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29. Edge S, Byrd D, Compton C, Fritz A, Greene F, Trotti A, editors. AJCC cancer staging man-
ual. 7th ed. New York: Springer; 2010.
30. Uronis HE, Bendell JC. Anal cancer: an overview. Oncologist. 2007;12:524–34.
31. Raghunathan G, Mortele KJ. Magnetic resonance imaging of anorectal neoplasms. Clin
Gastroenterol Hepatol. 2009;7:379–88.
32. Partovi S, Kohan A, Rubbert C, Vercher-Conejero JL, Gaeta C, Yuh R, Zipp L, Herrmann KA,
Robbin MR, Lee Z, Muzic Jr RF, Faulhaber P, Ros PR. Clinical oncologic applications of PET/
MRI: a new horizon. Am J Nucl Med Mol Imaging. 2014;4:202–12.
33. Kim H, Kim JH, Lim JS, Choi JY, Chung YE, Park MS, Kim MJ, Kim KW, Kim SK. MRI
fi ndings of rectal submucosal tumors. Korean J Radiol. 2011;12:487–98.
34. Levy AD, Remotti HE, Thompson WM, Sobin LH, Miettinen M. Gastrointestinal stromal
tumors: radiologic features with pathologic correlation. Radiographics. 2003;23:283–304.
35. Levy AD, Sobin LH. Gastrointestinal carcinoids: imaging features with clinicopathologic
comparison. Radiographics. 2007;27:237–57.
36. Ghai S, Pattison J, Ghai S, O’Malley ME, Khalili K, Stephens M. Primary gastrointestinal
lymphoma: spectrum of imaging fi ndings with pathologic correlation. Radiographics.
2007;27:1371–88.
37. Woodward PJ, Sohaey R, Mezzetti TP. Endometriosis: radiologic-pathologic correlation.
Radiographics. 2001;27:193–215.
38. Coutinho Jr A, Bittencourt LK, Pires CE, Junqueira F, de Oliveira Lima CMA, Coutinho E,
Domingues MA, Domingues RC, Marchiori E. MR Imaging in deep pelvic endometriosis: a
pictorial essay. Radiographics. 2011;31:549–67.
39. Dahan H, Arrivé L, Wendum D, Ducou le Pointe H, Djouhri H, Tubiana JM. Retrorectal devel-
opmental cysts in adults: clinical and radiologic-histopathologic review, differential diagnosis,
and treatment. Radiographics. 2001;21:575–84.
40. Yang DM, Park CH, Jin W, Chang SK, Kim JE, Choi SJ, Jung DH. Tailgut cyst: MRI evalua-
tion. AJR Am J Roentgenol. 2005;184:1519–23.
41. Sneider EB, Maykel JA. Anal abscess and fi stula. Gastroenterol Clin North Am. 2013;43:
773–84.
42. Ommer A, Herold A, Berg E, Furst A, Sailer M, Schiedeck T. German S3 guideline: anal
abscess. Int J Colorectal Dis. 2012;27:831–7.
43. Vanbeckevoort D, Bielen D, Vanslembrouck R, Van Assche G. Magnetic resonance imaging of
perianal fi stulas. Magn Reson Imaging Clin N Am. 2014;22:113–23.
44. O’Malley R, Al-Hawary M, Kaza R, Wasnik A, Liu P, Hussain H. Rectal imaging: part 2,
perianal fi stula evaluation on pelvic MR- what the radiologist needs to know. Am J Roentgenol.
2012;199:43–53.
45. Hammer MR, Dillman JR, Smith EA, Al-Hawary M. Magnetic resonance imaging of perianal
and perineal Crohn’s disease in children and adolescents. Magn Reson Imaging Clin N Am.
2013;21:813–28.
46. Joyce M, Veniero JC, Kiran RP. Magnetic resonance imaging in the management of anal fi stula
and anorectal sepsis. Clin Colon Rectal Surg. 2008;21:213–9.
47. Dwarkasing S, Hussain SM, Hop WC, Krestin GP. Anovaginal fi stulas: evaluation with endo-
anal MR imaging. Radiology. 2004;231:123–8.
