AnoRectal fissure,Abscess &fistula

AnoRectal fissure,Abscess &fistula

• 1.
  Dr. BezanBaloch Assistant Professor ANALFISSURE,PERIANAL ABSCESS &FISTULA IN ANO
• 2.
  An anal fissureis a linear ulcer that occurs in the anal canal just distal to the dentate line. It affects both men and women and the highest incidence is in the third and fourth decades of life.
• 3.
  Anal fissure ●● Acuteor chronic ●● Ischaemic ulcer in the midline of the anal canal at 6 or 12 o clock positions. Symptoms: ●● Pain on defaecation ●● Bright-red bleeding ●● Mucus discharge ●● Constipation
• 4.
  Aetiology and pathology >Thminoranal trauma caused by passage of a constipated stool > The main underlying pathology, however, appears to be a high resting anal pressure caused by increased internalsphincter tone. The blood supply to the anal canal has to passthrough the internal sphincter and therefore spasm of thismuscle reduces the blood flow and the oxygen tension in the skin of the anal canal. Interestingly, the fissures tend to occur at the watershed of the blood supply, i.e. the anterior and posterior midline in women and the posterior midline in men.
• 5.
  Clinical features The typicalclinical features are of pain on defecation associated with bright red bleeding. This may be associated with pruritus ani and discharge of mucus. On examination there is usually a skin tag overlying the fissure and the fissure itself can be seen by everting the anal canal using lateral traction This will reveal a sharply defined ulcer and it may be possible to see the lower fibres of the internal sphincter at its base. Digital rectal examination or proctoscopy should not be attempted in the conscious patient as this will cause considerable discomfort.
• 8.
  Treatment conservative management shouldresult in the healing of almost all acute and the majority of chronic fissures. normalisation of bowel habits such that the passage of stool is less traumatic. The addition of fibre to the diet to bulk up the stool, stool softeners and adequate water intake are simple and helpful measures. Warm baths and topical
• 9.
  local anaesthetic agentsrelieve pain. The mainstay of current conservative management is the topical application of pharmacological agents that relax the internal sphincter, patients with more severe symptoms, however, the use of 0.2% GTN) cream applied two or three times a day can produce healing of fissures in about 50% of cases. The healing takes about 6–12 weeks.
• 10.
  Historically, forced anal dilatation(Lord procedure) was performed and, although effective, this was associated with an unacceptable level of incontinence. The surgical treatment of choice is now a lateral sphincterotomy, which involves dividing the internal sphincter at one point on the lateral wall of the anal canal up to the level of the dentate line.
• 12.
  Lateral sphincterotomy successful inabout 95% of cases, but patients should be warned that it can be associated with minor degrees of incontinence to flatus or mucus. complications of sphincterotomy include haemorrhage, haematoma, bruising, perianal abscess and fistula.
• 13.
  Dr.bezan baloch assistant professor su11 PERIANALSEPSIS & FISTULA IN ANO
• 14.
  Anal canal anatomy Theanorectal ring The anorectal ring marks the junction between the rectum and the anal canal . It is formed by the joining of the puborectalis muscle. The puborectalis muscle Puborectalis, part of the funnel-shaped muscular pelvic diaphragm, maintains the angle between the anal canal and rectum and hence is an important component in the continence Mechanism
• 16.
  The external sphincter Theexternal sphincter forms the bulk of the anal sphincter complex and, although traditionally it has been subdivided into deep, superficial and subcutaneous portions, it is a single muscle which is variably divided by lateral extensions from the longitudinal muscle layer.
• 17.
  The internal sphincter Theinternal sphincter is the thickened (2–5 mm) distal continuation of the circular muscle coat of the rectum, which hasdeveloped special properties and which is in a tonic state of contraction. on the sphincter muscles
• 18.
  The intersphincteric plane Betweenthe external sphincter muscle laterally and the longitudinal muscle medially exists a potential space, the intersphincteric plane. This plane is important as it contains intersphincteric anal glands (see below) and is also a route for the spread of pus, which occurs along the extensions from the longitudinal muscle layer. The plane can be opened up surgically to provide access for operations
• 19.
  Examination of analcanal ●● A rectal examination is essential for any patient with anorectal and/or bowel symptoms – ‘If you don’t put your finger in, you might put your foot in it’ ●● A proctosigmoidoscopy is essential in any patient with bowel symptoms, and particularly if there is rectal bleeding
• 20.
  perianal sepsis andfistulaformation are related to the the anal glands. These glands are situated in the intersphincteric space and open into the anal canal at the dentate line via a duct that transverses the internal sphincter. The function of these glands is not clear but as they secrete mucin they may have a lubricant function. It is thought theseglands may become infected if the duct becomes blocked and, when this occurs, pus accumulates within the gland.The pus may then track superiorly, inferiorly, laterally orcircumferentially
• 21.
