Several potential spaces around anorectumAE/- 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 - MixedClassification 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 retensionTreatment no time lostdon’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 incisionSubmucous abscess(5%)
after haemorrhoidal sclerotherapy Above dentate line Pelvirectal abscess:Bet. Upper surface of levator ani and pelvic peritoneumFissure abscessSequel:Draining cure rate 50%50% …..anal fistulaDifrential diagnosis: - Pilonidal sinus with abscess- bartholin’s abscess- Hidradenitis supurativaA 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 ring1- low level fistulae: open in to anal canal below2- high level fistulae: at or aboveClassification:Parks’ classificationClinical features
for unknown cause is more common in male3rd,4th and 5th decade of lifePrincipal 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)(Clinical assessment(Approach to fistulae
Obstetric ,GIT,surgical,continence)) medical historyDigital exam.: int. opening can be felt as a nodule thickening from skin to inside exclude any Ca. or massProctoscopy : internal opening ,hypertrophied papillaType 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 biopsy2-Fistulectomy : risk of injury to the M. is more so incontinence moreHigh level fistula:The treatment is difficult because if treated like low level ……incontinence will follow1- intersphincteric F.: Int.sphincter is divided2- 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 + colostomy3- Extrasph. Difficult Seton +colostomy4- Supralevator F: crohns dis.,Ca. rectum,perforation,trauma