History and Physical Examination

The clinical presentation of perianal granuloma may vary widely, ranging from asymptomatic with minimal physical signs to recurrent or persistent problems that are highly distressing. Manifestations of disease may range from an asymptomatic nodule to a simple fistula or a draining sinus to the complex presentations of multiple, draining fistulas or sinuses and wide involvement, with undermining of previously normal tissues.^[20]

Crohn disease

In about 9% of patients with Crohn disease (CD), anorectal manifestations are the first indication of the disease (see the images below). The lesions are usually abscesses or fistulas and may be solitary or multiple, simple or complex. Crohn fistulae may look relatively indolent in comparison with the more typical chronic fistula-in-ano.^{[21, 22]}

Perianal granuloma and multiple fistulous tracts in patient with severe perianal Crohn disease. Note noncutting seton in place.

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Perianal granuloma in patient with severe perianal Crohn disease.

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Tuberculosis

Anorectal tuberculosis often manifests as complex fistulous disease that has not been sufficiently well managed by initial surgical therapy. Approximately 10% of patients with anorectal tuberculosis have active pulmonary tuberculosis as well, and nearly all of the remaining patients have evidence of old pulmonary tuberculosis on chest radiographs.^[23] The diagnosis of tubercular anorectal disease should be considered whenever anorectal fistulas or abscesses heal poorly or recur after initial therapy.

Most cases of anorectal tuberculosis are primary presentations, though secondary infection of the pilonidal sinus has been reported. The most frequent presentations are suppurations and fistulae, but the disease can also present as anal pain, fever, weight loss, or perianal nonhealing ulcers.^[18]

The typical histologic lesion is the epithelioid and giant cell tubercle around a zone of caseous necrosis, but the pathognomonic presence of caseation is not constant and presents a diagnostic challenge, especially in cases of coexisting CD with perianal localization.^[24]

Other

The remaining causes are clarified with the help of tissue biopsies for histopathologic, serologic, and other special testing.

Workup

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Assa A, Amitai M, Greer ML, Castro DA, Kuint RC, Martínez-León M, et al. Perianal Pediatric Crohn Disease Is Associated With a Distinct Phenotype and Greater Inflammatory Burden. J Pediatr Gastroenterol Nutr. 2017 Sep. 65 (3):293-298. [QxMD MEDLINE Link].
El-Gazzaz G, Hull T, Church JM. Biological immunomodulators improve the healing rate in surgically treated perianal Crohn's fistulas. Colorectal Dis. 2012 Oct. 14 (10):1217-23. [QxMD MEDLINE Link].
Le Q, Melmed G, Dubinsky M, McGovern D, Vasiliauskas EA, Murrell Z, et al. Surgical outcome of ileal pouch-anal anastomosis when used intentionally for well-defined Crohn's disease. Inflamm Bowel Dis. 2013 Jan. 19 (1):30-6. [QxMD MEDLINE Link].
Dederichs F, Iesalnieks I, Sladek M, Tzivinikos C, Hansen R, Muñoz C, et al. Genital Granulomatosis in Male and Female Patients With Crohn's Disease: Clinical Presentation and Treatment Outcomes. J Crohns Colitis. 2018 Jan 24. 12 (2):197-203. [QxMD MEDLINE Link].
Ferreira Cardoso M, Carneiro C, Carvalho Lourenço L, Graça Rodrigues C, Folgado Alberto S, Alagoa João A, et al. Actinomycosis Causing Recurrent Perianal Fistulae. ACG Case Rep J. 2017. 4:e82. [QxMD MEDLINE Link].
Coremans G, Margaritis V, Van Poppel HP, Christiaens MR, Gruwez J, Geboes K, et al. Actinomycosis, a rare and unsuspected cause of anal fistulous abscess: report of three cases and review of the literature. Dis Colon Rectum. 2005 Mar. 48 (3):575-81. [QxMD MEDLINE Link].
Bauer P, Sultan S, Atienza P. Perianal actinomycosis: diagnostic and management considerations: a review of six cases. Gastroenterol Clin Biol. 2006 Jan. 30 (1):29-32. [QxMD MEDLINE Link].
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Kouklakis G, Efremidou EI, Papageorgiou MS, Pavlidou E, Manolas KJ, Liratzopoulos N. Complicated Crohn's-like colitis, associated with Hermansky-Pudlak syndrome, treated with Infliximab: a case report and brief review of the literature. J Med Case Rep. 2007 Dec 8. 1:176. [QxMD MEDLINE Link]. [Full Text].
Grucela AL, Patel P, Goldstein E, Palmon R, Sachar DB, Steinhagen RM. Granulomatous enterocolitis associated with Hermansky-Pudlak syndrome. Am J Gastroenterol. 2006 Sep. 101 (9):2090-5. [QxMD MEDLINE Link].
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The facts about inflammatory bowel diseases. Crohn's and Colitis Foundation of America. Available at http://www.crohnscolitisfoundation.org/assets/pdfs/updatedibdfactbook.pdf. November 2014; Accessed: November 9, 2022.
Inflammatory bowel diseases: briefing paper. National Institute for Health and Care Excellence. Available at https://www.nice.org.uk/guidance/qs81/documents/inflammatory-bowel-disease-briefing-paper2. April 30, 2014; Accessed: November 9, 2022.
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Liu CK, Liu CP, Leung CH, Sun FJ. Clinical and microbiological analysis of adult perianal abscess. J Microbiol Immunol Infect. 2011 Jun. 44 (3):204-8. [QxMD MEDLINE Link].
Afşarlar CE, Karaman A, Tanır G, Karaman I, Yılmaz E, Erdoğan D, et al. Perianal abscess and fistula-in-ano in children: clinical characteristic, management and outcome. Pediatr Surg Int. 2011 Oct. 27 (10):1063-8. [QxMD MEDLINE Link].
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Jayanthi V, Robinson RJ, Malathi S, Rani B, Balambal R, Chari S, et al. Does Crohn's disease need differentiation from tuberculosis?. J Gastroenterol Hepatol. 1996 Feb. 11 (2):183-6. [QxMD MEDLINE Link].
Van der Bij AK, Spaargaren J, Morré SA, Fennema HS, Mindel A, Coutinho RA, et al. Diagnostic and clinical implications of anorectal lymphogranuloma venereum in men who have sex with men: a retrospective case-control study. Clin Infect Dis. 2006 Jan 15. 42 (2):186-94. [QxMD MEDLINE Link].
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Media Gallery