  Anorectal abscess ●● Usuallyproduces a painful, throbbing swelling in the anal region. The patient often has swinging pyrexia ●● Subdivided according to anatomical site into perianal, ischiorectal, submucous and pelvirectal ●● Underlying conditions include fistula-in-ano (most common), Crohn’s disease, diabetes, immunosuppression
• 22.
  Most commonly, thepus will pass downwards in the intersphincteric plane to form a perianal abscess. It may also find its way through the external sphincter into the ischiorectal fossa and thus form an ischiorectal abscess.
• 24.
  PERIANAL ABSCESS TYPES MUCOCUTENOUSOR MARGINAL PERIANAL OR SUPERFACIAL ISCHIORECTAL INTERSPHINCTERIC PELVIRECTAL SUPRALEVATOR SUBMUCOUS
• 26.
  Axial magnetic resonanceimaging scan showing posterior horseshoe spread of sepsis within the intersphincteric space.
• 27.
  When a perianal orischiorectal abscess discharges through the skin, either spontaneously or as a result of surgical intervention. it may resolve completely. However, if the duct between the gland and the dentate line remains patent and becomes infected, the patient may then be left with a fistulous communication between the dentate line and the skin.
• 28.
  Incision &Drainage (I& D) of an abscess. The cavity is explored and, if septa exist, they should be broken down gently with a finger and the necrotic tissue lining the walls of the abscess removed by the finger wrapped in gauze. It is wise to biopsy the wall and send the pus for culture. Nothing further is done at this stage.
• 30.
  Fistula in ano DR.BEZANBALOCH ASSISTANT PROFESSOR SU11
• 31.
  defination A fistula-in-ano isan abnormal hollow tract or cavity that is lined with granulation tissue and that connects a primary opening inside the anal canal to a secondary opening in the perianal skin; secondary tracts may be multiple and can extend from the same primary opening.
• 32.
  Presentation For reasons thatare unknown, non-specific anal fistulae aremore common in men than women. The overall incidence is about 9 cases per 100 000 population per year in western Europe, and those in their third, fourth and fifth decades of life are most commonly affected
• 34.
  CLINICAL FEATURES Patients usuallycomplain of intermittent purulent discharge (which may be bloody) and pain (which increases until temporary relief occurs when the pus discharges). There is often, but not invariably, a previous episode of acute anorectal sepsis that settled (incompletely) spontaneously or with antibiotics, or which wassurgically drained.
• 36.
  Clinical assessment The keypoints to determine are the site of the internal opening; the site of the externalopening(s); the course of the primary track; the presence of secondary extensions; and the presence of other conditions complicating the fistula. Palpable induration between external opening and anal margin suggests a relatively superficial track, whereas supralevator induration suggests a primary track above the levators or high in the roof of the ischiorectal Fossa.
• 37.
  PARK CLASSIFICATION (SITE) INTERSPHINTERIC TRANS SPHINCTERIC SUPRALEVATOR EXTRSPHINCTERIC
• 38.
  SIMPLE CLASSIFICATION LOW ANALFISTULA HIGH ANAL FISTUAL
• 40.
  Fistulography This technique involvesinjection of contrast via the internal opening, which is followed by anteroposterior, lateral, and oblique radiographic images to outline the course of the fistula tract. Fistulography is relatively well tolerated but it can be painful when injecting the contrast material into the fistulous tract. It requires the ability to visualize the internal opening. Questions have been raised about its accuracy, which has been reported to range from 16% to 48%. Because of these limitations, fistulography is generally reserved for cases in which there is a concern about a fistulous connection between the rectum and adjacent organs such as the bladder, where it may be slightly more useful than a careful examination under anesthesia
• 41.
  Magnetic resonance imaging Findingson magnetic resonance imaging (MRI) show 80-90% concordance with operative findings when a primary tract course and secondary extensions are observed. MRI is becoming the study of choice for the evaluation of complex fistulas and recurrent fistulas. It has been shown to reduce recurrence rates by providing information on otherwise unknown extensions.
• 42.
  Special investigations MRI isacknowledged to be the ‘gold standard’ for fistula imaging but it is limited by availability and cost and is usually reserved for difficult recurrent cases. The great advantage of MRI is its ability to demonstrate secondary extensions, which may be missed at surgery and which are the cause of persistence . Fistulography and computed tomography (CT) both have limitations but are useful techniques
• 43.
  Coronal magnetic resonanceimaging scan demonstrating a primary track running up the right ischiorectal space which then crosses the sphincters to open into the anal canal just below the puborectalis. However, there is a blind secondary extension passing to the contralateral side in the roof of the left ischiorectal fossa (and involving the levators), which was missed at surgery and which was the cause of fistula persistence.
• 44.
  Goodsall’s rule related toanal fistulas suggests that fistulas with an external opening anterior to a line drawn horizontally through the anal canal progress forwards in a radial fashion, whereas fistulas with an external opening posterior to the horizontal line curve backwards and ultimately have an internal opening in the midline posteriorly. It is possible for fistulas to extend laterally on both sides, leading to the characteristic horseshoe fistulas
• 46.
