CLINICAL CASE PRESENTATION

DR. IAN ALBERT S. SANGELES

Objectives:
1. Discuss the differential diagnoses of perianal pain. 2. Discuss the pathogenesis, diagnosis, and management of perianal abscess/fistula-inano. 3. Discuss ACC/AHA guidelines of cardiopulmonary clearance prior to surgery. 4. Present the Family Assessment Tools applied to the patient.

Patients General Data:

J.A. 30 yo Male Filipino Married Malabon City, MM

CHIEF COMPLAINT: PERIANAL PAIN

Table 1. Likely Diagnosis of Anorectal Pain Pain Alone Pain and Lump Pain and Bleeding Pain with Lump and Bleeding Hemorrhoids Ulcerated Perianal Hematoma

Anal Fissure Anusitis Ulcerative Proctitis Proctalgia Fugax

Perianal Anal Fissure Hematoma Proctitis Strangulated Internal Hemorrhoid Abscess Pilonidal Sinus

Australian Family Physician Journal. June 2010

Pain, bleeding, with/without Pus Draining Pain with Lump, Pus Draining, with/without Bleeding Pain with Lump, Pus Draining, and Bleeding Pain with Lump, Pus Draining, Bleeding, and Necrotic Tissue Fourniers Gangrene

Perianal Crohns Disease

Hidradenitis Suppurativa

Fistula-in-Ano Perianal Tumors

FISSURE IN ANO It is a tear in the anoderm distal to the dentate line. The pathophysiology of anal fissure is thought to be related to trauma from either the passage of hard stool and prolonged diarrhea. Tearing pain with defecation. Pain may last for several hours after bowel movement. Hematochezzia External Skin Tag

Ulceration with heaped-up edges

Schwartzs Principles of Surgery 9th Edition

ANUSITIS

Inflammation of the mucosal lining of the anal canal. The most common etiology is infectious organisms (gonorrhea, syphilis). Hx of Anal Intercourse Fever Anal Pain/Tenesmus Intense Pruritus Rectal Bleeding/Rectal Discharge Fistula formation Inguinal Adenopathy Vesicles/Painful Ulcers Schwartzs Principles of Surgery 9th Edition

INFLAMMATORY Ulcerative BOWEL Proctitis DISEASE Inflammatory bowel CROHNS ULCERATIVE disease (ulcerative DISEASE colitis, crohns disease or indeterminate COLITIS colitis) which, in rare cases, can alcohol, be limited Multiple etiologies: diet, infection, in the distal large intestine. use, smoking, oral contraceptive Anal pain autoimmune defect. Perianal Colon and ulcers/fistulas Rectum Mouth to the Anus Abdominal pain Mucosal Transmural Vomiting Continuous Rectal sparing or involvement of the skip lesions Bloody Diarrhea colon and rectum Fever Continuous ulcers Cobblestone Weight Loss appearance Schwartzs Principles of Surgery 9th Edition

Proctalgia fugax Results from levator spasm without any other anorectal findings. Anal Pain (Spasm-like, excrutiating, lasting for 20 minutes or longer)

Schwartzs Principles of Surgery 9th Edition

Perianal Hematoma A type of hematoma located in, or on the border of the anus. It can be misdiagnosed as a hemorrhoid, but is sometimes referred to as an external hemorrhoid. It is caused by the rupture of a small vein that drains blood from the anus. This rupture may be the result of a forceful or strained bowel movement or caused by heavy lifting, coughing, or straining. Pain which may last for days. Hematoma

Wikipedia

Hemorrhoids They are cushions of submucosal tissue containing venules, arterioles, and smoothmuscle fibers that are located in the anal canal. Excessive straining, increased abdominal pressure, and hard stools increase venous engorgement of the the hemorrhoidal plexus and cause prolapse of hemorrhoidal tissures, pain, and bleeding. Pain Hematochezzia Mass Skin Tag Schwartzs Principles of Surgery 9th Edition

Perianal Abscess/Fistula in Ano Infection of the anal glands which result to abscess and fistula formation.
Anal/Perianal Pain

Anal/Perianal Itching Swelling Tenderness Abscess Fever Sepsis Fistula Formation Schwartzs Principles of Surgery 9th Edition

Pilonidal Disease It consists of a hair-containing sinus or abscess that involves the skin and subcutaneous tissues in the postsacral intergluteal region.
Fever Hair-containing abscess (Intergluteal Region) Purulent Drainage Perianal Pain Tenderness

