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DEFINITION
Abscesses and anal fistulas should be regarded as the same condition in different evolutionary stage, in fact the anal fistula was created as perianal abscess is therefore to be considered as the acute phase of an infection of one or more glands of the anal canal. An anal abscess results from an acute to a small gland just inside the anus for entry of bacteria or foreign material to the gland. In 10% of cases, however, the anal suppuration may have cause specific M.di Crohn’s, UC, immune deficiency (AIDS), infections (tuberculosis, Chlamydia), trauma, diverticulitis.
Often chronic anal fistulas are an expression of an ‘anal abscess. Each crypt has 2-3 outlets glandular, the glands penetrate the muscle layer until you pass the anal sphincters.
An anal fistula is formed by an external orifice on the perianal skin, a fistula main, sometimes of fistulae secondary and an orifice fistulous internal to the anal canal.
It is essential to discover the internal orifice, the infection tends to propagate through the muscles thanks to the channels glandular to then open into the skin by means of an external orifice. The infection is spread between the external sphincter and the internal sphincter (infection intersfinterica primitive).This infection subsequently propagates towards diffusion pathways different, is in this way that explains the tramiti multiple infections towards the anal margin, through the external sphincter and into the thickness of the rectal wall.
SYMPTOMS
The main symptoms of anal fistulas include: pain, discharge of pus or blood swelling. If the area becomes hot anal abscess, swollen and very painful to touch.[/vc_column_text][ultimate_carousel slider_type=”horizontal” slide_to_scroll=”all” slides_on_desk=”6″ slides_on_tabs=”3″ slides_on_mob=”2″ infinite_loop=”off” speed=”300″ autoplay=”off” autoplay_speed=”5000″ arrows=”show” arrow_style=”default” border_size=”2″ arrow_color=”#333333″ arrow_size=”24″ next_icon=”ultsl-arrow-right4″ prev_icon=”ultsl-arrow-left4″ dots=”off” dots_color=”#333333″ dots_icon=”ultsl-record” draggable=”on” touch_move=”on” item_space=”15″][vc_single_image image=”62″ alignment=”center” border_color=”grey” img_link_large=”” img_link_target=”_self”][vc_single_image image=”63″ alignment=”center” border_color=”grey” img_link_large=”” img_link_target=”_self”][vc_single_image image=”66″ alignment=”center” border_color=”grey” img_link_large=”” img_link_target=”_self”][vc_single_image image=”83″ alignment=”center” border_color=”grey” img_link_large=”” img_link_target=”_self”][vc_single_image image=”103″ alignment=”center” border_color=”grey” img_link_large=”” img_link_target=”_self”][vc_single_image image=”112″ alignment=”center” border_color=”grey” img_link_large=”” img_link_target=”_self”][vc_single_image image=”115″ alignment=”center” border_color=”grey” img_link_large=”” img_link_target=”_self”][/ultimate_carousel][vc_column_text]
FISTULA CLASSIFICATION BY PARKS (1976)
This classification is based on the seat and on the course of the fistula:
1) Intersfinteriche fistulas (45-50%) in the course intersphincteric space
2) Fistulae Transfinteriche (28-32%) through the sphincters and pass into the ischiorectal space or outer skin
3) Soprasfinteriche fistulas (17-22%) pass through the levator muscle and reach the ischio-rectal fossa exiting the skin, these fistulas do not cross the sphincters
4) Extrasfinteriche fistulas (2-7%) through the levator ani and arrive in the pelvic space.
DIAGNOSIS
The diagnosis is first of all clinical, through the proctological examination you can view the orifices and external secretions of pus and serum, through the anoscopy with the aid of hydrogen peroxide can highlight any internal orifices, when visible. To complete diagnostic is very important to the execution of the ‘Ultrasound transanal for displaying abscess cavities, fistulae of primary and secondary and their location with respect to the muscular structures of the anal canal. Pelvic MRI is another important consideration for the display of anorectal and pelvic abscess and pelvic muscle structures.
TREATMENT
The only treatment is surgery, and often must be programmed in more times, in the case of anal abscess you must run the drainage of purulent material present within the abscess through surgical incision and the simultaneous search of any fistulae.
A colon and rectal surgeon experienced no where to be too aggressive in the treatment of anal suppuration, or risk dissect a disproportionate share of the anal sphincter causing incontinence faeces, or too cautious to avoid the risk of an incomplete removal of the base of the fistula, favoring recurrence. It should be recognized that surgical treatment of perianal fistulas must be performed by a specialist accredited, as it is not free from complications therefore should always be performed by those who are able to respect the anatomy and function of the anal sphincters.
Anal fistulas are treated by removing the infected tissue fistula and when it crosses the anal muscles (anal sphincters) placing a rubber band (seton) that will be held in place for a few months to maintain the same muscles and allow the formation of scar tissue and fibrotic without creating sphincter injury which may result in fecal constipation later (fistulectomy PARTIAL cerclage with seton).
Surgical treatment of fistulas is always depending on the severity and complexity of the fistula is therefore not possible to standardize a single technique while it is convenient to associate the treatment principles of technique. During the outpatient controls the seton will be progressively shortened. Once healed the wound and perianal reduced the amount of muscle taken from the seton, rub off on it, leaving the wound to heal spontaneously (fistulectomy). In the case of complex fistulas with more tramiti you should put more setoni. For fistulas involving so important to the sphincter muscle apparatus may require a repair of arms with a mucosal flap, a technique that allows the cleaning of the fistula and closing the orifice from the inside of the anal canal with a flap of mucous rectum .
After these types of intervention always remains an open wound that causes pain and discharge blood serum. You will need to a brief period of rest, running hot and lukewarm baths using gauze or panty liner for the first 15 days. After approximately one week after surgery will be executed also with self-dilatations Dilatan for about 5 minutes 3 times per day to allow the seton to cut faster the fabric or simply to facilitate the healing of the wound without hesitation in anal stenosis, until the complete healing of the wounds. Important is also the maintenance of a regular bowel function with soft stool by intake of an adequate amount of water and fibers. One technique of repairing fistulas introduced recently is the use of the plug that can ‘be a valid technique as an alternative to fistulotomy (plug gore® bio-a®).[/vc_column_text][vc_row_inner][vc_column_inner el_class=”” width=”1/3″][ultimate_modal icon_type=”none” modal_title=”Intervention pictures” modal_contain=”ult-html” modal_on=”button” onload_delay=”2″ btn_size=”lg” btn_bg_color=”#325b7b” btn_txt_color=”#ffffff” modal_on_align=”center” btn_text=”Intervention pictures” txt_color=”#f60f60″ modal_size=”medium” modal_style=”overlay-cornerbottomleft” overlay_bg_color=”#333333″ header_text_color=”#333333″ modal_border_width=”2″ modal_border_color=”#333333″ modal_border_radius=”0″]
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Informed consent for anal fistulas
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