  Intersphincteric fistula make upabout 50% of all fistulas and usually consist of a straightforward tract between the dentate line and the skin incorporating part of the internal sphincter.
• 47.
  Trans-sphincteric fistulas account forabout 30% and consist of a tract passing through the external sphincter. This may be low or high and occasionally may be associated with a blind high tract in the ischiorectal fossa which may even penetrate the levator ani muscles.
• 48.
  Suprasphincteric fistula run abovethe puborectalis muscle and then descend down through the levator ani muscles into the ischiorectal fossa.
• 49.
  Extrasphincteric fistulas bypass thesphincter complex completely and extend from the lower rectum through the levator ani muscles and into the ischiorectal fossa
• 50.
  MANAGMENT FISTULOTOMY FISTULECTOMY SETON MUCOSAL ADVANCMENT FLAP PLUGS&ADHESIVE(FIBRIN) LIFT PROCEDURE DIVERSION COLOSTOMY
• 51.
  The best treatmentfor fistula in ano is undoubtedly a fistulotomy, laying open of the entire tract, curetting out of the granulation tissue and leaving the wound to granulate. This is done most easily by cutting down onto the groove on the concave aspect of the fistula probe, and then using a small Volkmann’s spoon to curette.
• 52.
  fistulotomy generally safe witha simple intersphincteric fistula as the only muscle that will be divided will be the lower part of the internal sphincter. If, however, the fistula is transsphincteric then a fistulotomy creates a risk of incontinence. A fistulotomy of a suprasphincteric or extrasphincteric fistula will inevitably result in complete incontinence
• 53.
  Lockhart-Mummery fistula probe.
• 55.
  Under normal circumstancesit is relatively easy to pass the probe from the external opening along the tract to the internalopening at the dentate line . In doing this it is important not to use too much force, as it is possible to create a false tract in so doing. If it proves to be impossible to find the internal opening using this technique a valuable manoeuvre is to instil a very small amount of hydrogen peroxide into the external opening by means of a fine cannula. With an retractor in place within the anal canal it is then usually possible to see bubbles appearing at the site of the internal opening. This will guide further probing. In the process of probing a fistula it is important to look for extensions to the main tract. Indeed, if the probe cannot easily pass along the tract it is probably falling into a blind extension bypassing the main tract.
• 56.
  Fistulectomy This technique involvescoring out of the fistula, usually by diathermy cautery; it allows better definition of fistula anatomy than fistulotomy, especially the level at which the track crosses the sphincters and the presence of secondary extensions. If the sphincteric component of the fistula is deemed low enough to allow safe fistulotomy, then this may proceed
• 57.
  SETON suprasphincteric, then amore conservative approach must be taken. The most widely used approach is to ensure complete drainage of all the sepsis and to leave the seton in place for several weeks. When all the sepsis and inflammation has resolved the seton can then be removed and this will result in healing in about 50% of cases.
• 59.
  The seton graduallycuts its way through the fistula tract leaving fibrosis behind it. Although the sphincter is divided more slowly than in fistulotomy the effect on continence is not very much different with some degree of incontinence in about 60% of cases.
• 60.
  Trans-sphincteric fistula isfistulectomy and advancement flap repair. Here the fistula tract is excised or cored out by following it up from the external orifice and dissecting through the external sphincter muscle. A flap of mucosa and internal sphincter is then raised above the internal opening and sutured down over it
• 61.
  A high trans-sphinctericfistula or a suprasphincteric fistula incontinence is inevitable with fistulotomy, and one approach is to give the patient a temporary colostomy, lay open the fistula and then carry out a sphincter repair after healing has taken place. Alternatively the patient may opt to live with a longterm loose seton in place. This approach is the safest in a variety of situations, including multiple fistulas and Crohn’s disease.
• 62.
  A variety ofapproaches have been taken to try and induce healing of anal fistulas without resorting to fistulotomy or fistulectomy.
• 63.
  Injection of fibringlue was used quite extensively. Initial results seemed promising but long-term results have been poor with high recurrence rates. The liquid consistency of fibrin glue is possibly not ideal for the purpose of closing anorectal fistulas, because the glue is easily extruded from the fistula tract by increased intraluminal pressure.
• 64.
  Current interest surroundsthe LIFT (ligation of intersphincteric fistula tract) procedure. This involves dissection upwards in the intersphincteric space to the level of the fistula which is then ligated and divided. The external fistula is curetted.
• 66.
  Postoperative Care After theoperation, most patients can be treated in an ambulatory setting with discharge instructions and close follow-up care. Sitz baths, analgesics, and stool-bulking agents (eg, bran and ISPHAGUL) are used in follow-up care
• 67.
  Complications Early postoperative complications: Urinary retention Bleeding Fecal impaction Thrombosed hemorrhoids Delayed postoperative complications may include the following: Recurrence Incontinence (stool) Anal stenosis Delayed wound healing - Complete healing occurs by 12 weeks , recurrence, Crohn disease