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Frontiers in Pediatrics 2022The aim of this study was to explore potential correlation of the MR imaging features and clinical characteristics with formation of perianal abscess in children with...
PURPOSE
The aim of this study was to explore potential correlation of the MR imaging features and clinical characteristics with formation of perianal abscess in children with Crohn's perianal fistulas (CPF).
METHODS
From 2010 to 2020, pediatric patients with CPF diagnosis on their first pelvic MRI were identified retrospectively. All patients were divided into two groups based on the presence or absence of perianal abscess. Baseline clinical and MRI characteristics were recorded for each patient. All the statistical calculations were performed using R (version 3.6.3).
RESULTS
A total of 60 patients [F:M 17:43, median age 14 years (IQR 10-15), ranging 3-18 years] were included in this study. Forty-four abscesses were identified in 36/60 children (mean volume 3 ± 8.6 ml, median 0.3 ml). In 24/60 patients with perianal disease, no abscess was detected on the MRI. Ten patients (28%) showed perianal abscess on pelvic MRI at the initial diagnosis. The rate of active disease on colonoscopy (visible ulcerations/aphthous ulcers) was similar in both groups (95% vs. 94%). With regards to disease location, the majority of patients (40/60, 66.6%) in both groups had ileocolonic CD. All patients without abscess had a single perianal fistula ( = 24; 3 simple and 21 complex fistulae), however, patients with perianal abscess tended to have >1 fistulous tracts ( = 50 fistulas; all complex, 27 single, 10 double and 1 triple). Intersphincteric fistula was the most common fistula type in both groups (79% and 66%, = 0.1). The total length of fistula (3.8 ± 1.7 vs. 2.8 ± 0.8 cm, = 0.006) and presence of multiple external openings ( = 25 vs. 7, = 0.019) were significantly higher in patients with abscesses, and fistula length >3.3 cm showed 80% specificity and 83% PPV for the presence of perianal abscess. Fistulas were symptomatic (pain, bleeding or drainage) at similar rates in both groups (68% and 70%, = 0.1).
CONCLUSION
Pediatric patients with CPF who develop perianal abscess have a distinct imaging phenotype defined by longer fistula length (>3.3 cm), multiple skin openings and multiple fistulous tracts (≥2) on MRI. Patients who have these features but does not have an abscess on imaging may merit more aggressive treatment (and close monitoring) to prevent the development of an abscess.
PubMed: 36507146
DOI: 10.3389/fped.2022.1045583 -
The Israel Medical Association Journal... Jul 2023Perianal abscesses require immediate incision and drainage (I&D). However, prompt bedside drainage is controversial as it may compromise exposure and thorough anal...
BACKGROUND
Perianal abscesses require immediate incision and drainage (I&D). However, prompt bedside drainage is controversial as it may compromise exposure and thorough anal examination.
OBJECTIVES
To examine outcomes of bedside I&D of perianal abscesses in the emergency department (ED) vs. the operating room (OR).
METHODS
We conducted a retrospective review of all patients presented to the ED with a perianal abscesses between January 2018 and March 2020. Patients with Crohn's disease, horseshoe or recurrent abscesses were excluded.
RESULTS
The study comprised 248 patients; 151 (60.89%) underwent I&D in the OR and 97 (39.11%) in the ED. Patients elected to bedside I&D had smaller abscess sizes (P = 0.01), presented with no fever, and had lower rates of inflammatory markers. The interval time from diagnosis to intervention was significantly shorter among the bedside I&D group 2.13 ± 2.34 hours vs. 10.41 ± 8.48 hours (P < 0.001). Of patients who underwent I&D in the OR, 7.3% had synchronous fistulas, whereas none at bedside had (P = 0.007). At median follow-up of 24 months, recurrence rate of abscess and fistula formation in patients treated in the ED were 11.3% and 6.2%, respectively, vs. 19.9% and 15.23% (P = 0.023, 0.006). Fever (OR 5.71, P = 0.005) and abscess size (OR 1.7, P = 0.026) at initial presentation were risk factors for late fistula formation.
