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.

1. Presentation
Topic : Anorectal abscess
Department of surgery
Swornim Gyawali
Intern GMC

2. Todays objective
• Patient complaint 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:
• 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

6. 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
Necrotic
Tissue
Perianal Crohn’s
Disease
Hidradenitis
Suppurativa
Fistula-in-Ano
Perianal Tumors
Fournier’s
Gangrene
Differential diagnosis

8. 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

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

10. Anatomy review

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

12. Classification

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 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

15. 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%.

16. 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

17. 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.

18. 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.

20. 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.

21. COMPLICATIONS
Fistula-in-Ano
Fournier’s Gangrene
Carcinoma
Death
Fecal Incontinence

22. PROGNOSIS
Drainage alone results in 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