Presentation

Topic : Anorectal abscess

Department of surgery
Swornim Gyawali
Intern GMC
 Todays objective
• Patient complaint and clinical finding
• Differential diagnosis
• Workup
• Ano-rectal anatomy review
• Topic discussion
• Management
 Patient complaints of :
• dull perianal discomfort and pruritus

• exacerbated by movement and increased perineal

pressure from sitting or defecation

• present with swelling around the rectum

• perirectal drainage that may be bloody, purulent, or

mucoid

( note: ischiorectal abscess often present with systemic

fevers, chills, and severe perirectal pain)
 On examination:
• normal vital signs on initial evaluation

• Physical examination: a small, erythematous,

well-defined, fluctuant, subcutaneous mass
near the anal orifice

• DRE: a fluctuant, indurated mass may be

encountered
 Differential diagnosis
Likely Diagnosis of Anorectal Pain
Pain Alone Pain and Lump Pain and Bleeding Pain with Lump
and Bleeding
• Anal Fissure • Perianal Hematoma • Anal Fissure • Hemorrhoids
• Anusitis • Strangulated • Proctitis • Ulcerated
• Ulcerative Proctitis Internal Hemorrhoid Perianal
• Proctalgia Fugax • Abscess Hematoma
• Pilonidal Sinus

Pain, bleeding, Pain with Lump, Pus Pain with Lump, Pus Pain with
with/without Pus Draining, Draining, and Bleeding Lump, Pus
Draining with/without Draining,
Bleeding Bleeding, and
Necrotic
Tissue

Perianal Crohn’s Hidradenitis Fistula-in-Ano Fournier’s

Disease Suppurativa Perianal Tumors Gangrene
 Workup/Investigations :
• CBC with differential : may show leukocytosis
• Pus cultures
• Blood cultures
• confirmation by means of anal
ultrasonography, CT or MRI
• Plain x-rays little clinical significance
 Anorectal Abscess
infection arising in the cryptoglandular
epithelium lining the anal canal
Anatomy review
Types /classification
1. Perianal (60%) :of suppuration in an anal
gland
2. Ischorectal (30%): extension laterally through
the external sphincter
3. Submucous
4. Pelvirectal : situated between the upper
surface of the levator ani and the pelvic
penitoneum
5. Fissure abscess
Classification
 Etiology
• Non specific :Cryptoglandular in origin.

• Specific :
1. Infection : E.coli , Staph. , strep. , Bacteroids
2. Irritation : Crohn’s disease, ulcerative colitis, FB
3. Immune compromised state : DM,AIDS,malignancy
4. Others : TB, STDs, Radiation therapy,
 PATHOPHYSIOLOGY
Originates from an infection arising in the
crypto glandular epithelium lining the anal
canal

The internal anal sphincter normally serves

as a barrier to infection passing from the gut
lumen to the deep perirectal tissues.

This barrier can be breached through the

crypts of Morgagni, which can penetrate
through the internal sphincter into the
intersphincteric space
 PATHOPHYSIOLOGY

Once infection gains access to the

intersphincteric space, it has easy
access to the adjacent perirectal
spaces

Extension of the infection can

involve the intersphincteric
space 2–5%, ischiorectal space
20-25% , or even the
supralevator space 2.5%.
 Epidemology
• May resolve itself
• third and fourth decades of life
• quite common in infants too
• Men are affected more frequently than
women 2:1 – 3:1
• relation between the formation of ano-rectal
abscesses and bowel habits
 Management
• Early surgical drainage of the purulent
collection
• Primary antibiotic therapy alone is ineffective
• Any delay : augments tissue damage, may
impair sphincter continence function,
promote stricture and/or fistula formation
• Ability to drain an anorectal abscess depends
on patient comfort and on the location and
accessibility of abscess.
 Drainage of perianal or superficial
abscesses

A small cruciate incision is made over the area of fluctuancy in

close proximity to the anal verge.

Pus is collected and sent for culture. Hemostasis is achieved with

manual pressure, and the wound is packed with iodophor gauze.

The gauze is removed after 24 hours, and the patient is instructed

to take sitz baths 3 times a day and after bowel movements.
 Post operative
• analgesics and stool softeners are prescribed
to relieve pain and prevent constipation.
• Antibiotic therapy when indicated– to cover
aerobes and anaerobes e.g. ciprofloxacin 500
mg PO 2x daily for 5 days
• follow up: 2-3 weeks for wound evaluation
and inspection for possible fistula-in-ano.
 COMPLICATIONS
Fistula-in-Ano
Fournier’s Gangrene
Death
Carcinoma
Fecal Incontinence
 PROGNOSIS

Drainage alone results in cure for

50%.

50% will have recurrences and

develop an anal fistula.
 Thank you !!!
• Refrences
Bailey & Love's Short Practice of Surgery 25th
edition
Manipal manual of surgery 3rd edition
SRB’s manual of surgery 4th edition