Anorectal abscess: Difference between revisions
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==Background== | <languages/> | ||
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==Background== <!--T:1--> | |||
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[[File:Abscess diag 02.png|thumb|Anorectal abscess types and their locations.]] | [[File:Abscess diag 02.png|thumb|Anorectal abscess types and their locations.]] | ||
*Usually begin via blocked anal gland (leads to infection/[[abscess]] formation) | *Usually begin via blocked anal gland (leads to infection/[[Special:MyLanguage/abscess|abscess]] formation) | ||
**Can progress to involve any of the potential spaces. | **Can progress to involve any of the potential spaces. | ||
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{| {{table}} | {| {{table}} | ||
| align="center" style="background:#f0f0f0;"|''' ''' | | align="center" style="background:#f0f0f0;"|''' ''' | ||
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| '''Symptoms'''||Located close to anal verge, posterior midline, superficial tender mass||Larger, indurated, well-circumscribed, located laterally on medial aspect of buttocks||Rectal pain, skin signs may not be present | | '''Symptoms'''||Located close to anal verge, posterior midline, superficial tender mass||Larger, indurated, well-circumscribed, located laterally on medial aspect of buttocks||Rectal pain, skin signs may not be present | ||
|- | |- | ||
| '''Comments'''||High incidence of [[anal fistula|fistula]] formation even with drainage||||Constitutional symptoms often present | | '''Comments'''||High incidence of [[Special:MyLanguage/anal fistula|fistula]] formation even with drainage||||Constitutional symptoms often present | ||
|} | |} | ||
==Clinical Features== | ===Risk Factors=== <!--T:4--> | ||
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*[[Special:MyLanguage/Crohn's disease|Crohn's disease]] | |||
*Chronic [[Special:MyLanguage/constipation|constipation]] | |||
*[[Special:MyLanguage/Diabetes mellitus|Diabetes mellitus]] | |||
*Chronic [[Special:MyLanguage/corticosteroid|corticosteroid]] use | |||
==Clinical Features== <!--T:6--> | |||
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[[File:Perianalabscess.jpg|thumb|Perianal abscess.]] | [[File:Perianalabscess.jpg|thumb|Perianal abscess.]] | ||
[[File:Perianalabszess 01.jpg|thumb|Perianal abscess.]] | [[File:Perianalabszess 01.jpg|thumb|Perianal abscess.]] | ||
*Worsening pain around bowel movement, with decreased pain post rectal evacuation | *Worsening pain around bowel movement, with decreased pain post rectal evacuation | ||
*Perirectal abscesses often accompanied by [[fever]], [[leukocytosis]] | *Perirectal abscesses often accompanied by [[Special:MyLanguage/fever|fever]], [[Special:MyLanguage/leukocytosis|leukocytosis]] | ||
**May only be palpable via digital rectal exam | **May only be palpable via digital rectal exam | ||
**Perianal abscesses typically do not cause fever in immunocompetent individuals | **Perianal abscesses typically do not cause fever in immunocompetent individuals | ||
*Tender inguinal [[lymphadenopathy]] may be only clue to deeper abscesses | *Tender inguinal [[Special:MyLanguage/lymphadenopathy|lymphadenopathy]] may be only clue to deeper abscesses | ||
==Differential Diagnosis== | ==Differential Diagnosis== <!--T:8--> | ||
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{{Anorectal DDX}} | {{Anorectal DDX}} | ||
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{{SSTI DDX}} | {{SSTI DDX}} | ||
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==Evaluation== <!--T:9--> | |||
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*CT with IV contrast can be useful to define deep abscesses (especially with pain out of proportion to exam) | *CT with IV contrast can be useful to define deep abscesses (especially with pain out of proportion to exam) | ||
*May consider [[ultrasound]] or MRI as alternatives | *May consider [[Special:MyLanguage/ultrasound|ultrasound]] or MRI as alternatives | ||
==Management== <!--T:11--> | |||
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*Isolated perianal [[abscess]] is only type of anorectal [[abscess]] that should be treated in ED | *Isolated perianal [[Special:MyLanguage/abscess|abscess]] is only type of anorectal [[Special:MyLanguage/abscess|abscess]] that should be treated in ED | ||
