PERIANAL ABSCESS

Anorectal anatomy
Cryptoglandular

origin 6- 14 glands where internal and external anal sphincters meet Glands drain into crypts at Dentate line

 Obstruction

of crypt

Fecal matter Trauma polyp

Infection abscess

Symptoms and signs

Severe

anal pain

Continuous Worse with ambulation/ straining

Discharge

fever

examination
Palpable

mass

Warm Painful Semi soft

complications
Sepsis Fistulas

Pain decreases Discharge Different directions

Outward Inward

(muscle, vagina, urethra, prostate, bladder)

treatment
Drain

abcess Antibiotics
fistulotomy

HEMORROIDS
External

H. Internal H.

Signs and symptoms

Sudden,

severe pain Bright red blood Perianal mass Rectal fullness Mucus discharge

Visible mass Palpable mass soft Retractable Non- retractable Edema Gangrenous Skin tag from previous H.

treatment
Diet

Liquids fiber Avoid constipating food

Exercise Avoid

straining Avoid too much time on the commode

Advanced treatment
Band

Ligation Sclerosis cryosurgery hemorrhoidectomy

ANAL FISSURE
Split

in posterior anoderm (90%) CAUSES: Straining

Hard,

large fecal matter

trauma

Signs and symptoms

Tearing pain on defecation Spasm after defecation lasts hours

Red blood Skin atrophy Fear of pain

ischemia

Constipation

Ignore urge to deffecate Harder stool (fecal matter)

Common in ER

inspection

MUSCLE

SPASM MIDLINE FISSURE SKIN TAG

TREATMENT
STOOL

SOFTENER SITZ BATH

BOTULINUM

TOXIN NITROGLYCERIN OINTMENT

NO RELAXES MUSCLE, DILATES BLOOD VESSELS

 INTERNAL

SPHINCTEROTOMY

CUT INTERNAL SPHINCTER

INCONTINENCE?
GAS

PILONIDAL CYST
INFECTED

HAIR FOLLICLE ABSCESS HIRSUTE MALES

Tx:

Qx

CLINICAL CASE Present Illness

A

40year old male presents with fever (2 weeks) and superficial abdominal and back pain. He feels bubbles under the abdominal skin.

ID
MCO

40years
Trailer

Driver No religion Studied 6th grade Resident of Morelia, Mich.

FAMILY HISTORY
Father

died of heart attack Mother diabetic

Personal History
Good nutrition Bath every day Plays soccer 1/week

Smokes 3cigarrettes/ week for 15years 3 drinks 1/ month

No allergies

Clinical History
Chicken Asthma Qx:

pox at age 8 since age 12 tx salbutamol

inguinal hernioplasty at age 14

Anal

abscess 2 months ago tx oral antibiotic for 2 weeks

Review of Systems
General:

Fever 2 weeks, lost 3 Kg in 2 weeks, weakness, anxiety last asthma attack 6

Respiratory:

years ago

Gatrointestinal:

constipation sometimes, feces sometimes with white liquid material

 Genitourinary:

no urinary symptoms 4 sexual partners in last 2 years, bisexual Hematological: no symptoms Endocrine: no symptoms Neurological: occasional headaches tx with aspirin, often stress and anxiety

 Musculoskeletal: Skin

no symptoms

and nails: pain under abdominal and back skin for 2 weeks, crepitant skin

Physical Exam
1.72m,

70Kg 130/70 mmHg Temp. 37.8 C Heart rate 88/min Respiratory rate 20/min

general
Pale

skin color Anxious

Head and Neck

Pale

skin Nose and pharynx OK Neck OK

Thorax

Abdomen
Reddened,

warm skin on right side of abdomen, crepitant skin subcutaneous emphysema Painful
Same

on skin in back and right gluteal skin

Genital / perineal/ perianal area

Reddened

perineum 4x3cm mass on right gluteus, painfull when compressed Reddish skin on right gluteus, appears gluteal inflammation Rectal exam reveals wood-like material on sides

Extremities
Reddened,

crepitant skin on right leg, on the posterior and inner portions, painful when touched movement OK

Preliminary Dx
?

Labs
Complete

Blood Count CBC

Hb 14 mg/dL HTC 42 % WBC 16000/mm3 PLT 230000/mm3

Abdominal x-ray
Air

under skin

Subcutaneous emphysema

Blood culture
Staphilococcus

aureus

Skin biopsy
Necrotic

tissue