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| ==Overview==
| | {{Roseola}} |
| 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 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.
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| ==Historical Perspective==
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| *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== | | ==[[Roseola overview|Overview]]== |
| 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><ref name="SteeleKumar2011">{{cite journal|last1=Steele|first1=Scott R.|last2=Kumar|first2=Ravin|last3=Feingold|first3=Daniel L.|last4=Rafferty|first4=Janice L.|last5=Buie|first5=W. Donald|title=Practice Parameters for the Management of Perianal Abscess and Fistula-in-Ano|journal=Diseases of the Colon & Rectum|volume=54|issue=12|year=2011|pages=1465–1474|issn=0012-3706|doi=10.1097/DCR.0b013e31823122b3}}</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:<ref name="pmid20109632">{{cite journal| author=Rizzo JA, Naig AL, Johnson EK| title=Anorectal abscess and fistula-in-ano: evidence-based management. | journal=Surg Clin North Am | year= 2010 | volume= 90 | issue= 1 | pages= 45-68, Table of Contents | pmid=20109632 | doi=10.1016/j.suc.2009.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20109632 }} </ref>
| | ==[[Roseola historical perspective|Historical Perspective]]== |
| *'''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 classification|Classification]]== |
| ===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><ref name="pmid14687825">{{cite journal| author=Coremans G, Dockx S, Wyndaele J, Hendrickx A| title=Do anal fistulas in Crohn's disease behave differently and defy Goodsall's rule more frequently than fistulas that are cryptoglandular in origin? | journal=Am J Gastroenterol | year= 2003 | volume= 98 | issue= 12 | pages= 2732-5 | pmid=14687825 | doi=10.1111/j.1572-0241.2003.08716.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14687825 }} </ref>
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| ==Causes== | | ==[[Roseola pathophysiology|Pathophysiology]]== |
| ===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 causes|Causes]]== |
| Organisms commonly causing anorectal abscess include:
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| *[[E.coli]]
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| *[[Staphylococcus aureus]]
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| *[[MRSA]]<ref name="pmid17525863">{{cite journal| author=Albright JB, Pidala MJ, Cali JR, Snyder MJ, Voloyiannis T, Bailey HR| title=MRSA-related perianal abscesses: an underrecognized disease entity. | journal=Dis Colon Rectum | year= 2007 | volume= 50 | issue= 7 | pages= 996-1003 | pmid=17525863 | doi=10.1007/s10350-007-0221-x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17525863 }} </ref>
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| ==Epidemiology and Demographics== | | ==[[Roseola differential diagnosis|Differentiating Any Disease from other Diseases]]== |
| ===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 epidemiology and demographics|Epidemiology and Demographics]]== |
| *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 risk factors|Risk Factors]]== |
| *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 screening|Screening]]== |
| *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 natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| [[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>:
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| *[[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]]<ref name="GoldbergOrkin1994">{{cite journal|last1=Goldberg|first1=Gary S.|last2=Orkin|first2=Bruce A.|last3=Smith|first3=Lee E.|title=Microbiology of human immunodeficiency virus anorectal disease|journal=Diseases of the Colon & Rectum|volume=37|issue=5|year=1994|pages=439–443|issn=0012-3706|doi=10.1007/BF02076188}}</ref>
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| *Receptive [[anal sex]]
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| ==Differential Diagnosis==
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| 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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| {| class="wikitable"
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| !Disease
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| !Definition
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| !Causes
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| !Clinical Features
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| !Diagnosis
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| |[[Fistula in ano]]
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| *A epithelialized track formed between the anorectum and the perianal skin secondary to rupture of [[anorectal abscess]]
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| *Chronic manifestation of anorectal abscess
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| *[[Anorectal abscess]]
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| *[[Crohn's Disease]]
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| *[[Radiation Proctitis]]
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| *[[Lymphogranuloma venereum]]
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| *[[Actinomycosis]]
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| *[[Anal pain]] with [[bowel movement]] and sitting
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| *Perianal discharge
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| *Perianal [[pruritus]]
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| *Presence of exteral opening on examination
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| *Perianal inflammation
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| *Endoanal [[ultrasound]]
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| *[[Fistulography]]
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| *[[Computed tomography]]
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| |[[Anal Fissure]]
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| *Tear in the anoderm distal to the [[dentate line]]
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| *Anal Trauma
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| *Receptive [[anal sex]]
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| *[[Inflammatory bowel disease]]
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| *Pain with passing of stools
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| *Minimal [[bright red rectal bleeding]] on the toilet paper or stool
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| *On examination acute fissure appears as a fresh laceration
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| *Chronic fissure has raised edges with anal skin tag
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| *Clinical Diagnosis
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| |Thrombosed [[External Hemorrhoids]]
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| *Anal pain
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| *Anal [[pruritus]]
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| *[[Rectal bleeding]] with bowel movement
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| *Tenderness on examination with a palpable thrombus
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| *Clinical diagnosis
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| |[[Levator spasm]]
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| *Severe, intermittent episodes of rectal pain
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| *Seen in patients with perfectionistic, anxious somatic, and/or neurotic tendencies
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| *Severe anal pain lasting for seconds to 5 minutes
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| *Diagnosis is by Rome IV criteria
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| *It is diagnosis of exlusion
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| |[[Proctatitis]]
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| *Epithelial damage to the rectum secondary to radiation associated with minimal or no inflammation
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| *Radiation therapy
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| *Diarrhea within six weeks of radiation therapy
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| *Urgency
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| *Tenesmus
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| *Rectal bleeding.
