Minor Surgery - Best treatment › Therapeutic skills
Incisions and drainage
See: 'Skills' > (Abcesses - Iincision and Drainage) and (Paronychia - Incision and Drainage)
Abscesses
An abscess is an infection that results in a collection of purulent material in a circumscribed and closed cavity (Fig. 1, 2). When an abscess is in the early stages of development (Fig. 3), it may be treated with warm compresses. If this treatment is unsuccessful, incision and drainage (I & D) may need to be performed on a wound that has abscessed (U.S. Army Medical Department Center and School) .
Fig. 1. Skin abscess caused by methicillin-resistant Staphylococcus aureus (MRSA)
Fig. 2. Large skin abscess in the elbow region: marked swelling and redness is apparent just above the antecubital fossa. This is caused by an abscess, the result of bacteria innoculated under the skin during injection drug abuse.
[Reproduced, with permission, from: http://medicine.ucsd.edu/clinicalimg (Catalog of Clinical Images by Dr. Charles Goldberg, MD; © Regents of the University of California)]
Fig. 3. Cellulitis of the hand
[Reproduced, with permission, from: http://medicine.ucsd.edu/clinicalimg (Catalog of Clinical Images by Dr. Charles Goldberg, MD; © Regents of the University of California)]
An acute abscess can be dealt with by opening and draining when it has reached the stage where sufficient pus has been formed. The causative agent is usually Staphylococcus aureus.
Uncomplicated superficial skin abscesses should be treated by incision and drainage without antibiotics [Evidence grade B] (Kunnamo I (ed), 2005) , (Llera JL, Levy RC, 1985) , (Macfie J, Harvey J, 1977) , (Stewart MP, Laing MR, Krukowski ZH, 1985) .
See: ‘Skills’ > (Abcesses - Iincision and Drainage)
Antibiotic treatment is indicated, if:
- the patient has fever or general symptoms,
- the abscess is large and tissue damage extensive (Fig. 1),
- the abscess is located in the nasal region,
- concomitant diseases make the patient susceptible to infections (e.g. diabetes, immune deficiency, treatment with corticosteroids) (Kunnamo I (ed), 2005) .
The drug of choice is first generation cephalosporine (adults 500 mg x 3; children 50 mg/kg/day). Alternatively, amoxicillin + clavulanic acid preparations or cloxacillin can be administered (Kunnamo I (ed), 2005) .
Thrombosed external piles (haemorrhoids)
Haemorrhoids or piles are varicosities or swelling and inflammation of veins in the rectum and anus. It has been estimated that fifty per cent of the population suffer from this problem by the time they are fifty years old.
Although haemorrhoids contain many blood vessels, they are not varicose veins. They are the result of a sliding down of the lining of the bowel caused by straining.
Haemorrhoids can be either internal or external, and patients may have both types (Brisinda G, 2000) , (Corman ML, 1998) .
- External haemorrhoids occur below the dentate line and are generally painful. Then can be seen when enlarged. When inflamed they become red and tender,and if they become thrombosed they can cause severe pain and be felt as a tender mass in the anal area.
- Internal haemorrhoids are located proximal to the dentate line, outside the rectal columns, and are usually painless. If they protrude into, but do not prolapse out of the anal canal, they are classed as grade I; if they prolapse on defecation but spontaneously reduce they are grade II; haemorrhoids that require manual reduction are grade III; and if they cannot be reduced they are grade IV. Haemorrhoids that remain prolapsed may develop thrombosis and gangraene (Brisinda G, 2000) , (Corman ML, 1998) .
Both types of haemorrhoids can be sources of bleeding when abraded. This type of bleeding is bright red compared to bleeding higher up in the GI tract where the blood is occult and must be identified by chemical tests.
External haemorrhoids, i.e. those that occur outside of the anal verge (the distal end of the anal canal), can be painful, and accompanied by swelling and irritation. If the vein ruptures and a blood clot develops, the haemorrhoid becomes a thrombosed haemorrhoid (Fig. 4)
Fig. 4. Thrombosed haemorrhoid
[Reproduced, with permission, from: http://medicine.ucsd.edu/clinicalimg (Catalog of Clinical Images by Dr. Charles Goldberg, MD; © Regents of the University of California)]
