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| ==Overview==
| | {{Roseola}} |
| ==Historical Perspective==
| | {{CMG}}:{{AE}}{{DAMI}} |
| *In 1880, Herman and Desfosses described the anal glands within the internal sphincter, [[sub-mucosa]] and their opening into the [[anal crypts]] and demonstrated that the infection of these glands and the spread of the infection through the intersphincteric space can result in the formation of a anorectal [[abscess]].<ref name="pmid22379401">{{cite journal| author=Abcarian H| title=Anorectal infection: abscess-fistula. | journal=Clin Colon Rectal Surg | year= 2011 | volume= 24 | issue= 1 | pages= 14-21 | pmid=22379401 | doi=10.1055/s-0031-1272819 | pmc=3140329 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22379401 }} </ref>
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| *Tucker and Hellwig, provided evidence that the initial infection occurs in the [[anal ducts]] allowing the [[infection]] to spread from the anal lumen into the [[anal canal]] wall.<ref name="pmid22379401">{{cite journal| author=Abcarian H| title=Anorectal infection: abscess-fistula. | journal=Clin Colon Rectal Surg | year= 2011 | volume= 24 | issue= 1 | pages= 14-21 | pmid=22379401 | doi=10.1055/s-0031-1272819 | pmc=3140329 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22379401 }} </ref>
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| *In 1950, Goligher described the treatment for [[anorectal abscess]] with [[incision and curettage]] with [[antibiotic bath]] and [[primary closure]].<ref name="pmid22379401">{{cite journal| author=Abcarian H| title=Anorectal infection: abscess-fistula. | journal=Clin Colon Rectal Surg | year= 2011 | volume= 24 | issue= 1 | pages= 14-21 | pmid=22379401 | doi=10.1055/s-0031-1272819 | pmc=3140329 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22379401 }} </ref>
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| ==Classification==
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| 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 <ref>{{cite journal |author=Janicke DM, Pundt MR |title=Anorectal disorders |journal=Emerg. Med. Clin. North Am. |volume=14 |issue=4 |pages=757–88 |year=1996 |month=November |pmid=8921768 |doi= 10.1016/S0733-8627(05)70278-9|url=}}</ref>
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| *'''Perianal abscess:''' When the infection reaches the anal verge passing between the [[internal sphicter]] and [[external sphincter]], it results in the formation of a perianal abscess.
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| *'''Ischiorectal abscess:''' If the infection ruptures through the [[external sphincter]] it results in a formation of a ischiorectal abscess.
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| *'''Supralevator abscess:''' If the infection extends [[superiorly]], it can form a supralevator abscess.
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| *'''Horseshoe abscess:''' Extension of the [[abscess]] to both the ischiorectal fossa results in the formation of a horseshoe abscess.
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| Based on the location the abscesses can also be classified into:
| | ==[[Roseola overview|Overview]]== |
| *'''High anorectal abscess:''' These include intersphincteric, perianal, and ischiorectal abscesses.
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| *'''Low anorectal abscess:''' These incude submucosal, supralevator abscesses.
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| ==Pathophysiology== | | ==[[Roseola historical perspective|Historical Perspective]]== |
| ===Pathogenesis===
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| *[[Anal canal]] is a 2 to 4cm in length, starts at the anorectal junction to the end of [[anal verge]].<ref name="urlAnatomy and Embryology - Springer">{{cite web |url=http://link.springer.com/chapter/10.1007%2F978-1-4419-1584-9_1 |title=Anatomy and Embryology - Springer |format= |work= |accessdate=}}</ref>
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| *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]].<ref name="urlAnatomy and Embryology - Springer">{{cite web |url=http://link.springer.com/chapter/10.1007%2F978-1-4419-1584-9_1 |title=Anatomy and Embryology - Springer |format= |work= |accessdate=}}</ref>
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| *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.<ref name="urlAnatomy and Embryology - Springer">{{cite web |url=http://link.springer.com/chapter/10.1007%2F978-1-4419-1584-9_1 |title=Anatomy and Embryology - Springer |format= |work= |accessdate=}}</ref>
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| *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.<ref name="pmid15740520">{{cite journal| author=Rickard MJ| title=Anal abscesses and fistulas. | journal=ANZ J Surg | year= 2005 | volume= 75 | issue= 1-2 | pages= 64-72 | pmid=15740520 | doi=10.1111/j.1445-2197.2005.03280.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15740520 }} </ref>
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| *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.<ref name="pmid13732880">{{cite journal| author=PARKS AG| title=Pathogenesis and treatment of fistuila-in-ano. | journal=Br Med J | year= 1961 | volume= 1 | issue= 5224 | pages= 463-9 | pmid=13732880 | doi= | pmc=1953161 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=13732880 }} </ref>
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| ==Causes== | | ==[[Roseola classification|Classification]]== |
| ===Source of Infection===
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| *Supralevator [[abscess]] can be caused by the spread of infection from [[abdominal infections]] such as [[appendicitis]], [[diverticulitis]], or gynecologic sepsis.
