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Cureus Apr 2024Perianal abscess is a clinical infective and/or inflammatory collection in the perianal region, one entity of a large group of anal and perianal disorders. Perianal...
BACKGROUND
Perianal abscess is a clinical infective and/or inflammatory collection in the perianal region, one entity of a large group of anal and perianal disorders. Perianal abscesses are often seen as a complication of grade 2 and grade 4 perianal fistulas from St. James's University Hospital classification. Several imaging modalities have been tried in the past for adequate assessment of perianal abscess with contrast-enhanced magnetic resonance imaging (CE-MRI) providing the most accurate results. Diffusion-weighted imaging (DWI) is an emerging sequence that can provide comparable results to CE-MRI in diagnosing and characterizing perianal abscess. The main objective of this study is to assess the role of DWI in adequate identification and assessment of perianal abscess and compare the final results with contrast-enhanced images.
METHODS
Twenty patients with complicated perianal fistula with clinically suspected perianal abscess were evaluated with DWI and CE-MRI. This study was a comparative cross-sectional study conducted in the Department of Radiodiagnosis and Imaging, All India Institute of Medical Sciences, Bhopal, India. Chi-square test was done to find the association between categorical variables. Kappa test was used to find the agreement between two different tests. Receiver operating characteristics (ROC) analysis was done to estimate the area under the curve in predicting the outcome. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy were used to measure the validity of the tests.
RESULTS
DWI is a very sensitive MRI sequence and is equivalent to CE-MRI to detect the location and analyzing the loco-regional extent of abscess in complicated perianal fistula cases. DWI is also very sensitive and superior to T2 short tau inversion recovery (STIR) in differentiating perianal abscess from perianal inflammation without abscess.
CONCLUSION
DWI can be used as an alternative to post-contrast fat-suppressed MRI in precisely defining the location and extent of anal and perianal abscesses and disease activity in complicated fistula cases.
PubMed: 38800169
DOI: 10.7759/cureus.59035 -
Current Opinion in Gastroenterology Jul 2021Multiple new medications with novel mechanisms of action are now available to treat Crohn's disease (CD). However, they have varying effectiveness in the management of... (Review)
Review
PURPOSE OF REVIEW
Multiple new medications with novel mechanisms of action are now available to treat Crohn's disease (CD). However, they have varying effectiveness in the management of perianal CD. Identifying the most appropriate therapy and optimizing it is essential to maximize effectiveness of therapy. Additionally, the management of perianal CD requires imaging of the perianal area to identify the fistula anatomy and local complications such as abscesses that require surgical drainage. Initial surgical assessment is key to drain abscesses and allow fistula healing with medical therapy.
RECENT FINDINGS
Although anti-tumor necrosis factor (TNFs) remain the most effective medications to treat perianal CD, real-world data suggests that ustekinumab may be a 2nd-line option in patients nonresponsive to an anti-TNF or having contraindications. Mesenchymal stem cells are an emerging therapeutic approach that is currently in Phase 3 trials in the United States and poised to play a major role in the treatment algorithm.
SUMMARY
The management of perianal CD requires a multidisciplinary approach with a combination of initial imaging and surgical assessment to adequately control local sepsis, optimization of biological therapy with adjunct antibiotics or immunomodulators, and close clinical follow-up with imaging to evaluate response to therapy and guide further surgical management options.
Topics: Crohn Disease; Humans; Rectal Fistula; Treatment Outcome; Tumor Necrosis Factor Inhibitors; Tumor Necrosis Factor-alpha
PubMed: 33899777
DOI: 10.1097/MOG.0000000000000751 -
Ugeskrift For Laeger Dec 2020Anal abscesses are well-known conditions worldwide. The golden standard of acute treatment is incision and drainage. Knowledge of the anatomy of the anal area and the... (Review)
Review
Anal abscesses are well-known conditions worldwide. The golden standard of acute treatment is incision and drainage. Knowledge of the anatomy of the anal area and the abscess involvement of perianal spaces is crucial in order to perform safe and correct surgical treatment as summarised in this review. Pre- and perioperative imaging with magnetic resonance imaging, endoanal ultrasonography or CT facilitates correct incision and drainage, while antibiotics as conservative approach have no place in the treatment of abscesses. One third of the patients have an underlying fistula, and if suspected referral to a fistula centre is warranted.