**Consider either linear incision with packing, elliptical incision, or cruciate incision without packing | **Consider either linear incision with packing, elliptical incision, or cruciate incision without packing | ||
**Frequent sitz baths | **Frequent sitz baths | ||
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*All anorectal abscesses require surgical referral and follow up | *All anorectal abscesses require surgical referral and follow up | ||
===Antibiotics=== <!--T:13--> | |||
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''Causative organisms: Mixed infection with fecal flora for [[Special:MyLanguage/anaerobes|anaerobes]] and [[Special:MyLanguage/Gram Negatives|Gram Negatives]] ([[Special:MyLanguage/Bacteroides fragilis|Bacteroides fragilis]] and [[Special:MyLanguage/Escherichia coli|Escherichia coli]])'' | |||
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'''Use is controversial''' | '''Use is controversial''' | ||
*Only recommended in high risk patients:<ref>BMJ Best Practice Anorectal [[abscess]] http://bestpractice.bmj.com/best-practice/monograph/644/treatment/step-by-step.html</ref><ref>Guidelines.gov - Practice parameters for the management of perianal [[abscess]] and fistula-in-ano.http://www.guideline.gov/content.aspx?id=36077</ref> | *Only recommended in high risk patients:<ref>BMJ Best Practice Anorectal [[Special:MyLanguage/abscess|abscess]] http://bestpractice.bmj.com/best-practice/monograph/644/treatment/step-by-step.html</ref><ref>Guidelines.gov - Practice parameters for the management of perianal [[Special:MyLanguage/abscess|abscess]] and fistula-in-ano.http://www.guideline.gov/content.aspx?id=36077</ref> | ||
**Elderly | **Elderly | ||
**Diabetics | **Diabetics | ||
**Systemic signs ([[fever]], [[leukocytosis]]) | **Systemic signs ([[Special:MyLanguage/fever|fever]], [[Special:MyLanguage/leukocytosis|leukocytosis]]) | ||
**[[Valvular heart disease]] | **[[Special:MyLanguage/Valvular heart disease|Valvular heart disease]] | ||
**[[Cellulitis]] | **[[Special:MyLanguage/Cellulitis|Cellulitis]] | ||
**Immunosuppression | **Immunosuppression | ||
*Possibly prevent [[anal fistula|fistula]] formation in otherwise healthy patients<ref>Mocanu V, Dang JT, Ladak F, et al. Antibiotic use in prevention of anal fistulas following incision and drainage of anorectal abscesses: A systematic review and meta-analysis. Am J Surg. 2019;217(5):910-917.</ref> | *Possibly prevent [[Special:MyLanguage/anal fistula|fistula]] formation in otherwise healthy patients<ref>Mocanu V, Dang JT, Ladak F, et al. Antibiotic use in prevention of anal fistulas following incision and drainage of anorectal abscesses: A systematic review and meta-analysis. Am J Surg. 2019;217(5):910-917.</ref> | ||
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'''Treatment options:''' | '''Treatment options:''' | ||
*[[Augmentin]] | *[[Special:MyLanguage/Augmentin|Augmentin]] | ||
*[[Ciprofloxacin]] 500mg PO BID '''and''' [[Metronidazole]] 500mg PO TID | *[[Special:MyLanguage/Ciprofloxacin|Ciprofloxacin]] 500mg PO BID '''and''' [[Special:MyLanguage/Metronidazole|Metronidazole]] 500mg PO TID | ||
==Disposition== <!--T:17--> | |||
===Discharge=== <!--T:18--> | |||
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*Perianal abscess | *Perianal abscess | ||
==External Links== | ==See Also== <!--T:20--> | ||
[http://vimeo.com/59270692 Rob Orman Lecture] | |||
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*[[Special:MyLanguage/Anorectal Disorders|Anorectal Disorders]] | |||
==External Links== <!--T:22--> | |||
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*[http://vimeo.com/59270692 Rob Orman Lecture] | |||
==References== <!--T:24--> | |||
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<references/> | <references/> | ||
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[[Category:GI]] | [[Category:GI]] | ||
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Latest revision as of 20:30, 6 January 2026
Background
- Usually begin via blocked anal gland (leads to infection/abscess formation)
- Can progress to involve any of the potential spaces.
