Abscesses – Peri anal v peri rectal

  • presentation is most consistent with
  •  perianal abscess.
Skin exam reveals Overlying cellulitis with surrounding induration and fluctuance in the middle. Abscess is Already open and draining purulent discharge.
Systemically, patient has no signs or symptoms of systemic infection specifically no fever, no tachycardia, no leukocytosis and well-appearing.
Therefore advised for Incision and drainage by the ED given that this appears to be a perianal abscess without proximity to rectal sphincter that an incision worried because injury to the sphincter.
Analgesia provided with prescription for Norco and patient advised to take ibuprofen at home initially. Patient advised not to drink drive or take other Tylenol-containing substances.
Unfortunately patient declined incision and drainage. Risk of infection worsening given lack of source control is significant and patient informed if this however has capacity and therefore we will oblige his request. Patient has primary care physician and plans to follow-up with PMD.
  • Peri-rectal implies deep in rectum, requires CT, likely operative source control given extent of depth. 
  • Peri-anal implies just around anal region. Can be excised if and only if it does not communicate with the sphincter (based upon exam) and that there is no tenederness/fluctuance on digital rectal exam (to exclude fistula)). 


Anorectal diseases
  • Anorectal abscess
    • //originate at crypts at dentate line//
    • simple:
      • peri-anal
        • we can drain as long as not too close to spincter
        • Peri-anal implies just around anal region. Can be excised if and only if it does not communicate with the sphincter (based upon exam) and that there is no tenederness/fluctuance on digital rectal exam (to exclude fistula)). 
        • tx
          • Sitz bath
          • high fiber diet (gradual increase to prevent cramping)
          • pain meds
            • toradol
            • norco
            • no abx given no immunocompromised, no overlying cellulitis, DM, valvular disease
      • ischioanal (peri-rectal)
        • we can drain as long as not deep
        • tx 
          • I&D //pt should be constented, 50% develop fistula
    • complex
      • intersphincteric
        • inside, just outside of dentate line, feel fullness on rectal exam,
        • nothing on outside //which is what is distringuishes from peri-anal/ischioanal
        • DRE reveals fullness
        • OR drain
      • supralevator
        • very high up
        • needs CT for
          • dfficulty urinating
          • abdominal pain
        • operative treatment
          • no I&D if ANC <1k (won’t heal, would try empiric abx)
    • Hx:
      • duration
      • f/c
      • bleeding
      • PMH
        • Chron’s
        • immunosuppresed
        • recurrence
    • Exam
      • DRE (if not limited by exam)
      • rubor, calor, dolor, tumor (swelling)
      • //describe w/ anteror/posterior, pt’s R/L (don’t use clock)
    • Tx
      • I&D at site of max pain
  • Hemorrhoids
    • External
      • painful
      • Tx
        • lidocaine/hydrocortisone cream (analpram)
        • sitz bath
        • high fiber diet
        • non-operative repair
        • No suppositories
      • Thrombosed external hemorrhoid
        • abrupt onset
        • very painful
        • blueish lump
        • tx
          • pain peaks at 48 hrs
          • excise if <48 hrs after onset of sx
          • no excision if > 48 hrs of onset
    • internal 
      • painless
      • grading 1-4
      • incarcerated
      • strangulated
        • surgical emergent if out and not reducible
    • Note sugar doesn’t help reduce
  • rectal prolapse
    • sugar to reduce
    • reduce








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 Given that the examination is consistent with a perianal abscess , there’s no evidence of deep tissue infection, rectal exam does not reveal intersphincteric involvement , and there is no evidence of deeper track into the women of the rectum and abscesses below the dentate line, and incision and drainage was performed in the emergency department.

Quote from.question bank peer 9
 uncomplicated perianal abscesses below dentate line maybe drained and emergency department. Perirectal abscesses are complicated and require definitive surgical management. This is contingent upon their not being involvement of the actual sphincter. 



Patients with a perianal abscess are drained in the office setting, emergency room, or minor operating room, using local anesthetic. (See ‘Perianal’ above
More complicated anorectal abscesses, such as intersphincteric, supralevator, and horseshoe abscesses, are treated in the operating room setting. (See ‘Complex’ above.)

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