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| *Spread of infection of ano-rectal [[Crohn's disease]].
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| *[[Trauma]] to the [[anal canal]]
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| *[[Cancer]] of the [[anal canal]] or the anal glands
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| ===Microbial Causes=== | | ==[[Roseola pathophysiology|Pathophysiology]]== |
| Organisms commonly causing anorectal abscess include:
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| *[[E.coli]]
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| *[[Staphylococcus aureus]]
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| *[[MRSA]]
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| ==Epidemiology and Demographics== | | ==[[Roseola causes|Causes]]== |
| ===Incidence===
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| *The [[incidence]] of [[anorectal abscess]] is estimated to be around 68,000 to 96,000 cases per year in the United States.<ref name="pmid22379401">{{cite journal| author=Abcarian H| title=Anorectal infection: abscess-fistula. | journal=Clin Colon Rectal Surg | year= 2011 | volume= 24 | issue= 1 | pages= 14-21 | pmid=22379401 | doi=10.1055/s-0031-1272819 | pmc=3140329 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22379401 }} </ref>
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| ===Gender=== | | ==[[Roseola differential diagnosis|Differentiating Any Disease from other Diseases]]== |
| *Anorectal abscesses are two times more frequently seen in men than women.<ref name="pmid22362468">{{cite journal| author=Ommer A, Herold A, Berg E, Fürst A, Sailer M, Schiedeck T| title=German S3 guideline: anal abscess. | journal=Int J Colorectal Dis | year= 2012 | volume= 27 | issue= 6 | pages= 831-7 | pmid=22362468 | doi=10.1007/s00384-012-1430-x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22362468 }} </ref>
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| ===Age=== | | ==[[Roseola epidemiology and demographics|Epidemiology and Demographics]]== |
| *Patients with anorectal abscess present between ages of 20 to 60 years with a mean age of 40 in both sexes.<ref name="pmid22379401">{{cite journal| author=Abcarian H| title=Anorectal infection: abscess-fistula. | journal=Clin Colon Rectal Surg | year= 2011 | volume= 24 | issue= 1 | pages= 14-21 | pmid=22379401 | doi=10.1055/s-0031-1272819 | pmc=3140329 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22379401 }} </ref>
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| ===Race=== | | ==[[Roseola risk factors|Risk Factors]]== |
| *There are limited [[epidemiological studies]] which studied the [[frequency]] of [[anorectal abscess]] with race differences, however a study in Chicago reported a 92% of the patients presented with [[anorectal abscess]] were of African American origin.<ref name="pmid527452">{{cite journal| author=Read DR, Abcarian H| title=A prospective survey of 474 patients with anorectal abscess. | journal=Dis Colon Rectum | year= 1979 | volume= 22 | issue= 8 | pages= 566-8 | pmid=527452 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=527452 }} </ref>
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| ==Risk Factors== | | ==[[Roseola screening|Screening]]== |
| [[Risk factors]] for the development of recurrent of [[anal abscesses]] include<ref name="pmid26768004">{{cite journal| author=Adamo K, Sandblom G, Brännström F, Strigård K| title=Prevalence and recurrence rate of perianal abscess--a population-based study, Sweden 1997-2009. | journal=Int J Colorectal Dis | year= 2016 | volume= 31 | issue= 3 | pages= 669-73 | pmid=26768004 | doi=10.1007/s00384-015-2500-7 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26768004 }} </ref>: | |
| *[[Crohn's disease]]
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| *[[Diabetes mellitus]]
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| *History of [[abscess]] in the [[ischiorectal]] location
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| *[[HIV infection]]
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| *Receptive [[anal sex]]
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| ==Differential Diagnosis== | | ==[[Roseola natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| 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]].<ref name="pmid26805351">{{cite journal| author=Adikrisna R, Udagawa M, Sugita Y, Ishii T, Okamoto H, Yabata E| title=[A Case of Squamous Cell Carcinoma of the Anal Canal with a Perianal Abscess]. | journal=Gan To Kagaku Ryoho | year= 2015 | volume= 42 | issue= 12 | pages= 2322-4 | pmid=26805351 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26805351 }} </ref>
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| ==Natural History, Prognosis, Complications==
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| ===Natural History===
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| ===Complications===
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| *Recurrence usually to incomplete drainage of the [[abscess]]
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| *[[Sepsis]]
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| *[[Fistula]] formation
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| *[[Scarring]]
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| ==Diagnosis== | | ==Diagnosis== |
| ===History and Symptoms===