Perianal granuloma and multiple fistulous tracts in patient with severe perianal Crohn disease. Note noncutting seton in place.
Perianal granuloma in patient with severe perianal Crohn disease.

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Author

Burt Cagir, MD, FACS Associate Regional Dean and Professor of Surgery, Geisinger Commonwealth School of Medicine; Director, General Surgery Residency Program, Executive Director, Donald Guthrie Foundation for Research and Education, Guthrie Robert Packer Hospital; Medical Director, Guthrie/RPH Skills and Simulation Lab; Associate in Surgery, Guthrie Robert Packer Hospital and Corning Hospital

Burt Cagir, MD, FACS is a member of the following medical societies: American College of Surgeons, Association of Program Directors in Surgery, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Coauthor(s)

Andres Fleury, MD Clinical Assistant Instructor, Department of Surgery, State University of New York Upstate Medical University; Resident, Department of Surgery, Robert Packer Hospital

Andres Fleury, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, National Hispanic Medical Association

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, MSc, DSc, AGAF Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow; Fellow of the Royal Society of Medicine

John Geibel, MD, MSc, DSc, AGAF is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Acknowledgements

Michael A Grosso, MD Consulting Staff, Department of Cardiothoracic Surgery, St Francis Hospital

Michael A Grosso, MD is a member of the following medical societies: American College of Surgeons, Society of Thoracic Surgeons, and Society of University Surgeons

Disclosure: Nothing to disclose.

Juan B Ochoa, MD Assistant Professor, Department of Surgery, University of Pittsburgh School of Medicine; Medical and Scientific Director, HCN, Nestle Healthcare Nutrition

Disclosure: Nothing to disclose.

Jan Rakinic, MD Chief, Section of Colorectal Surgery, Program Director, SIU Residency in Colorectal Surgery, Southern Illinois University School of Medicine

Jan Rakinic, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Medical Women's Association, American Society of Colon and Rectal Surgeons, and Illinois State Medical Society

Disclosure: Nothing to disclose.

Carol E H Scott-Conner, MD, PhD Professor, Department of Surgery, University of Iowa College of Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment