Perianal Suppuration Research Articles

OP35 Natural history of anal ulcerations in pediatric-onset Crohn’s Disease: A population-based study

Abstract Background Anal ulcerations are frequently observed in Crohn’s disease (CD). Their natural history remains poorly known, especially in pediatric-onset CD. The aims of this study were: to determine in a population-based study the risk of anal ulcerations in pediatric onset CD; to identify risk factors for anal ulcerations; to evaluate the risk of progression towards suppurative lesions; to evaluate the risk factors of progression towards suppurative lesions. Methods All patients with a diagnosis of CD before the age of 17 years between 1988 and 2011 within the population-based registry EPIMAD were followed retrospectively until 2013. A specific collection of additional data was performed in patients with anal ulcerations at diagnosis or during follow-up. The variables collected included: proctological examination, diagnostic management (perineal MRI, endoscopic ultrasound, examination under general anaesthesia) and treatment (medical or surgical). Multivariate Cox models were used to identify factors associated with anal ulcerations and factors of progression towards suppurative lesions. An adjusted time-dependent Cox model was used to evaluate the risk of progression of anal ulcerations towards suppurative lesions. Results 1005 patients were included (females, 450 (44.8%); median age at diagnosis 14.4 years (IQR, 12.0–16.1)). 257 (25.6%) had anal ulceration at diagnosis. Cumulative incidence of anal ulceration at 5 and 10 years from diagnosis was 38.4% (CI95%, 35.2–41.4) and 44.0% (CI95%, 40.5–47.2). The presence of extra-intestinal manifestations (HR 1.46, CI95% 1.19–1.80, p=0.0003) and upper digestive location (HR 1.51, CI95% 1.23–1.86, p<0.0001) at diagnosis were associated with the occurrence of anal ulceration. Conversely, ileal location at diagnosis was associated with a lower risk of anal ulceration (L2 vs L1 HR 1.51, CI95% 1.11–2.06, p=0.0087; L3 vs L1 HR 1.42, CI95% 1.08–1.85, p=0.0116). Among the 352 patients with at least one episode of anal ulceration, 82 (23.3%) developed perianal suppuration after a median follow-up of 5.7 years (IQR, 2.8–10.6). The risk of perianal suppuration was doubled in patients with anal ulceration compared to those who did not have any ulceration (HR 2.0, CI95% 1.45–2.74, p<0.0001). In patients with anal ulceration, the diagnostic period (before or since the “biologic era”), exposure to immunosuppressants and/or anti-TNF did not influence the risk of perianal suppuration. Conclusion Anal ulceration is frequent in pediatric-onset CD, with nearly half of patients presenting with at least one episode after 10 years of evolution. Perianal suppurations are twice as frequent in patients with present or past anal ulceration. These results plead for a proactive therapeutic approach in case of anal ulcerations.

Evolution of treatment for rectal fistula: from resection to FiLaC® laser ablation

Rectal fistula – one of the most common coloproctological diseases. Annually, thousands of patients with anal fistula have had treated around the world. Treatment of this disease is an actual problem in coloproctology nowadays due to the high frequency of recurrence and anal incontinency. The chronic persistent perianal suppuration and multiple surgical interventions the main predictor of emergence of the anal incontinence, which could be achieve almost 50 %, according the literature data. The risk of emergence the anal incontinence is particularly high in the treatment of complex fistulas. Therefore, the problem of complex rectal fistulas treating remains an actual task in the clinical practice of a coloproctologist.

Recurrent Perianal Abscess Secondary to Cutaneous B-cell Lymphoma

Fistula-in-ano lies at the chronic end of the spectrum of perianal suppuration which is responsible for waxing and waning coarse of the disease. Recurrent infection of the fistulous tract is responsible for off and on abscess formation. Recurrent abscess formation without a fistula is a very rare entity. Here, we present a case of recurrent perianal abscess without a perianal fistula. A 45-year-old male with renal transplant on immunosuppression presented with recurrent perianal abscess which was drained multiple times and prescribed antibiotics as per culture sensitivity. Magnetic resonance imaging was Performed which did not reveal any fistula formation. The patient was subjected to a biopsy of the lesion which came out to be a B-cell lymphoma. The patient was successfully treated by a multidisciplinary team at our tertiary care center. With this case report, we conclude that recurrent abscess formation in perianal area in an immunosupressed patient may be due to an underlying cutaneous lymphoma. This disease needs multidisciplinary approach for successful management.