CONCLUSIONS
Bedside I&D significantly shortens waiting time and does not increase the rates of long-term complications in patients with small primary perianal abscesses.
Topics: Humans; Abscess; Rectal Fistula; Anus Diseases; Drainage; Retrospective Studies; Skin Diseases
PubMed: 37461172
DOI: No ID Found -
Annals of Coloproctology Oct 2021Actinomycosis is a serious suppurative, bacterial infection caused by the gram-positive anaerobic Actinomyces species. Primary perianal actinomycosis is rare and... (Review)
Review
Actinomycosis is a serious suppurative, bacterial infection caused by the gram-positive anaerobic Actinomyces species. Primary perianal actinomycosis is rare and challenging for the colorectal surgeon. We aimed to present our experience and compare this with available literature. All patients with isolated Actinomyces on microbiology reports, between January 2013 and February 2021, were identified and reviewed. Data collection was retrospective based on electronic patient records. The site of infection and treatment strategy were examined. Perianal cases were evaluated in depth. All publications available in the literature were interrogated. Fifty-nine cases of positive actinomycosis cultures were reviewed. Six cases of colonization were excluded. Actinomyces turicensis was the most common organism isolated. Five cases of perianal actinomycosis were identified requiring prolonged antibiotic and surgical therapy. Twenty-one studies, most case reports, published since 1951 were also reviewed. Diagnosis of perianal actinomycosis may be challenging but should be suspected particularly in recurrent cases. Prolonged bacterial cultures in anaerobic conditions are necessary to identify the bacterium. An extended course of antibiotic therapy (months) is required for eradication in certain cases.
PubMed: 34731938
DOI: 10.3393/ac.2021.00332.0047 -
Inflammatory Bowel Diseases Oct 2022Perianal Crohn's disease (pCD) is a potentially severe phenotype of CD. We conducted a systematic review with meta-analysis to estimate cumulative incidence, risk... (Meta-Analysis)
Meta-Analysis
BACKGROUND AND AIMS
Perianal Crohn's disease (pCD) is a potentially severe phenotype of CD. We conducted a systematic review with meta-analysis to estimate cumulative incidence, risk factors, and outcomes of pCD in population-based cohort studies.
METHODS
Through a systematic literature review through March 1, 2021, we identified population-based inception cohort studies reporting cumulative incidence of perianal disease (primarily abscess and/or fistula) in patients with CD. We estimated the cumulative incidence of pCD at presentation and 1-, 5-, and 10-year follow-up, and risk factors for perianal disease and outcomes including risk of major (bowel resection, proctectomy, ostomy) and minor perianal (incision and drainage, seton placement, etc.) surgery.
RESULTS
In 12 population-based studies, prevalence of pCD was 18.7% (95% confidence interval [CI], 12.5%-27.0%) with 1-, 5-, and 10-year risk of perianal disease being 14.3% (95% CI, 7.9%-24.6%), 17.6% (95% CI, 11.3%-26.5%), and 18.9% (95% CI, 15.0%-23.4%), respectively. Approximately 11.5% of patients (95% CI, 6.7%-19.0%) had perianal disease at or before CD diagnosis. Colonic disease location and rectal involvement were associated with higher risk of pCD. Overall, 63.3% of patients (95% CI, 53.3-72.3) required minor perianal surgery and 6.4% of patients (95% CI, 1.8%-20.6%) required major abdominal surgery for pCD. Use of biologic therapy for pCD is common and has steadily increased throughout the years.
CONCLUSIONS
Approximately 1 in 5 patients with CD develops perianal disease within 10 years of CD diagnosis, including 11.5% who have perianal disease at presentation. Approximately two-thirds of patients require perianal surgery, with a smaller fraction requiring major abdominal surgery.
