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Cureus Nov 2023Hidradenitis suppurativa (HS) is a chronic, debilitating inflammatory disorder of the hair follicles that localizes to the intertriginous and anogenital regions of the...
Hidradenitis suppurativa (HS) is a chronic, debilitating inflammatory disorder of the hair follicles that localizes to the intertriginous and anogenital regions of the body. Lesions are characterized by inflammatory nodules, subcutaneous abscesses, fibrosis, and sinus tracts. Crohn's disease (CD) is an idiopathic chronic inflammatory bowel disease that affects any part of the gastrointestinal tract. Multiple treatment options exist for CD, including monoclonal anti-tumor necrosis factor alpha (TNF-α) antibodies like adalimumab (Humira). Adalimumab is an anti-TNF agent that has been approved by the United States Food and Drug Administration (FDA) for the treatment of HS. A 35-year-old African American male with a history of fistulizing CD presented to the hospital for evaluation of severe pain and purulent drainage from open sores in his bilateral axillary regions, groin, buttocks, and face for four days. He was on adalimumab for two years, during which time he noted the development of Hurley stage III HS. The physical exam was remarkable for a cachectic, painful-appearing male, with multiple abscesses on his lower jaw extending to his upper neck draining thick serosanguinous fluid, with similar findings in his bilateral axillary regions, bilateral groin, and perianal regions. He was treated with intravenous antibiotics consisting of a fourth-generation cephalosporin and vancomycin. While the etiology of HS in this patient is inconclusive, the timing of its development closely aligns with the initiation of Humira and is not a manifestation of CD. Paradoxical adverse effects describe a phenomenon in which a medication can induce a condition that it classically can be used to treat. In this patient's case, it was HS.
PubMed: 38161925
DOI: 10.7759/cureus.49637 -
Cureus Nov 2023Rectal perforation secondary to an ingested foreign body is a rare occurrence that can be challenging to diagnose. It may initially present as a perianal abscess....
Rectal perforation secondary to an ingested foreign body is a rare occurrence that can be challenging to diagnose. It may initially present as a perianal abscess. Herein, we report a rare incident involving a patient who presented with a perianal abscess. The initial assessment and an abdominal CT scan revealed a large horseshoe perianal abscess with a small linear hyperdensity noted near the anal verge. The patient was taken to the operating room, where he was found to have perforated the rectum due to an ingested chicken bone. The procedure involved the incision and drainage of the abscess, along with the removal of the foreign body.
PubMed: 38161867
DOI: 10.7759/cureus.49673 -
Diseases of the Colon and Rectum Apr 2024
Topics: Humans; Abscess; Anus Diseases; Drainage; Skin Diseases; Rectal Fistula; Treatment Outcome
PubMed: 38150305
DOI: 10.1097/DCR.0000000000002949 -
Cureus Nov 2023Background Diagnosis and management of perianal abscesses (PAA) are based on history and clinical examination. Imaging is not indicated except in complicated cases, as...
Background Diagnosis and management of perianal abscesses (PAA) are based on history and clinical examination. Imaging is not indicated except in complicated cases, as determined by the surgical team. The monetary, ionizing radiation, and resource utilization costs of a computed tomography (CT) scan in the emergency room must be considered when used for diagnostic purposes of PAAs. Methods A retrospective analysis of 129 patients diagnosed with a diagnosis of PAA between 2015-2020 was performed. The primary endpoints included length of stay, CT performed, time from patient presentation to CT, and CT scan completion prior to surgical consultation. Data is reported as n (%) or median (IQR). Results Of the 129 patients diagnosed with PAA, 81 underwent CT, and 48 did not. General surgery was consulted in 88% of cases. There were no statistically significant differences in age (p=0.562), sex (p=0.531), or ethnicity (p=0.356). The median hospitalization time was two days when CT was performed (p=0.001). The median time elapsed from presentation to the emergency department and CT scan performed was 16 hours (p=0.001). CT scans were ordered before the surgical consultation in 65% of cases (p=0.001) and 17% after a surgical consultation was placed (p=0.009). Conclusion Performing CT scans prior to surgical evaluation for the diagnosis of PAA is not a responsible practice. The cost, resources, and radiation exposure must be considered. This study demonstrated that more CT scans are ordered prior to surgical consultation for PAA, resulting in a prolonged wait time in the emergency department.
PubMed: 38149138
DOI: 10.7759/cureus.49417 -
Asian Journal of Surgery Mar 2024
Topics: Humans; Abscess; Anus Diseases; Rectal Fistula
PubMed: 38143172
DOI: 10.1016/j.asjsur.2023.12.071 -
ANZ Journal of Surgery May 2024Acute surgical units (ASU) are increasingly being adopted and in our system are staffed by colorectal and non-colorectal general surgeons. This study aims to evaluate...
