- Hafiizh Dwi Pramudito-

ANATOMY

Anorectal Abscess

Infection of an anal fissure, sexually transmitted infections, and blocked perianal glands are all thought to be inciting factors. Diabetes, immunocompromised states, inflammatory bowel disease, or who engage in receptive anal sex, appear to be at higher risk for developing an abscess. An anorectal abscess originates from an infection arising in the cryptoglandular epithelium lining the anal canal. The internal anal sphincter is believed to serve normally as a barrier to infection. This barrier can be breached through the crypts of Morgagni.

The classic locations of anorectal abscesses listed in order of decreasing frequency are as follows: perianal 60%, ischiorectal 20%, intersphincteric 5%, supralevator 4%, and submucosal 1%

Abscess Perianal Abscess Ischioanal Abscess Intersphincteric (Intermuscular) Abscess Deep postanal (Retrorectal) Abscess Marginal Abscess Submucosa Abscess Supralevator (Pelvirectal)

OTHERS

Horse Shoe Abscess : Abses lateral meluas ke ke segitiga dibelakang anal canal ke sisi kontralateral

Hourglass Abscess : Meluas dari Supralevator space kebawah melalui levator ke fossa ischiorectal

Symptoms :

Unable to sit comfortably Difficulty or pain with passing stool Dysuria Redness or pain around anus Abscess felt around anus or within anal canal Peri-rectal swelling Pain may be throbbing, sharp, or dull, Fever may be seen in severe case Bleeding or discharge if abscess is drained or accidentally ruptures. If the abscess ruptures and leaves a fissure that opens into the anal canal, a fistula is formed.

WORK UP

Laboratory Studies No specific laboratory studies are indicated in the evaluation of a patient with a perianal or anorectal abscess. Imaging Studies CT scanning, MRI, or anal ultrasonography. (intersphincteric abscess)

TREATMENT
Medical Therapy : - Antibiotik ( sepsis,selulitis)

ineffective in resolving the underlying infection and simply postpones surgical intervention

- Analgetik Surgical Therapy : - Early surgical drainage Any delay in surgical drainage of anorectal abscesses prolongs infection, tissue damage, and may impair

INCISION DRAINAGE
1.

Using local anesthetics, Infiltrate the skin overlying the abscess with lidocaine. A small incision is made over the area of fluctuancy in close proximity to the anal verge. Deeper abscess and fistulas need to be opened, drained, and removed in the hospital under general anesthesia. Pus is collected and sent for culture. Draw up saline irrigation solution with Betadine and Perhidrol, Use gentle pressure on syringe plunger to irrigate abscess cavity well. Irrigate multiple times. You may also want to insert a finger to break up any loculations of pus.

2.

3.

4. 5.

HANLEY PROCEDURE :
1. 2. 3.

4. 5.

6.

7.

Anesthesi Regional/general Posisi prone jackknife Lokasi infeksi paling sering di deep postanal space Insisi midline Spreading sfingter eksterna untuk mencapai abscess Buka di posterior midline dan separuh bawah sfingter interna dipotong utk drainage Counter incision di sisi lateral untuk drainage ekstensi anterior di ischianal space

FISTULA IN ANO

An anorectal fistula (Fistula-in-Ano) is an abnormal communication between the anus and perianal skin. Fistulas can occur spontaneously or secondary to a perianal (or perirectal) abscess, 50% chance of developing a chronic fistula.

Etiology

Previous anorectal abscess Trauma Crohn disease anal fissures Carcinoma radiation therapy actinomycoses, tuberculosis, and chlamydial infections.

Pathophysiology

The cryptoglandular hypothesis states that an infection begins in the anal gland and progresses into the muscular wall of the anal sphincters to cause an anorectal abscess. Following surgical or spontaneous drainage in the perianal skin, occasionally a granulation tissuelined tract is left behind, causing recurrent symptoms.

Classification (Parks)

Transsphincteric fistulae (25%) are the result of ischiorectal abscesses, with extension of the tract through the external sphincter.

Intersphincteric fistulae (70%) are confined to the intersphincteric space and internal sphincter. They result from perianal abscesses.

Suprasphincteric fistulae (5%) are the result of supralevator abscesses. They pass through the levator ani muscle, over the top of the puborectalis muscle, and into the intersphincteric space.

Extrasphincteric fistulae (1%) bypass the anal canal and sphincter mechanism, passing through the

Signs and Symptoms

Perianal discharge Pain Swelling Bleeding Diarrhea Skin excoriation External opening Digital rectal examination
may reveal a fibrous tract or cord beneath the skin. It also helps delineate any further acute inflammation that is not yet drained.

Goodsall's Rule

the patient in the lithotomy position: If the external opening is anterior to an imaginary line drawn horizontally through the anal canal, the fistula usually runs directly into the anal canal. If the external opening is posterior to the line, the fistula usually curves to the posterior midline of the anal canal. It should be noted, however, that the further away the external opening is from the anus, the less reliable Goodsall's rule becomes. Additionally,

Work Up

Laboratory Studies
No specific laboratory studies are required

Fistulography Endoanal/endorectal ultrasound MRI CT Scan A barium enema/small bowel series Anal manometry Proctosigmoidoscopy/colonoscopy

TREATMENT

1.
2. 3. 1.

2.

Prinsip : Eliminasi Fistel Mencegah rekurensi Mempertahankan fungsi sfingter Cara : Identifikasi internal opening Probe,methylen blue, jaringan granulasi, Noting puckering anal cript Seminimal mungkin membelah otot Tehnik : Lay Open, Seton, Anorectal Advancement flap,

There are two problems that make the treatment of fistula in ano difficult: a. The anus is an area that can never be completely clean or sterile. b. Often we cannot completely lay open or excise the fistula because it lies too close or goes through the anal sphincter muscles.

FISTULOTOMI LAY OPEN vs FISTULEKTOMI

SETON

A seton a is thread of nylon, prolene, rubber or other material that is non absorbable and is placed through the fistula track with the purpose of keeping it open for a certain period of time. The principle of seton is that no fistula will close permanently if the feeding abscess or infection does not drain completely A seton may stay in place for a long time: 3 -12