1. Surgery Case 5
Sy, Jamelle; Sydiongco, Paula Marie; Tacata, Patricia; Tady, Clarissa Marie

2. CHIEF COMPLAINT
PERIANAL PAIN

3. HISTORY 1 wk PTA Pain at the anal region after passing out hard stools
2 days PTA
Soft mass over the R perianal region; (+) tenderness
4 hrs PTA
Painful sensation on the anal region, aggravated when sitting

4. PHYSICAL EXAMINATION VS: BP= 120/80; PR= 85/min; RR= 18/min;
T C
HEENT: anicteric sclera, pink palpebral conjunctivae
HEART & LUNGS: unremarkable
ABDOMEN: flat, soft, non-tender w/ normoactive bowel sounds
DRE: erhythematous, warm and tender 5x4 cm mass at the perianal region; DRE cannot be tolerated by the patient

5. SALIENT FEATURES 59 y/o male Diabetic T- 37.8 0 C
Erythematous, warm and tender 5x4 cm mass on the R perianal region
DRE cannot be tolerated by the patient

6. DIFFERENTIAL DIAGNOSIS

7. RECTAL CA HSV PERIANAL ABSCESS Perianal Pain * Aggravated by
LYMPHOGRANULOMA
VENEREUM
HSV
PERIANAL ABSCESS
Perianal Pain
* Aggravated by
sitting done
* Prior to bowel
movement
(-) ✔
Palpable mass
Present
Genital ulcers
Genital ulcer
Fever and Chills
Rectal Discharge
Constipation

8. CLINICAL FEATURES Perianal abscess Patient’s Symptoms Perianal Pain
* Aggravated by
sitting done
* Prior to bowel
movement ✔
Palpable mass
Fever and Chills
Rectal Discharge ✖
Constipation
Even though all features of Perianal abscess are not present in our patient. The three important features– perianal pain, palpable mass and fever, seen in our patient would suggest a diagnosis of perianal abscess.

9. DIAGNOSIS:
PERI-ANAL ABSCESS

10. PERI-ANAL ABSCESS
Represents an infection of the soft tissues surrounding the anal canal, with formation of a discrete abscess cavity..
The severity and depth of the abscess are quite variable, and the abscess cavity is often associated with formation of a fistulous tract
Common organisms implicated in abscess formation include Escherichia coli, Enterococcus species, and Bacteroides species; however, no specific bacterium has been identified as a unique cause of abscesses.

11. INCIDENCE AND EPIDEMIOLOGY
M > F (3:1)
peak incidence: 3rd to 5th decade of life.
The disease is more prevalent in immunocompromised patients such
Diabetics
hematologic disorders
inflammatory bowel disease (IBD)
HIV positive
These disorders should be considered in patients with recurrent perianal infections.

12. PATHOPHYSIOLOGY
Originates from an infection arising in the cryptoglandular 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

13. 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%.

14. PATHOPHYSIOLOGY

15. CLINICAL PRESENTATION
HALLMARK: Perianal pain and fever
dull perianal discomfort and pruritus
perianal pain often is exacerbated by movement and increased perineal pressure from sitting or defecation.

16. CLINICAL PRESENTATION
PE: demonstrates a small, erythematous, well-defined, fluctuant, subcutaneous mass near the anal orifice.
LABORATORY EVALUATION: elevated WBC count
DIAGNOSTIC PROCEDURES are rarely necessary unless evaluating a recurrent abscess.
A CT scan or MRI has an accuracy of 80% in determining incomplete drainage.

17. MANAGEMENT Early surgical drainage of the purulent collection.
Primary antibiotic therapy alone is ineffective in resolving the underlying infection and simply postpones surgical intervention.
Any delay in surgical drainage of anorectal abscesses prolongs infection, augments tissue damage, and may impair sphincter continence function, as well as promote stricture and/or fistula formation.
The ability to drain an anorectal abscess depends on patient comfort and on the location and accessibility of the abscess.

18. Drainage of perianal or superficial abscesses
Can be accomplished in the office or emergency department, using local anesthetics
For patients who have a complicated abscess or who are diabetic or immunocompromised, drainage should be performed in a operating room under anesthesia. These patients are at greater risk for developing necrotizing fasciitis.

19. Drainage of perianal or superficial abscesses
A small cruciate incision is made over the area of fluctuancy in close proximity to the anal verge.
Pus is collected and sent for culture. Hemostasis is achieved with manual pressure, and the wound is packed with iodophor gauze.
The gauze is removed after 24 hours, and the patient is instructed to take sitz baths 3 times a day and after bowel movements.

20. Postoperative analgesics and stool softeners are prescribed to relieve pain and prevent constipation.
The patient typically will follow up with his/her physician in 2-3 weeks for wound evaluation and inspection for possible fistula-in-ano.

21. ANTIBIOTIC THERAPY
Antibiotic therapy when indicated– to cover aerobes and anaerobes e.g. ciprofloxacin 500 mg PO 2x daily for 5 days