Topics: Abscess; Anal Canal; Anus Diseases; Drainage; Humans; Rectal Fistula
PubMed: 33317691
DOI: No ID Found -
ANZ Journal of Surgery Jul 2022Perianal abscesses are a common surgical emergency. Due to their perceived ease, drainage is often delegated to junior trainees with varying levels of experience. The...
BACKGROUND
Perianal abscesses are a common surgical emergency. Due to their perceived ease, drainage is often delegated to junior trainees with varying levels of experience. The purpose of this study is to evaluate the current trend in perianal abscesses management at our institution, and identify factors that predict subsequent fistula formation or abscess recurrence.
METHODS
All acute patients admitted to a major teaching hospital who required surgical drainage of a perianal abscess were analysed over a two-year period from January 2019 to December 2020. Patient demographics, clinical and laboratory findings were retrospectively reviewed. Proceduralist experience, operative management strategy and recurrence rates (fistula or abscess) were analysed.
RESULTS
The mean age of patients was 43 years old, and 73% were male. Trainees performed 96% of the procedures. Re-presentation with a fistula or abscess recurrence requiring further surgery was 31%. Comorbidities of IBD, diabetes, or malignancy were present in one-third of patients and significantly increased the risk of recurrence (P = 0.01). Searching for a fistula tract was performed in 41% of cases but did not reduce recurrence (P = 0.9). Seton insertion occurred in 10%, and fistulotomy in 2%.
CONCLUSION
Perianal abscess drainage at our institution is almost exclusively performed by trainees, the majority of which occurs after-hours. Patients who present with a fever, inflammatory bowel disease, diabetes mellitus or malignancy are at an increased risk of recurrent abscess or a subsequent fistula after drainage, and input from an experienced surgeon may be of value when considering seton insertion or fistulotomy.
Topics: Abscess; Adult; Anus Diseases; Drainage; Female; Humans; Male; Rectal Fistula; Recurrence; Retrospective Studies; Skin Diseases; Treatment Outcome
PubMed: 35485429
DOI: 10.1111/ans.17750 -
Archives de Pediatrie : Organe Officiel... Apr 2022Benign anorectal disease refers to a diverse group of frequent anorectal complaints that cause considerable discomfort, disability, and often constitute a significant... (Review)
Review
Benign anorectal disease refers to a diverse group of frequent anorectal complaints that cause considerable discomfort, disability, and often constitute a significant problem for the child and his or her family. Hemorrhoids, fissures, rectal prolapse, and perianal abscess and fistulas are the most common anorectal disorders in pediatric population and their appearance may be age-specific. Although they generally follow a benign course, a careful examination must be performed in order to exclude other serious and complicated underlying pathology. Their diagnosis is based on the patient's medical history, physical examination, endoscopy, and imaging. Moreover, the management of these disorders includes medical and surgical treatment options, and if they are treated promptly and properly may be limited and short lived. This review presents the currently available data in the literature on the diverse aspects of these disorders, including the definition, epidemiology, clinical presentation, pathogenesis, diagnosis, indications for surgery, and long-term outcomes.
