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106 V. de Parades et al.
Fig. 9 Release of pus, under
pressure, from a cutaneous
perianal secondary opening
(circle). (Collection Ahlem El
Mituialy)
Fig. 10 Catheterization, with
a probe, of the primary
opening of the fistula tract.
(Collection Ahlem El
Mituialy)
7 Clinical Assessment of Anal Cryptoglandular Abscess and Fistula 107
Fig. 11 Catheterization, with
a probe, of the secondary
opening of the fistula tract.
(Collection Ahlem El
Mituialy)
be considered suggestiveof high intersphinctericabscess. In any case, gentle palpation
clearly increases the intensity of the pain, but also makes it possible to assess the size
of the purulent collection (Parks et al. 1976; Eisenhammer 1978; Gerrard-Gough et al.
1978;Marcusetal.1995; Hughes and Mehta 2002;Jain2020).
In the particular case of low anovulvar or anovaginal tracts, the abscess-related
collection may resemble a Bartholin’s cyst (Cripps and Northover 1998).
Sometimes, the collection is chronic and presents in the form of a hard, welldelimited mass, with little or no associated inflammation, particularly in cases of
inappropriate antibiotic or anti-inflammatory drug use. This pseudotumoral collection contains, above all, granulations and very little pus; it is often sclerotic and
displays a slow and torpid progression (Marcus et al. 1995).
In the particular case of malignant hemopathies, particularly those with neutropenia, the purulent collection may be barely perceptible, and erythema painful on contact
should lead to a diagnosis of suppuration being considered (Grewal et al. 1994).
4.5 Possible Secondary Extensions
Secondary extensions are not very frequent. They occur particularly in cases of
high fistula tracts (Rosa et al. 2006), especially if treatment is initiated late. They
may sometimes be favore d by the inappropriate administration of antibiotics and/or
108 V. de Parades et al.
Fig. 12 Abscess-related
collection in the posterior anal
margin
Fig. 13 Abscess-related
collection in the left ischioanal
fossa
7 Clinical Assessment of Anal Cryptoglandular Abscess and Fistula 109
anti-inflammatory drugs. They are also favored by previous surgical interventions.
Their detection is important, because they are a classic source of recurrence when
missed (Becker et al. 2006; Millan et al. 2006; de Parades et al. 2012 ).
The palpable infiltration, on digital rectal examination, of a supralevatorial extension
is unique in that this extension is “suspended,” leaving a healthy zone between the
internal border and the anal canal. Such extensions can thus be distinguished from high
intersphincteric extensions, which are located in the continuity of the primary opening
and which prevent palpation of the puborectal muscle along its entire length. This
distinction is vital, because it is important not to confuse these types of secondary
extensions. Indeed, the resolution of a high intersphincteric extension via the ischioanal
route or of a supralevatorian extension via the endorectal route would lead to the creation
of a false extrasphincteric tract, which would render the fistula more difficult to treat
(Gerrard-Gough et al. 1978; Garcia-Granero et al. 2014;Téouleetal.2018).
“Horseshoe” extensions occur in less than 15% of anal cryptoglandular fistulae.
They follow a posterior course, generally via the posterior subsphincteric space, more
frequently than an anterior course, but they may also pass by the intersphincteric
space, or via the supralevatorian space (Rosen et al. 2006; de Parades et al. 2012).
4.6 Evaluation of the Anatomy of the Anal Canal
and of the Sphincter
This evaluation is particularly useful in patients who have already undergone surgery
or in cases of obstetric antecedents. The aim is to evaluate the basal tonus and
amplitude of voluntary contraction of the sphincter and the length of the anal canal.
This evaluation is also used to search for scars, or even deformations of the anal
canal and/or perineum suggestive of possible lesions of the sphincter.
It is important to provide these diverse data before surgery, due to the risk of anal
continence after fistulotomy, particularly in cases in which the fistula tract is high or
anterior in women (Garcia-Aguilar et al. 1996). In this situation, the use of a
sphincter-saving technique can be envisaged, with a lower cure rate than fistulotomy,
but with the advantage of preserving the anal continence of the patient.
5 Conclusion
The clinical assessment of anal cryptoglandular fistulae is fundamental, to ensure a
cure without sequelae. There are a few “universal” rules that it is important to be aware
of, both in consultations and during surgery (Table 4). There are also a certain number
of errors to avoid, and these errors are the principal causes of failures to cure anal
cryptoglandular fistulae and of the recurrence of this condition after surgery (Table 5).
