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fistula

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fistula

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    1. Fistula

    3. Aetiology Inflammatory causes : ulcerative colitis, Crohn’s 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

    4. 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.

    5. 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.

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

    7. 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.

    8. Investigations Digital examination Proctoscopy Probing under anaesthesia radiography X- ray Chest Routine investigations like Hb, TC, DC, ESR Differential diagnosis Ulcerative colitis Crohn’s disease of the anal canal and rectum Anal tuberculosis (look for PT) Actinomycosis Cancer rectum

    9. Complications Branching of the fistulous track Water can perineum

    10. 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 Seton’s suture – II stage laying the rest of the tract open

    11. Evolution of a fistula

    12. Low fistula in ano

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

    14. Perirectal abscess

    15. Fistula in ano external opening Fistula-In-Ano: External opening of fistulus tract is apparent in photo above. Proximal opening would be at level of crypts, within the anal canal. Fistulas are frequently associated with perirectal abscesses, though none are present in this case. Fistula-In-Ano: External opening of fistulus tract is apparent in photo above. Proximal opening wouldbe at level of crypts, within the anal canal. Fistulas are frequently associated with perirectal abscesses, though none are present in this case.

    16. 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

    17. 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

    18. 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

    19. 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)

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

    23. Ischiorectal fossa

    24. Anorectal musculature – frontal section

    25. 1.intersphincteric 2.transsphincteric 3.supralevator

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