| | [[Roseola history and symptoms|History and Symptoms]] | [[Roseola physical examination|Physical Examination]] | [[Roseola laboratory findings|Laboratory Findings]] | [[Roseola electrocardiogram|Electrocardiogram]] | [[Roseola chest x ray|Chest X Ray]] | [[Roseola CT|CT]] | [[Roseola MRI|MRI]] | [[Roseola echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[Roseola other imaging findings|Other Imaging Findings]] | [[Roseola other diagnostic studies|Other Diagnostic Studies]] |
| *Patients with low abscess typically present with [[anal pain]]. Other findings include:
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| **[[Anal pain]]
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| **[[Pain]] associated with [[bowel movement]]: It is worse when the person sits down and right before a [[bowel movement]]. After the individual has a [[bowel movement]], the pain usually lessens.<ref>{{cite book | last = Ferri | first = Fred | title = Ferri's clinical advisor 2015 : 5 books in 1 | publisher = Elsevier/Mosby | location = Philadelphia, PA | year = 2015 | isbn = 978-0323083751 }}</ref>
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| **[[Swelling]]
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| **[[Chills]]
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| **[[Constipation]]
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| **[[pus|Discharge of pus]] from the [[rectum]]
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| **[[Fever]]
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| *Patients with high abscess present with :
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| **[[Fever]]
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| **[[Malaise]]
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| **[[Anal pain]]
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| ===Physical Examination===
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| ====General Appearance====
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| *Patients with high abscess present with [[fever]], elevated [[body temperature]] can be noticed.
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| ====Digital Rectal Examination====
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| *It is difficult to perform [[digital rectal examination]] due to the severe [[pain]], therefore patient should be examined under [[local anesthesia]] to identify the location of the [[abscess]] and also if suspicion of a high abscess (Supralevator abscess) is present.
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| *[[Anoscopy]] should not be performed.<ref name="pmid27723447">{{cite journal| author=Chang J, Mclemore E, Tejirian T| title=Anal Health Care Basics. | journal=Perm J | year= 2016 | volume= 20 | issue= 4 | pages= 74-80 | pmid=27723447 | doi=10.7812/TPP/15-222 | pmc=5101094 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27723447 }} </ref>
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| *Anorectal abscess is a clinical diagnosis and presence of [[induration]], [[tenderness]] and [[fluctulance]] are diagnostic of perianal and ishciorectal [[abscess]]. In patients with intersphincteric or supralevator abscesses external findings are minimal only pelvic or rectal [[tenderness]] or [[fluctulance]] on [[digital rectal examination]] can be demonstrated.
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| Physical examination findings demonstrated in anorectal [[abscess]] include:
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| *[[Erythema]]
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| *[[Warmth]]
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| *[[Tenderness]]
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| *[[Induration]]
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| *[[Fluctulance]]
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| <div align="left">
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| <gallery heights="175" widths="175">
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| Image:Gu perirectal abscess2.jpg|Perianal abscess
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| Image:Gu perirectal abscess.jpg|Perianal abscess
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| </gallery>
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| </div>
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| <small>(Images courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA)</small>
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| ===Laboratory Findings===
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| *[[Anorectal abscess]] is a clinical diagnosis and physical examination is sufficient to make the diagnosis, therefore laboratory testing is not done in most of the patients.
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| *Complete blood picture will show a [[neutrophilia]] with a left shift, and elevated [[ESR]].
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| *[[Bleeding time]] and [[clotting time]] and routine [[pre-operative evaluation]] must be performed.
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| ===Imaging===
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| ====Ultrasound====
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| *Endoanal [[ultrasound]] is useful in detecting horse-shoe abscesses extension and presence of [[fistula]] tracts with high [[sensitivity]].