BACKGROUND
Acute surgical units (ASU) are increasingly being adopted and in our system are staffed by colorectal and non-colorectal general surgeons. This study aims to evaluate whether surgeon specialization was associated with improved outcomes in perianal abscess.
METHODS
Patients with perianal abscess admitted to the ASU between 2016 and 2020 were identified from a prospective database and their medical records reviewed. Patients with IBD, treatment for fistula-in-ano within the preceding year, or perianal sepsis of non-cryptoglandular origin were excluded. Patients admitted under an ASU colorectal (CR) consultant were compared with those under a non-CR general surgeon in a retrospective cohort study. Primary outcome was perianal abscess recurrence. For those without initial fistula, hazard of recurrent abscess or fistula was analysed. Multivariable Cox PH regression analysis was performed.
RESULTS
Four-hundred and eight patients were included (150 CR, 258 non-CR). The CR group more frequently had a fistula identified at index operation (34.0% versus 10.9%, P < 0.0001). However, Cox multivariable analysis found no difference in hazard of recurrent abscess between groups (HR 1.12, 95% CI 0.65-1.95, P = 0.681)). Abscess recurred in 18.7% CR and 15.5% non-CR. Subsequent fistula developed in 14.7% in both groups. For patients without initial fistula, there was no difference between groups in hazard of recurrent abscess or fistula (HR 1.18, 95% CI 0.69-2.01, P = 0.539).
CONCLUSION
Surgeon specialization was not associated with improved outcomes for ASU patients with perianal abscess, albeit with potential selection bias. CR surgeons were more proactive identifying fistulas; this raises the possibility that drainage alone may be adequate treatment.
Topics: Humans; Male; Female; Middle Aged; Retrospective Studies; Abscess; Adult; Anus Diseases; Recurrence; Treatment Outcome; Rectal Fistula; Surgeons; Acute Disease; Specialization; Aged
PubMed: 38131396
DOI: 10.1111/ans.18836 -
Cureus Dec 2023A 34-year-old male presented with spontaneous rectal pain. He was diagnosed with a posterior rectal wall abscess 7 cm proximal to the anal verge that was confirmed on...
A 34-year-old male presented with spontaneous rectal pain. He was diagnosed with a posterior rectal wall abscess 7 cm proximal to the anal verge that was confirmed on an MRI (magnetic resonance imaging) pelvis. This abscess was drained through a transrectal route. Rectal wall abscess is an exceedingly rare pathology compared to perianal abscess; therefore, this case highlights the key aspects of its management.
PubMed: 38125696
DOI: 10.7759/cureus.50759 -
Alimentary Pharmacology & Therapeutics Mar 2024Few population-based studies have investigated the prevalence and disease course of perianal manifestation in Crohn's disease.
Burden of perianal disease in Crohn's disease: Accelerating medical therapy and high rates of perianal surgery over the last four decades - Results from a population-based study over four decades.
BACKGROUND
Few population-based studies have investigated the prevalence and disease course of perianal manifestation in Crohn's disease.
AIMS
To analyse the prevalence and outcomes of perianal Crohn's disease including medical therapies and need for perianal surgery, over different therapeutic eras based on the time of diagnosis; cohort A (1977-1995), cohort B (1996-2008), and cohort C (2009-2018) METHODS: Patient inclusion lasted between 1977 and 2018. We followed patients prospectively, and regularly reviewed both in-hospital and outpatient records. We defined a perianal surgical procedure as any perianal incision and excision, fistulotomy, or abscess drainage.
RESULTS
We included 946 incident patients. Perianal disease at diagnosis was present in 17.4% (n = 165) of the total cohort, with a declining prevalence in cohorts A/B/C, respectively (24.7%/18.5%/13.2%; p = 0.001). By the end of follow-up, an additional 9.3% (n = 88) of the total cohort developed perianal disease. Cumulative immunosuppressive and biologic exposure increased over time; biologic use was higher in patients with perianal disease [pLog Rank < 0.001]. The overall rate of perianal surgery was 44.7% (113/253), with a probability of 28.3% (95% CI: 25.4-31.2) after 10 years, 41.0% (95% CI: 37.5-44.5) after 20 years, and 64.1% (95% CI: 59-69.2) after 30 years. There was no statistically significant difference in the probability of first perianal surgery among cohorts A/B/C [Log Rank = 0.594].
CONCLUSIONS
The burden of perianal disease and perianal surgery rates were high in this cohort. Therapeutic strategy was accelerated in patients with perianal Crohn's over time with higher exposure to immunosuppressives and biologics. Surgical management of perianal disease remained unchanged amongst the cohorts.
