1. 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

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

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

6. 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

8. 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

9. 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

10. 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

11. 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)

12. 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

14. 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 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)

16. 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

17. (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)

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

19. 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

20. 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

21. 3-Advancement flaps 4-Glues (fibrin glue) other biological agents