However, this essential evaluation is sometimes difficult, and, given the major
repercussions for the patient, doctors should not hesitate to seek support from a more
110 V. de Parades et al.
Table 4 Principal rules for clinical examination of an anal cryptoglandular fistula during surgery
Rule Reason
Injection of a stain via the SO To facilitate the identification of the PO, the fistula
Do not catheterize a PO in the absence
of certainty
Do not use force to catheterize a fistula
tract
Do not hesitate to suspend explorations
in cases of doubt about the PO
Search for a possible secondary
extension
PO primary opening, SO secondary opening
Table 5 Principal causes of a failure to cure anal cryptoglandular fistulae and of their recurrence
after treatment by fistulotomy
Error in the identification of the primary opening and/or fistula tract
Ignorance of an atypical fistula (Y-shaped tract, spiroid tract, multiple tracts, etc.)
Ignorance of a secondary extension (contralateral horseshoe, high intersphincteric,
supralevatorian, etc.)
Inadequate treatment of a secondary extension (e.g., high intersphincteric via the ischioanal space)
or creation of an iatrogenic secondary extension (e.g., superior pelvi-rectal in cases of perforation
of the deep pelvic aponeurosis by a forceps inadvertently pushed into the depths of the
supralevatorian space)
Diagnostic error (pilonidal disease, hidradenitis suppurativa, etc.)
Unidentified specific cause (Crohn’s disease, tuberculosis, actinomycosis, lymphogranuloma
venereum, gonococcosis, colloid cancer, etc.)
tract, and possible secondary extension
To avoid creating a false PO or a false tract
To avoid making an initially simple fistula more
complex or connecting the anal canal to a non-fistular
perianal suppuration
Ignorance of the existence of such an extension
exposes the patient to a risk of persistent seepage after
surgery, and/or subsequent recurrence
experienced specialist if necessary (Nwaejike and Gilliland 2007; Fucini and Giani
2011; Dudukgian and Abcarian 2011).
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Clinical Assessment of Crohn Perianal Abscesses and Fistulas
Pierluigi Puca, Loris Riccardo Lopetuso, Lucrezia Laterza,
Marco Pizzoferrato, and Franco Scaldaferri
Contents
1 Introduction . ............... .................................................................. 114
1.1 Physical Examination of the Anus and Rectum: General Principles . ............... 115
1.2 Inspection . ................. ............................................................ 116
1.3 Palpation ............................................................................... 116
1.4 Endoscopy ................ .................................................... ......... 116
2 Clinical Presentation ......................................................................... 117
2.1 Skin Lesions ....... .................................................................... 117
2.2 Fistulas ................................................................................. 117
2.3 Abscesses .................................................... .......................... 118
2.4 Diagnostic Workup .................................................................... 118
2.5 US ............................ ............................... .......................... 118
2.6 Effectiveness and Sensitivity ................................... ....................... 120
2.7 MRI................... ................................................................. 121
2.8 Diagnostic Follow-up ............................... ............................... ... 124
References ............................ ............................................... ............ 125
8
Abstract
Introduction: Perianal presentation (abscesses and fistulas) can be present in up
to 43% of patients diagnosed with Crohn disease; in several cases, it can be the
first presentation of Crohn disease.
An abscess is defined as a localized collection of infected fluid; it can be deep
or superficial.
P. Puca · F. Scaldaferri (*)
Dipartimento di Medicina e chirurgia traslazionale, CEMAD – UOC di Medicina Interna e
Gastroenterologia – Fondazione Policlinico “A. Gemelli” IRCCS, Rome, Italy
Università Cattolica del Sacro Cuore, Rome, Italy
e-mail: pierluigi.puca01@icatt.it; franco.scaldaferri@unicatt.it
L. R. Lopetuso · L. Laterza · M. Pizzoferrato
Università Cattolica del Sacro Cuore, Rome, Italy
© Springer Nature Switzerland AG 2022
C. Ratto et al. (eds.), Anal Fistula and Abscess, Coloproctology,
https://doi.org/10.1007/978-3-030-76670-2_10
113
114 P. Puca et al.
A fistula is defined as a connection between the anal canal and the external cute.
According to Park’sclassification, fistulas can be classified as intersphincteric,
transsphincteric, suprasphincteric, and extrasphincteric.
Physical examination and clinical presentation: Inspection of the perianal
region can show skin lesions, also called skin tags, associated with perianal CD.
