Anorectal Abscesses Several potential spaces around anorectum AE/ - Infection of anal glands (90%) - Extension of cutaneous boil - Blood born inf. - Penetrating of the rectal wall (fish bone) - Rectal CA. - crohn’s dis. Predisposing dis: D.M. AIDS

Bacteriology - 60% E. coli - 23% staph. Aureus - bacteroides - Proteus , streptoccous - Mixed

Classification Depend on anatomy -Perianal abscess 60% -Ischiorectal 30% -Submucous - pelvirectal

Perianal abscess - Suppuration of anal gland - May from external thrombosed H Clinical features : all ages not uncommon in infant, childhood More common in male -Sever anal pain (throbbing) aggravated by walking,straining&coughing.(2-3 days) -Constitutional symptoms (pyrexia) On exam. Tender round cystic lump at anal verge urinary retension

Treatment no time lost don’t wait till fluctuation + operation: cruciate incision draining pus …C/S excision skin edges biopsy the wall of cavity to exclude specific cause

Ischiorectal abscess Extension laterally through external sphincter Ischiorectal fossa communicate with opposite side via postsphincteric space Horseshoe abscess Clinical features similar to perianal abscess Tender brawny induration palpable on corresponding side of anal canal & floor of fossa Treatment: cruciate incision

Submucous abscess(5%) after haemorrhoidal sclerotherapy Above dentate line Pelvirectal abscess: Bet. Upper surface of levator ani and pelvic peritoneum Fissure abscess Sequel: Draining cure rate 50% 50% …..anal fistula Difrential diagnosis: - Pilonidal sinus with abscess - bartholin’s abscess - Hidradenitis supurativa

Fistula in ano (anal fistula) A track lined by granulation tissue which connect which deeply in the anal canal or rectum & superficially on the skin around the anus or to buttock (or rarely to the vagina) AE/ Anorectal abscess (burst spontaneously or inadequately,non specific ,idiopathic or cryptoglandular) Continue to discharge blood stained or purulent Is seldom if ever closed permanently without surgical aid (high intrarectal pressure)

Types of anal fistula Two groups ……internal opening …anorectal ring 1- low level fistulae: open in to anal canal below 2- high level fistulae: at or above Classification: Parks’ classification

Clinical features for unknown cause is more common in male 3rd,4th and 5th decade of life Principal symptom .: persistent seropurulent discharge itching pruritis history of perianal abscess if orifice occluded …pain passage of flatus of faeces (rectum) On exam. Solitary external opening ..3-4 cm of the anus with small elevation of granulation tissue pouting out There may be 2 or 3 ext. opening (on right or left) When ischiorectal fossa involved ..2 opening (horseshoe fistula)

Fistula with an ext. opening in relation to anterior half tend to be direct type ,those related to post. ½ (more common) curved to midline to solitary int. opening

(Clinical assessment(Approach to fistulae Obstetric ,GIT,surgical,continence)) medical history Digital exam.: int. opening can be felt as a nodule thickening from skin to inside exclude any Ca. or mass Proctoscopy : internal opening ,hypertrophied papilla Type of fistula ,No.of external opening,Goodsall’s rule, Associated diseases (TB,crohn’s disease,actinomycosis,malignancy ,foreign body, rectal duplication ,lymphogranuloma venereum)

Sigmoidoscopy Endoluminal u/s ,MRI Fistulography and CTscan Manometery (function of the sphincter) Probing under GA in theater to find internal opening

Treatment 1-Fistulotomy :fistulous track laid open from it is termination to it is source . Step 1:preoperative cleaning (enema), lithotomy Step 2: probing Step 3:laying open and curetting granulation tissue Step 4: edge of track are trimmed Followed by digital dilitation Biopsy : always send a piece of track for biopsy

2-Fistulectomy : risk of injury to the M. is more so incontinence more High level fistula: The treatment is difficult because if treated like low level ……incontinence will follow 1- intersphincteric F.: Int.sphincter is divided 2- transphinceric F: opening till the anorectal ring then inserting Seton (silk,nylon ligature) is applied and ligated act as drain also cutting fibrosis some time + colostomy 3- Extrasph. Difficult Seton +colostomy 4- Supralevator F: crohns dis.,Ca. rectum,perforation,trauma

3-Advancement flaps 4-Glues (fibrin glue) other biological agents