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| *[[Three dimensional ultrasound]] is useful in patients to identify the anatomical locations of complex perianal abscesses and [[fistula]] tracts.
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| ====CT Scan====
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| *[[CT scan]] is useful in patients with complex [[suppurative]] anorectal conditions such as supralevator abscess and to identify other etiologies causing anorectal [[abscess]] such as [[pelvic infections]], [[appendicitis]], [[Crohn's disease]] and [[diverticulitis]].
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| ==Treatment== | | ==Treatment== |
| ===Medical Therapy===
| | [[Roseola medical therapy|Medical Therapy]] | [[Roseola surgery|Surgery]] | [[Roseola primary prevention|Primary Prevention]] | [[Roseola secondary prevention|Secondary Prevention]] | [[Roseola cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Roseola future or investigational therapies|Future or Investigational Therapies]] |
| *Medical therapy is not recommended in patients with anal abscess as the [[antibiotics]] have poor penetration in to the [[abscess]] cavity and are not helpful to in treatment of the [[infection]] or [[wound healing]].
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| *[[Antibiotics]] may be considered in patients with extensive [[cellulitis]], [[HIV infection]] and [[diabetes mellitus]].
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| *Patients with low [[neutrophil]] count (500-1000/mm³) and also in patients with no fluctulance medical therapy can be helpful in resolution of the abscess, however in patients with [[neutrophil]] count of >1000/mm³ and with fluctulance surgical drainage is a better option for treatment.
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| *[[Prophylactic antibiotics]] prior to [[incision and drainage]] is recommended by [[American Heart Association]], in patients with [[prosthetic valves]], previous [[bacterial endocarditis]], [[congenital heart disease]], and [[heart transplant]] recipients with valve pathology.
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| ===Surgical Therapy===
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| *Management of anal [[abscess]] should be prompt as the risk of involving the surrounding tissue resulting in perineal [[cellulitis]] and [[sepsis]] is high.<ref name="pmid24881481">{{cite journal| author=Slauf P, Antoš F, Marx J| title=[Acute periproctal abscesses]. | journal=Rozhl Chir | year= 2014 | volume= 93 | issue= 4 | pages= 226-31 | pmid=24881481 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24881481 }} </ref>
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| *Primary treatment for anorectal [[abscess]] is [[incision and drainage]] and it should be performed within 24 hours of presentation.
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| *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]].
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| *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]].
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| ====Procedure====
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| *Under aseptic precautions a [[scalpel]] is used to make a [[cruciate]] or [[elliptical]] incision over the area of flactulance. The incision should be close to the [[anal verge]] to minimize the length of a potential [[fistula]].
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| *After [[incision]] is made the [[necrotic tissue]] is removed and [[loculations]] are broken using a [[hemostat]] or a finger.
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| *After the procedure the wound is packed with a gauze sponge which is removed after 24 hours.<ref name="pmid27562822">{{cite journal| author=Smith SR, Newton K, Smith JA, Dumville JC, Iheozor-Ejiofor Z, Pearce LE et al.| title=Internal dressings for healing perianal abscess cavities. | journal=Cochrane Database Syst Rev | year= 2016 | volume= | issue= 8 | pages= CD011193 | pmid=27562822 | doi=10.1002/14651858.CD011193.pub2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27562822 }} </ref>
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| *Regular [[sitz bath]] is recommended after the surgery, it will help in local cleansing and wound healing.
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| *A variation in the [[incision and drainage]] is using a small latex [[catheter]] (Pezzer catheter). After a small [[incision]] is made the [[catheter]] is inserted into the cavity and is left in place for a duration of 3 to 10 days till the [[abscess]] cavity is drained and the cavity closes around the [[catheter]].
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| ====Complications====
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| *[[Recurrence]] of the abscess: The [[recurrence]] rate depends on the location of the [[abscess]] and the duration of [[follow-up]], the rate ranges from 3% to 44%. Other factors influencing the [[recurrence]] rate include incomplete initial drainage, failure to break up loculations within the [[abscess]], missed abscess undiagnosed [[fistula]]. Recurrence rates are high in horseshoe abscess with a range from 18% to 50% which require multiple surgeries.
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| *[[Urinary retention]]
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| *Postoperative [[bleeding]]
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| ==Prevention==
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| ===Primary Prevention===
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| ===Secondary Prevention===
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| ==References== | | ==Case Studies== |
| {{Reflist|2}}
| | [[Roseola case study one|Case #1]] |