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CDHB

Perianal Abscess

History and Examination

• Painful perianal lump, fluctuance, surrounding cellulitis, systemic sepsis.
• Consider Crohn’s disease if there is a history of altered bowel habit and/or abdominal pain. Check for family history of Crohn's disease.
• Make sure the infection is not secondary to neutropaenia, check CBC + diff.

Management

Initial Management

• Nil by mouth, IV fluids, analgesia.
• VTE prophylaxis if indicated.
• IV antibiotics if cellulitis, amoxicillin/ clavulanate 1.2 g q8h. Consider gentamicin ± metronidazole.

Surgical Management

• Perianal abscesses usually require incision and drainage in theatre:
  • GA, lithotomy position.
  • Rigid sigmoidoscopy to check for proctitis.
  • Incise abscess adequately to drain all pus. Send pus for culture.
• Biopsy if Crohn's disease is possibility.
  • If a fistula is obvious consider seton ligature.
  • Only lay open a fistula with senior surgical input.
  • Loosely pack cavity with alginate.

Postoperative Management

• Continue antibiotics only if surrounding cellulitis and/or systemic sepsis.
  • Amoxicillin/ clavulanate 1.2 g q8h IV initially. Then change to amoxicillin/ clavulanate 625 mg PO TDS when afebrile and cellulitis improving.
  • If the patient deteriorates or fails to improve, inadequate drainage should be considered. The case should be discussed with the Consultant Surgeon and repeat examination under anaesthetic and/or MRI considered.
• After discharge:
  • District nurse dressing for large wounds (ongoing packing is usually not required).
  • GP follow up at 2 and 6 weeks with referral to surgical OPD if not healing/persistent fistula.
  • Complicated disease (e.g., Crohn's disease, identified fistula with seton) will require surgical OPD follow-up at six weeks.

Topic Code: 66064