Topics: Abscess; Anus Diseases; Child; Endoscopy; Female; Hemorrhoids; Humans; Male; Rectal Diseases; Rectal Fistula; Rectal Prolapse
PubMed: 35249800
DOI: 10.1016/j.arcped.2022.01.015 -
Paediatric Drugs Nov 2023Hidradenitis suppurativa (HS) is a chronic, recurrent, inflammatory skin condition that manifests as painful, deep-seated, inflamed nodules and abscesses in the... (Review)
Review
Hidradenitis suppurativa (HS) is a chronic, recurrent, inflammatory skin condition that manifests as painful, deep-seated, inflamed nodules and abscesses in the axillary, groin, perianal, perineal, and inframammary regions. The associated pain, malodour, and disfigurement contribute to its profound negative impact on psychosocial spheres and overall quality of life in affected individuals. Although the symptoms of HS classically begin in the second or third decade of life, HS affects children and adolescents as well. Despite this, there are limited pediatric data on treatment, which are largely based on expert opinion, extrapolation of efficacy data in adults with HS, and safety information from medication use in other pediatric diseases. On this basis, there exist several pharmacological modalities in the treatment of children and adolescents with HS including topical therapies, systemic therapies, and biologics. The goals of this review article are to: (1) review the efficacy of different pharmacological treatment modalities in children and adolescents with HS, and (2) review the safety and monitoring considerations of the different treatment options in children and adolescents with HS.
Topics: Adult; Humans; Child; Adolescent; Quality of Life; Hidradenitis Suppurativa; Pain
PubMed: 37782437
DOI: 10.1007/s40272-023-00595-6 -
British Journal of Hospital Medicine... Nov 2023A best evidence topic in general surgery was written according to a structured protocol, to address the question: in adult patients with perianal abscesses, should... (Review)
Review
A best evidence topic in general surgery was written according to a structured protocol, to address the question: in adult patients with perianal abscesses, should postoperative wound packing be undertaken considering the rates of pain experienced, wound healing and abscess recurrence? The literature search identified 159 papers on Ovid, Embase and Medline and 48 on PubMed. These were independently screened, and three articles were included in this review as these offered the best information to answer the question. One was a systematic review without meta-analysis, one was a randomised controlled trial and one was a multicentre observational study. Review of these articles led the authors to conclude that routine postoperative packing of perianal abscesses following incision and drainage is costly, associated with increased pain and confers no protection against recurrence of abscesses or formation of fistulae.
Topics: Adult; Humans; Abscess; Drainage; Multicenter Studies as Topic; Observational Studies as Topic; Pain; Postoperative Period; Randomized Controlled Trials as Topic; Skin Diseases
PubMed: 38019208
DOI: 10.12968/hmed.2023.0308 -
Journal of Crohn's & Colitis Aug 2023Perianal lesion is a refractory phenotype of Crohn's disease [CD] with significantly diminished quality of life. We evaluated the clinical characteristics of perianal...
Diagnosis and Clinical Features of Perianal Lesions in Newly Diagnosed Crohn's Disease: Subgroup Analysis from Inception Cohort Registry Study of Patients with Crohn's Disease (iCREST-CD).
BACKGROUND AND AIMS
Perianal lesion is a refractory phenotype of Crohn's disease [CD] with significantly diminished quality of life. We evaluated the clinical characteristics of perianal lesions in newly diagnosed CD patients and the impact of perianal lesions on the quality of life in Japanese patients with CD.
METHODS
Patients newly diagnosed with CD after June 2016 were included between December 2018 and June 2020 from the Inception Cohort Registry Study of Patients with CD [iCREST-CD].
RESULTS
Perianal lesions were present in 324 [48.2%] of 672 patients with newly diagnosed CD; 71.9% [233/324] were male. The prevalence of perianal lesions was higher in patients aged <40 years vs ≥40 years, and it decreased with age. Perianal fistula [59.9%] and abscess [30.6%] were the most common perianal lesions. In multivariate analyses, male sex, age <40 years and ileocolonic disease location were significantly associated with a high prevalence of perianal lesions, whereas stricturing behaviour and alcohol intake were associated with low prevalence. Fatigue was more frequent [33.3% vs 21.6%] while work productivity and activity impairment-work time missed [36.3% vs 29.5%] and activity impairment [51.9% vs 41.1%] were numerically higher in patients with than those without perianal lesions.
CONCLUSIONS
At the time of CD diagnosis, approximately half of the patients had perianal lesions; perianal abscesses and perianal fistulas were the most common. Young age, male sex, disease location and behaviour were significantly associated with the presence of perianal lesions. The presence of perianal lesion was associated with fatigue and impairment of daily activities.