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| *Biopsy
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| |[[Hidradenitis suppurativa]]
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| *Suppurative disorder of sweat glands
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| *Causes unidentified
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| *Anal pain
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| *Anal mass
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| *Recurrent and relapsing symptoms
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| *Nodules and scarring is demonstrated on examination
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| *Clinical Diagnosis
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| *Biopsy should be done to rule out cancer
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| |Infected skin [[furuncle]]
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| *Well-circumscribed, painful, suppurative inflammatory nodule involving hair follicles
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| *[[Staphylococcus aureus]]
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| *Anal pain
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| *Inflammed and red, tender elevated pustular lesion on examination
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| *Clinical diagnosis
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| |[[Bartholin's abscess]]
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| *Obstruction of the bartholin's duct, results in abscess formation
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| *E.coli
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| *Vulvar pain
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| *Palpable bartholin gland on examination
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| *Clinical diagnosis
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| *Incision and drainage
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| |}
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| ==Natural History, Prognosis, Complications==
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| ===Natural History===
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| 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.<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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| ===Prognosis===
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| 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.<ref name="pmid6468199">{{cite journal| author=Ramanujam PS, Prasad ML, Abcarian H, Tan AB| title=Perianal abscesses and fistulas. A study of 1023 patients. | journal=Dis Colon Rectum | year= 1984 | volume= 27 | issue= 9 | pages= 593-7 | pmid=6468199 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6468199 }} </ref>
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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:<ref name="pmid15933794">{{cite journal| author=Whiteford MH, Kilkenny J, Hyman N, Buie WD, Cohen J, Orsay C et al.| title=Practice parameters for the treatment of perianal abscess and fistula-in-ano (revised). | journal=Dis Colon Rectum | year= 2005 | volume= 48 | issue= 7 | pages= 1337-42 | pmid=15933794 | doi=10.1007/s10350-005-0055-3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15933794 }} </ref>
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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.<ref name="SteeleKumar2011">{{cite journal|last1=Steele|first1=Scott R.|last2=Kumar|first2=Ravin|last3=Feingold|first3=Daniel L.|last4=Rafferty|first4=Janice L.|last5=Buie|first5=W. Donald|title=Practice Parameters for the Management of Perianal Abscess and Fistula-in-Ano|journal=Diseases of the Colon & Rectum|volume=54|issue=12|year=2011|pages=1465–1474|issn=0012-3706|doi=10.1097/DCR.0b013e31823122b3}}</ref>
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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: <ref name="SteeleKumar2011">{{cite journal|last1=Steele|first1=Scott R.|last2=Kumar|first2=Ravin|last3=Feingold|first3=Daniel L.|last4=Rafferty|first4=Janice L.|last5=Buie|first5=W. Donald|title=Practice Parameters for the Management of Perianal Abscess and Fistula-in-Ano|journal=Diseases of the Colon & Rectum|volume=54|issue=12|year=2011|pages=1465–1474|issn=0012-3706|doi=10.1097/DCR.0b013e31823122b3}}</ref>
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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
| |
| </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===
| |
| *[[Anorectal abscess]] is a clinical diagnosis and physical examination is sufficient to make the diagnosis, therefore complete laboratory testing is not done in most of the patients.<ref name="SteeleKumar2011">{{cite journal|last1=Steele|first1=Scott R.|last2=Kumar|first2=Ravin|last3=Feingold|first3=Daniel L.|last4=Rafferty|first4=Janice L.|last5=Buie|first5=W. Donald|title=Practice Parameters for the Management of Perianal Abscess and Fistula-in-Ano|journal=Diseases of the Colon & Rectum|volume=54|issue=12|year=2011|pages=1465–1474|issn=0012-3706|doi=10.1097/DCR.0b013e31823122b3}}</ref>
| |
| *[[Complete blood count]] will demonstrate a [[neutrophilia]] and elevated [[ESR]].
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| *[[Bleeding time]] and [[clotting time]] and routine [[pre-operative evaluation]] must be performed.
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| *[[Culture]] and [[gram staining]] of the necrotic tissue is done to establish cause of infection.