Schwartzs Principles of Surgery 9th Edition

Hidradenitis Suppurativa It is an infection of the cutaneous appocrine sweat glands. Infected glands rupture and form subcutaneous sinus tracts Fever Erythematous Swelling with Suppuration Perianal Pain

Tenderness Superficial Cutaneous Involvement Only

Schwartzs Principles of Surgery 9th Edition

ANAL/PERIANAL TUMORS (Squamous, Basal, Epidermoid, Adenocarcinoma, Melanoma) Perianal Pain

Perianal Itching Tenesmus Purulent Drainage Rectal Bleeding Anal Mass Nonhealing Ulceration Anorexia/Weight Loss

Schwartzs Principles of Surgery 9th Edition

FourniersGangrene Necroctizing anorectal infections caused by either monobacterial or mixed synergistic flora. Necrotic Skin Underlying Tissue Necrosis Purulent Drainage Anal/Perianal Pain Tenderness Fever Sepsis Immunocompromised

Schwartzs Principles of Surgery 9th Edition

History Of Present Illness

1 year PTA (+) Recurrent Mild Perianal Pain (+) Recurrent Purulent Soiling No bloody perianal discharge. No consult done. No medicines taken.

2 weeks PTA

(+) Perianal Pain recurred with increased intensity esp upon defecation. (+) Perianal Lump, Right/Left Consult done: Cefalexin 500mg Tab q8h x 7 days. Mefenamic Acid 500 mg Cap q6h prn pain.

5 Days PTA (+) Persistence of perianal pain and swelling. (+) Purulent, non-bloody discharge draining from the Right/Left Perianal Areas. Consult done. Referred to the Surgery Department. Advised Surgical Intervention.

Day Of Admission
(+) Still with perianal pain, perianal swelling, and purulent perianal discharge.

Patient came in for surgical intervention as advised.

Past Medical History:

(-) HPN (-) DM (-) BA (-) Drug/Food Allergy (+) Inguinal Herniorrhapy, Left. 1984.

Family History: (-) DM (-) BA (+) HPN Father (-) Cancer

LEGEND:

FAMILY GENOGRAM
Amisola-Araneta Family as of July 2012

Edilberto, 60 yo Marina, 59 yo 1979

Ben, 57 yo 1984

Joy, 58 yo

Mark, 32 yo

Jefren, 30 yo

Glenn, 27 yo

Beth, 28 yo

2006

Legend: HPN
Jeff, 5 yo Jag Whisley, 3 yo

BA

APGAR
Areas of the APGAR Family Member 1 (Jefren) 2 Family Member 2 (Beth) 2 Average A I am satisfied I can turn to my family for help when something is troubling me. (Akoy nasisiyahan dahil sa nakakaasa ako ng tulong sa aking pamilya) 2

P - I am satisfied with the way my family talks over things with me and shares problems with me. (Akoy nasisiyahan sa paraang nakikipagtalakayan sa akin ang aking pamilya tungkol sa aking problema)

G I am satisfied that my family accepts and supports my wishes to take on new activities or directions. (Akoy nasisiyahan at ang aking pamilya ay tinatanggap at sinusuportahan ang aking mga nais gawin patungo sa mga bagong landas para sa aking ikauunlad) A I am satisfied with the way my family expresses affection and responds to my emotions, such as anger, sorrow or love. (Akoy nasisiyahan sa paraang ipinadadama ng aking pamilya ang kanilang pagmamahal at nauunawaan ang aking damdamin katulad ng galit, lungkot at pag-ibig)

R I am satisfied with the way my family and I share time together. ( Akoy nasisiyahan na ang aking pamilya at ako ay nagkakaroon ng panahon sa isat isa).

Over-all assessment

Personal/Social History:

Seafarer Non-smoker
(+) Occasional Alcoholic beverage drinker

REVIEW OF SYSTEMS: General: (-) Fever, (-) Anorexia, (-) Weight Loss, (-) Body Malaise HEENT: (-) Headache, (-) Ear/Nasal discharge, (-) Sore throat

RESPIRATORY: (-) Cough, (-) DOB

CARDIO: (-) Chest pain, (-) Palpitations ENDOCRINE: Unremarkable GASTRO: (-) Abd pain, (-) Vomiting, (-) Loose stools GENITOURINARY:(-) Dysuria, (-) Hematuria

HEMATOLOGIC: (-) Easy bruisability, (-) Hematoma NEUROLOGIC: (-) LOC, (-) Seizures

SALIENT FEATURES From the History: (+) Recurrent Purulent Soiling, (+) Perianal Pain esp upon defecation, (+) Perianal Swelling R/L, (+) Purulent Perianal discharge. No anorexia. No weight loss.

