Perianal abscess

(Redirected from Anal abscess)
Jump to: navigation, search

WikiDoc Resources for Perianal abscess

Articles

Most recent articles on Perianal abscess

Most cited articles on Perianal abscess

Review articles on Perianal abscess

Articles on Perianal abscess in N Eng J Med, Lancet, BMJ

Media

Powerpoint slides on Perianal abscess

Images of Perianal abscess

Photos of Perianal abscess

Podcasts & MP3s on Perianal abscess

Videos on Perianal abscess

Evidence Based Medicine

Cochrane Collaboration on Perianal abscess

Bandolier on Perianal abscess

TRIP on Perianal abscess

Clinical Trials

Ongoing Trials on Perianal abscess at Clinical Trials.gov

Trial results on Perianal abscess

Clinical Trials on Perianal abscess at Google

Guidelines / Policies / Govt

US National Guidelines Clearinghouse on Perianal abscess

NICE Guidance on Perianal abscess

NHS PRODIGY Guidance

FDA on Perianal abscess

CDC on Perianal abscess

Books

Books on Perianal abscess

News

Perianal abscess in the news

Be alerted to news on Perianal abscess

News trends on Perianal abscess

Commentary

Blogs on Perianal abscess

Definitions

Definitions of Perianal abscess

Patient Resources / Community

Patient resources on Perianal abscess

Discussion groups on Perianal abscess

Patient Handouts on Perianal abscess

Directions to Hospitals Treating Perianal abscess

Risk calculators and risk factors for Perianal abscess

Healthcare Provider Resources

Symptoms of Perianal abscess

Causes & Risk Factors for Perianal abscess

Diagnostic studies for Perianal abscess

Treatment of Perianal abscess

Continuing Medical Education (CME)

CME Programs on Perianal abscess

International

Perianal abscess en Espanol

Perianal abscess en Francais

Business

Perianal abscess in the Marketplace

Patents on Perianal abscess

Experimental / Informatics

List of terms related to Perianal abscess

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aravind Kuchkuntla, M.B.B.S[2]

Synonyms and Keywords: Anorectal abscess, Ischiorectal abscess, Supralevator abscess, Horse shoe abscess
To return to abscess main page, click here.

Overview

Anorectal abscess is secondary to blockade of the anal gland ducts, resulting in a infection of the gland. The anatomical position of the anal glands in relation to the anal canal is responsible for the variation in the location of the abscess. Initial infection occurs in the anal gland duct and it takes the path of least resistance. The anorectal abscess are classified into low abscess and high based on the location of the abscess. Patients with low abscess present with anal pain associated with bowel movement, and patients with high abscess present systemic manifestations such as fever and malaise in addition to anal pain. On examination tenderness and flactulance suggest anorectal abscess. It is an emergency condition and must be treated promptly within 24 hours of presentation as spread of infection can result in perineal cellulitis and sepsis. Incision and drainage is the definitive treatment and should be performed under local or general anesthesia based on the location of the abscess. With treatment prognosis is good but a risk of recurrence and formation of a fistula is high in patients with improper drainage and failure to identify existing fistula. Antibiotic therapy does not help with treatment of the infection and wound healing.

Historical Perspective

Classification

Based on the location of the abscess in relation to the anal canal and the spread of infection to the surrounding structures, anorectal abscess can be classified into [2][3]

  • Perianal abscess: When the infection reaches the anal verge passing between the internal sphincter and external sphincter, it results in the formation of a perianal abscess.
  • Ischiorectal abscess: If the infection ruptures through the external sphincter it results in a formation of a ischiorectal abscess.
  • Supralevator abscess: If the infection extends superiorly, it can form a supralevator abscess.
  • Horseshoe abscess: Extension of the abscess to both the ischiorectal fossa results in the formation of a horseshoe abscess.

Based on the location the abscesses can also be classified into:[4]

  • High anorectal abscess: These include intersphincteric, perianal, and ischiorectal abscesses.
  • Low anorectal abscess: These incude submucosal, supralevator abscesses.

