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ANO-RECTAL ABSCESS

I MADE MAHAYASA
DEPARTMENT OF SURGERY SANGLAH GENERAL
HOSPITAL DENPASAR
INTRODUCTION
Evaluation and treatment of ano-
rectal abscess required the
understanding of anal anatomy
Understanding the anatomy helps
determine the origin and the
subsequent course helps to
therapeutic intervention.
ANATOMY

Anal verge is the true


distal anal canal
Anal verge is demarcation
between skin of the anal
canal margin and the
anoderm
Midway up the anal canal
lies the dentate line
Anal gland present at the
level dentate line
Anal gland are etiology of
the most ano-rectal
abscess
ANATOMY

The inner circular muscle of


the rectal wall become the
internal sphincter
Internal spincter muscle is
encircled by external
sphincter muscle, puborental
sling and levator
Two layer are separated by
fibrous extension of the
outer longitudinal muscle of
the rectum
The lower border this plane
in intersphincteric groove
The intersphincteric groove
can be palpated at the lower
border of the sphinceric
complex
ETIOLOGY
Most peri-rectal abscess
originated from an infected anal
gland
Anal gland are in the base of the
anal crypt
Extend down into the internal
sphincter and up to and the inter-
sphincteric groove
Obstruction of the gland lead
stasis, bacterial overgrowth, and
ultimate abscess that located at
inter sphincteric groove
Approximately 10% of ano-rectal
abscess not doe to infected anal
glands
Specific causes as Crohn disease,
trauma, human
immunodeficiency, virus,
sexually transmitted disease,
radiation therapy or foreign body
ETIOLOGY OF ANORECTAL
ABSCESS
Nonspecific
Cryptoglandular
Specific
Inflammatory bowel disease
Crohns disease
Ulcerative colitis
Infection
Tuberculosis
Actinomycosis
Lymphogranuloma venereum
Trauma
Impalement
Foreign body
Surgery
Episiotomy
Hemorrhoidectomy
Prostatectomy
Malignancy
Carcinoma
Leukemia
Lymphoma
Radiation

Vasilevsky CA. The ASCRS Textbook of Colon and Rectal


ANO-RECTAL SPACES

Vasilevsky CA. The ASCRS Textbook of Colon and Rectal


Surgery: 2007; 192-214
ROUTE of the ABSCESS
The most common are
downward to the
anoderm (perianal
abscess)
Across the external
sphincter into
ischiorectal fossa
Less common via
intersphicteric groove to
the supralevator
Circumferencial spread
(intersphincteric,
ischiorectal,
supralevator)
Held (1986). Dis Colon
CLASSIFICATION of ANO-RECTAL
ABSCESS
Abscess are classified to
their location
Perianal abscess is the
most common
Supralevator is the rarest
Pus also can spread
circumferentially
Horseshoe abscess is
abscess which spreading
via deep postanal space
FREQUENCY (%) OF SITES OF ANORECTAL SEPSIS

Anorectal abscess in Surgery of the Anus, Rectum and


Colon (1993):397-417
SYMPTOMS

Pain
Swelling
Fever
Supralevator and intersphincteric abscess
- Gluteal pain
- Rectal pain
- Urinary symptom
- dysuria
- retention
- inability to void
Rectal bleeding
PHYSICAL EXAMINATION
Inspection
Erythema
Sweliing
Fluctuation
Excruciating pain without external manifestation
Beware intersphincteric or supralevatos abscesses
DRE and vaginal examination
Tenderness
Mass
Anoscopy and sigmoidoscopy examination
DIAGNOSIS

Arise indolent onset acute anal pain


Localized swelling
Erythema
Fluctuance
If diagnosis is not clear , examination
under anesthesia
ANAL ULTRASONOGRAPHY

Proved the position of abscesses


preoperatively
Determine the relationship between
the abscess and the sphincter muscle
Only 28% fistula identified by intra
rectal ultrasonography
An alternative to fistulogrqphy

Cataldo PA. Dis Colon Rectum


1993;36:554
DIFFERENTIAL DIAGNOSIS
Thromboses hemorrhoid
Perianal cellulitis
Bartholin abscess
Hidradenitis suppurativa
Anal fissured
Malignancy
Inflamatory bowel disease
TREATMENT

GENERAL PRINCIPLE
Incision and adequate drainage
Close to the anus
Possible to shorten the length to subsequent fistula tract.

BEWARE
Acute recurrent in 10% cases
Chronic fistula occurs up to 50% cases
Watcfull and waiting under cover antibiotic is ineffective
Suppurative progress make more complicated abscess
Possible injured to the sphincter mechanism
Delay management can caused life-threathening necrotizing
infection
TREATMENT

Most perianal abscess treated as office procedure.