Topics: Humans; Crohn Disease; Follow-Up Studies; Immunosuppressive Agents; Disease Progression; Drainage; Rectal Fistula; Treatment Outcome
PubMed: 38115207
DOI: 10.1111/apt.17836 -
The Indian Journal of Radiology &... Jan 2024Perianal fistula and its recurrence is a challenging entity for surgeons. It is a well-establi1shed fact that magnetic resonance imaging (MRI) findings influence...
Perianal fistula and its recurrence is a challenging entity for surgeons. It is a well-establi1shed fact that magnetic resonance imaging (MRI) findings influence surgical procedures and reduce the rate of recurrence. In this study, we assessed the contrast-enhanced (CE) three dimensional T1 sequences [sampling perfection with application optimized contrast using different flip angle evolution (SPACE) and volumetric interpolated breath-hold examination (VIBE)] in a 3T MRI system to evaluate perianal fistulas and compared them with two-dimensional (2D) sequences. Forty-four patients (mean age, 38.8 ± 15.3 [standard deviation]; 32 males, 12 females) with perianal fistula were included in this prospective study. The patients underwent conventional noncontrast, 2D sequences, diffusion-weighted imaging, followed by postcontrast, 2D T1 images in both axial and coronal planes, and 3D sequences at 3T. Acquisition times were recorded for each sequence. Each postcontrast sequence was evaluated in terms of image quality, presence of artifacts, fistula type, presence of an abscess, visibility, and number of internal orifices. The surgical findings were considered the gold standard. The imaging findings were compared with the surgical findings. In all three sequences, the fistula type and abscess were identified correctly in all patients. The sensitivity value for identification of ramifications utilizing CE 3D T1 VIBE sequence, CE 3D T1 SPACE, and CE 2D T1 images was 100, 86, and 36%, respectively. The number of internal orifices was identified by the CE 3D T1 VIBE and CE 3D T1 SPACE sequences in 100 and 92% of patients, respectively. CE 2D T1 images correctly identified internal orifices in 80% of patients. The overall scan time for each 3D sequence was shorter than for the combined postcontrast 2D sequences. CE 3D T1 SPACE and CE 3D T1 VIBE sequences outperformed conventional CE 2D sequences in the evaluation of perianal fistulas in terms of visibility and the number of internal orifices with a shorter scanning time. Among the 3D sequences, CE 3D T1 VIBE is slightly superior to CE 3D T1 SPACE sequence.
PubMed: 38106872
DOI: 10.1055/s-0043-1775738 -
Journal of Pediatric Surgery Jun 2024Pediatric patients with perianal Crohn's Disease (CD) suffer recalcitrant fistulas, abscesses, and strictures. Fecal diversion is a palliative last resort, but the...
INTRODUCTION
Pediatric patients with perianal Crohn's Disease (CD) suffer recalcitrant fistulas, abscesses, and strictures. Fecal diversion is a palliative last resort, but the expected clinical course and long-term management of the ostomy for this population is unclear. We sought to identify factors predictive of ostomy takedown and establish management recommendations for fistulizing and stenosing disease.
METHODS
We reviewed our institutional registry for patients aged 1-18 years with CD who received perianal surgery from 2011 to 2021. We analyzed medical therapy, examinations under anesthesia (EUA), fistula and stenosis response, and rates of fecal diversion and reversal.
RESULTS
There were 109 patients with fistulizing CD and 21 with stenosing CD. There were 8 diverted for fistula and 4 due to stricture [8/109 (7 %) vs 4/21 (19 %), p = 0.213]. Three patients with fistulizing disease had their ostomy reversed at an average of 1.46 years. Each demonstrated consistent CD control and with no additional perianal flares. The remainder have been diverted 3.15 ± 4.57 years with 2.1 ± 2.8 EUAs. Only one patient with stricture was durably reversed, but they still require serial anal dilation. Two were reversed but required re-diversion due to stricture progression.
CONCLUSION
Reversal rates after fecal diversion for pediatric perianal CD remain disappointingly low and diversion does not obviate the possibility of future EUAs. While reversal was successful for medically responsive patients with fistulizing disease, those with stenosing disease remained dependent on anal dilations and were more likely to fail reversal. Fecal diversion does nothing to reverse an established stricture and such patients will likely need to decide between indefinite dilations or permanent ostomy.
LEVEL OF EVIDENCE
IV.
TYPE OF STUDY
Retrospective review.
Topics: Humans; Crohn Disease; Child; Adolescent; Male; Female; Child, Preschool; Retrospective Studies; Infant; Ostomy; Constriction, Pathologic; Rectal Fistula; Anus Diseases
PubMed: 38104035
DOI: 10.1016/j.jpedsurg.2023.11.009