PHYSICAL EXAMINATION:
VS: BP=110/80; CR=88; RR=17; T= 36.8 C

Conscious, coherent, ambulatory with support, afebrile, NIRD, Normocephalic, Pinkish Conjunctivae, Anicteric Sclerae, (-)Ear/Nasal discharge,

Nonhyperemic/Unenlarged tonsils, (-) CLAD/Abn Neck Mass, (-) NVE, SCE, CBS, AP, (-) Murmurs Flabby Abdomen, NABS, Soft, Nontender. (?) Inguinal Adenopathy. Grossly normal extremities. No pedal edema.

(+) Erythematous/Tender Swelling R Perianal Area 1x3 inches, (+) Pus Draining from two openings: 10 & 3 oclock positions approx 3 cm anal opening.

DRE: (-) Skin/Mucosal Tags, Good Rectal Tone, Full Rectal Vault, (+) Solid Mass (Right/Left, Tender), (+) Tenderness R/L side, (+) Pus on examining finger.

SALIENT FEATURES From PE:

Pertinent Positives:

Erythematous and tender swelling at the R/L perianal areas, pus draining from two external openings , Tenderness upon DRE, Solid Mass at 3 oclock position (Tender), Pus on examining finger

SALIENT FEATURES From PE:

Pertinent Negatives:

(-) Vesicles; (-) Painful Ulcers; (-) Hair-containing Abscess (Intergluteal Region); (-) Skin/Mucosal Tag; (-) Hematoma

DIFFERENTIAL DIAGNOSES

Fissure-in-Ano
Constipation
Diarrhea

OUR PATIENT

Tearing Pain

Tenderness
Hematochezzia Skin Tag Ulceration

PRESENT

ANUSITIS

OUR PATIENT

Hx of Anal Intercourse Fever Anal Pain/Tenesmus Intense Pruritus Bleeding Discharge Fistula Formation Vesicles Painful Ulcers

PRESENT PRESENT PRESENT

Ulcerative Proctitis
Anal Pain/Tenesmus/ Tenderness Ulcers

OUR PATIENT

PRESENT PRESENT

Fistula Abdominal Pain

Vomiting
Bloody Diarrhea

Proctalgia Fugax
Anal Pain Without any other anorectal findings

OUR PATIENT

PRESENT

Perianal Hematoma
Anal Pain History of strained bowel movement, recent heavy lifting, or coughing. Perianal Hematoma

OUR PATIENT

PRESENT

PRESENT

Hemorrhoids
Anal Pain
History of constipation/chronic, heavy lifting. Hematochezzia Mass Skin Tag

OUR PATIENT

PRESENT PRESENT

Perianal Abscess/ OUR PATIENT Fistula-in-Ano Anal/Perianal Pain PRESENT

Anal/Perianal Itching

Swelling Tenderness Abscess Tenesmus Fever Sepsis Fistula Formation

PRESENT
PRESENT PRESENT PRESENT

PRESENT

PILONIDAL DSE
Fever Hair-containing Abscess (Intergluteal Region) Purulent Drainage Perianal Pain Tenderness

OUR PATIENT

PRESENT PRESENT PRESENT

HIDRADENITIS SUPPURATIVA
Fever Erythematous Swelling with Suppuration Perianal Pain Tenderness Superficial Cutaneous Involvement Only

OUR PATIENT
PRESENT

PRESENT
PRESENT

ANAL/PERIANAL TUMORS Weight Loss Perianal Pain Perianal Itching Tenesmus Purulent Drainage Bleeding Mass Nonhealing Ulceration

OUR PATIENT

PRESENT

PRESENT PRESENT PRESENT

Fourniers Gangrene Necrosis Purulent Drainage Anal/Perianal Pain Tenderness Tenesmus Sepsis Immunocompromised

OUR PATIENT
PRESENT PRESENT

PRESENT
PRESENT

WORKING DIAGNOSIS: Perianal Abscess R/L; Fistula-In-Ano

Cardio-pulmonary Clearance Diagnostics: CXR PA Hct 0.44 CBC, FBS, ECG 12 L, CXR PA, Normal RBC 4.61 Urinalysis Urinalysis Hgb 145 SG 1.025 FBS WBC 12.7 pH Acidic Lymph .29 Sugar Neg 103 mg/dl Mono .02 Pro Neg ECG 12 L Eos .02 Pus 0-1 NSR Polys 0.67 RBC 0-1