Clinical and diagnostic profile of patients with anal fistula: a cross sectional study from Vilasrao Deshmukh Government Institute of Medical Sciences, Latur, Maharashtra

Background: Anal fistulas are one of the commonest causes for a persistent discharge seropurulent in nature that irritates the skin in the neighbourhood and leads to discomfort. Fistula-in-ano is seen quite frequently in perirectal perianal suppuration. The objective of this study to study the clinical profile and diagnosis of anal fistula at surgical OPD of VDGIMS.Methods: The present cross-sectional observational study was carried out in patients with fistula-in-ano admitted at surgical department of VDGIMS, Latur during the period of 2017-19 in 50 diagnosed patients. Data was analysed by using SPSS 24.0 version IBM USA.Results: Majority of the patients with anal fistula were from 41-50 years age group i.e. 15 (30%) and males were predominantly affected 40 (80%) compared to females i.e. 10 (20%). Male to female ratio was 4:1. Perianal discomfort was the commonest symptom in all patients i.e. 100%. It is followed by perianal discharge complained by 54% and perianal itching in 38% cases. The anterior position of external opening is found to be significant (p<0.05). Fistulogram showed external opening in all patients i.e. 50 cases whereas internal opening in 46 (92%) cases. Findings of MRI revealed that anal fistula was intra sphincteric in 28 cases i.e. 56%, extra sphincteric in 2 cases i.e. 4% and trans sphincteric in 20 cases i.e. 40%.Conclusions: Commonest age group affected in our study was 40-50 years with male predominance. Perianal discomfort and discharge were the commonest symptom. E. coli was the predominant organism isolated. Fistulogram and MRI is useful in detecting the aetiology of fistula in ano.

Outcomes of Management of Anal and Perianal Suppuration at Niamey National Hospital, Niger

Bakground: Anal and perianal sepsis is common anorectal disorders found in surgical practice. This study aims to report epidemiological aspects and outcomes of management of anal and perianal suppuration. Methods: This was a retrospective study from January 2011 to June 2016 at Niamey National Hospital. Patients operated on for anal and perianal suppuration of non-specific anorectal origin were included. Results: During the study period, we collected 141 cases of anal and perianal suppurations. The average age of our patients was 42±8.8 years. The sex ratio was 3.27 in favor of men. The origin of the patients was urban in 73.8% of the cases. The history of diabetes mellitus was found in 14.2% (n=20). Anal fistulas and anal abscesses (n=115) were simple in 46% (n=53) and complex in 54% (n=62). A fistulectomy with the placement of an elastic seton was performed for 41.13% of cases (n=58) and fistulotomy in 29.78%. The evolution of 6 months was marked by a recurrence in 10.63% (n = 15), the anal incontinence of gas at 9.21% (n=13). Deaths (n=4) were recorded in patients with Fournier’s gangrene. Uncomplicated therapeutic success was 80.13% (n=113). Conclusion: The surgical treatment of anal fistula (the main cause of anal and perianal suppuration) aims to eradicate the suppuration and to preserve the anal continence. The fistulotomy done in the context of the management of a simple fistula gives a better outcome. Incontinence-related complications and relapses must impose thoroughness and patience in the surgical treatment of complex fistulas.

Fournier's Gangrene as Seen in University of Maiduguri Teaching Hospital

Background. Fournier's gangrene is uncommon but increasingly being seen over the last two decades probably due to increasing socioeconomic problems including an upsurge in HIV infection especially in the tropics. Patients and Methods. The study retrospectively reviewed all patients with Fournier's gangrene managed in UMTH between January 2007 and December 2012. Results. Thirty-eight males aged 2 weeks to 80 years (mean 37.82) were reviewed, with most aged 30–39 years (13 (34.21%)). Clinical features were scrotal pain and swelling, 36 (94.74%), fever, 19 (50.00%), and discharging scrotal wound, 19 (50.00%). The predisposing conditions were UTI secondary to obstructive uropathy in 11 (28.95%), perianal suppuration, and HIV, in 8 (21.05%) patients each. Wound biopsy culture revealed mixed organisms in 27 (71.05%). Twenty-six (68.42%) had blood transfusions. Thirty-seven (97.37%) patients had wound debridement. Twenty (52.63%) had flap rotation for skin cover. There were 6 (15.79%) mortalities, of which 4 (10.53%) were HIV positive, 1 (2.63%) was diabetic, and 1 (2.63%) was both diabetic and HIV positive. Conclusion. Fournier's gangrene is a fulminant synergistic necrotising fasciitis of the perineum and genitalia with poor prognosis especially when associated with HIV and diabetes, requiringprompt and aggressive management for good outcome.

Les fistules anales de cause infectieuse spécifique

Most cases of fistula-in-ano are caused by cryptoglandular infections, usually accompanied by mixed, non-specific, colonic flora. Sometimes infectious specific causes are revealed, requiring targeted treatments, in addition to conventional surgery, to avoid recurrence. Tuberculosis, lymphogranuloma venereum (caused by Chlamydia trachomatis), Neisseria gonorrhoeae and actinomycosis can cause perianal suppuration, resulting in a specific clinical presentation requiring a specific treatment strategy.