Abscesses can present as areas of swelling and cutaneous erythema, sometimes
presenting with fever or other symptoms of generic malaise. Fistulas can present
with serous or purulent secretions.
The physical examination starts with the inspection of the perianal region,
followed by digital exploration of the rectum and observation of the external
openings of fistulas.
Diagnostic workup: The first level methodic of imaging is ultrasonography,
whose sensitivity and specificity is implemented if the exam is performed with
transrectal sound. The most precise imaging exam is, though, the pelvis MRI with
contrast enhancement, which allows to make differential diagnosis with all the
other conditions mimicking perianal Crohn disease. If performed together, US
and MRI can get close to 100% in sensitivity and specificity.
The traditional diagnostic gold standard, though, is still considered the exploration under anesthesia.
Endoscopic evaluation (anoscopy or proctosigmoidoscopy) is useful to evaluate the status of the anal canal and rectum and the internal openings of fistulas.
Fistulography is an obsolete diagnostic tool.
Diagnostic follow-up: No clear instructions are given by guidelines about the
follow-up of patients with perianal CD. Visiting the patients every 6 months/1 year
could be a reasonable period of follow-up timing according to our experience.
Keywords
Abscesses · Fistulas · Perianal Crohn disease · Parks classification · Digital
exploration · MRI · Transrectal ultrasonography · Rectoscopy · EUA (exploration
under anesthesia) · Fistulography
1 Introduction
Crohn’s disease is a heterogeneous disease that can affect every tract of the gastrointes-
tinal tube, from mouth to anal canal. About 18–43% of Crohn disease display, throughout the course of the disease, perianal manifestations such as abscesses and fistulas
(Rankin et al. 1979).Therelativelyhighfrequencyofperianal disease in these patients
requires a clear commitment into an early diagnosis, a correct clinical assessment in
order to provide patients with high-quality cares and to prevent future complications.
Pills from anatomy of the anal canal need to be acknowledged also by clinicians in order
to perform a correct and conscious clinical examination. We may argue that a proper
visit of a Crohn’s disease patient requires anal inspection and exploration.
8 Clinical Assessment of Crohn Perianal Abscesses and Fistulas 115
The anal canal is surrounded by two muscular sphincters. The internal one is a
nonvoluntary sphincter, made up of smooth muscle; the external one is made up of
voluntary muscles. In the mid-point of the anal canal is the dentate line, which is the
demarcation between columnar epithelium superiorly and squamous epithelium
inferiorly. The mucosa is thrown into folds, usually in the region of 4–6 major
folds, with occasional intervening minor folds (Lawson 1974).
Definition of perianal abscess: An abscess is a localized collection of infected
fluid. In most cases, the term “ perianal abscess” is used. Abscesses, tough, are
classified as superficial or deep in relation to the anal sphincter. If the infection
bursts through the external sphincter, it will form an ischiorectal abscess. If it spreads
laterally on both sides, it can form a collection of sepsis, which forms a “horseshoe”
around the sphincters. Perianal abscesses are a common complication in Crohn
disease; in this setting, they are often associated with fistulas (Sahnan et al. 2017).
Definition of perianal fistula: An anorectal fistula is a connection between the
anorectal canal and perianal area (Jimenez and Mandava 1976). The most simple
classification of fistula divides fistulas into simple and complex ones: a simple fistula
presents a lower anatomical position and one external opening; furthermore, it never
presents recto-vagin al communication and never gets complicated by stenosis. On
the contrary, a complex fistula has a higher anatomical position (above pectinate
line), and can present with multiple external openings, recto vaginal communication
and can be complicated by stenosis.
The most used classification of anorectal fistula was made by Parks in the 1970s.
According to this classification, fistulas are classified as the following:
• Type I: intersphincteric
• Type II: transsphincteric
• Type III: suprasphincteric
• Type IV: extrasphincteric (Parks et al. 1976).
In order to provide the patient with the best diagnostic and therapeutic approach
and path to care, it is desirable to follow a multidisciplinary approach since the first
evaluation of the patient.
Especially during the diagnostic phase, in fact, the interplay between physician,
surgeon, radiologist, ultrasonographist, and the patient himself assures the best
diagnostic performance, thus leading to the best therapeutic pathway.
1.1 Physical Examination of the Anus and Rectum: General Principles
Every patient presenting with perianal disturbances should be firstly examined with a
detailed history. A fundamental aspect of the anamnesis is active listening. In fact,
active listenings allow the patient to correctly explain his disturbances, to overcome
his anxiety and his shame to talk about anal-related problems, and to install a correct