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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]].<ref name="pmid23730047">{{cite journal| author=Sheikh P| title=Controversies in fistula in ano. | journal=Indian J Surg | year= 2012 | volume= 74 | issue= 3 | pages= 217-20 | pmid=23730047 | doi=10.1007/s12262-012-0594-5 | pmc=3397182 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23730047 }} </ref>
| |
| *[[Three dimensional ultrasound]] is useful in patients to identify the anatomical locations of complex perianal abscesses and [[fistula]] tracts.<ref name="pmid17237912">{{cite journal| author=Santoro GA, Fortling B| title=The advantages of volume rendering in three-dimensional endosonography of the anorectum. | journal=Dis Colon Rectum | year= 2007 | volume= 50 | issue= 3 | pages= 359-68 | pmid=17237912 | doi=10.1007/s10350-006-0767-z | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17237912 }} </ref>
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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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|
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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]].<ref name="pmid3881155">{{cite journal| author=Stewart MP, Laing MR, Krukowski ZH| title=Treatment of acute abscesses by incision, curettage and primary suture without antibiotics: a controlled clinical trial. | journal=Br J Surg | year= 1985 | volume= 72 | issue= 1 | pages= 66-7 | pmid=3881155 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3881155 }} </ref><ref name="SteeleKumar2011">{{cite journal|last1=Steele|first1=Scott R.|last2=Kumar|first2=Ravin|last3=Feingold|first3=Daniel L.|last4=Rafferty|first4=Janice L.|last5=Buie|first5=W. Donald|title=Practice Parameters for the Management of Perianal Abscess and Fistula-in-Ano|journal=Diseases of the Colon & Rectum|volume=54|issue=12|year=2011|pages=1465–1474|issn=0012-3706|doi=10.1097/DCR.0b013e31823122b3}}</ref>
| |
| *[[Antibiotics]] may be considered in patients with extensive [[cellulitis]], [[HIV infection]] and [[diabetes mellitus]].<ref name="SteeleKumar2011">{{cite journal|last1=Steele|first1=Scott R.|last2=Kumar|first2=Ravin|last3=Feingold|first3=Daniel L.|last4=Rafferty|first4=Janice L.|last5=Buie|first5=W. Donald|title=Practice Parameters for the Management of Perianal Abscess and Fistula-in-Ano|journal=Diseases of the Colon & Rectum|volume=54|issue=12|year=2011|pages=1465–1474|issn=0012-3706|doi=10.1097/DCR.0b013e31823122b3}}</ref>
| |
| *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.<ref name="pmid322789">{{cite journal| author=Macfie J, Harvey J| title=The treatment of acute superficial abscesses: a prospective clinical trial. | journal=Br J Surg | year= 1977 | volume= 64 | issue= 4 | pages= 264-6 | pmid=322789 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=322789 }} </ref><ref name="SteeleKumar2011">{{cite journal|last1=Steele|first1=Scott R.|last2=Kumar|first2=Ravin|last3=Feingold|first3=Daniel L.|last4=Rafferty|first4=Janice L.|last5=Buie|first5=W. Donald|title=Practice Parameters for the Management of Perianal Abscess and Fistula-in-Ano|journal=Diseases of the Colon & Rectum|volume=54|issue=12|year=2011|pages=1465–1474|issn=0012-3706|doi=10.1097/DCR.0b013e31823122b3}}</ref>
| |
| *[[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.<ref name="pmid17446442">{{cite journal| author=Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M et al.| title=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. | journal=Circulation | year= 2007 | volume= 116 | issue= 15 | pages= 1736-54 | pmid=17446442 | doi=10.1161/CIRCULATIONAHA.106.183095 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17446442 }} </ref><ref name="SteeleKumar2011">{{cite journal|last1=Steele|first1=Scott R.|last2=Kumar|first2=Ravin|last3=Feingold|first3=Daniel L.|last4=Rafferty|first4=Janice L.|last5=Buie|first5=W. Donald|title=Practice Parameters for the Management of Perianal Abscess and Fistula-in-Ano|journal=Diseases of the Colon & Rectum|volume=54|issue=12|year=2011|pages=1465–1474|issn=0012-3706|doi=10.1097/DCR.0b013e31823122b3}}</ref>
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| | |
| ===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.<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>
| |
| *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]]. <ref name="SteeleKumar2011">{{cite journal|last1=Steele|first1=Scott R.|last2=Kumar|first2=Ravin|last3=Feingold|first3=Daniel L.|last4=Rafferty|first4=Janice L.|last5=Buie|first5=W. Donald|title=Practice Parameters for the Management of Perianal Abscess and Fistula-in-Ano|journal=Diseases of the Colon & Rectum|volume=54|issue=12|year=2011|pages=1465–1474|issn=0012-3706|doi=10.1097/DCR.0b013e31823122b3}}</ref>