The role of stem cells in suppurative environments

Purpose: The management of suppurative perianal lesions presents an extremely challenging problem. Stem cells (SC) extracted from certain tissues, such as adipose tissue, can differentiate into various cell types. Therefore, we have tried to use such cells to stimulate healing in a purulent environment. Methods: In the beginning, we designed a phase I clinical trial, involving five patients with Crohn's disease. We inoculated nine fistulas in four patients with autologous adipose‐derived stem cells (ADSC) and were followed at least 8 weeks. Seventy‐five percent became healed, and 25% showed a decrease in output flow. No adverse effects were observed in any patient. This study evidenced that such cells are safe. Then, we started a research line using SC in different suppurative environments. During the course of these studies, we had the opportunity to treat a patient with perianal hidradenitis suppurativa using our current protocol of ADSC transplantation. Eight weeks after injection, patient had no perianal suppuration, and a year later remains well. Discussion: The biological mechanism that underlies the therapeutic success of ADSC transplantation is unknown. Cell differentiation, secretion of growth factors or immunomodulatory effects have been suggested. No ethical conflicts were identified by our Ethics Committee, because the cells were autologous. Conclusions: Our study shows that ADSC are safe for the treatment of suppurative processes. The actual number of patients included and the uncontrolled nature of these pilot studies do not allow demonstration of the effectiveness of the treatment. However, the results encourage the performance of further studies.

Is routine endoanal ultrasound useful in anal fistulas?

To evaluate the effectiveness of endoanal ultrasound with hydrogen peroxide enhancement in the assessment of anal fistula (tract and internal opening), and to value the utility of this examination for anal or perianal suppuration when performed by a colorectal surgeon trained in this technique. Endoanal ultrasound was performed in 103 patients with anal or perianal suppuration. Twenty patients were excluded: 9 had the external opening closed, and 11 had cryptoglandular abscesses. All ultrasound scans were performed by the same explorer using a BK Diagnostic Ultrasound System with a 7 MHz endoprobe. The examination was based on the identification of the three anal planes, then hydrogen peroxide was infused and the procedure was repeated. Out of 83 patients included, 11 had a perianal sinus and 72 an anal fistula. In all fistulas the main tract was found: 24 were inter-sphinteric (33.33%), 33 trans-sphincteric (45.83%), 3 supra-sphincteric (4.17%), and 12 extra-sphincteric (16.67%). An internal opening was identified in 69 (95.83%). Endoanal ultrasound with hydrogen peroxide enhancement is an effective examination to visualize fistulous tracts and internal openings. We think it is highly useful for anal or perianal suppuration to identify abscesses, to recognize a perianal sinus, to check the sphincteric condition, and to plan subsequent surgery.

Perianal Crohn's disease

This study relates our experience with local surgical management of perianal Crohn's disease. Of 1,735 patients with Crohn's disease seen between 1980 and 1990, records of 66 patients (3.8 percent) with symptomatic perianal Crohn's disease treated by local operations were retrospectively reviewed to study outcome of local surgical intervention. All patients had intestinal disease that was limited to the colon in 32 patients (48 percent), ileocolonic region in 22 patients (33 percent), and ileum in 12 patients (18 percent). Types of perianal disease encountered included perianal suppuration (57), anal fistula (47), anal fissure (21), anal stenosis (5), gluteal abscess (3), scrotal abscess (2), and anovaginal fistula (2). A total of 321 episodes of anal complications necessitated 256 local surgical interventions. Local anorectal operations performed included simple incision and drainage of abscess (57), fistulotomy (35), incision and drainage of complex anorectal abscesses and fistulas and insertion of seton (24), internal sphincterotomy (6), fissurectomy (1), and anal dilation (3). Of 24 patients with horseshoe abscesses and fistulas managed with insertion of a seton and 35 patients who underwent fistulotomy as a primary procedure or in conjunction with drainage of an abscess, none experienced fecal incontinence as a direct result of the operation. Thirteen patients required proctectomy to control perianal disease, and a similar number underwent total proctocolectomy for extensive intestinal disease. Forty patients (61 percent) continue to retain a functional anus. Patients with symptomatic low anal fistula involving minimum sphincter musculature can be treated safely with fistulotomy. In treatment of patients with horseshoe abscesses and high fistulas, aggressive local surgical intervention using a seton permits preservation of the sphincter and good postoperative function.

Acute Perianal and Pilonidal Suppuration

Acute Perianal and Pilonidal Suppuration

A Case of Lympho-Granuloma Inguinale producing Rectal Stricture

A case of rectal stricture of recent onset occurring in a middle-aged woman. Other symptoms include marked loss in weight, pyrexia and, at one time, symptoms suggesting an acute abdominal condition. Clinical and X-ray findings revealed a stricture of the rectum. The association of enlarged lymph nodes, peri-anal suppuration and a strongly positive Frei test leads one to a diagnosis of lymphogranuloma inguinale. My thanks are due to Mr. C. A. Horder and Dr. W. Addey for their kind permission to publish this case.