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Perianal abscesses and fistulae

Perianal Abscesses

Definition
  • A perianal abscess is a collection of pus in the tissues surrounding the anus and rectum.
Etiology
  • Often result from infection of an anal gland which spreads to the perianal tissue.
  • Common organisms: Escherichia coli, Staphylococcus aureus, and mixed anaerobes.
  • Associated conditions: inflammatory bowel disease, diabetes mellitus, immunosuppression, and trauma.
Clinical Presentation
  • Pain, swelling, and redness around the anus.
  • Possible fever and malaise.
  • Discharge of pus from the anus.
Management
  • Incision and drainage: primary treatment.
  • Antibiotics if cellulitis is present or if the patient is immunocompromised.

Perianal Fistulae

Definition
  • A perianal fistula is an abnormal tract or tunnel between the anal canal and the skin near the anus.
Etiology
  • Often arises after a perianal abscess has drained, either spontaneously or surgically.
  • Other causes: Crohn’s disease, trauma, malignancy, tuberculosis, and radiation.
Clinical Presentation
  • Recurrent perianal abscesses.
  • Persistent discharge of pus or blood from the perianal skin.
  • Possible anal pain, itching, or irritation.
Investigations
  • Examination under anaesthesia (EUA): to assess the extent and direction of the fistula.
  • MRI: can help delineate the fistula tract, especially in complex or recurrent cases.
  • Fistulography: contrast study but less commonly used due to the superior detail of MRI.
Management
  • Fistulotomy: surgical opening and laying open the fistula tract.
  • Seton placement: for complex or high fistulae. Helps to drain the fistula and can be tightened over time to cut through the fistula tract gradually.
  • Fibrin glue or fistula plug: less invasive methods, but with a higher recurrence rate.
  • Management of underlying conditions, e.g., Crohn’s disease.
Complications
  • Recurrence of abscess or fistula.
  • Anal incontinence, especially with repeated surgeries or high fistulae.
  • Sepsis if untreated.

It’s important to approach patients with a suspected perianal abscess or fistula with a thorough clinical assessment, followed by appropriate investigations and timely management.

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