Operating theatre are for
- failed with office procedure
- cellulitis without fluctuance
- abscess with systemic sign
- extensive abscess
- systemic symptom
- immunocompromised - chronic medical
immunosuppression
- diabetes mellitus - cancer therapy
- aquired immunodefficiency syndrome
TREATMENT

Where the location of the abscess ?


The main treatment is to drain it !
How the surgeon to drain it ?
PERIANAL ABSCESS

The sugery is usually as


outpatient
Incision in the most
prominent of the abscess
Flap on the skin trimmed
Abscess scraped (digitally)
and flush out
Pus is sent for culture
CATHETER DRAINAGE

No severe sepsis or
no serious systemic
illness
Office treatment
Incision close as
possible to anus
INTERSPHINCTERIC ABSCES)

Performed in OT
Under regional or
general anesthesia
Incision into canal
lining
Drain the abscess
down through
internal sphincter
muscle
ISCHIOANAL ABSCESS
(between the Ischium and Anus or Rectum )
Drain in the OT
Under regional or general
anesthesia
Small abscess treats similar
to perianalabscess
Wide local drainage
Sometime abscess are
sufficiently deep
Abscess can progress to
spread to one or both side
(horseshoe)
Neglected abscesses can
lead to necrotizing infection
HANLEYS PROCEDURE
Drainage of horseshoe
abscess
The location of the abscess
is often in the deep
postanal space
Access by midlinee incision
between the coccyx and
anus
An openingis made
posterior midline
Counter incision are made
over ischioanal fossa
SUPRALEVATOR ABSCESS
(above the levator muscle)

Drain depend on the origin


of the abscess
Intersphincteric abscess
upward drain it to the
rectum
Iscioanal abscess upward
drain it to ischioanal
fossa through the skin
Due to intraabdominal
(such Crohn disease or
divertikulitis) drain to
treat the disorder
SUPRALEVATOR
(internal drainage)

Aspiration
culture
Incision into
cavity
Insert Pezzer or
Foley catheter
SUPRALEVATOR
(internal drainage)

Internal drainage is
performed
transvaginally
Needle aspiration
Insertion the
catheter into the
cavity
SUPRALEVATOR ABSCESS
(external drainage)

Incision should be
as medial as
possible
Inserted catheter
for drainage
Unusual approach
(eq. For secondary
to Crohns disease
NECROTIZING INFECTION

Delay diagnosis and treatment


Associated with
- diabetes mellitus
- immunocompromized patients
Treatment required :
- antibiotics
- nutritional support
- wide debridement
- adequate drainage
Usually need proximal diversion

Invasive necrotizing infection secondary to anorectal


abscess. Dis Colon
Rectum 1982;25:416
PRIMARY FISTULOTOMY

Fistulotomy at the same time with abscess drainage


Proponent:
The incidence of fistula and recurrent abscess is high ( up to 50%)
Fistula superficial and internal opening easily identified
Curative and avoid next fistula surgery and second hospitalization
Recurrent sepsis 3% and final incotinence 39%
Opponent
2/3 abscess never progress to fistula
Difficult to distinguish a high or low fistula.
Primary fistulotomy potential complication unneccessary
Recurrent sepsis 41% and final incotinence 21%
Prudent policy
Candidate primary fistulotomy is uncomplicated anorectal abscess,
and the tract is superficial.
Delayed fistulotomy until fistula become manifest can lower
morbidity

Whiteford MH. Clinic in Colon and Rectal Surgery


2007;20:102-109
Shouten WR. Dis Colon Rectum 1991:34;60-63
Anorectal abscess in Surgery of the Anus, Rectum and
Colon(1993):397-417
The need of colostomy ?
It is debatable

Has been recommeded colostomy if :


Sphincter muscle grossly infected
Colon or rectal peforation
Rectal wound is large
Immunocompromized patient
Incontinent is present
THE ROLE of ANTIBIOTIC
Unneccessary for uncomplicated abscess
Have not to improve healing time
Not reduce recurrent rate
Used during surgical drainage
Consider for patient with high risk condition
- diabetes
- immunocompromized
- extensive cellulitis
- prosthetic divices
- immunosuppresion
Anorectal abscess in Surgery of the Anus, Rectum and Colon
(1993):397-417
RECURRENT ABSCESS

Failure to identify an internal opening


Inadequate the extent of the abscess
Spontaneous rupture
Present the underlying disease
Dr.Sutomo General
Hospital Experience
2006-2010
Mean Age
Male : 42 years old
Female : 51 years old

Mean Time of Complain : 16 days


Mean post operative Length of stay : 4
days
Chief Complain
Location of Abcess
Proctoscopy
Internal opening
found :
2 pts
incision+drainage
+ fistulectomy
1 pt
incision+drainage
+seton
Procedures
Pus Culture
THANK YOU