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RESEARCH ON ANO-RECTAL FISTULA

FISTULA

Definition- A communicating tract between two epithelial surfaces, commonly between a hollow viscous and the skin or between two hollow viscera. The tract is lined with granulation tissue which is subsequently epithelialised.

VERAITY-

          1. Brachial

         2. Tracheo-Oesophageal

         3. Anteriovenous

          4. Preauricular

          5. Ano-rectal

EXAMINATION-

        By Probe-

1. Direction & Depth of Fistula

2. Presence of any foreign body at wound

3. Communication of Fistula

4. Discharge from Fistula

           X-ray-

1. Injection of Radio-opaque fluid into the fistula tract.

2. Straight x-ray for foreign body or osteomilectic change in body.

ANO-RECTAL ABSCESS

Abscess around lower rectum and anal canal are known as ano-rectal abscess. These are important as this often culminates in fistula-in-ano.The causative organism is usually E.coli, less commonly Staphylococcus aureus, Bacteroids, Streptococcus, B.proteus etc.In 90% of the cases the abscess starts as an infection of an anal gland. In remaining 10% of cases infection may come from blood borne infection.e.g extension of a cutaneous boil etc.

CLASSIFICATION

 Followings are the type of ano-rectal abscesses.

i.                   Peri-anal

ii.                Ischio-rectal

iii.             Submucous

iv.              Pelvi-rectal

 Of these peri-anal (60%) and ischio-rectal (30%) are the common abscesses.

PERI-ANAL ABSCESS

CAUSE

i.                   Majority of these abscesses arise from acute inflammation of anal gland. The pus collects with in the internal sphincter and gradually paves its way between the internal sphincter and conjoint longitudinal muscle to tract down and comes superficial in the perianal region.

ii.                Infection of a thrombosed external pile may also result perianal abscess.

CLINICAL FEATURES

Patient complains of throbbing pain around anus.This pain becomes exaggerated during defaecation.Some constitutional symptoms such as fever; head ache may be associated with this condition. On inspection an acute angry lump may be seen at the anal margin. Some times this may not be obviously seen, but felt by finger in the anal canal just below the dentate line. It is a very tender cystic lump.

TREATMENT

Treatment is incision and drainage of the pus. This should be done immediately under antibiotic cover. An inadequate and defective incision will lead to anal fistula. The cruciate incision is placed on the most prominent part of the swelling preferably under general anesthesia. The incision must be bold and should open the abscess cavity adequately. The sinus forceps is passed into the abscess cavity, the blade of the forcep are opened to break the loculi and is brought out with the open blades for adequate drainage. A finger should then be passed into the abscess cavity and all the loculi should be broken. The internal sphincter is separated from the mucosa and the lower part of the internal sphincter should be incised to prevent fistula formation. The skin edges are incised to keep the wound wide open. The cavity is packed and healing will start by granulation.

Sequelae- If untreated, perinial abscess may

i.                   rupture into anal canal.

ii.                 may rupture into the exterior causing fistula-in-ano.

iii.              may pass laterally through the external sphincter to form ischio-rectal abscess.

ISCHIORECTAL ABSCESS

CAUSE-

i.                   The commonest cause of is extension of anal gland inflamanation of laterally through the external sphincter.

ii.                Infection may be through blood or lymph

iii.             Penetrating injury causing direct infection from out side

iv.              Extension from pelvi- rectal abscess through hiatus of Schwalbe

PATHOPHYSIOLOGY

Ischio-rectal fossa is full of fat and poorly vascularised, so infection continues for a long time and gradually the whole fossa becomes involved. The ischiorectal fossa is connected to the other side posterior to anal sphincter. So ischiorectal abscess may spread to the opposite side if not treated early.

CLINICAL FEATURES

Patient presents with acute pain by the side of the anus

, pain becomes exuberant during defaecation. Constitutional symptoms and fever may be present. On examination, a tendered browny indurated swelling is seen and felt superficial to the ischiorectal fossa on one side of the anus.

TREATMENT

Under general anesthesia early incision and drainage of the abscess is the main theme of treatment. A cruciate incision is made on the most prominent part of the swelling. The incision should extend more than the edge of the swelling. Adequate portion of the skin which the roof of the abscess should be excised. The cavity is explored with a finger. Septa are divided with the finger and necrotic tissue lining the walls of the abscess cavity is removed by the finger wrapped with gauze. An attempt should be made to find out whether the abscess has come from perinial abscess or from pelvi-rectal abscess above. If it is an extension from a perinial abscess, the treatment should be passage of probe into the anal canal through that opening and sphincterotomy right upto the probe to lay open the track as performed in case of fistula-in-ano. If the abscess has extended from pelvirectal abscess, the hiatus of Schewalbe is enlarged for better drainage and the abscess cavity above is curetted. The whole cavity is lightly packed with gauze wrung out in any weak antiseptic solution. A T-bandage is applied. The wound will heal by granulation tissue from the deapth.

SUBMUCOUS ABSCESS

This abscess is situated just deep to the mucous membrane of the anal canal above the dentate line. It occurs usually form spread of infection from the anal gland or even after injection of hemorrhoids. This is drained by a small incision either by stretching the anus or by a proctoscope.