CLINICAL RISK FACTORS:

Course In The Wards

On Day of Admission S/O Findings: (+) Perianal Pain (+) Erythematous Swelling R Perianal Area (+) Perianal Tenderness (+) Purulent/Bloody Discharge from external opening. A: Perianal Abscess R/L; Fistula-In-Ano; T/C IFG Plan: > NPO Post Midnight > Start IVF at 9am D5LR 1L at 125 cc/Hour > Nubain 10 mg IM on call to OR > Promethazine 50 mg IM on call to OR

Intra-operative Findings: S/O Findings: Anal Fistula with external (-) Fever/Perianal Pain/Swelling opening at R 10 oclock (+) Erythema Perianal Area and 2 oclock positions approx (+) Tenderness over Surgical Site 3 cm from the anal verge A: Ischiorectal Abscess R/L; Fistula-In-Ano; Operation

1st HD 1st Post-op Day

S/P Fistulectomy; T/C IFG Performed: Plan:2x2 inches abscess formation > Anal > Post-op Orders in the right ischiorectal space > DAT once fully awake Fistulectomy > Mefenamic Acid 500 mg cap tid x 7 days > Oxycodone 5 mg IV q4h x 4 doses > Cefalexin 500 mg cap 1 Cap qid > Hot Sitz Bath BID.

2nd HD 2nd Post-op Day S/O Findings: (-) Fever/Perianal Pain/Swelling (+) Decreased Erythema R Perianal Area A: Ischiorectal Abscess R/L; Fistula-In-Ano; S/P Fistulectomy; T/C IFG Plan: > Continue Mefenamic and Cefalexin as previously ordered. > Lactulose 30 cc OD at HS. > May go home tomorrow.

3rd HD 3rd Post-op Day

S/O Findings: (-) Fever/Perianal Pain/Swelling (+) Decreased Erythema R Perianal Area A: Ischiorectal Abscess R/L; Fistula-In-Ano; S/P Fistulectomy; T/C IFG Plan: > MGH. > Home Meds: > Cefalexin 500 mg Cap TID for 1 week. > Ibuprofen 200 mg Tab TID with meals prn for pain. > FF-up check-up after 1 week.

FINAL DIAGNOSIS Ischiorectal Abscess R/L; Fistula-In-Ano; s/p Fistulectomy;

T/C Impaired Fasting Glucose

CASE DISCUSSION

ANORECTAL ANATOMY

INFERIOR RECTUM

INTERNAL HEMORRHOIDAL PLEXUSES INTERNAL SPHINCTERS EXTERNAL SPHINCTERS

DENTATE LINE

INTERSPHINCTERIC PLANE

ANAL CRYPTS

EXTERNAL HEMORRHOIDAL PLEXUSES

CORONAL VIEW

Communication of Spaces
Perianal space: around anus below transverse septum Ischiorectal space: posteriorly around anorectal region via deep postanal space Supralevator space: posteriorly around rectum via presacral

PATHOGENESIS

INFECTION/ INFLAMMATION

ABSCESS FORMATION

FISTULA FORMATION

GOODSALLS RULE

DEMOGRAPHY
Peak Incidence 20-40 y.o. M:F ~2:1 Increased Incidence in the
IMMUNOCOMPROMISED

CLINICAL MANIFESTATIONS
Anal Pain Palpable Mass Erythema Tenderness Draining Pus Fever Urinary Retention Sepsis

DIAGNOSIS
History

Physical Exam/DRE
Anoscopy Proctoscopy

INTRAOPERATIVE

TREATMENT
Medical Antibiotics (ineffective if alone) Antibiotics indicated only in: >Extensive Cellulitis >Immunocompromised >Valvular Heart Disease

Analgesics

TREATMENT
SURGICAL Incision and Drainage Sphincterotomy Transrectal Through the Skin
Fistulotomy/Fistulectomy Curettage/Cautery

TREATMENT
OTHERS Hot Sitz Bath

COMPLICATIONS Fistula-in-Ano

Fourniers Gangrene
Death Carcinoma

Fecal Incontinence

PROGNOSIS
Drainage alone results in cure for 50%. 50% will have recurrences and develop an anal fistula.

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