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Return to: Twitter Facebook Linkedin Reddit Get Citation Citation AMA Citation Anorectal Abscess & Fistula. In: Doherty GM. Doherty G.M. Ed. Gerard M. Doherty.eds. Quick Answers Surgery New York, NY: McGraw-Hill; 2010. http://accesssurgery.mhmedical.com/content.aspx?bookid=853§ionid=49661990. Accessed June 29, 2017. MLA Citation . "Anorectal Abscess & Fistula." Quick Answers Surgery Doherty GM. Doherty G.M. Ed. Gerard M. Doherty. New York, NY: McGraw-Hill, 2010, http://accesssurgery.mhmedical.com/content.aspx?bookid=853§ionid=49661990. Download citation file: RIS (Zotero) EndNote BibTex Medlars ProCite RefWorks Reference Manager © Copyright Tools Search Book Top Return Clip Anorectal Abscess & Fistula + Essential Features Print Section + • Result from occlusion of anal glands and crypts at the dentate line• Occlusion may follow impaction of vegetable matter or edema from trauma• Abscesses are classified according to space they invade-Supralevator-Ischiorectal-Superficial-Intersphincteric-Transphincteric• May also develop as a result of inflammatory bowel disease (Crohn)• Fistula-in-ano from the anus to the perianal skin develops when abscess cavity maintains persistent communication with the crypt• Goodsall rule: Used to identify direction of fistula tract -Anterior external opening: Tract extends in a radial direction to the dentate line -Posterior external opening: Fistula tract curves to the posterior midline ++ Epidemiology + • 10% of patients with Crohn disease have anorectal abscess fistulous disease with no prior history of inflammatory bowel disease + Clinical Findings Print Section ++ Symptoms and Signs + • Severe anal/perianal pain, usually continuous and throbbing• Pain may worsen with movement and straining• Swelling and discharge may be noted• Patients may have fever, urinary retention• Severe, life-threatening perineal sepsis may develop• Patients with fistula-in-ano may have pain and bloody discharge• Exam findings may include tender perianal or rectal mass• Fistula: Internal and external openings with mucopurulent drainage• Fistulous tract is often palpable and firm ++ Laboratory Findings + • May have elevated WBC count, especially with perineal sepsis• Drainage may have white blood cells, bacteria ++ Imaging Findings + • Imaging studies are unnecessary in uncomplicated cases• Sinogram may reveal fistulous tract and branches• Transrectal US may reveal extent of sphincter involvement• CT scan may be helpful in identifying supralevator abscesses + Diagnostic Considerations Print Section + • Inflammatory bowel disease (Crohn disease)• Pilonidal disease• Hidradenitis suppurativa• Anal tuberculosis• Actinomycosis• Trauma• Anal fissure• Anal malignancy• Radiation injury• Chlamydiosis• Diverticulitis• Retrorectal tumors ++ Rule Out + • Crohn disease• Anorectal malignancy + Work-up Print Section + • History and physical exam-Is there history of diabetes or immunocompromised conditions, including medications (steroids, chemotherapy)?• Imaging studies are not indicated for uncomplicated cases ++ When to Admit + • Abscesses should be drained; admission will depend on extent of abscess drainage required• Signs of perineal sepsis or complicated abscess• Fistula-in-ano by itself is not a surgical emergency + Treatment and Management Print Section + • Treatment for abscess is surgical drainage• Intersphincteric abscesses are treated with internal sphincterotomy• Perianal and ischiorectal abscesses are drained through the perianal skin• Fistula-in-ano: Fistulotomy, currette tract and granulation tissue, heal by secondary intention• Fistula-in-ano: Involving external sphincter may be treated with seton placement or drainage with delayed repair with an endorectal advancement flap ++ Surgery ++ Indications + • Anorectal abscesses require surgical drainage• Patients with diabetes or immunocompromised require urgent attention since these patients are prone to necrotizing anorectal infections and sepsis ++ Contraindications + • Fistulotomy may be delayed until abscess is drained and inflammation subsides to allow identification of internal opening ++ Medications + • Antibiotics are not necessary unless patient is immunocompromised, diabetic, has extensive cellulitis, or has valvular heart disease ++ Complications + • Recurrence• Incomplete drainage• Sphincter injury/fecal incontinence ++ Prognosis + • Once the source for infection is identified and adequately drained, prognosis is good• 50% of patients are cured with drainage alone• Chronic fistula develops in 50% of patients• Seton placement for fistula has 17% incontinence rate + Resources Print Section ++ References ++Chapple KS et al: Prognostic value of magnetic resonance imaging in the management of fistula-in-ano. Dis Colon Rectum 2000;43:511. [PubMed: 10789748] ++Cintron JR et al: Repair of fistulas-in-ano using fibrin adhesive: long-term follow-up. Dis Colon Rectum 2000;43:944. [PubMed: 10910240] ++Knoefel WT et al: The initial approach to anorectal abscesses: fistulotomy is safe and reduces the chance of recurrences. Dig Surg 2000;17:274. [PubMed: 10867462] ++Ky AJ et al: Collagen fistula plug for the treatment of anal fistulas. Dis Colon Rectum 2008;51:838. [PubMed: 18330649] ++Nelson RL et al: Dermal island-flap anoplasty for transsphincteric fistula-in-ano: assessment of treatment failures. Dis Colon Rectum 2000;43:681. [PubMed: 10826431] ++Park JJ et al: Repair of chronic anorectal fistulae using commercial fibrin sealant. Arch Surg 2000;135:166. [PubMed: 10668875] ++Practice parameters for treatment of fistula-in-ano—supporting documentation. The Standards Practice Task Force. The American Society of Colon and Rectal Surgeons. Dis Colon Rectum 1996;39:1363.