Françoise Smets Gastroentérologie et Hépatologie Pédiatrique Perianal abscesses in children: Pitfalls in diagnosis and treatment BeSPGHAN-BELAPS October 2016 Françoise Smets Gastroentérologie et Hépatologie Pédiatrique

Infection of an anal gland Young children (50% before 1 year old) “Classic abscess” Infection of an anal gland Young children (50% before 1 year old) Mostly boys Red, painful, close to anal margin Frequent underlying fistula >70% spontaneous healing?, minimum 10% recurrence no recurrence if fistula is surgically treated ? (! sphincters)

Spontaneous healing ? 18 boys with abscess Age : 0.3-9.7 months 4 incision and drainage under local anaesthesia 3 for discomfort 1 for fever 3 fistulae with spontaneous healing 14 conservative follow-up 11 fistulae All spontaneous recovery after a mean of 6 +/- 4 months No antibiotics, no surgery Rosen NG, Gibbs DL, Soffer SZ, Sher M, Pena A. J Pediatr Surg 2000:35;938-9

Spontaneous healing ? Christison-Lagay et al 2007 : If incision-drainage : 50/83 fistulae (60%), lower if antibiotics If no drainage : 9/57 fistulae (16%) Ezer et al 2010 : Incision-drainage : 85% recurrence King et al 2010 : Incision-drainage + fistula laid open : 12% recurrence Malik et al 2010 (Cochrane – adults) : Recurrence lower if fistula laid open RR recurrence 0.13 (0.07-0.24) King SK et al. J Paediatr Child Health 2010:46;273-4

Anal abscess with underlying disease Crohn disease : Older children, exceptional before 8-10 years old Could be multiple abscesses or fistulae Could be the only symptom! Infectious disease : Streptococcus (+ anitis) Pseudomonas aeruginosa = echtyma gangrenosum (in case of immune-deficiency and/or leukemia)

Perianal disease at diagnosis in IBD patients 12 465 IBD patients < 20 years 511 (4.1%) with perianal disease 480 with Crohn disease (94%) OR to be a girl = 0.63 (0.52-0.76, p<0.001) No increased growth failure Showed Higher risk of surgery Longer hospital stay Higher hospital charges Zwintscher NP et al. Int J Colorectal Dis 2015:30;1275-9

Perianal disease in Crohn patients and surgery 57 pediatric patients with at least 1 surgery Median age 13 years (0.5-17) 63% boys Skin tags 49% Superficial fistulae 49% Deep fistulae 37% Superficial abscesses 68% Deep abscesses 9% Anal strictures 7% Skin breakdown (19%) Seeman NM et al. J Pediatr Surg 2015:50;140-3

Perianal disease in Crohn patients and infliximab 380 patients, 40 < 18 years Lindsay JO et al. Aliment Pharmacol Ther 2013:38;52-61

What do surgeon think?