Pathophysiology

Pathogenesis

  • Anal canal is a 2 to 4cm in length, starts at the anorectal junction to the end of anal verge.[5]
  • It is divided into a upper and a lower part by transition zone that is seen at the dentate line or pectinate line which is surrounded by longitudinal mucosal folds, called columns of morgagni.[5]
  • Each of this fold contains anal crypts, each of which contains 3 to 12 anal glands, the distribution of these glands is not uniform with most of the glands present anterior to the position of the anal canal and fewer in the posterior position.[5]
  • The initial infection occurs in the ducts of the anal glands and the spread of infection results in the formation of the abscess, various theories were put forward to describe the pathogenesis and the most accepted one is the cryptoglandular theory.[6]
  • The crytoglandular theory states that obstruction of anal gland duct results in a infection and due to the presence of these glands deep in relation to the anal canal and sphincter, the infection follows the path of least resistance resulting in abscess formation at the termination of the gland.[7][8]

Causes

Source of Infection

Microbial Causes

Organisms commonly causing anorectal abscess include:

Epidemiology and Demographics

Incidence

Gender

  • Anorectal abscesses are two times more frequently seen in men than women.[10]

Age

  • Patients with anorectal abscess present between ages of 20 to 60 years with a mean age of 40 in both sexes.[1]

Race

Risk Factors

Risk factors for the development of recurrent of anal abscesses include[12]:

Differential Diagnosis

Anorectal abscess must be differentiated from other causes of anal pain including anal fissure, thrombosed hemorrhoids, levator spasm, sexually transmitted disease, proctitis, hidradenitis suppurativa, infected skin furuncles, herpes simplex virus, tuberculosis, syphilis, actinomycosis and cancer.[14]

Disease Definition Causes Clinical Features Diagnosis
Fistula in ano
  • A epithelialized track formed between the anorectum and the perianal skin secondary to rupture of anorectal abscess
  • Chronic manifestation of anorectal abscess
Anal Fissure
  • Clinical diagnosis
Thrombosed External Hemorrhoids
  • Engorged fibrovascular cushions lining the anal canal
  • Constipation
  • Prolonged straining
  • Clinical diagnosis
Levator spasm
  • Seen in patients with perfectionistic, anxious somatic, and/or neurotic tendencies
  • Severe anal pain lasting for seconds to 5 minutes
  • Diagnosis is by Rome IV criteria
  • It is diagnosis of exlusion
Proctatitis
Hidradenitis suppurativa
  • Causes unidentified
Infected skin furuncle
  • Well-circumscribed, painful, suppurative inflammatory nodule involving hair follicles
  • Clinical diagnosis
Bartholin's abscess

Perianal absscess must be differentiated from other diseases that cause anal discomfort and pain with defecation such as hemorrhoids, anal fissure and anal cancer.

Disease History Physical exam findings Sample image
Hemorrhoids

External hemorrhoids

  • External hemorrhoids are painful as the skin below the punctate line is sensitive to pain.[1]
  • Blood clots may form in external hemorrhoids.
  • Thrombosed external hemorrhoids cause bleeding, painful swelling, or a hard lump around the anus.
  • When the blood clot dissolves, extra skin is left behind. This skin can become irritated or itch.
  • Excessive straining, rubbing, or cleaning around the anus may make symptoms, such as itching and irritation, worse.

Internal hemorrhoids

  • The most common symptom of internal hemorrhoids is bright red blood on stool, on toilet paper, or in the toilet bowl after a bowel movement.
  • Internal hemorrhoids that are not prolapsed are usually not painful.
  • Prolapsed hemorrhoids often cause pain, discomfort, and anal itching

Skin examination

  • Inspection of the anal verge may show scratch marks and skin tags.
  • Inspection also may reveal external hemorrhoids or prolapsed internal hemorrhoids.