CLINICAL TRIALS REGISTRY
University Hospital Medical Information Network Clinical Trials Registry System [UMIN-CTR, UMIN000032237].
Topics: Male; Female; Humans; Crohn Disease; Quality of Life; Constriction, Pathologic; Anus Diseases; Abscess; Rectal Fistula; Registries
PubMed: 36869815
DOI: 10.1093/ecco-jcc/jjad038 -
The American Surgeon Jun 2021Perianal abscess and anal fistula are 2 common anorectal diseases in infants and young children. However, their causes, clinical diagnosis, and treatment remain... (Review)
Review
Perianal abscess and anal fistula are 2 common anorectal diseases in infants and young children. However, their causes, clinical diagnosis, and treatment remain controversial. Compared to adults, infants with these 2 diseases exhibit unique clinical characteristics. Blind pursuit of conservative treatment or surgery may worsen the condition, resulting in increased pain in young patients and greater economic burden and psychological harm to parents. Therefore, it is crucial to select correct and effective treatments. This review summarizes the relevant literature from the past 10 years and systematically explains the pathogenesis, clinical characteristics, and treatment measures of perianal abscess and anal fistula in infants with the goal of providing clinicians a deeper understanding of perianal abscess and anal fistula in infants and summarizing safe and effective treatment methods.
Topics: Abscess; Anus Diseases; Child; Child, Preschool; Humans; Infant; Infant, Newborn; Rectal Fistula
PubMed: 33284051
DOI: 10.1177/0003134820954829 -
Journal of Pediatric Surgery Jul 2023Perianal abscesses and anal fistulas are common. The principle of intention-to-treat has not been considered in previous systemic reviews. Thus, the comparison between... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Perianal abscesses and anal fistulas are common. The principle of intention-to-treat has not been considered in previous systemic reviews. Thus, the comparison between primary and post-recurrence management was confused, and the recommendation of primary treatment is obscure. The current study aims to identify the optimal initial treatment for pediatric patients.
METHODS
Using PRISMA guidelines, studies were identified from MEDLINE, EMBASE, PubMed, Cochrane Library, and Google Scholar without any language or study design restriction. The inclusion criteria include original articles or articles with original data, studies of management for a perianal abscess with or without anal fistula, and patient age of <18 years. Patients with local malignancy, Crohn's disease, or other underlying predisposing conditions were excluded. Studies without analyzing recurrence, case series of <5, and irrelevant articles were excluded in the screening stage. Of the 124 screened articles, 14 articles had no full texts or detailed information. Articles written in a language other than English or Mandarin were translated by Google Translation first and confirmed with native speakers. After the eligibility process, studies that compared identified primary managements were then included in the qualitative synthesis.
RESULTS
Thirty-one studies involving 2507 pediatric patients met the inclusion criteria. The study design consisted of two prospective case series of 47 patients and retrospective cohort studies. No randomized control trials were identified. Meta-analyses for recurrence after initial management were performed with a random-effects model. Conservative treatment and drainage revealed no difference (Odds ratio [OR], 1.222; 95% Confidential interval [CI]: 0.615-2.427, p = 0.567). Conservative management had a higher risk of recurrence than surgery without statistical significance (OR 0.278, 95% CI: 0.109-0.707, p = 0.007). Compared with incision/drainage, surgery can prevent recurrence remarkably (OR 4.360, 95% CI: 1.761-10.792, p = 0.001). Subgroup analysis of different approaches within conservative treatment and operation was not performed for lacking information.
CONCLUSION
Strong recommendations cannot be made due to the lack of prospective or randomized controlled studies. However, the current study based on real primary management supports initial surgical intervention for pediatric patients with perianal abscesses and anal fistula to prevent recurrence.
LEVEL OF EVIDENCE
Type of study: Systemic review; Evidence level: Level II.
Topics: Adolescent; Child; Humans; Abscess; Anus Diseases; Drainage; Rectal Fistula; Retrospective Studies; Treatment Outcome
PubMed: 36894443
DOI: 10.1016/j.jpedsurg.2023.01.055