Topics: Cohort Studies; Crohn Disease; Humans; Incidence; Proctectomy; Rectal Fistula; Treatment Outcome
PubMed: 34792604
DOI: 10.1093/ibd/izab287 -
Scientific Reports Sep 2022Perianal abscesses are frequent diseases in general surgery. Principles of standard patient care are surgical drainage with exploration and concomitant treatment of...
Perianal abscesses are frequent diseases in general surgery. Principles of standard patient care are surgical drainage with exploration and concomitant treatment of fistula. Antiinfective therapy is frequently applied in cases of severe local disease and perianal sepsis. However, the role of microbiologic testing of purulence from perianal abscesses is disputed and the knowledge concerning bacteriology and bacterial resistances is very limited. A retrospective cohort study was performed of consecutive patients (≥ 12 years of age) from a tertiary care hospital, who underwent surgical treatment for perianal abscess from 01/2008 to 12/2019. Subdividing the cohort into three groups regarding microbiological testing results: no microbiological testing of purulence (No_Swab, n = 456), no detection of drug resistant bacteria [DR(-), n = 141] or detection of bacteria with acquired drug resistances from purulence [DR(+), n = 220]. Group comparisons were performed using Kruskall-Wallis test and, if applicable, followed by Dunn´s multiple comparisons test for continuous variables or Fishers exact or Pearson's X test for categorical data. Fistula persistence was estimated by Kaplan Meier and compared between the groups using Log rank test. Corralation analysis between perioperative outcome parameters and bacteriology was performed using Spearman´s rho rank correlation. Higher pretherapeutic C-reactive protein (p < 0.0001) and white blood cell count (p < 0.0001), higher rates of supralevatoric or pararectal abscesses (p = 0.0062) and of complicated fistula-in-ano requiring drainage procedure during index surgery (p < 0.0001) reflect more severe diseases in DR(+) patients. The necessity of antibiotic therapy (p < 0.0001), change of antibiotic regimen upon microbiologic testing results (p = 0.0001) and the rate of re-debridements during short-term follow-up (p = 0.0001) were the highest, the duration until definitive fistula repair was the longest in DR(+) patients (p = 0.0061). Escherichia coli, Bacteroides, Streptococcus and Staphylococcus species with acquired drug resistances were detected frequently. High rates of resistances against everyday antibiotics, including perioperative antibiotic prophylaxis were alarming. In conclusion, the knowledge about individual bacteriology is relevant in cases of complex and severe local disease, including locally advanced infection with extended soft tissue affection and perianal sepsis, signs of systemic inflammatory response as well as the need of re-do surgery for local debridements during short-term and fistula repair during long-term follow-up. Higher rates of acquired antibiotic resistances are to be expected in patients with more severe diseases.
Topics: Abscess; Anti-Bacterial Agents; Anus Diseases; Bacteria; Humans; Retrospective Studies; Sepsis; Skin Diseases; Treatment Outcome
PubMed: 36050427
DOI: 10.1038/s41598-022-19123-6 -
American Journal of Translational... 2023This study aimed to comprehensively evaluate perianal fistulas and their related complications using magnetic resonance imaging (MRI).
OBJECTIVE
This study aimed to comprehensively evaluate perianal fistulas and their related complications using magnetic resonance imaging (MRI).
METHODS
We enrolled 115 eligible patients who underwent preoperative perianal MRI. Primary fistulas, internal and external openings, and related complications were evaluated using MRI. All fistulas were classified according to Park's classification, Standard Practice Task Force classification, St. James's grade, and the position of the internal opening.
