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Journal Club Case Presentation

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1 Journal Club Case Presentation
By: Areeb Siddiquie

2 Subjective A 35-year old male presents to the clinic complaining of anal pain. Patient states that 4 days ago he first felt a slightly tender pimple-like mass at the anus which has progressively gotten extremely painful and much larger in size. Pain is 8/10 and throbbing in nature. He complains that the pain prevents him from having any BM’s or being able to sit. He denies fever, N/V, abdominal pain, blood in stool, or history of trauma. PMH is significant for DM II.

3 Objective Vitals within normal range
Physical examination shows a firm erythematous mass near the anal orifice which is extremely tender to palpation (consistent with dx of abscess). Diagnosis is primarily clinical; imaging studies are not necessary except in recurrent or complex cases: Pelvic CT is best to locate abscess if there is suspicion based on history but negative findings on physical exam Transrectal US best to evaluate depth or extent of abscess MRI best for deep or extensive fistulas

4 Assessment/Plan Anorectal Abscess:
Perianal: Around the opening of the anus (most common; but usually an extension of a deeper abscess) R/o: Perirectal (aka supralevator), ischiorectal, or intersphincteric abscesses extending to superficial skin Treatment: Surgical I&D Antibiotic therapy has not been shown to decrease healing time or reduce recurrence, therefore is not primary therapy

5 Surgical Intervention
Surgical drainage under general anesthesia in the OR is almost always required to evaluate the extent of the abscess and to find and treat any fistulas Superficial perianal abscess seen in the clinic may be the tip of a deeper perirectal or ischiorectal abscess Delay in surgical intervention can lead to stricture formation which impairs anal continence, or systemic infection and death Diabetics are especially prone to necrotizing anorectal infections if not treated in the OR immediately

6 Anorectal Abscesses: Classified by Location

7 Anorectal Abscesses Usually occur due to obstruction of crypts/glands at the dentate line with fecal matter , edema from trauma, or foreign body MC in middle aged males DM, HIV, Crohn’s , and STDs are predisposing conditions Signs and symptoms may also include pelvic pain, constipation, urinary retention, and fever


9 Surgical Technique Incision and pus collection for culture
Blunt disruption of all loculations (with fingers) Irrigation of cavity Determine extent of abscess and look for fistula Treatment of fistula depends on it’s tract and how much sphincter muscle it penetrates or passes through Intersphincteric abscess is treated with internal sphincterotomy which also destroys the crypt Perirectal and Ischiorectal abscesses are drained with a cathether or a large excision to prevent premature skin closure and reaccmuluation of abscess (catheter preferred over large incision b/c less invasive to sensitive rectal skin and no surgical packing required)

10 Surgical Technique If a superficial fistula tract identified, fistulotomy is performed Incision of tract, ablation of gland (to eliminate source of obstruction), and saucerization of skin (opening at the exit) If a high fistula or a deep tract penetrating the external sphincter or more is identified (determined by probing through internal opening) treat with: Collagen fistula plug or Fibrin glue (best initial option because no risk of sphincter damage, but higher recurrence rates) Core fistulectomy with mucosal advancement flap (in very complex rectal fistulas: allows small opening to drain and then covers w/ flap) Seton stitch: Staged fistulotomy (since actual incision is difficult in deep penetrating fistulas) Tight: Cuts through fistula over time: high rate of damage to sphincters Loose: Slow fibrosis, prevents sphincter muslces from being damaged, and allows long term drainage (takes too long to treat)

11 Post Op Advise patient to perform daily sitz bath (shown to speed up healing) Antibiotics based on cultures, usually as prophylaxis to prevent spread of infection, but not shown to prevent recurrence Most commonly staph aureus, E.coli, and Bacteroides Pain management Follow up to check for recurrence and look for fistula if it was not found during the procedure Internal opening of fistula is difficult to find during procedure due to active inflammation and pus hence wound should always be left open to prevent recurrence and allow follow up evaluation of fistula

12 Reference AccessMedicine, Essentials of General Surgery: anorectal disease: Medscape Perianal abscess and fistula treatment:

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