From the Guidelines
The initial management for a patient presenting with a peri-rectal abscess is prompt surgical incision and drainage, which should be performed as soon as possible after diagnosis, as recommended by the most recent guidelines 1. The procedure involves making an incision over the fluctuant area, breaking up loculations, and establishing adequate drainage.
- Local anesthesia may be sufficient for small, superficial abscesses, but deeper or more complex abscesses often require procedural sedation or general anesthesia.
- After drainage, the wound is typically left open to allow healing by secondary intention.
- The use of imaging investigations such as MRI, CT scan, or endosonography may be helpful in cases with atypical presentation, suspicion of occult supralevator abscesses, complex anal fistula, or perianal Crohn’s disease 1.
- Antibiotics are not routinely required for uncomplicated peri-rectal abscesses in immunocompetent patients, as drainage alone is usually sufficient, but should be considered for patients with systemic symptoms, immunosuppression, diabetes, valvular heart disease, or extensive cellulitis 1.
- Pain management with acetaminophen and NSAIDs is important, with opioids reserved for severe pain.
- Patients should be instructed to take sitz baths 2-3 times daily and maintain good perianal hygiene. Surgical drainage is essential because peri-rectal abscesses represent localized infections that have formed collections of pus, and antibiotics alone cannot adequately penetrate these collections to resolve the infection. The timing for surgery is dictated by the patient’s clinical condition and comorbidities: the presence of sepsis, severe sepsis or septic shock, immunosuppression, diabetes mellitus, and diffuse cellulitis should prompt an emergent drainage 1. In fit, immunocompetent patients with a small perianal abscess and without systemic signs of sepsis, outpatient management may be considered 1. No recommendation can be made regarding the use of packing after drainage of an anorectal abscess, based on the available literature 1.
From the Research
Initial Management of Peri-Rectal Abscess
The initial management of a patient presenting with a peri-rectal abscess typically involves incision and drainage (I&D) in conjunction with antibiotics 2.
Importance of Antibiotic Coverage
It is crucial to provide adequate antibiotic coverage to prevent recurrence and improve patient outcomes. A study found that inadequate antibiotic therapy resulted in a six-fold increase in the re-admission rate for abscess recurrence 2.
Alternative Drainage Methods
In some cases, alternative drainage methods such as endoscopic ultrasound-guided transrectal drainage may be considered, especially in patients with Crohn's disease 3, 4.
Treatment of Peri-Rectal Abscess in Crohn's Disease
In patients with Crohn's disease, the treatment of peri-rectal abscesses may involve long-term catheter drainage, which can offer substantial benefit in the overall outcome of treatment 5. Seton and catheter drainage are safe and highly effective in treating perianal abscesses in Crohn's disease 6.
Key Considerations
- Adequate antibiotic coverage is essential to prevent recurrence and improve patient outcomes
- Incision and drainage (I&D) is a common initial management approach
- Alternative drainage methods, such as endoscopic ultrasound-guided transrectal drainage, may be considered in certain cases
- Treatment of peri-rectal abscesses in Crohn's disease may involve long-term catheter drainage and seton drainage.