Recurring Perianal Abscesses and Persistent Anal Fistula in a 40-Year-Old Male

Case at a Glance

A 40-year-old male with BMI 35.3 presents with an 8-9 year history of recurring deep perianal abscesses and a persistent anal fistula with continuous drainage. Despite extensive gastrointestinal evaluation, the underlying etiology remains unclear.

Patient's Story

This 40-year-old male has experienced recurrent deep perianal abscesses for nearly a decade. Approximately 8-9 years ago, an abscess developed into a fistula that has drained continuously since. New abscesses develop every 3-5 years, either spontaneously rupturing into the existing fistula tract or requiring surgical drainage. The patient reports the current abscess is particularly deep and painful, not responding to conservative management. He has a longstanding history of gastroesophageal reflux disease spanning over 12 years. The persistent fistula produces minimal but consistent purulent drainage, requiring daily protective padding.

Initial Assessment

Physical examination reveals a deep, tender perianal mass consistent with abscess formation. The patient appears comfortable but reports significant pain with sitting and defecation. Current medications include bronchodilators (ventolin, advair), antihypertensive therapy (lisinopril), and proton pump inhibitor (omeprazole) for GERD management, along with various nutritional supplements.

The Diagnostic Journey

Comprehensive gastrointestinal evaluation was performed 1-2 years prior, including colonoscopy and upper endoscopy. Colonoscopy identified the internal fistula opening and revealed several precancerous polyps that were removed. Upper endoscopy demonstrated a hiatal hernia consistent with his GERD symptoms. Importantly, no evidence of inflammatory bowel disease (Crohn's disease or ulcerative colitis) was found. Multiple gastroenterology consultations have been inconclusive regarding the etiology of the recurrent abscesses and persistent fistula.

Final Diagnosis

Recurrent cryptoglandular perianal abscesses with complex anal fistula, etiology undetermined. Differential diagnosis includes occult inflammatory bowel disease, hidradenitis suppurativa, or idiopathic cryptoglandular infection.

Treatment Plan

Immediate management focuses on drainage of the current deep abscess, likely requiring surgical intervention under anesthesia given the depth and location. Long-term management discussions include fistula repair options, though previous surgical consultations noted potential for recurrence or tract migration. Conservative management with continued drainage has been the approach to date. Further evaluation by colorectal surgery is planned following recent relocation.

Outcome and Follow-up

The patient continues to experience periodic abscess formation requiring intervention. The chronic fistula remains patent with ongoing drainage managed conservatively with protective padding. Gastroenterology follow-up shows no progression to overt inflammatory bowel disease. The patient is seeking new subspecialty care for comprehensive evaluation of treatment options, including potential hidradenitis suppurativa evaluation and consideration of definitive fistula repair versus continued conservative management.