Rosen & Barkin's 5-Minute Emergency Medicine Consult (534 page)

• Aspirin: 81–325 mg/d
  
• Cilostazol: 100 mg BID
  
• Clopidogrel: 75 mg/d
  
• Heparin: 80 U/kg bolus IV followed by 18 U/h IV
  
• Pentoxifylline: 400 mg TID
  

FOLLOW-UP

• All patients with AAI are admitted for evaluation and revascularization.
  
• CAI: Consider admission for rapidly progressive claudication or ischemic pain at rest:
  
  • To undergo heparinization and angiography to rule out an acute thrombosis
    
• Atheroembolism admission indicated with large areas involved, significant pain, infection, or renal compromise
  

• Atheroembolism:
  
  • If they have small lesions, adequate pain control, no evidence of renal compromise or superinfection, and follow-up within 24 hr
    
• CAI:
  
  • No evidence of rapid progression, critical leg ischemia, gangrene, or infection
    

• CAI will need urgent referral to vascular surgery.
  
• Atheroembolism, depending on the origin of the emboli, may need referral to vascular surgery or to cardiology.
  

CAI without acute ischemia and atheroembolism with minimal involvement should have close follow-up to evaluate the extent of their disease.

• Alonso-Coello P, Bellmunt S, McGorrian C, et al. Antithrombotic therapy in peripheral artery disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed.: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
  Chest.
  2012;141:e669S–e690S.
  
• Creager MA, Kaufman JA, Conte MS. Clinical practice. Acute limb ischemia.
  N Engl J Med.
  2012;366:2198–2206.
  
• Grenon SM, Gagnon J, Hsiang Y. Video in clinical medicine. Ankle–brachial index for assessment peripheral arterial disease.
  N Engl J Med
  . 2009;361:e40.
  
• Norgren L, Hiatt WR, Dormandy JA, et al. Inter-society consensus for the management of peripheral arterial disease (TASC II).
  J Vasc Surg
  . 2007;45:SA5–S67.
  
• Rooke TW, Hirsch AT, Misra S, et al. 2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (updating the 2005 guideline): A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
  J Am Coll Cardiol.
  2011;58:2020–2045.
  
• White C. Clinical practice. Intermittent claudication.
  N Engl J Med
  . 2007;356:1241–1250.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Arterial Occlusion
  
• Venous Insufficiency
  

CODES

• 440.20 Atherosclerosis of native arteries of the extremities, unspecified
  
• 443.9 Peripheral vascular disease, unspecified
  
• 444.22 Arterial embolism and thrombosis of lower extremity
  

BASICS

Localized infection and accumulation of purulent material adjacent to anus or rectum

• Anal crypt gland infection, with spread to adjacent areas separated by muscle and fascia:
  
  • Perianal:
    
    • Most common
      
    • Usually with red bulge near anus
      
  • Ischiorectal:
    
    • Large potential space
      
    • May become very large before diagnosed
      
    • Can communicate posteriorly with other side forming “horseshoe” abscess
      
  • Intersphincteric:
    
    • Contained at primary site of origin between internal and external sphincters
      
  • Supralevator:
    
    • Very deep above levator ani
      
    • Needs operative débridement under general anesthesia
      
    • Often systemic symptoms before diagnosis is made
      
• Bacterial cause is typically a mix of stool pathogens:
  
• Associated diseases:
  
  • Diabetes
    
  • Inflammatory bowel disease
    
  • Malignancy
    
  • Immunocompromised host
    

DIAGNOSIS

• Pain: Perianal, rectal, or pelvic
  
• Swelling, fluctuance, drainage, fever
  

• Perianal pain:
  
  • Aggravated by defecation, sitting, coughing
    
• Dull deep pelvic or rectal pain:
  
  • Less pain if arises above dentate line (ischiorectal and supralevator)
    
• Rectal or perirectal drainage
  
• Fever/chills
  
• Constipation
  

• Perianal swelling, erythema, induration, fluctuance, tenderness
  
• Inner cleft buttock abscess = red flag
  
  • Rectal abscess can track out to buttock
    
• Rectal exam is the most important diagnostic intervention
  
  • Rectal swelling or tenderness
    
  • Fistula can be probed, or palpated as a cord
    

• Careful history and physical exam with rectal exam are paramount in making diagnosis.
  
• Have high index of suspicion for any constant perirectal pain.
  

No labs or imaging routinely indicated

• CBC: Leukocytosis with left shift
  
• Wound culture: Not typically indicated
  
• Blood cultures: Mainly for sepsis
  

• CT (with IV contrast, +/– PO contrast)
  
• MRI (helpful with detecting fistulas)
  
• Endoanal US sometimes used
  

Incision and drainage (I&D) is the definitive management.

• Anal fissure
  
• Sentinel pile in the posterior midline or anterior midline
  
• Thrombosed or inflamed hemorrhoids
  
• Anal ulcer (i.e., HIV)
  
• Proctitis (i.e., gonococcal)
  
• Anorectal carcinoma
  

TREATMENT

Pain medication

• Delayed drainage may worsen outcome
  
• Bedside drainage:
  
  • Only if localized perianal abscess
    
    • Probe to rule out deeper tract
      
  • Radial incision close to anal verge
    
  • Explore cavity, breaking any loculations.
    
  • Irrigate liberally.
    
  • Loose packing removed at 48 hr.
    
• Operative debridement under general anesthesia:
  
  • If local anesthesia is inadequate, or deeper abscess
    
• Antibiotics rarely necessary:
  
  • Extensive cellulitis
    
  • Immunosuppression
    
  • Valvular heart disease
    
  • Systemic infection
    
  • Prosthetic device
    
  • PO:
    
    • Amoxicillin clavulanate or fluoroquinolone
      
    • Consider MRSA coverage
      
  • IV:
    
    • Cefoxitin
      
    • Ampicillin sulbactam
      
    • Combination therapy with ampicillin, gentamicin, and clindamycin or metronidazole
      
• Postoperative care:
  
  • Sitz baths TID 24 hr after I&D
    
  • High-fiber diet or bulking agent
    
  • Analgesic