48. Tonolini M, Campari A, Bianco R. Ileal pouch and related complications: spectrum of imaging
fi ndings with emphasis on MRI. Abdom Imaging. 2011;36:698–706.
49. Broder J, Tkacz J, Anderson S, Soto J, Gupta A. Ileal-pouch anal anastomosis surgery: imag-
ing and intervention for post-operative complications. Radiographics. 2010;30:221–33.
50. Tonolini M, Villa C, Campari A, Ravelli A, Bianco R, Conralba G. Common and unusual
urogenital Crohn’s disease complications: spectrum of cross-sectional imaging fi ndings.
Abdom Imaging. 2013;38:32–41.
51. Francone T, Champagne B. Considerations and complications in patients undergoing ileal
pouch anal anastomosis. Surg Clin North Am. 2013;93:107–43.
52. Nadgir R, Soto J, Dendrinos K, Lucy B, Becker J, Farraye F. MRI of complicated pouchitis.
Am J Roentgenol. 2006;187:374–86.
M.K. Feldman et al.
Part II
Pathology and Treatment
Anorectal Abscess
Nicole M. Saur and Dana R. Sands
Anorectal abscesses and associated fi stulae are entities in a complicated disease
spectrum. While the abscess represents the acute phase of the disease, the fi stula
represents the chronic phase of the disease [ 1 ]. The exact numbers are diffi cult to
fi nd due to the variety of settings where perianal abscesses are cared for from the
emergency department to the operating room, but it has been postulated that perianal abscesses affect 68,000–98,000 patients annually with a persistent fi stula in
approximately 35 % of those patients [ 1 – 4 ]. Anorectal abscesses are more common
in men with a ratio of 2:1 to 5:1 reported in the literature [ 1 , 5 – 7 ]. It is imperative
that physicians maintain a high level of suspicion for anorectal abscess in any
patient with complaints of perianal pain. Proper management of anorectal sepsis
depends on a thorough understanding of both the anatomy of the region and appropriate drainage strategies.
4
4.1 Anatomy and Pathophysiology
Perianal abscesses originate in the anal glands and crypts [ 8 , 9 ]. Pus is then able to
travel along the natural planes to reach the perianal, ischiorectal, intersphincteric,
supralevator, and deep postanal spaces (Fig. 4.1 ) [ 6 , 7 , 10 – 12 ]. The appropriate
treatment of anorectal abscesses is dependent on the space involved and is geared to
maximize opportunity for resolution of the abscess and minimize postoperative
complications such as recurrence and incontinence.
N. M. Saur , MD • D. R. Sands , MD (*)
Department of Colorectal Surgery , Cleveland Clinic Florida ,
2950 Cleveland Clinic Blvd. , Weston , FL 33331 , USA
saurn@ccf.org; sandsd@ccf.org
e-mail:
© Springer International Publishing Switzerland 2016
M. Zutshi (ed.), Anorectal Disease, DOI 10.1007/978-3-319-23147-1_4
79
80
a
Supralevator Intersphincteric
N.M. Saur and D.R. Sands
Ischioanal
Perianal
Submucosal
b
Retrorectal
Supralevator
Deep postanal
Superficial postanal
Fig. 4.1 ( a and b ) Normal anatomy of the perianal region sagittal ( a ) and lateral ( b ) views
4 Anorectal Abscess
81
4.2 General Considerations
There is little to no role for antibiotics in the treatment of uncomplicated anorectal
abscesses [ 13 ]. Sözener et al. showed that antibiotics do not prevent fi stula forma-
tion after abscess drainage [ 14 ]. However, antibiotics can be considered in the treat-
ment of signifi cant cellulitis. In addition, patients with underlying immunosuppression
such as HIV infection may benefi t from antibiotics. Finally, the American Heart
Association recommends preoperative antibiotics prior to incision and drainage for
patients with prosthetic valves and history of bacterial endocarditis or congenital
heart disease [ 10 , 13 ].