RESULTS
In total, 169 primary fistulas were detected in 115 patients; 73 (63.5%) patients had a single primary tract and 42 (36.5%) patients had multiple primary tracts, and 198 internal and 129 external openings were identified. Based on Park's classification, 150 (88.7%) primary fistulas were classified into the following types: intersphincteric (82, 54.7%), trans-sphincteric (58, 38.6%), suprasphincteric (8, 5.3%), extrasphincteric (1, 0.7%), and diffuse intersphincteric with trans-sphincteric (1, 0.7%) types. Based on St. James's grade, 149 fistulas were classified into grade 1 (52, 34.9%), grade 2 (30, 20.1%), grade 3 (20, 13.4%), grade 4 (38, 25.5%), and grade 5 (9, 6.1%). We detected 92 (54.4%) simple and 77 (45.6%) complex perianal fistulas and 72 (42.6%) high and 97 (57.4%) low perianal fistulas. Furthermore, we detected 32 secondary tracts in 23 (20.0%) patients and 87 abscesses in 60 (52.2%) patients. Levator ani muscle involvement and extensive soft tissue edema were detected in 12 (10.4%) and 24 (20.9%) patients, respectively.
CONCLUSION
MRI is a valuable and comprehensive tool that can not only be used to determine the general condition of perianal fistulas but also to classify them and identify related complications.
PubMed: 37303685
DOI: No ID Found -
The Turkish Journal of Gastroenterology... Mar 2021Perianal disease is reported more widely in pediatric Crohn patients than in the past, and has been stated as an independent modifier of the disease behavior. In this...
BACKGROUND
Perianal disease is reported more widely in pediatric Crohn patients than in the past, and has been stated as an independent modifier of the disease behavior. In this study, we aimed to analyze the clinical characteristics and outcomes of fistulising perianal Crohn's disease (fpCD) in the pediatric age group.
METHODS
A total number of 149 children with an established diagnosis of inflammatory bowel disease who have been diagnosed before 18 years of age and followed in our tertiary center were revised. Clinical, endoscopic, laboratory, and radiologic data of 50 patients with CD, who had at least 18 months follow-up data, were compiled.
RESULTS
Of 50 patients, 26 (52%) were diagnosed as fpCD (38% at onset). More than half of the patients without any notable external orifices around the perianal area were diagnosed as fpCD by an magnetic resonance imaging (MRI). Pediatric fpCD patients had a higher disease activity score and platelet count, lower serum albumin level, and a higher rate of granuloma in the biopsy samples, compared with non-fistulising patients. A considerably high rate of surgical interventions (i.e., seton placement 46% and abscess drainage 15%) was performed in combination with infliximab.
CONCLUSION
Fistulising perianal Crohn's disease seems to be more common than previously reported in the pediatric age group. A severe course of the disease might serve as a warning for the development of fpCD. A careful physical examination and use of perianal MRI with a high index of suspicion may increase the likelihood of fistula detection, hence may change the treatment strategy.
Topics: Child; Crohn Disease; Humans; Rectal Fistula; Treatment Outcome
PubMed: 34160353
DOI: 10.5152/tjg.2021.191034 -
Surgical Infections Jun 2022Non-surgical intervention has been proposed for the management of perianal abscess (PA) and fistula-in-ano (FIA), with potential benefits in terms of quality of life,...
Non-surgical intervention has been proposed for the management of perianal abscess (PA) and fistula-in-ano (FIA), with potential benefits in terms of quality of life, wound healing, and functional outcome, although this strategy remains rare and controversial. Here, we aimed to compare the intermediate-term outcomes of non-surgical management with those of surgical incision and/or drainage. A study of pediatric patients with first-time PA and/or FIA was conducted retrospectively from January 2010 to December 2020. The patient population was stratified by surgical and non-surgical management. The clinical outcomes, including PA recurrence, FIA formation, and wound healing time, were compared between the surgical and non-surgical management groups. A total of 457 patients managed for first-time PA and/or FIA were eligible for the current study. Of these patients, 169 (50.9%) patients received non-surgical intervention. There were no differences in terms of age, gender distribution, wound healing course, or abscess size between the two groups. Furthermore, no difference was noted between the two groups in terms of PA recurrence and/or FIA development rates and revisits for additional treatment. Although PA/FIA management is still controversial, non-surgical intervention exhibited promising outcomes for most cases of first-time PA/FIA, with fewer hospital admissions and surgical procedures and similar recurrence and fistula formation incidences. Immediate surgical intervention might be avoided because PA/FIA has a chance for spontaneous resolution in children.