Digital rectal examination

External hemorrhoids - By Dr. Joachim Guntau - www.Endoskopiebilder.de, CC BY-SA 3.0, httpscommons.wikimedia.orgwindex.phpcurid=18660115
Anal fissure
  • Anal fissure usually presents with tearing pain with every bowel movement.[15]
  • Pain usually lasts for minutes to hours after every bowel movement.
  • Patient is typically afraid of going to the bathroom to avoid the pain, which leads to a viscious cycle. The fissure worsens the constipation and the constipation (hard stool) aggravates the fissure.
  • About two-thirds of the patients present with bright red blood streaks on toilet papers or on the surface of stools.
  • May be accompanied by pruritis and discharge.
Anal fissure - Own work, Public Domain, httpscommons.wikimedia.orgwindex.phpcurid=8885750
Rectal prolapse
  • Rectal prolapse most commonly occurs in multiparous females over 40 years old.[17]
  • Appears as a progressive mass protrusion from the anus. The protrusion first appears with straining and defecation, then progresses to the degree when it is no longer replaced back.
  • It presents with abdominal discomfort and incomplete defecation.
  • Fecal incontinence and anal discharge.
  • Pain is not usually present.
Rectal prolapse - By Dr. K.-H. Günther, Klinikum Main Spessart, Lohr am Main - Dr. K.-H. Günther, Klinikum Main Spessart, Lohr am Main, CC BY 3.0, httpscommons.wikimedia.orgwindex.phpcurid=20649968
Perianal abscess
  • Perianal abscess presents with severe, continuous, dull, aching pain in the perianal area.[19]
  • Pain is exacerbated with bowel movements, but is not exclusive to it.
  • Constipation due to fear of bowel movements.
  • Fever, headache, and chills may accompany the pain.
  • If the abscess starts to drain, discharge of purulent or bloody fluid may be noticed.
  • Flatulent, erythematous, and tender area of skin overlying the abscess.
  • If abscess is deep, tenderness is elicited with digital rectal examination.
Anal cancer
  • Rectal bleeding is the most common presentation.[20]
  • Mass sensation in the anus.
  • Mucoid discharge may occur.
  • Patient may give a history of anal condyloma (especially homosexual men).[21]
  • Fecal incontinence.
  • On digital rectal examination, solid hemorrhagic mass that is firmly fixed to the surrounding structures is noted.
  • Femoral and inguinal lymph nodes may show lymphadenopathy secondary to spread of cancer.
Anal Cancer - By Internet Archive Book Images - httpswww.flickr.comphotosinternetarchivebookimages14598073128Source book page httpsarchive.orgstreamdiseasesofrectum00gantdiseasesofrectum00gant-pagen653mode1up, No restrictions, httpsc
Condylomata acuminata
  • Patient may give a history of unprotected anal sex with an infected partner.
  • Having multiple sexual partners is a risk factor and should be investigated.[22]
  • Condyloma acuminata presents with painless warts that vary in size, shape, and color.
  • Pruritis and discharge may accompany the warts.
  • Anal condyloma acuminata may be accompanied by cervical, vaginal, or even ororpharyngeal warts, so the patient should be examined thoroughly.[23]

Natural History, Prognosis, Complications

Natural History

If left untreated, anorectal abscess can spread to the surrounding tissue and can cause perineal cellulitis and sepsis. Perianal abscess is the most common type followed by ischiorectal abscess.[11]

Prognosis

Prognosis of patients is good with incision and drainage and most patients do not require any antibiotic therapy after the procedure, except for patients with HIV infection, Crohn's disease. Majority of patients have relief of pain after abscess drainage and healing takes time as it heals by secondary intention.[24]

Complications

Diagnosis

History and Symptoms

Physical Examination

General Appearance

Digital Rectal Examination

Physical examination findings demonstrated in anorectal abscess include: [3]

(Images courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA)

Laboratory Findings

Imaging

Ultrasound

  • Endoanal ultrasound is useful in detecting horse-shoe abscesses extension and presence of fistula tracts with high sensitivity.[28]
  • Three dimensional ultrasound is useful in patients to identify the anatomical locations of complex perianal abscesses and fistula tracts.[29]

CT Scan

Treatment

Medical Therapy

Surgical Therapy

  • Management of anal abscess should be prompt as the risk of involving the surrounding tissue resulting in perineal cellulitis and sepsis is high.[33]
  • Primary treatment for anorectal abscess is incision and drainage and it should be performed within 24 hours of presentation.
  • Patients with perianal abscess and ischiorectal abscess can be treated in a outpatient setting under local anesthesia using 1% lidocaine or bupivacaine with epinephrine is injected subcutaneously into the area affected by the abscess to provide adequate infilteration into the skin. [3]
  • Patients with loculations or large ischiorectal, intersphincteric, supralevator, or horseshoe abscesses should be admitted to the hospital and the procedure should be performed under anesthesia.[3]

