0521779407-17 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:18
1158 Perirectal Abscesses and Fistulas■Barium enema and/or endoscopy may be necessary to look for
Crohn’s disease
■Exam under anesthesia occasionally necessary to identify a deep or
complex abscess in a patient with pain but no clear external signs of
infection
differential diagnosis
■Fissure in ano will severe pain with defecation
■Anodynia causes chronic pain without signs or symptoms of inflam-
mation
■Consider Crohn’s disease with unusual or multiple fistulae
■Rarely, tumors such as Kaposi’s sarcoma may be mistaken for an
abscess
■Hemorrhoids should not cause pain
management
■Perirectal abscesses should be drained surgically, often but not nec-
essarily always in the operating room
■Antibiotics should be given for complex abscesses and may be given
by some, but not all surgeons at the time of drainage of an abscess
■Fistulae are best treated electively after the inflammation of an
abscess has subsided
specific therapy
■Superficial abscesses may be opened under local anesthesia in the
office.
■More complex abscesses should be treated in the operating room.
■Occasionally, debridement of devitalized tissue may be necessary
associated with drainage of the abscess
■Rarely, a fistula may be treated definitively at the same time as
drainage of a perirectal abscess
■Fistulae typically require surgery to open the tract. Complex fistu-
lae may require staged repairs, sometimes including the use of a
seton, (a tie that will cut through the sphincter muscles slowly in
order to prevent incontinence), and occasionally may even require
a colostomy
■Some fistulae may respond to injection of the tract with fibrin glue
■Fistulae associated with Crohn’s disease may respond to anti-TNF
antibodies (infliximab)
follow-up
■An abscess that resolves completely with drainage requires no further
followup