Topics: Abscess; Anus Diseases; Child; Humans; Quality of Life; Rectal Fistula; Retrospective Studies; Treatment Outcome
PubMed: 35647894
DOI: 10.1089/sur.2021.351 -
Biomedicines Oct 2020Inflammatory bowel diseases (IBD) are gastrointestinal tract pathologies of unknown etiology; they have an alternating trend, with active and silent phases. IBD are... (Review)
Review
Inflammatory bowel diseases (IBD) are gastrointestinal tract pathologies of unknown etiology; they have an alternating trend, with active and silent phases. IBD are classified in two main forms: ulcerative colitis (UC) and Crohn's disease (CD). Both have chronic and recurrent course, gastrointestinal symptoms, and extraintestinal manifestations. The altered immune response role seems to be important both in UC and CD. In the majority of cases, CD begins with abdominal pain, diarrhea, decrease in appetite, and weight loss; there can be also perianal fistulas, rhagades, and perianal recurrent abscesses. In addition, retarded growth and delayed puberty can precede the development of the disease or can even be predominant at onset. Growth retardation is found in 40% of IBD patients, but the underlying mechanism of this and other extra-intestinal manifestations are partially known: the main hypotheses are represented by malnutrition and inflammatory response during the active phase of the disease. The increased level of pro-inflammatory cytokines can influence growth, but also the onset of puberty and its progression. In addition, it could be essential to clarify the role and the possible effects of all the currently used treatments concerning growth failure and delayed puberty.
PubMed: 33138015
DOI: 10.3390/biomedicines8110458 -
Frontiers in Surgery 2022Anal canal duplication (ACD) is a very rare duplication of the gastrointestinal tract and is described as a secondary anal orifice along the posterior side of the normal... (Review)
Review
BACKGROUND
Anal canal duplication (ACD) is a very rare duplication of the gastrointestinal tract and is described as a secondary anal orifice along the posterior side of the normal anal canal. Early surgical removal is advisable, also in asymptomatic patients, because of the risk of inflammatory complications, such as recurrent crissum abscess, and malignant changes.
CASE PRESENTATION
A previously healthy 2-year-old boy was evaluated in the emergency department with fever. He complained of anal pain in the absence of incentive. Physical examination and ultrasound confirmed a diagnosis of perianal abscess. He was treated with incision and drainage of the abscess and intravenous antibiotics. Two months after his discharge from the hospital, he developed fever and had intervals discharge pus and pain in the same locations. Colorectal endoscopy revealed that there was no fistula opening at the rectal wall. Intraoperative fistulography showed a fistulous tract that was connected to a subcutaneous cavity. Excision of the fistulous tract and wide drainage of the deep postanal space were performed. The patient was referred to our hospital for further evaluation 6 months later. Physical examination showed a secondary anus that had not been noticed before. MRI showed an anal fistula between 1 and 3 o'clock, and preoperative fistulography revealed a 3-cm-long tubular structure without any connection with the rectum. The diagnosis of ACD was made by intraoperative examination with a metal catheter and the postoperative pathological analysis. The duplicated anal canal was resected completely via a perianal approach without any rectal injury. Histology showed a squamous epithelium in the distal end with some smooth-muscle fibers. After a follow-up of 8 months, the patient has been doing well.
CONCLUSION
Recurrent crissum abscess should raise clinical attention to alimentary tract congenital malformations such as ACD. Prompt recognition of these unique presentations of ACD is needed, and complete excision through a perineal approach or posterior sagittal approach is recommended.
PubMed: 35647015
DOI: 10.3389/fsurg.2022.908390