Perianal abscesses can be cared for in various clinical settings. Simple perianal
abscesses can be treated at the bedside with local anesthetic, while intersphincteric
abscesses usually require exam under anesthesia (EUA) to fully characterize and treat
the abscess. Patients can generally be treated on an outpatient basis, but immunocompromised patients and those with advancing cellulitis or concern for developing necrotizing infection warrant inpatient monitoring. Delaying I&D while treating with
antibiotics is inappropriate and may lead to a larger abscess that involves more of the
sphincter complex and, in extreme circumstances, to necrotizing infection [ 3 , 8 , 13 ].
4.3 Workup and Treatment of Abscesses
4.3.1 Perianal Abscess
4.3.1.1 Incidence
Perianal abscesses make up 34.5–58.4 % percent of anorectal abscesses in several
series [ 6 , 7 , 11 , 12 , 15 ].
4.3.1.2 Symptoms
Their symptoms are along the spectrum of fever, perianal pain, fl uctuance, or spontaneous drainage of abscess [ 3 , 10 , 13 , 16 , 17 ].
4.3.1.3 Evaluation
Physical examination may reveal tenderness, erythema, induration, and/or fl uctuance. Typically no further tests are needed for diagnosis. However, for patients
where physical examination does not reveal an obvious abscess, endoanal ultrasound (EUS) can be used as an adjunct in the offi ce setting.
4.3.1.4 Treatment
The treatment of perianal abscesses is incision and drainage. The area of maximal
pain or fl uctuance is identifi ed, local anesthesia is injected (1 % lidocaine with epinephrine 1:200,000 or 0.25 % Marcaine with epinephrine 1:200,000), a cruciate
incision is made, and purulence is expressed. Figure 4.2 demonstrates the location
and appropriate drainage technique of a perianal abscess. Tonkin et al. demonstrated
that it was safe and effective to not pack wounds after incision and drainage by
82
a
Perianal
N.M. Saur and D.R. Sands
b
Fig. 4.2 ( a ) Perianal abscess. ( b and c ) Drainage of perianal abscess
c
showing similar rates ( p >0.2) of recurrence, fi stulas, healing times, and pain scores
at the fi rst dressing change [ 2 ]. These results were verifi ed by Perera et al. who
showed that the non-packing group had a faster healing time with less pain while
having similar recurrence rates [
5 ]. Therefore, no packing is required unless neces-
sary for hemostasis.
4.3.2 Ischiorectal Abscess
4.3.2.1 Incidence
Incidence of ischiorectal abscesses has been reported as 22–33.9 % in several studies [ 6 , 7 , 11 , 12 ].
4 Anorectal Abscess
83
4.3.2.2 Symptoms
Their symptoms are similar to those for perianal abscess and fall along the same
spectrum of fever, perianal pain, fl uctuance, or spontaneous purulent drainage [ 3 , 8 ,
10 , 13 ].
4.3.2.3 Evaluation
Physical examination may reveal tenderness, erythema, induration, and/or fl uctuance. Typically no further tests are needed for diagnosis.
4.3.2.4 Treatment
Ischiorectal abscesses can be drained in a similar fashion to perianal abscesses.
However, it is important to note that the incision should be made as close as possible
to the anal verge to shorten the potential fi stula tract. Large ischiorectal or horseshoe
abscesses are best drained under spinal or general anesthesia [ 15 , 16 ]. In addition,
if the abscess cavity is large, it is necessary to break up loculations to achieve adequate drainage [ 16 , 17 ]. However, one is cautioned to avoid causing sphincter injury
with aggressive disruption of loculations [ 18 ]. Figure 4.3 demonstrates the location
and proper drainage technique for ischiorectal abscesses.
Alternatively, catheter drainage can be used instead of incision and drainage in
stable patients without signs of sepsis. Local anesthetic of choice is injected at the
area of maximal fl uctuance and the surrounding skin. A stab incision is made as
close as possible to the anal verge to minimize potential fi stula length and complexity. The pus is evacuated and a 10–16 French mushroom catheter is placed in the
incision. If the incision and mushroom catheter are sized appropriately, no sutures
are needed. The mushroom catheter is trimmed to 2–3 cm from the skin to avoid
making the external portion too short so it will not fall into the wound. The catheter
is left in place until the drainage decreases to an acceptable level [ 8 ] .
