weekly_question 22/8/2021

[Admin]

A three-month old child has a recently drained perianal abscess and presents with a draining fistula at the site of the incision. What is the best next step in management of this infant with a perianal fistula?

A fistulotomy

B infliximab

C seton placement

D antibiotics

E observation

[Admin]

Correct Answer

E observation

The majority of perianal abscesses in infants are in boys. The etiology is felt to be an infection of a deep anal crypt. There is large variation in care in the literature regarding perianal abscesses and the resulting perianal fistula. Options include no treatment, antibiotics alone, aspiration, formal incision and drainage, and anal fistulotomy. All of these methods achieve acceptable results in the majority of patients.

There is no consensus on the medical management of perianal abscess in children. In otherwise well infants, the spectrum of medical therapies includes warm compresses, perianal hygiene, antibiotics and close observation for signs of worsening pain or systemic sepsis. In a prospective study of 18 male infants presenting with perianal abscess, 14 were successfully treated with observation. The four others were treated with incision and drainage due to patient discomfort or fever. None of the 18 patients received antibiotics.

Less than half of children treated with incision and drainage for perianal abscess will develop recurrent abscesses or fistula. Published recurrence rates after I&D vary widely, but most range from 15 to 35%. Incision and drainage of a perianal abscess in the less than two-year old age group will result in the occurrence of an anal fistula in up to 30% of patients. Alternatively, some may heal and demonstrate a recurrent abscess.

Some surgeons recommend early fistulotomy as treatment for a perianal abscess and report good results. A period of observation for three to six months after the development of afistula does not appear to injure the patient and seems to result in healing of the fistula without further surgical intervention in about 40% of patients. Because the fistula in this setting is superficial and communicates with a perianal crypt, sphincter injury is not an issue. Anal manometry has been measured after surgical excision of the FIA and found no changes in sphincter pressures following the procedure.

Some series have advocated the use of antibiotics only in those who are systemically ill at the time of their presentation, using sitz baths as the alternative treatment. Antibiotics do not appear to be essential after the fistula has been surgically treated.

While large series of patients do not exist, inflammatory bowel disease screening does not appear indicated in the toddler age group. Even in patients over eight years of age, the incidence appears to be quite small.

[Ahmednabilps]

E

[Sharon]

E

[Admin]

Correct Answer

E observation

The majority of perianal abscesses in infants are in boys. The etiology is felt to be an infection of a deep anal crypt. There is large variation in care in the literature regarding perianal abscesses and the resulting perianal fistula. Options include no treatment, antibiotics alone, aspiration, formal incision and drainage, and anal fistulotomy. All of these methods achieve acceptable results in the majority of patients.

There is no consensus on the medical management of perianal abscess in children. In otherwise well infants, the spectrum of medical therapies includes warm compresses, perianal hygiene, antibiotics and close observation for signs of worsening pain or systemic sepsis. In a prospective study of 18 male infants presenting with perianal abscess, 14 were successfully treated with observation. The four others were treated with incision and drainage due to patient discomfort or fever. None of the 18 patients received antibiotics.

Less than half of children treated with incision and drainage for perianal abscess will develop recurrent abscesses or fistula. Published recurrence rates after I&D vary widely, but most range from 15 to 35%. Incision and drainage of a perianal abscess in the less than two-year old age group will result in the occurrence of an anal fistula in up to 30% of patients. Alternatively, some may heal and demonstrate a recurrent abscess.

Some surgeons recommend early fistulotomy as treatment for a perianal abscess and report good results. A period of observation for three to six months after the development of afistula does not appear to injure the patient and seems to result in healing of the fistula without further surgical intervention in about 40% of patients. Because the fistula in this setting is superficial and communicates with a perianal crypt, sphincter injury is not an issue. Anal manometry has been measured after surgical excision of the FIA and found no changes in sphincter pressures following the procedure.

Some series have advocated the use of antibiotics only in those who are systemically ill at the time of their presentation, using sitz baths as the alternative treatment. Antibiotics do not appear to be essential after the fistula has been surgically treated.

While large series of patients do not exist, inflammatory bowel disease screening does not appear indicated in the toddler age group. Even in patients over eight years of age, the incidence appears to be quite small.

[Guest]

Observation has been known to work very well on children in this age group. Most of the time, when parents are anxious for early resolution use of antibiotics can help to get a good response.
Attempting surgical drainage may result in what was observed in this case, combination of sitz bath and antibiotics can bring about quick resolution.