*Małgorzata Kołodziejczak1, Przemysław Ciesielski1, 2
Anal abscess – a trivial disease or a serious one?
Ropień odbytu – choroba błaha czy poważna?
1Warsaw Proctology Centre, Saint Elizabeth’s Hospital, Mokotów Medical Centre, Warsaw
Head of Centre: Associate Professor Małgorzata Kołodziejczak, PhD
2General Surgery Unit, District Hospital in Wołomin
Head of Department: Przemysław Ciesielski, MD, PhD
Pacjent, który zgłasza się do szpitala z powodu ropnia odbytu, niejednokrotnie traktowany jest jako pacjent „lekko chory”, chociaż w około 40% ropień może zapoczątkować rozwój przetoki odbytu, a nieopróżniony lub niedostatecznie opróżniony ropień może też stać się przyczyną komplikacji septycznych zagrażających bezpośrednio życiu pacjenta. Przyczyną większości chorób zapalnych w odbycie, w tym ropni i przetok odbytu, jest rozwijająca się infekcja w kryptach odbytowych. W ostatnich latach dużą grupę chorych z ropniami odbytu stanowią pacjenci z chorobami zapalnymi jelit, a także z obniżoną odpornością, np. w przebiegu zakażenia wirusem HIV. Leczeniem ropnia odbytu w każdym przypadku jest pilne jego otwarcie i drenaż. Większość pacjentów z ropniami odbytu powinno być przyjęta do szpitala i operowana w warunkach bloku operacyjnego, w adekwatnym znieczuleniu (przewodowym lub ogólnym). W artykule omówiono zalecenia dotyczące otwarcia ropni niskich i wysokich, postępowanie pooperacyjne i możliwe komplikacje związane z tą chorobą i z nieprawidłowym jej leczeniem. Ropień odbytu, powszechnie uważany za chorobę błahą, nieumiejętnie leczony może stać się przyczyną poważnych komplikacji.
A patient who reports to the hospital due to anal abscess is often treated as not seriously ill, although in about 40% of cases, abscess may initiate anal fistula development, and the one that is not or insufficiently emptied, may also cause septic complications that directly threaten patient’s life. The majority of inflammatory diseases in the rectum, including abscesses and anal fistulae, are a growing infection in the anal crypts. In recent years, a large group of patients with rectal abscesses have been patients with inflammatory bowel diseases, as well as immunocompromised patients, e.g. in the course of HIV infection. The anal abscess in any case should be urgently treated by its opening and drainage. The majority of patients with rectal abscesses should be admitted to the hospital and operated in the operating block, in adequate anesthesia (regional or general). The article discusses recommendations for the opening of low and high abscesses, postoperative management and possible complications associated with this disease and its inappropriate treatment. An abscess of the anus, generally considered a trivial disease, treated inappropriately, can cause serious complications.
A patient who reports to the hospital because of an anal abscess is often treated as not seriously ill. They are often operated by the least experienced doctor on duty, and the procedure happens to be limited to a shallow incision under local anesthesia at the hospital emergency ward. And yet, in about 40% of cases, abscess may initiate the development of chronic proctological disease and anal fistula. Furthermore, the unloaded or insufficiently empty abscess may cause septic complications that directly threaten the patient’s life. There are no accurate data on the occurrence of rectal abscesses. Not all patients report to the doctor, as some abscesses undergo spontaneous perforation. Some patients are operated on an outpatient basis, so epidemiological data are generally only for patients hospitalized for abscesses. In the United States, about 100,000 patients with anorectal infection are reported each year, and the average age of the patient is 40 years. The disease affects twice as much men as women (1, 2).
For many years, researchers have agreed that the cause of the majority of inflammatory diseases in the anus, including abscesses and anal fistula, is the growing infection in the anal crypts. This theory dates back to the nineteenth century, when in 1880, Hermann and Desfosses first described the anal glands as an anatomic structure in the anal canal. The theory was also confirmed by other great coloproctologists such as Lockhart-Mummery (1929), Gordon-Watson and Dodd (1935), Kratzer and Dockerty (1947). It was also confirmed in later works by Eisenhammer (1956, 1977, 1961) and Parks (1961), as well as by contemporary coloproctologists such as Abcarian (1, 3). The anal glands are anatomical structures of the anal canal of every human being. If clogged, they can cause infection. Infection spreads along the intercostal space, between the muscles of the internal and external sphincter in various directions: most often down with the power of gravity, to the edge of the anus forming peripheral abscesses (subcutaneous). It can also pass through the muscle of the external sphincter into the sinuses and the aneurysms, forming sciatic and rectal abscesses. It may spread along the rectum wall to form high and low intersphincteral abscesses, or above the levator muscles to create surgeon abscesses. High over-leverage abscesses may also be caused by infectious diseases in the pelvis, such as appendicitis, diverticulitis, and genital infections. This division of abscesses presented by Corman and based on the location of abscesses in anatomical spaces is so logical and practical that it works in the literature to this day, it is historical, though.