4.3.3 Intersphincteric Abscess
4.3.3.1 Incidence
Intersphincteric abscesses represent 23–47 % of anorectal abscesses in several large
series [ 1 , 6 , 7 , 10 ].
4.3.3.2 Symptoms
Patients typically present with pain without external signs of infection [ 3 , 8 ].
4.3.3.3 Evaluation
In a patient with no external signs of infection but with pain, an intersphincteric
abscess should be suspected and an examination under anesthesia undertaken.
Because of increased patient pain and lack of diagnostic information at the bedside, it would be inappropriate to proceed with further invasive testing in this
setting [ 3 , 8 ].
84
a
Ischioanal
N.M. Saur and D.R. Sands
bc
Fig. 4.3 ( a ) Ischioanal abscess. ( b and c ) Drainage of ischioanal abscess
4.3.3.4 Treatment
Exam under anesthesia is mandated for intersphincteric abscesses secondary to the
lack of physical examination fi ndings and the pain out of proportion to examination
when evaluating the patient at the bedside. Under anesthesia, a digital rectal examination frequently reveals an area of fullness. The area of fl uctuance in the intersphincteric
plane should be opened with a knife. The internal sphincter muscle must be opened
enough to express the pus in the intersphincteric space. The wound can then be marsupialized for better healing and to keep the tract open. A low intersphincteric abscess can
typically be treated with drainage, division of the internal sphincter, and marsupialization. High intersphincteric abscesses, although uncommon, typically require placement
of a mushroom catheter for adequate drainage [ 19 ]. Figure 4.4 demonstrates the ana-
tomic location and proper drainage technique of an intersphincteric abscess.
4 Anorectal Abscess
a
85
Intersphincteric
b
Fig. 4.4 ( a ) Intersphincteric abscess. ( b and c ) Drainage of intersphincteric abscess
c
86
N.M. Saur and D.R. Sands
4.3.4 Supralevator Abscess
4.3.4.1 Incidence
Supralevator abscesses have been estimated to represent 9–42 % of abscesses in the
literature [ 6 , 12 ].
4.3.4.2 Symptoms
Patients typically present with perianal pain, pelvic pain, rectal bleeding, ileus, and/
or urinary retention [ 3 , 8 , 12 ].
4.3.4.3 Evaluation
Supralevator abscesses can arise from ischiorectal or intersphincteric abscesses
extending upward or from pelvic abscesses secondary to diverticulitis, appendicitis,
or tubo-ovarian abscess draining downward. Because of the varied treatment based
on origin of infection, supralevator abscesses are often evaluated with imaging
(CT or MRI) [ 8 , 20 ].
4.3.4.4 Treatment
If the abscess is arising from an ischiorectal abscess, it can be drained through the
perianal skin. However, if it is arising from an intersphincteric abscess, it should be
drained through the internal sphincter and into the rectum to avoid the creation of a
suprasphincteric fi stula. If the abscess arises in the pelvis, it can be drained through
the rectum, through the perianal skin, or percutaneously under imaging guidance
depending on the size and position of the abscess [ 8 ]. In addition, if the abscess is
associated with perforated viscus or infl ammatory condition, the abscess should be
treated according to treatment principles for these conditions and may require operative intervention [ 21 ]. Figure 4.5 demonstrates the location and proper drainage
technique for supralevator abscesses arising from either an ischiorectal abscess or
an intra-abdominal process.
4.3.5 Deep Posterior Anal Space (Horseshoe) Abscess
4.3.5.1 Overview
The deep postanal space is the potential space between the external sphincter
complex anteriorly, the coccyx and anococcygeal ligament inferiorly and posteriorly, and the levator plates superiorly. Purulent material can track to this space, and
when it extends laterally into the ischioanal fossa, the abscess is termed a horseshoe
abscess [ 22 ].
4.3.5.2 Symptoms
Patients typically present with perianal pain, pelvic pain, rectal bleeding, and/or
urinary retention [ 3 , 8 , 12 ].