Surgery Case 5 Sy, Jamelle; Sydiongco, Paula Marie; Tacata, Patricia; Tady, Clarissa Marie

CHIEF COMPLAINT PERIANAL PAIN

HISTORY 1 wk PTA Pain at the anal region after passing out hard stools 2 days PTA Soft mass over the R perianal region; (+) tenderness 4 hrs PTA Painful sensation on the anal region, aggravated when sitting

PHYSICAL EXAMINATION VS: BP= 120/80; PR= 85/min; RR= 18/min; T- 37.8 0 C HEENT: anicteric sclera, pink palpebral conjunctivae HEART & LUNGS: unremarkable ABDOMEN: flat, soft, non-tender w/ normoactive bowel sounds DRE: erhythematous, warm and tender 5x4 cm mass at the perianal region; DRE cannot be tolerated by the patient

SALIENT FEATURES 59 y/o male Diabetic T- 37.8 0 C Erythematous, warm and tender 5x4 cm mass on the R perianal region DRE cannot be tolerated by the patient

DIFFERENTIAL DIAGNOSIS

RECTAL CA HSV PERIANAL ABSCESS Perianal Pain * Aggravated by LYMPHOGRANULOMA VENEREUM HSV PERIANAL ABSCESS Perianal Pain * Aggravated by sitting done * Prior to bowel movement (-) ✔ Palpable mass Present Genital ulcers Genital ulcer Fever and Chills Rectal Discharge Constipation

CLINICAL FEATURES Perianal abscess Patient’s Symptoms Perianal Pain * Aggravated by sitting done * Prior to bowel movement ✔ Palpable mass Fever and Chills Rectal Discharge ✖ Constipation Even though all features of Perianal abscess are not present in our patient. The three important features– perianal pain, palpable mass and fever, seen in our patient would suggest a diagnosis of perianal abscess.

DIAGNOSIS: PERI-ANAL ABSCESS

PERI-ANAL ABSCESS Represents an infection of the soft tissues surrounding the anal canal, with formation of a discrete abscess cavity.. The severity and depth of the abscess are quite variable, and the abscess cavity is often associated with formation of a fistulous tract Common organisms implicated in abscess formation include Escherichia coli, Enterococcus species, and Bacteroides species; however, no specific bacterium has been identified as a unique cause of abscesses.

INCIDENCE AND EPIDEMIOLOGY M > F (3:1) peak incidence: 3rd to 5th decade of life. The disease is more prevalent in immunocompromised patients such Diabetics hematologic disorders inflammatory bowel disease (IBD) HIV positive These disorders should be considered in patients with recurrent perianal infections.

PATHOPHYSIOLOGY Originates from an infection arising in the cryptoglandular epithelium lining the anal canal The internal anal sphincter normally serves as a barrier to infection passing from the gut lumen to the deep perirectal tissues. This barrier can be breached through the crypts of Morgagni, which can penetrate through the internal sphincter into the intersphincteric space

PATHOPHYSIOLOGY Once infection gains access to the intersphincteric space, it has easy access to the adjacent perirectal spaces Extension of the infection can involve the intersphincteric space 2–5%, ischiorectal space 20-25% , or even the supralevator space 2.5%.

PATHOPHYSIOLOGY

CLINICAL PRESENTATION HALLMARK: Perianal pain and fever dull perianal discomfort and pruritus perianal pain often is exacerbated by movement and increased perineal pressure from sitting or defecation.

CLINICAL PRESENTATION PE: demonstrates a small, erythematous, well-defined, fluctuant, subcutaneous mass near the anal orifice. LABORATORY EVALUATION: elevated WBC count DIAGNOSTIC PROCEDURES are rarely necessary unless evaluating a recurrent abscess. A CT scan or MRI has an accuracy of 80% in determining incomplete drainage.

MANAGEMENT Early surgical drainage of the purulent collection. Primary antibiotic therapy alone is ineffective in resolving the underlying infection and simply postpones surgical intervention. Any delay in surgical drainage of anorectal abscesses prolongs infection, augments tissue damage, and may impair sphincter continence function, as well as promote stricture and/or fistula formation. The ability to drain an anorectal abscess depends on patient comfort and on the location and accessibility of the abscess.

Drainage of perianal or superficial abscesses Can be accomplished in the office or emergency department, using local anesthetics For patients who have a complicated abscess or who are diabetic or immunocompromised, drainage should be performed in a operating room under anesthesia. These patients are at greater risk for developing necrotizing fasciitis.

Drainage of perianal or superficial abscesses A small cruciate incision is made over the area of fluctuancy in close proximity to the anal verge. Pus is collected and sent for culture. Hemostasis is achieved with manual pressure, and the wound is packed with iodophor gauze. The gauze is removed after 24 hours, and the patient is instructed to take sitz baths 3 times a day and after bowel movements.

Postoperative analgesics and stool softeners are prescribed to relieve pain and prevent constipation. The patient typically will follow up with his/her physician in 2-3 weeks for wound evaluation and inspection for possible fistula-in-ano.

ANTIBIOTIC THERAPY Antibiotic therapy when indicated– to cover aerobes and anaerobes e.g. ciprofloxacin 500 mg PO 2x daily for 5 days