Radya Agna Nugraha

1610211011
Tutorial C3
• Rektum memiliki panjang 12-15 cm
• Terdapat linea dentata atau pectinate yang
membatasi transisi dari epitel kolumnar mukosa
rektum dengan epitel skuamousa dari anoderm.
Daerah mukosa 1-2 cm proksimal dari linea
dentata memiliki epitel kolumnar, kuboidal, dan
squamous. Daerah ini disebut dengan “anal
transition zone”.
• Linea dentata ini dikelilingi oleh lipatan mukosa
longitudinal, yang disebut dengan “columna
morgagni”, dimana pada lokasi ini terdapat kripta
anal. Kripta anal inilah yang merupakan sumber
abses  Spread to the anal duct and gland 
submucose,subcutaneus,or transsfingter
(sourrounding tissue)
 Anorectal abscess (also known as an anal/rectal abscess, or perianal/perirectal
abscess) is an abscess adjacent to the anus. It arises from an infection at one of the
anal sinuses which leads to inflammation and abscess formation.
 Abses Anorectum adalah rongga abnormal berisi cairan di daerah anorektum.
(Harrison,192)
 Pria > Wanita
3:1
 Insidensi puncak pada dekade ke 3-5 kehidupan.
 Orang2 dengan imunitas rendah : DM & HIV
 Inflamatory Bowel Disease
 Medication that supress the body’s immune
 Sexually transmitted
 Both aerobic and anaerobic bacteria have been found to be responsible for abscess
formation.
 The anaerobes most commonly implicated are Bacteroides fragilis,
Peptostreptococcus, Prevotella, Fusobacterium, Porphyromonas, and Clostridium.
 The aerobes most commonly implicated are Staphylococcus aureus, Streptococcus,
and Escherichia coli.
 More recent studies have noted community-acquired methicillin-resistant S aureus
(MRSA) as a pathogen leading to abscess formation.
 Approximately 10% of anorectal abscesses may be caused by reasons other than
anal gland infection, including Crohn disease, trauma, immunodeficiency resulting
from HIV infection or malignancy (both hematologic and anorectal cancer),
tuberculosis, hidradenitis suppurativa, sexually transmitted diseases, radiation
therapy, foreign bodies, perforated diverticular disease, inflammatory bowel disease.
 Anorectal abscesses are classified according to their anatomic location; the following
are the most common locations :
 Perianal 40-50%
 Ischiorectal 20-25%
 Intersphincteric 2-5%
 Supralevator <2% (2,5%)
 Submucosal (1%)
 Perianal abscesses represent the most common type of anorectal abscesses,
accounting for approximately 60% of reported cases. These superficial collections of
purulent material are located beneath the skin of the anal canal (dibawah kulit lubang
anus) and do not transverse the external sphincter.
 Ischiorectal abscesses are the next most common type. These abscesses form when
suppuration transverses the deep external anal sphincter into the ischiorectal
space. An ischiorectal abscess may traverse the deep postanal space into the
contralateral side, forming a so-called horseshoe abscess.
 Intersphincteric abscesses, the third most common type, result from suppuration
contained between the internal and external anal sphincters. They may lie
completely within the anal canal, leading to severe pain, and may only be found by
digital rectal examination or anoscopy.
 Supralevator abscesses, the least common of the four major types, may form from
cephalad extension of the intersphincteric abscess above the levator ani or from
caudal extension of a suppurative abdominal process (eg, appendicitis, diverticular
disease, gynecologic sepsis) into the supralevator space. These abscesses may be
diagnosed by means of computed tomography (CT), and they cause pelvic and rectal
pain.
 Pain in the perianal area is the most common symptom of an anorectal abscess.
 Demam sistemik
 Swelling
 Eritem Jika terletak di Submucose dan
 Tenderness Subcutan