PELVIRECTAL ABSCESS

This is situated above the levator ani (pelvic floor) and below the pelvic peritoneum. It is a simple pelvic abscess which may occur from appendicitis, diverticulitis, salpingitis, and parametritis. It may occur from below by extension of ischiorectal abscess. This is due to overenthusiastic attempts to drain ischiorectal abscess and may push a probe or a curette through the attachment of the pelvic floor.

TREATMENT

Drainage of the pelvi-rectal abscess either through fornix of the vagina or though the anterior wall of the rectum. When ischio-rectal abscess has formed following this condition, the ischio-rectal abscess is drained and the opening in the levator ani is widened for better drainage.

FISTULA- IN –ANO

An inflammatory tract which has an external opening in perianal skin and an internal opening in anal canal or rectum caused by fibrous tissue.

CAUSE

1. Perianal abscess in inter sphincteric space of the anal canal from infection of anal gland due to tone of internal sphincter; the duet can’t aptly discharge the content of the gland. Stasis and secondary infection leads to abscess formation from anal gland in inter sphinteric region. The internal opening traverse through the internal sphincter to open into the anal canal and abscess usually tracks down and open in perianal skin externally thus fistula in ano is formed.

OTHER CAUSE

Ulcerative colitis,

Crohn’s disease

Tuberculosis

Coloid carcinoma of rectum

DIVISION.

 2 TYPES

1. Lower fistula

2. High fistula

LOWER FISTULA(below ano-rectal ring)	HIGH LEVEL FISTULA (above the ring or anal canal opening)
1.Subcutaneous	1.Supralevator type
2.Submucous	2.Transpincteric
3.Interspinteric	3.Pelvic-rectal
4.Transspinteric
5.Supraspincteric

(These may be single or multiple)

CLINICAL FEATURES

Past history of perianal abscess. It formed & ruptured by itself & a tiny discharging sinus is formed the process continued and at a stage the heal up process failed & discharge continued. It also causes a multiple fistula. Tuberculosis is one of main cause for multiple fistula. An external opening for each side of ischio-rectal fossa may be seen with inter communicating tract laying posterior to anus. (Horse shoe fistula)

RECTAL EXAMINATION

The external opening must be felt by digital examination. If it is above the ano-rectal ring it is a high fistula and treatment is different from lower fistula. The number of internal opening must be noted.

PROCTOSCOPY

It may help in visualizing the internal opening.

LIPOIDAL INJECTION

For radiography through lipoidal injection shows the tract of fistula in ano. Its utility is doubt as it gives more information and on contrary it cause recrudescence of inflammation.

·       If fistula in ano discharge watery and the surrounding is discolored it strongly suggests a tubercular origin.

If cause is doubtful then it may be due to –

1. Tuberocular proctitis

2. Ulcerative colitis

3. Crohn’s disease

4. Bilharziasis

5. Lymphogranuloma inguinal

6. Colloid carcinoma of rectum

TREATMENT

LOWER LEVEL FISTULA

The patient is in lithotomy position. By digital examination is done under anesthesia to reveal cord, like induration representing the tract. A probe is inserted through the tract. Carefully and not to create a false passage. Pro pointed directed is now introduced through external opening and its tip comes out through internal opening with a knife the track is now open on dissector. If there are multiple fistulas the pro pointed dissector is passed through individual external opening and correspondent tract is lead open with knife. After opening

i.                   Unhealthy granulation tissue on wall of fistula is scraped off with Volkmann spoon.

ii.                Whole track with the fibrous tissue is excised.

The cavity is packed with gauze with antiseptic lotion.

HIGH LEVEL FISTULA

i.                   Supra levator fistula is mostly secondary to Crohn’s disease or Ulcerative colitis or carcinoma or foreign body. It requires treatment in primary stage.

ii.                Transpinteric fistula with a perforating secondary tract.

             In a lower fistula, if care is not taken, while inserting a probe- pointed director, the director will go into the high secondary tract and if passed hard will open into rectum above the ano-rectal ring transforming the condition into high fistula. In this types of fistula lower tract is open as usual and upper tack opening is made wide with scrapping, the high fistula with Volkmann spoon. Upper track will heal by itself along with lower.

Lower tract is treated by fistulotomy. Then a Seton of heavy black silk or a rubber band is passed around the deeper part of the track. This will include intact fibers of the sphincter and the anal canal mucous membrane. The silk is tied loosely outside and kept in situ for two weeks. This stimulates fibrosis adjacent to the sphincter muscle. In the second stage, after 6 weeks, the remaining parts of the track including the fibres of the sphincter muscles incorporated within the tie is excised. Fibrosis, from the previous operation, prevents retraction of the freshly cut sphincter fibres. So incontinence which is the most serious complication of this operation is avoided. This operation is known as Gabriel’s two stage operation

                                  Instead of passing the silk, a stainless steel wire may be passed round the deeper part of the track. After 2 weeks, the knot is gradually tightened during subsequent dressing. The wire cuts through the sphincter muscle but the sphincter will not gape as fibrosis has already developed. Healing occurs in parts as the new portion is cut and the old portion heals.