Procedure

Complications

Prevention

Primary Prevention

Secondary Prevention

References

  1. 1.0 1.1 1.2 1.3 1.4 Abcarian H (2011). "Anorectal infection: abscess-fistula.". Clin Colon Rectal Surg. 24 (1): 14–21. PMC 3140329Freely accessible. PMID 22379401. doi:10.1055/s-0031-1272819. 
  2. Janicke DM, Pundt MR (1996). "Anorectal disorders". Emerg. Med. Clin. North Am. 14 (4): 757–88. PMID 8921768. doi:10.1016/S0733-8627(05)70278-9. 
  3. 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 Steele, Scott R.; Kumar, Ravin; Feingold, Daniel L.; Rafferty, Janice L.; Buie, W. Donald (2011). "Practice Parameters for the Management of Perianal Abscess and Fistula-in-Ano". Diseases of the Colon & Rectum. 54 (12): 1465–1474. ISSN 0012-3706. doi:10.1097/DCR.0b013e31823122b3. 
  4. Rizzo JA, Naig AL, Johnson EK (2010). "Anorectal abscess and fistula-in-ano: evidence-based management.". Surg Clin North Am. 90 (1): 45–68, Table of Contents. PMID 20109632. doi:10.1016/j.suc.2009.10.001. 
  5. 5.0 5.1 5.2 "Anatomy and Embryology - Springer". 
  6. Rickard MJ (2005). "Anal abscesses and fistulas.". ANZ J Surg. 75 (1-2): 64–72. PMID 15740520. doi:10.1111/j.1445-2197.2005.03280.x. 
  7. PARKS AG (1961). "Pathogenesis and treatment of fistuila-in-ano.". Br Med J. 1 (5224): 463–9. PMC 1953161Freely accessible. PMID 13732880. 
  8. Coremans G, Dockx S, Wyndaele J, Hendrickx A (2003). "Do anal fistulas in Crohn's disease behave differently and defy Goodsall's rule more frequently than fistulas that are cryptoglandular in origin?". Am J Gastroenterol. 98 (12): 2732–5. PMID 14687825. doi:10.1111/j.1572-0241.2003.08716.x. 
  9. Albright JB, Pidala MJ, Cali JR, Snyder MJ, Voloyiannis T, Bailey HR (2007). "MRSA-related perianal abscesses: an underrecognized disease entity.". Dis Colon Rectum. 50 (7): 996–1003. PMID 17525863. doi:10.1007/s10350-007-0221-x. 
  10. Ommer A, Herold A, Berg E, Fürst A, Sailer M, Schiedeck T (2012). "German S3 guideline: anal abscess.". Int J Colorectal Dis. 27 (6): 831–7. PMID 22362468. doi:10.1007/s00384-012-1430-x. 
  11. 11.0 11.1 Read DR, Abcarian H (1979). "A prospective survey of 474 patients with anorectal abscess.". Dis Colon Rectum. 22 (8): 566–8. PMID 527452. 
  12. Adamo K, Sandblom G, Brännström F, Strigård K (2016). "Prevalence and recurrence rate of perianal abscess--a population-based study, Sweden 1997-2009.". Int J Colorectal Dis. 31 (3): 669–73. PMID 26768004. doi:10.1007/s00384-015-2500-7. 
  13. Goldberg, Gary S.; Orkin, Bruce A.; Smith, Lee E. (1994). "Microbiology of human immunodeficiency virus anorectal disease". Diseases of the Colon & Rectum. 37 (5): 439–443. ISSN 0012-3706. doi:10.1007/BF02076188. 
  14. Adikrisna R, Udagawa M, Sugita Y, Ishii T, Okamoto H, Yabata E (2015). "[A Case of Squamous Cell Carcinoma of the Anal Canal with a Perianal Abscess].". Gan To Kagaku Ryoho. 42 (12): 2322–4. PMID 26805351. 
  15. Schlichtemeier S, Engel A (2016). "Anal fissure". Aust Prescr. 39 (1): 14–7. PMC 4816871Freely accessible. PMID 27041801. doi:10.18773/austprescr.2016.007. 
  16. Beaty JS, Shashidharan M (2016). "Anal Fissure". Clin Colon Rectal Surg. 29 (1): 30–7. PMC 4755763Freely accessible. PMID 26929749. doi:10.1055/s-0035-1570390. 
  17. Cannon JA (2017). "Evaluation, Diagnosis, and Medical Management of Rectal Prolapse". Clin Colon Rectal Surg. 30 (1): 16–21. PMID 28144208. doi:10.1055/s-0036-1593431. 
  18. Blaker K, Anandam JL (2017). "Functional Disorders: Rectoanal Intussusception". Clin Colon Rectal Surg. 30 (1): 5–11. PMID 28144206. doi:10.1055/s-0036-1593433. 
  19. Sahnan K, Adegbola SO, Tozer PJ, Watfah J, Phillips RK (2017). "Perianal abscess". BMJ. 356: j475. PMID 28223268. 