| Perianal | Ischiorectal | Intersphincteric, deep postanal, pelvirectal | |
| Epidemiology | Most common | Second most common | Least common |
| Symptoms | Located close to anal verge, posterior midline, superficial tender mass | Larger, indurated, well-circumscribed, located laterally on medial aspect of buttocks | Rectal pain, skin signs may not be present |
| Comments | High incidence of fistula formation even with drainage | Constitutional symptoms often present |
Risk Factors
- Crohn's disease
- Chronic constipation
- Diabetes mellitus
- Chronic corticosteroid use
Clinical Features
- Worsening pain around bowel movement, with decreased pain post rectal evacuation
- Perirectal abscesses often accompanied by fever, leukocytosis
- May only be palpable via digital rectal exam
- Perianal abscesses typically do not cause fever in immunocompetent individuals
- Tender inguinal lymphadenopathy may be only clue to deeper abscesses
Differential Diagnosis
Anorectal Disorders
- Anal fissure
- Anal fistula
- Anal malignancy
- Anal tags
- Anorectal abscess
- Coccydynia
- Colorectal malignancy
- Condyloma acuminata
- Constipation
- Crohn's disease
- Cryptitis
- GC/Chlamydia
- Fecal impaction
- Hemorrhoids
- Levator ani syndrome
- Pedunculated polyp
- Pilonidal cyst
- Proctalgia fugax
- Proctitis
- Pruritus ani
- Enterobius (pinworms)
- Rectal foreign body
- Rectal prolapse
- Syphilitic fissure
Non-GI Look-a-Likes
Skin and Soft Tissue Infection
- Cellulitis
- Erysipelas
- Lymphangitis
- Folliculitis
- Hidradenitis suppurativa
- Skin abscess
- Necrotizing soft tissue infections
- Mycobacterium marinum
Look-A-Likes
- Sporotrichosis
- Osteomyelitis
- Deep venous thrombosis
- Pyomyositis
- Purple glove syndrome
- Tuberculosis (tuberculous inflammation of the skin)
Evaluation
- CT with IV contrast can be useful to define deep abscesses (especially with pain out of proportion to exam)
- May consider ultrasound or MRI as alternatives
Management
- Isolated perianal abscess is only type of anorectal abscess that should be treated in ED
- Consider either linear incision with packing, elliptical incision, or cruciate incision without packing
- Frequent sitz baths
- All perirectal abscesses (ischiorectal, intersphincteric, supralevator) should be drained in the OR
- All anorectal abscesses require surgical referral and follow up
Antibiotics
Causative organisms: Mixed infection with fecal flora for anaerobes and Gram Negatives (Bacteroides fragilis and Escherichia coli)
Use is controversial
- Only recommended in high risk patients:[1][2]
- Elderly
- Diabetics
- Systemic signs (fever, leukocytosis)
- Valvular heart disease
- Cellulitis
- Immunosuppression
- Possibly prevent fistula formation in otherwise healthy patients[3]
Treatment options:
- Augmentin
- Ciprofloxacin 500mg PO BID and Metronidazole 500mg PO TID
Disposition
Discharge
- Perianal abscess
See Also
External Links
References
- ↑ BMJ Best Practice Anorectal abscess http://bestpractice.bmj.com/best-practice/monograph/644/treatment/step-by-step.html
- ↑ Guidelines.gov - Practice parameters for the management of perianal abscess and fistula-in-ano.http://www.guideline.gov/content.aspx?id=36077
- ↑ Mocanu V, Dang JT, Ladak F, et al. Antibiotic use in prevention of anal fistulas following incision and drainage of anorectal abscesses: A systematic review and meta-analysis. Am J Surg. 2019;217(5):910-917.