Apart from inflammation of the anal glands, there are other reasons for the formation of anal abscesses. In old textbooks, tuberculosis, actinomycosis and venereal diseases are among the first reported non-cryptal causes of anal abscesses. At present, patients with inflammatory bowel diseases such as ulcerative colitis and Crohn’s disease often suffer from abscesses. Other common, frequent causes of anal abscess development include immunodeficiency syndrome in the course of HIV infection, as well as reduced immunity in the course of immunosuppression or chemotherapy obtained (patients with leukemia, patients prepared for bone marrow transplantation) (tab. 1). In her practice, the author had to deal with patients in whom anal abscess was the first clinical symptom of HIV infection twice. In patients at risk, the possibility of coexisting syphilis and abscess development on the basis of the rectal syphilis lumps should also be taken into account. An anal abscess may also arise as a result of infected traumatic anal wounds, introduction of foreign bodies into the anal canal or due to radiotherapy in the area.
Tab. 1. Possible reasons for the development of anal abscesses
|Reasons for anal abscesses|
|inflammation of the crypt|
|inflammatory bowel disease (ulcerative colitis, Crohn’s disease)|
|decreased immunity syndrome in the course of HIV infection|
|other reasons for decreased immunity (immunosuppression, chemotherapy)|
|injuries, foreign bodies|
|infectious disease in the pelvis – appendicitis, diverticulitis, inflammation of a genital organ as a reason for high over-levator abscesses|
Bacterial cultures from abscesses most often exhibit mixed bacterial flora, mainly Escherichia coli, followed by Proteus vulgaris, Staphylococcus aureus. In one study based on a large group of 183 patients treated for anal abscesses, researchers compared bacterial flora in patients with and without diabetes. In 60% of patients with diabetes, Klebsiella pneumoniae was found to be the most frequent pathogens, whereas in non-diabetic patients, the most common pathogen was Escherichia coli (67.1%), sensitive to first generation cephalosporins, which was also observed by us (4).
Most patients with low anal abscesses do not require diagnostic tests. An interview and a physical examination are enough to diagnose an abscess. The primary clinical symptom is anal pain and febrile states. In the proctology examination, painful swelling of the tissues is found in the anal area, and the skin is red and hot (fig. 1).
Fig. 1. Subcutaneous abscess
Patients with high abscesses may present a diagnostic problem, as in most cases, the pain does not occur (the inflammatory change is located above the crest line, i.e. above the pain innervation zone). The patient may feel urge, or urine may stop. Due to the late diagnosis of the disease, the course of the disease is often a few days, hence the patient may be in a septic state. The disproportion between the seemingly good local condition and the poor general condition of the patient is noteworthy. During a proctology examination, the abscess may be invisible outside. In such a case, it is recommended to examine the patient on the left side in the Sims position – balloting resistance may be then felt high in the rectum. In the case of suspected high anal abscess, ultrasound transrectal examination is very useful. Unfortunately, it is unavailable in most hospitals on call. In the case of diagnostic doubts, it is possible to use a regular linear head with the help of which a purulent tank can be visualized. In the case of high over-leverage abscesses, magnetic resonance is a better imaging examination than magnetic ultrasound. It is often necessary to examine the patient under anesthesia.
Treatment of the anal abscess in any case is its urgent opening and drainage.
The majority of patients with rectal abscesses should be admitted to the hospital and operated in the operating theater, in an adequate anesthesia (regional or general). This is an obligatory procedure especially when a patient suffers from additional diseases that lower their immunity (diabetes, immunosuppression). Only shallow, subcutaneous abscesses of the anus can be opened outpatially under local anesthesia.
The method of incision of low abscesses
The incision of the low abscess should be radial with respect to the anal canal, and relatively broad. The most frequently observed irregularity is a too economical incision and, consequently, insufficient drainage of the abscess.
The method of incision of high abscesses
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