Anorectal abscess: Difference between revisions

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==Background==
==Background==
*Usually begin via blocked anal gland (leads to infection/abscess formation)
[[File:Abscess diag 02.png|thumb|Anorectal abscess types and their locations.]]
**Can progress to involve any of the potential spaces:
*Usually begin via blocked anal gland (leads to infection/[[abscess]] formation)
***Perianal
**Can progress to involve any of the potential spaces.
****Most common
 
****Located close to anal verge, posterior midline, superficial tender mass
{| {{table}}
***Ischiorectal
| align="center" style="background:#f0f0f0;"|''' '''
****2nd most common
| align="center" style="background:#f0f0f0;"|'''Perianal'''
****Larger, indurated, well-circumscribed, located laterally on medial aspect of buttocks
| align="center" style="background:#f0f0f0;"|'''Ischiorectal'''
***Intersphincteric, deep postanal, pelvirectal
| align="center" style="background:#f0f0f0;"|'''Intersphincteric, deep postanal, pelvirectal'''
****Rectal pain, skin signs may not be present
|-
****Constitutional symptoms often present
| '''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 [[anal fistula|fistula]] formation even with drainage||||Constitutional symptoms often present
|}
 
===Risk Factors===
*[[Crohn's disease]]
*Chronic [[constipation]]
*[[Diabetes mellitus]]
*Chronic [[corticosteroid]] use


==Clinical Features==
==Clinical Features==
*Perirectal abscesses often accompanied by fever, leukocytosis
[[File:Perianalabscess.jpg|thumb|Perianal abscess.]]
**May only be paplpated via digital rectal exam
[[File:Perianalabszess 01.jpg|thumb|Perianal abscess.]]
*Tender inguinal adenopathy may be only clue to deeper abscesses
*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


==Diagnosis==
==Differential Diagnosis==
*CT or US can be useful to define deep abscesses (esp w/ pain out of proportion to exam)
{{Anorectal DDX}}
{{SSTI DDX}}


==Treatment==
==Evaluation==
*All perirectal abscesses should be drained in the OR
*CT with IV contrast can be useful to define deep abscesses (especially with pain out of proportion to exam)
*Isolated perianal abscess is only type of anorectal abscess that should be treated in ED
*May consider [[ultrasound]] or MRI as alternatives
**Consider either linear incision w/ packing or cruciate incision w/o packing
 
==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
**Frequent sitz baths
**Abx
*All perirectal abscesses (ischiorectal, intersphincteric, supralevator) should be drained in the OR
***Only indicated for:
*All anorectal abscesses require surgical referral and follow up
****Elderly
 
****Systemic signs (fever, leukocytosis)
===Antibiotics===
****Valvular heart disease
''Causative organisms: Mixed infection with fecal flora for [[anaerobes]] and [[Gram Negatives]] ([[Bacteroides fragilis]] and  [[Escherichia coli]])''
****Cellulitis
 
****Immunosuppression
'''Use is controversial'''
***Piperacillin-tazobactam 3.37gm IV q6hr OR ampicillin-sulbactam 3gm IV q6hr
*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>
**Elderly
**Diabetics
**Systemic signs ([[fever]], [[leukocytosis]])
**[[Valvular heart disease]]
**[[Cellulitis]]
**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>
 
'''Treatment options:'''
*[[Augmentin]]
*[[Ciprofloxacin]] 500mg PO BID '''and''' [[Metronidazole]] 500mg PO TID
 
==Disposition==
===Discharge===
*Perianal abscess
 
==See Also==
*[[Anorectal Disorders]]
 
==External Links==
*[http://vimeo.com/59270692 Rob Orman Lecture]


==Source==
==References==
Tintinalli
<references/>


[[Category:GI]]
[[Category:GI]]

Latest revision as of 19:46, 6 March 2024

Background

Anorectal abscess types and their locations.
  • 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

Clinical Features

Perianal abscess.
Perianal abscess.
  • 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

Non-GI Look-a-Likes

Skin and Soft Tissue Infection

Look-A-Likes

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

Treatment options:

Disposition

Discharge

  • Perianal abscess

See Also

External Links

References

  1. ↑ BMJ Best Practice Anorectal abscess http://bestpractice.bmj.com/best-practice/monograph/644/treatment/step-by-step.html
  2. ↑ Guidelines.gov - Practice parameters for the management of perianal abscess and fistula-in-ano.http://www.guideline.gov/content.aspx?id=36077
  3. ↑ 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.
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