Laboratory Studies

Laboratory tests in patients with perianal granuloma are of help only after it has become obvious that the disease process is due to some unusual causative organism. In general, laboratory tests are not diagnostic in Crohn disease (CD).

The choice of laboratory tests is dictated by the clinical presentation, and results are more indicative of the degree of illness than of the etiology.^[25] When an unusual etiology for the disease process becomes apparent, directed investigative tests become useful.

Superficial wound cultures are usually of no diagnostic use and yield only colonizing bacteria (usually of skin or gastrointestinal [GI] tract origin) rather than true pathogens. However, biopsy of a nonhealing or recurrent wound with stains and culture of the tissue may yield identification.

Other tests that may be useful include the following:

Potassium hydroxide (KOH) preparation - Can help to identify yeast organisms
Acid-fast bacillus (AFB) staining - Although commonly performed in this setting, this usually yields negative results (tissue cultures produce a higher yield but take 7-21 days)
A Tzanck preparation - May be helpful in excluding herpes

Imaging Studies

Imaging tests that aid in the diagnosis and evaluation of causative diseases in perianal granuloma include the following:

Radiography - Should be obtained when the possibility of perianal tuberculosis is being evaluated; nearly all patients with perianal or anorectal tuberculosis have chest radiographic findings suggestive of old or active pulmonary tuberculosis
Barium enemas - May be used to evaluate the colorectal mucosa in the differential diagnosis of CD
Upper GI/small-bowel series - Used to evaluate the upper GI tract and terminal ileum for CD

Procedures

Endoscopic evaluation may aid in obtaining material for pathology and culture. Proctoscopy is probably most useful. Sigmoidoscopy and colonoscopy can be helpful in the evaluation of inflammatory bowel disease (IBD) or in more proximal involvement of the colon with infectious agents.

Examination under anesthesia, with biopsy or scraping of wounds or ulcerations, can also yield material for diagnostic evaluation.

Histologic Findings

Regular histopathology should always be requested on tissue specimens. The presence of so-called sulfur granules is characteristic of Actinomyces. Granulomas, caseating or noncaseating, may be observed, though this is more rare in CD than is commonly believed. Other infectious agents (eg, fungi and parasites) may be identified with histopathology.

Treatment & Management

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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