Fistula

Definition Fistula is an abnormal connection between the exterior and a hollow viscus or between two hollow viscera. Fistula in ano is track, lined by granulation tissue, that conects deeply in the anal canal or rectum and superficially on the skin around the anus.

Aetiology Inflammatory causes : ulcerative colitis, Crohns disease etc, tuberculosis Neoplastic causes : cancer rectum or anal canal Incidence Common and may be simple or complex Classified into high or low depending on whether the track passes above or below the anorectal ring

Pathophysiology Inflammation ulceration penetration of the ulcer through all layers of the wall of the viscus involvement of the adjacent hollow viscus in the ulceration connection established. Or the ulceration may involve the abdominal wall leading to openint of the hollow viscus to the outside.

Fistula in ano
Pathophysiology
Fistula in ano usually starts as a perianal abscess The abscess bursts open and discharges pus A track between the perianal skin and the anal canal is established The infection and suppuration commonly starts in an anal gland (glands found at the dentate line of the anal canal) and spreads to the perianal region.

Clinical Features
Signs and symptoms (in order of prevalence) Perianal discharge Pain Swelling Bleeding Diarrhea Skin excoriation External opening

Clinical features
purulent discharge and drainage of pus and/or stool near the anus, Irritation of the outer tissues Itching and discomfort. Pain occurs when fistulas become blocked and abscesses recur. Flatus (gas) may also escape from the fistulous tract.

Investigations Digital examination Proctoscopy Probing under anaesthesia radiography X- ray Chest Routine investigations like Hb, TC, DC, ESR

Differential diagnosis Ulcerative colitis Crohns disease of the anal canal and rectum Anal tuberculosis (look for PT) Actinomycosis Cancer rectum

Complications Branching of the fistulous track Water can perineum

Treatment

Ordinary fistulae need laying the track open and formation of a groove which will heal from the bottom of the groove

Occasionally a high fistula may need a two stage operation I stage of laying open as far as possible then inserting a Setons suture II stage laying the rest of the tract open

Evolution of a fistula

Low fistula in ano

A fistula-in-ano is diagnosed when a probe has been passed between the opening on the skin's surface and the interior opening

Perirectal abscess

Perirectal Abscess

Fistula in ano external opening

Other considerations

Past medical history Important points in the history that may suggest a complex fistula include the following: Inflammatory bowel disease Diverticulitis Previous radiation therapy for prostate or rectal cancer Tuberculosis Steroid therapy HIV infection

Parks classification system The Parks classification system defines 4 types of fistula-in-ano that result from cryptoglandular infections. Intersphincteric
Common course - Via internal sphincter to the intersphincteric space and then to the perineum Seventy percent of all anal fistulae Other possible tracts - No perineal opening; high blind tract; high tract to lower rectum or pelvis

 Transsphincteric
Common course - Low via internal and external sphincters into the ischiorectal fossa and then to the perineum Twenty-five percent of all anal fistulae Other possible tracts - High tract with perineal opening; high blind tract

 Suprasphincteric
Common course - Via intersphincteric space superiorly to above puborectalis muscle into ischiorectal fossa and then to perineum Five percent of all anal fistulae Other possible tracts - High blind tract (ie, palpable through rectal wall above dentate line)

 Extrasphincteric
Common course - From perianal skin through levator ani muscles to the rectal wall completely outside sphincter mechanism One percent of all anal fistulae

Ischiorectal fossa

Anorectal musculature frontal section

1.intersphincteric 2.transsphincteric 3.supralevator