 Puss
 Anamnesis  HistoryTalking
 Px Fisik
 Px Penunjang
 Diff count  Infeksi
 Colok Dubur/Rectal Touche
 CT, Ultrasonography, and MRI  clinical
suspicion of an intersphincteric or
supralevator abscess may require
confirmation by means of CT, anal
ultrasonography, or MRI
 Pharmacology therapy
 Antibiotik
 The need for routine use of antibiotics in patients with anorectal abscesses has
not been established; they have not been shown to improve healing times or
reduce recurrence rates. In most of these patients, therefore, adjuvant medical
therapy with antibiotics is considered unnecessary. However, concomitant use
of antibiotics may be warranted in patients with conditions such as the following :
 Systemic inflammatory response or sepsis
 Extensive cellulitis
 Diabetes
 Immunosuppression
 Heart valve abnormalities or prostheses
 Clindamycin (Cleocin)
 Clindamycin is a semisynthetic antibiotic produced by 7(S)-chloro-substitution of the
7(R)-hydroxyl group of the parent compound, lincomycin. It inhibits bacterial growth,
possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-
dependent protein synthesis to arrest. Clindamycin is widely distributed in the body
without penetrating the central nervous system (CNS).
 Ampicillin
 Ampicillin, a broad-spectrum penicillin, interferes with bacterial cell-wall synthesis
during active replication, causing bactericidal activity against susceptible
organisms.
 Cefazolin
 Cefazolin is a first-generation semisynthetic cephalosporin that binds to one or
more penicillin-binding proteins, arresting bacterial cell wall synthesis and inhibiting
bacterial replication
 Ampicillin-sulbactam (Unasyn)
 Ampicillin-sulbactam represents a combination of a beta-lactamase inhibitor with a
penicillin. It interferes with bacterial cell-wall synthesis during active replication,
causing bactericidal activity against susceptible organisms.
 Analgesik
 Meperidine (Demerol, Meperitab)
 Meperidine is an analgesic with multiple actions similar to those of morphine; it may produce
less constipation, smooth muscle spasm.
 Surgical Intervention
 Treatment of anorectal abscesses involves early surgical drainage of the purulent
collection.
 When the abscess is perianal or superficial, drainage can usually be accomplished in
with local anesthesia.
 Treatment of ischiorectal, intersphincteric, and supralevator abscesses typically
requires general or regional anesthesia.
 To drain an ischiorectal abscess, a cruciate incision is made at the site of maximal
swelling. Pus is drained and cultured. The ischiorectal fossa is probed with a finger or
hemostat to disrupt loculations and facilitate drainage. Placement of a drain is
indicated only for the management of complex or bilateral abscesses.
 To drain an intersphincteric abscess, a transverse incision is made in the anal canal
below the dentate line posteriorly. The intersphincteric space is identified, and the
plane between the internal and external sphincters is exposed. The abscess is
opened to allow drainage, and a small mushroom catheter is sutured in situ to assist
drainage and prevent premature wound closure.
 The optimal drainage technique for a supralevator abscess is determined by the
location and etiology of the lesion. Evaluation with magnetic resonance imaging (MRI)
or computed tomography (CT) can exclude intra-abdominal or pelvic pathology as
possible sources.
 Fistula  komunikasi suatu rongga
abses dengan lubang interna di
rongga anus. Fistula anorektal timbul
oleh karena obstruksi dari kelenjar
dan/atau kripta anal, dimana ia
dapat diidentifikasi dengan adanya
sekresi purulen dari kanalis anal
atau dari kulit perianal sekitarnya
 Klasifikasi menurut Parks dan
persentase fistula anorektal adalah:
 1. Intersfingerik 70%
 2. Transfingterik 23%
 3. Ekstrasfingterik 5%
 4. Suprasfingterik 2%6
 Overall mortality from anorectal abscesses is quite low.
•Whiteford MH. Perianal abscess/fistula disease. Clin Colon Rectal Surg. 2007 May. 20(2):102-9.
[Medline]. [Full Text].

•Marcus RH, Stine RJ, Cohen MA. Perirectal abscess. Ann Emerg Med. 1995 May. 25(5):597-603.
[Medline].

•Pfenninger JL, Zainea GG. Common anorectal conditions: Part II. Lesions. Am Fam Physician.
2001 Jul 1. 64(1):77-88. [Medline].

•Rizzo JA, Naig AL, Johnson EK. Anorectal abscess and fistula-in-ano: evidence-based
management. Surg Clin North Am. 2010 Feb. 90 (1):45-68, Table of Contents. [Medline].

•Parks AG, Gordon PH, Hardcastle JD. A classification of fistula-in-ano. Br J Surg. 1976 Jan.
63(1):1-12. [Medline].