
- 1. Presentation Topic : Anorectalabscess Department of surgery Swornim Gyawali Intern GMC
- 2. Todays objective • Patientcomplaint and clinical finding • Differential diagnosis • Workup • Ano-rectal anatomy review • Topic discussion • Management
- 3. 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)
- 4. On examination: • normalvital 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
- 6. Likely Diagnosis ofAnorectal 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 Necrotic Tissue Perianal Crohn’s Disease Hidradenitis Suppurativa Fistula-in-Ano Perianal Tumors Fournier’s Gangrene Differential diagnosis
- 8. Workup/Investigations : • CBCwith differential : may show leukocytosis • Pus cultures • Blood cultures • confirmation by means of anal ultrasonography, CT or MRI • Plain x-rays little clinical significance
- 9. Anorectal Abscess infection arisingin the cryptoglandular epithelium lining the anal canal
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- 11. Types /classification 1. Perianal(60%) :of suppuration in an anal gland 2. Ischorectal (30%): extension laterally through the external sphincter 3. Submucous 4. Pelvirectal : situated between the upper surface of the levator ani and the pelvic penitoneum 5. Fissure abscess
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- 13. Etiology • Non specific:Cryptoglandular in origin. • Specific : 1. Infection : E.coli , Staph. , strep. , Bacteroids 2. Irritation : Crohn’s disease, ulcerative colitis, FB 3. Immune compromised state : DM,AIDS,malignancy 4. Others : TB, STDs, Radiation therapy,
- 14. PATHOPHYSIOLOGY Originates from aninfection 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
- 15. PATHOPHYSIOLOGY Once infection gainsaccess 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%.
- 16. Epidemology • May resolveitself • 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
- 17. Management • Early surgicaldrainage 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.
- 18. Drainage of perianalor 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.
- 20. Post operative • analgesicsand 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.
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- 22. PROGNOSIS Drainage alone resultsin cure for 50%. 50% will have recurrences and develop an anal fistula.
- 23. Thank you !!! •Refrences Bailey & Love's Short Practice of Surgery 25th edition Manipal manual of surgery 3rd edition SRB’s manual of surgery 4th edition