Perianal abscess and anal fistulas are the acute and chronic manifestations of perianal infection –. It is estimated one-third of patients with. A perianal abscess is a type of anorectal abscess that is confined to the perianal space. Other causes can include inflammatory bowel diseases. The perianal area is the most frequent and the supralevator the least. If any of these particular types of abscess spreads partially circumferentially around the.
|Language:||English, Spanish, French|
|Genre:||Health & Fitness|
|Distribution:||Free* [*Registration needed]|
Buy A Simple Guide To Anal Abscess And Fistula, Diagnosis, Treatment And Related Conditions: Read Kindle Store; ›; Kindle eBooks; ›; Medical eBooks. Rectal examination digitally and by sigmoidoscopy is necessary in all cases but found on clinical examination and an intra-anal abscess requires exclusion. Pain, swelling, and fever are the hallmarks associated with an abscess. The patient with a supralevator abscess complain of gluteal pain.4 Rectal bleeding.
Anorectal abscess is a common surgical condition, although its real incidence is unknown, because only patients with most symptomatic abscesses or needing drainage visit emergency departments.
It is estimated that approximately , cases per year are diagnosed in the United States [ 1 ].
It is usually considered a condition of minor severity and one that is easy to resolve with surgical drainage. However, a small percentage of cases can present as a complicated pelvic sepsis or perineal gangrene and produce a critical infection with associated complications and high mortality [ 2 ].
This is especially true in elderly patients with comorbidities and insidious presentations that are not identified by caregivers until clinical signs of systemic infection are noted.
In this case report we present an illustrative example of an anorectal abscess with an atypical presentation that developed infection and pelvic sepsis despite initial surgical drainage.
Case Presentation A year-old female presented to the emergency department with a medical history of hypothyroidism, idiopathic pulmonary fibrosis, and 16 years of severe Alzheimer dementia with loss of memory and verbal abilities and fecal incontinence; she was dependent for all activities. She lived with her husband, who was her main caregiver, and her daughters. She had presented to the emergency department several times in the last six months because of fever of unknown origin and apparent abdominal pain on examination; she was incapable of reporting any symptoms.
She was evaluated by the medical team in the emergency department and no urinary or pulmonary pathology was identified. After 24 hours in emergency department the surgical team was consultated because of the persistence of symptoms. On examination she had abdominal pain that was difficult to evaluate because of her lack of communication. A thorough physical examination identified a tender anal lump and swelling was noted. An anal fistula plug is an elongated piece of material that is placed throughout the length of the fistula tract to fill the tract space and incorporate itself into the tissue around it.
The plug also has the advantage of not requiring division of the sphincter muscle. An endoanal advancement flap is a procedure usually reserved for complex fistulas or for patients with an increased potential risk for suffering incontinence from a traditional fistulotomy. In this procedure, the internal opening of the fistula is covered over by healthy, native tissue in an attempt to close the point of origin of the fistula.
Although the sphincter muscle is not divided in this procedure, mild to moderate incontinence has still been reported. Yet another non-sphincter dividing treatment for anal fistula is the LIFT ligation of the intersphincteric fistula tract procedure. This procedure involves division of the fistula tract in the space between the internal and external sphincter muscles.
This procedure avoids division of the sphincter muscle, but has not been performed long enough to adequately assess its success or the most appropriate cases to attempt it on. Most of the operations can be performed on an outpatient basis, but in selected cases, may require hospitalization. Consider identifying a specialist in colon and rectal surgery who will be familiar with a number of potential operations to treat the fistula.
As mentioned above, if a significant amount of sphincter musculature is involved in the fistula tract, a fistulotomy may not be recommended as the initial procedure. Your surgeon may recommend the initial placement of a draining seton.
This is often a thin piece of rubber or suture which is placed through the entire fistula tract and the ends of the seton or drain are brought together and secured, thereby forming a ring around the anus involving the fistula tract. The seton may be left in place for weeks or indefinitely in selected cases , with the purpose of providing controlled drainage, thereby allowing all the inflammation to subside and form a solid tract of scar along the fistula tract.
This is associated with minimal pain and you can still have normal bowel function with a seton in place. Once all the inflammation has resolved, and a mature tract has formed, one may consider all the various surgical options detailed above as staged procedures. The treatment should be individualized to the specific patient and incorporate factors that may increase the potential for fecal incontinence.
Pain after surgery is controlled with pain pills, fiber and bulk laxatives. Patients should plan for time at home using sitz baths and avoiding the constipation that can be associated with prescription pain medication.
Discuss with your surgeon the specific care and time away from work prior to surgery to prepare yourself for post-operative care.
Despite proper treatment and apparent complete healing, fistulas can potentially recur, with recurrence rates dependent upon the particular surgical technique utilized. Should similar symptoms arise, suggesting recurrence, it is recommended that you find a colon and rectal surgeon to manage your condition. Colon and rectal surgeons are experts in the surgical and non-surgical treatment of diseases of the colon, rectum and anus. In general, minimally immunocompromised patients can undergo standard fistulotomy, whereas patients with higher degrees of immunosuppression should undergo placement of a noncutting draining seton.
Crohn's Disease Initial management should be directed at resolving rectal inflammation. Fistulotomy is a reasonable alternative in most cases of intersphincteric or low transsphincteric fistulas.
More complex fistulas can be treated with drainage, seton placement, or flap closure based on the patient's level of continence or extent of concomitant intestinal disease. Ultimately, a temporary or permanent stoma may be indicated. Reprinted from Dis Colon Rectum ;39 12 — All rights reserved.
American Society of Colon and Rectal Surgeons. References 1. Gordon PH. Louis: Quality Medical Publishing; — Google Scholar 2. Histoanatomy of anal glands. Dis Colon Rectum ;— PubMed Google Scholar 3. Parks AG. Br Med J ;— PubMed Google Scholar 4.
Essentials of Anorectal Surgery. Philadelphia: JB Lippincott; — Google Scholar 5. Abcarian H.
Surgical management of recurrent anorectal abscess. Contemp Surg ;— Google Scholar 6. PubMed Google Scholar 7. PubMed Google Scholar 8. Catheter drainage of ischiorectal abscesses. South Med J ;— PubMed Google Scholar 9. Hanley PH. Anorectal abscess fistula. Surg Clin North Am ;— PubMed Google Scholar Read DR, Abcarian H. A prospective survey of patients with anorectal abscess. Fucini C. One stage treatment of anal abscesses and fistulas.
A clinical appraisal on the basis of two different classifications. Int J Colorectal Dis ;— Incidence of fistulas subsequent to anal abscesses. Dis Colon Rectum ; — Prospective randomized trial of drainage alone vs drainage and fistulotomy for acute perianal abscesses with proven internal opening. Treatment of anorectal abscesses with or without primary fistulectomy: results of a prospective randomized trial.
Dis Colon Rectum ; 60— Buchan R, Grace RH. Anorectal suppuration: the results of treatment and factors influencing the recurrence rate. Br J Surg ;— Recurrent anorectal abscesses. Google Scholar Anal fistula. Br J Surg ; — Mazier WP. The treatment and care of anal fistulas: a study of patients. Necrotizing soft tissue infection from rectal abscess.