Anorectal abscess: Difference between revisions
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*Usually begin via blocked anal gland (leads to infection/[[abscess]] formation)
*Usually begin via blocked anal gland (leads to infection/[[abscess]] formation)
**Can progress to involve any of the potential spaces.
**Can progress to involve any of the potential spaces.
===Perianal===
*Most common
*Located close to anal verge, posterior midline, superficial tender mass
*High incidence of fistula formation even with drainage


===Ischiorectal===
{| {{table}}
*2nd most common
| align="center" style="background:#f0f0f0;"|''' '''
*Larger, indurated, well-circumscribed, located laterally on medial aspect of buttocks
| align="center" style="background:#f0f0f0;"|'''Perianal'''
===Intersphincteric, deep postanal, pelvirectal===
| align="center" style="background:#f0f0f0;"|'''Ischiorectal'''
*Rectal pain, skin signs may not be present
| align="center" style="background:#f0f0f0;"|'''Intersphincteric, deep postanal, pelvirectal'''
*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==
===Risk Factors===
*Crohn’s disease
*[[Crohn's disease]]
*Chronic constipation
*Chronic [[constipation]]
*Diabetes mellitus
*[[Diabetes mellitus]]
*Chronic corticosteroid use
*Chronic [[corticosteroid]] use


==Clinical Features==
==Clinical Features==
*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 [[fever]], [[leukocytosis]]
**May only be paplpated via digital rectal exam
**May only be palpable via digital rectal exam
*Tender inguinal adenopathy may be only clue to deeper abscesses
*Tender inguinal [[lymphadenopathy]] may be only clue to deeper abscesses


==Differential Diagnosis==
==Differential Diagnosis==
{{Anorectal DDX}}
{{Anorectal DDX}}
{{SSTI DDX}}


==Evaluation==
==Evaluation==
*CT or [[ultrasound]] can be useful to define deep abscesses (esp 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)
*MRI is an alternative
*May consider [[ultrasound]] or MRI as alternatives


==Management==
==Management==
*All perirectal abscesses should be drained in the OR
*All anorectal abscess requires surgical referral and followup
*Common bacteria: [[Staphylococcus aureus]], [[Escherichia coli]], [[Streptococcus]], Proteus and [[Bacteroides]]
*Isolated perianal [[abscess]] is only type of anorectal [[abscess]] that should be treated in ED
*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 with out packing
**Consider either linear incision with packing, elliptical incision, or cruciate incision without packing
**Frequent sitz baths
**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===
===Antibiotics===
Causative organisms: Mixed infection with fecal flora for anaerobes and Gram Negatives ([[Bacteroides fragilis]] and  [[Escherichia coli]])
''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:<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
**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>


'''Only indicated for:'''<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>
'''Treatment options:'''
*Elderly
*[[Augmentin]]
*Systemic signs (fever, leukocytosis)
*[[Ciprofloxacin]] 500mg PO BID '''and''' [[Metronidazole]] 500mg PO TID
*Valvular heart disease
*Cellulitis
*Immunosuppression


Treatment options:
==Disposition==
*[[Ciprofloxacin]] 500mg PO bid and [[Metronidazole]] 500mg PO tid
Discharge
*Perianal abscess


==See Also==
==See Also==
[[Anorectal Disorders]]
*[[Anorectal Disorders]]


==External Links==
==External Links==

Revision as of 19:06, 29 September 2019

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

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
  • Tender inguinal lymphadenopathy may be only clue to deeper abscesses

Differential Diagnosis

Anorectal Disorders

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

Rob Orman Lecture

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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