| |
| *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]].<ref name="SteeleKumar2011">{{cite journal|last1=Steele|first1=Scott R.|last2=Kumar|first2=Ravin|last3=Feingold|first3=Daniel L.|last4=Rafferty|first4=Janice L.|last5=Buie|first5=W. Donald|title=Practice Parameters for the Management of Perianal Abscess and Fistula-in-Ano|journal=Diseases of the Colon & Rectum|volume=54|issue=12|year=2011|pages=1465–1474|issn=0012-3706|doi=10.1097/DCR.0b013e31823122b3}}</ref>
| |
| ====Procedure====
| |
| *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]].<ref name="SteeleKumar2011">{{cite journal|last1=Steele|first1=Scott R.|last2=Kumar|first2=Ravin|last3=Feingold|first3=Daniel L.|last4=Rafferty|first4=Janice L.|last5=Buie|first5=W. Donald|title=Practice Parameters for the Management of Perianal Abscess and Fistula-in-Ano|journal=Diseases of the Colon & Rectum|volume=54|issue=12|year=2011|pages=1465–1474|issn=0012-3706|doi=10.1097/DCR.0b013e31823122b3}}</ref>
| |
| *After [[incision]] is made the [[necrotic tissue]] is removed and [[loculations]] are broken using a [[hemostat]] or a finger.<ref name="SteeleKumar2011">{{cite journal|last1=Steele|first1=Scott R.|last2=Kumar|first2=Ravin|last3=Feingold|first3=Daniel L.|last4=Rafferty|first4=Janice L.|last5=Buie|first5=W. Donald|title=Practice Parameters for the Management of Perianal Abscess and Fistula-in-Ano|journal=Diseases of the Colon & Rectum|volume=54|issue=12|year=2011|pages=1465–1474|issn=0012-3706|doi=10.1097/DCR.0b013e31823122b3}}</ref>
| |
| *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>
| |
| *Regular [[sitz bath]] is recommended after the surgery, it will help in local cleansing and wound healing.
| |
| *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]].<ref name="pmid27699001">{{cite journal| author=Hasan RM| title=A study assessing postoperative Corrugate Rubber drain of perianal abscess. | journal=Ann Med Surg (Lond) | year= 2016 | volume= 11 | issue= | pages= 42-46 | pmid=27699001 | doi=10.1016/j.amsu.2016.09.003 | pmc=5037211 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27699001 }} </ref>
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| | |
| ====Complications====
| |
| *[[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.<ref name="pmid9247434">{{cite journal| author=Cox SW, Senagore AJ, Luchtefeld MA, Mazier WP| title=Outcome after incision and drainage with fistulotomy for ischiorectal abscess. | journal=Am Surg | year= 1997 | volume= 63 | issue= 8 | pages= 686-9 | pmid=9247434 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9247434 }} </ref><ref name="pmid11598476">{{cite journal| author=Onaca N, Hirshberg A, Adar R| title=Early reoperation for perirectal abscess: a preventable complication. | journal=Dis Colon Rectum | year= 2001 | volume= 44 | issue= 10 | pages= 1469-73 | pmid=11598476 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11598476 }} </ref><ref name="pmid3792160">{{cite journal| author=Held D, Khubchandani I, Sheets J, Stasik J, Rosen L, Riether R| title=Management of anorectal horseshoe abscess and fistula. | journal=Dis Colon Rectum | year= 1986 | volume= 29 | issue= 12 | pages= 793-7 | pmid=3792160 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3792160 }} </ref><ref name="SteeleKumar2011">{{cite journal|last1=Steele|first1=Scott R.|last2=Kumar|first2=Ravin|last3=Feingold|first3=Daniel L.|last4=Rafferty|first4=Janice L.|last5=Buie|first5=W. Donald|title=Practice Parameters for the Management of Perianal Abscess and Fistula-in-Ano|journal=Diseases of the Colon & Rectum|volume=54|issue=12|year=2011|pages=1465–1474|issn=0012-3706|doi=10.1097/DCR.0b013e31823122b3}}</ref>
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| *[[Urinary retention]]
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| *Postoperative [[bleeding]]
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| ==Prevention==
| |
| ===Primary Prevention===
| |
| *Abstain from anal intercourse
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| *Adequate treatment of Crohn's disease and HIV infection
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| *Maintaining proper hygiene
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| ===Secondary Prevention===
| |
| *Early incision and drainage, with regular sitz bath is adviced in all patients.
| |
| *Identification of pre-existing fistula tract and fistulotomy during incision and drainage decreases the risk of recurrence and fistula formation.
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|
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|
| ==References== | | ==Case Studies== |
| {{Reflist|2}}
| | [[Roseola case study one|Case #1]] |