Anorectal abscess: Difference between revisions
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| '''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 | | '''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 | | '''Comments'''||High incidence of [[anal fistula|fistula]] formation even with drainage||||Constitutional symptoms often present | ||
|} | |} | ||
===Risk Factors=== | ===Risk Factors=== | ||
*[[ | *[[Crohn's disease]] | ||
*Chronic [[constipation]] | *Chronic [[constipation]] | ||
*[[Diabetes mellitus]] | *[[Diabetes mellitus]] | ||
| Line 24: | Line 24: | ||
==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 | **May only be palpable via digital rectal exam | ||
*Tender inguinal | *Tender inguinal [[lymphadenopathy]] may be only clue to deeper abscesses | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Anorectal DDX}} | {{Anorectal DDX}} | ||
{{SSTI DDX}} | |||
==Evaluation== | ==Evaluation== | ||
| Line 36: | Line 37: | ||
==Management== | ==Management== | ||
*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 | **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''' | ||
*Elderly | *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> | ||
*Systemic signs (fever, leukocytosis) | **Elderly | ||
*Valvular heart disease | **Systemic signs ([[fever]], [[leukocytosis]]) | ||
*Cellulitis | **[[Valvular heart disease]] | ||
*Immunosuppression | **[[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> | |||
Treatment options: | '''Treatment options:''' | ||
*[[Augmentin]] | |||
*[[Ciprofloxacin]] 500mg PO BID '''and''' [[Metronidazole]] 500mg PO TID | *[[Ciprofloxacin]] 500mg PO BID '''and''' [[Metronidazole]] 500mg PO TID | ||
==Disposition== | ==Disposition== | ||
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
- Crohn's disease
- Chronic constipation
- Diabetes mellitus
- Chronic corticosteroid use
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
- Anal fissure
- Anal fistula
- Anal malignancy
- Anal tags
- Anorectal abscess
- Colorectal malignancy
- Condyloma acuminata
- Constipation
- Crohn's disease
- Cryptitis
- GC/Chlamydia
- Hemorrhoids
- Pedunculated polyp
- Pilonidal cyst
- Proctitis
- Pruritus ani
- Rectal foreign body
- Rectal prolapse
- Syphilitic fissure
Skin and Soft Tissue Infection
- Cellulitis
- Erysipelas
- Lymphangitis
- Folliculitis
- Hidradenitis suppurativa
- Skin abscess
- Necrotizing soft tissue infections
- Mycobacterium marinum
Look-A-Likes
- Sporotrichosis
- Osteomyelitis
- Deep venous thrombosis
- Pyomyositis
- Purple glove syndrome
- Tuberculosis (tuberculous inflammation of the skin)
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
- Only recommended in high risk patients:[1][2]
- Elderly
- Systemic signs (fever, leukocytosis)
- Valvular heart disease
- Cellulitis
- Immunosuppression
- Possibly prevent fistula formation in otherwise healthy patients[3]
Treatment options:
- Augmentin
- Ciprofloxacin 500mg PO BID and Metronidazole 500mg PO TID
Disposition
Discharge
- Perianal abscess
See Also
External Links
References
- ↑ BMJ Best Practice Anorectal abscess http://bestpractice.bmj.com/best-practice/monograph/644/treatment/step-by-step.html
- ↑ Guidelines.gov - Practice parameters for the management of perianal abscess and fistula-in-ano.http://www.guideline.gov/content.aspx?id=36077
- ↑ 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.