1. Perianal mass

2. 54 year old Known diabetic

3. History of present illness One day PTA –Painful sensation at anal region after passing out hard stool 2 days PTA –patient felt a soft mass over the perianal region which was painful to touch Few hours PTA –patient started to experience painful sensation on the anal region which was aggravated when assuming sitting position

4. Review of system No dysuria, no frequency No change in bowel habit No nausea nor vomiting No weight loss

5. Past medical history –IDDM3 Family history –(-)HPN, CA –(+)DM

6. Physical exam BP-120/80, PR-85/min, RR-18/min, T-37.8°C HEENT: anicteric sclerae, pink palpable conjuctivae Heart&lungs: unremarkable Abdomen: flat, soft, nontender with normoactive bowel DRE: erythematous, warm, tender 5x4cm mass at right perianal region *DRE cannot be tolerated by patient

7. Differential diagnosis Patients complaint Thrombosed external hemorhoids Thrombosed internal hemorrhoids Anorectal sepsis & cryptoglandular abscess Anal fissure Painful sensation aggravated in sitting position Sudden pain mass Sudden painful mass Sudden very painful peri-anal bulge Spastic anal pain most severe during periods of anxiety, passage of feces &/0r flatus Hard stoolRecent diarrhea+/- bleeding+/- urinary retention Hard stool Soft mass at perianal region/cannot tolerate DRE Long history of small anal mas Long history of mass out the anus during defecation but spontaneously goes in Cannot tolerate DRE High strung person + slight fever+/- fever DRE: erythematous, warm, tender 5x4cm mass at right perianal region

8. Differential diagnosis Fistula in anoHerpes proctatis Internal hemorrhoids Rectal prolapseCarcinoma Painful fluctuant mass spontaneously ruptured Severe peri- anal pain painMass protudes thru anus on straining Masses on anal canal, anal verge and or perinanal skin Peri-anal skin opening Tenesmus+/- blood streaked stools Incontinence+/- pain Purulent, fecaloid material comes out Vesicles+/- blood dripping after defection Elderly female+/- discharge Sometimes no discharge, painful & fluctuant ContagiousComes out during strainig & defecation but spontaneously goes in after, must be pushed, irreducible Anal sex

9. assestment Thrombosed external hemorrhoids Anorectal abscess

10. Thrombosed external hemorrhoids distended vascular tissue in the anal canal distal to the dentate line present with pain on standing, sitting or defecating usually develop over time and may result from straining with stools, childbirth, lengthy car trips or prolonged sitting, constipation or diarrhea

12. Management: elliptical excision

14. Anorectal abscess More common in M>F Peak incidence 30-50y/o Prevalent in immunocompromised like diabetics, IBD & HIV positive Recurrent perianal infection

15. Presentation and evalutation Perianal pain Fever Difficultyu voiding Bloody stool On PE, large fluctuant area is readily visible

16. 40-50% - perianal 20-25% - ischiarectal 2-5% - intersphincter 2.5% - supralevator

17. Anatomy & physiology Abnormal fluid containing cavity in the anorectal rtegion Results from infection involving the glans surrounding the ana canal When stool accidentally enters the anal glands, the glands become infected and an abscess develops

18. Management Uncomplicated –Small incision close to anal verge is made & a malienkat drain in advanced into abscess cavity Complicated –Should perform in OR under anesthesia Antibiotics at least 2 weeks