  20. Moureau-Zabotto L, Vendrely V, Abramowitz L, Borg C, Francois E, Goere D, Huguet F, Peiffert D, Siproudhis L, Ducreux M, Bouché O (2017). "Anal cancer: French Intergroup Clinical Practice Guidelines for diagnosis, treatment and follow-up". Dig Liver Dis. PMID 28610905. doi:10.1016/j.dld.2017.05.011. 
  21. Prigge ES, von Knebel Doeberitz M, Reuschenbach M (2017). "Clinical relevance and implications of HPV-induced neoplasia in different anatomical locations". Mutat. Res. 772: 51–66. PMID 28528690. doi:10.1016/j.mrrev.2016.06.005. 
  22. Wieland U, Kreuter A (2017). "[Genital warts in HIV-infected individuals]". Hautarzt (in German). 68 (3): 192–198. PMID 28160045. doi:10.1007/s00105-017-3938-z. 
  23. Köhn FM, Schultheiss D, Krämer-Schultheiss K (2016). "[Dermatological diseases of the external male genitalia : Part 2: Infectious and malignant dermatological]". Urologe A (in German). 55 (7): 981–96. PMID 27364818. doi:10.1007/s00120-016-0163-9. 
  24. Ramanujam PS, Prasad ML, Abcarian H, Tan AB (1984). "Perianal abscesses and fistulas. A study of 1023 patients.". Dis Colon Rectum. 27 (9): 593–7. PMID 6468199. 
  25. Whiteford MH, Kilkenny J, Hyman N, Buie WD, Cohen J, Orsay C; et al. (2005). "Practice parameters for the treatment of perianal abscess and fistula-in-ano (revised).". Dis Colon Rectum. 48 (7): 1337–42. PMID 15933794. doi:10.1007/s10350-005-0055-3. 
  26. Ferri, Fred (2015). Ferri's clinical advisor 2015 : 5 books in 1. Philadelphia, PA: Elsevier/Mosby. ISBN 978-0323083751. 
  27. Chang J, Mclemore E, Tejirian T (2016). "Anal Health Care Basics.". Perm J. 20 (4): 74–80. PMC 5101094Freely accessible. PMID 27723447. doi:10.7812/TPP/15-222. 
  28. Sheikh P (2012). "Controversies in fistula in ano.". Indian J Surg. 74 (3): 217–20. PMC 3397182Freely accessible. PMID 23730047. doi:10.1007/s12262-012-0594-5. 
  29. Santoro GA, Fortling B (2007). "The advantages of volume rendering in three-dimensional endosonography of the anorectum.". Dis Colon Rectum. 50 (3): 359–68. PMID 17237912. doi:10.1007/s10350-006-0767-z. 
  30. Stewart MP, Laing MR, Krukowski ZH (1985). "Treatment of acute abscesses by incision, curettage and primary suture without antibiotics: a controlled clinical trial.". Br J Surg. 72 (1): 66–7. PMID 3881155. 
  31. Macfie J, Harvey J (1977). "The treatment of acute superficial abscesses: a prospective clinical trial.". Br J Surg. 64 (4): 264–6. PMID 322789. 
  32. Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M; et al. (2007). "Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group.". Circulation. 116 (15): 1736–54. PMID 17446442. doi:10.1161/CIRCULATIONAHA.106.183095. 
  33. Slauf P, Antoš F, Marx J (2014). "[Acute periproctal abscesses].". Rozhl Chir. 93 (4): 226–31. PMID 24881481. 
  34. Smith SR, Newton K, Smith JA, Dumville JC, Iheozor-Ejiofor Z, Pearce LE; et al. (2016). "Internal dressings for healing perianal abscess cavities.". Cochrane Database Syst Rev (8): CD011193. PMID 27562822. doi:10.1002/14651858.CD011193.pub2. 
  35. Hasan RM (2016). "A study assessing postoperative Corrugate Rubber drain of perianal abscess.". Ann Med Surg (Lond). 11: 42–46. PMC 5037211Freely accessible. PMID 27699001. doi:10.1016/j.amsu.2016.09.003. 
  36. Cox SW, Senagore AJ, Luchtefeld MA, Mazier WP (1997). "Outcome after incision and drainage with fistulotomy for ischiorectal abscess.". Am Surg. 63 (8): 686–9. PMID 9247434. 
  37. Onaca N, Hirshberg A, Adar R (2001). "Early reoperation for perirectal abscess: a preventable complication.". Dis Colon Rectum. 44 (10): 1469–73. PMID 11598476. 
  38. Held D, Khubchandani I, Sheets J, Stasik J, Rosen L, Riether R (1986). "Management of anorectal horseshoe abscess and fistula.". Dis Colon Rectum. 29 (12): 793–7. PMID 3792160. 

Linked-in.jpg