ANORECTAL ABSCESSES ANORECTAL ABSCESSES AND FISTULA-IN-ANOAND FISTULA-IN-ANO

INTRODUCTIONINTRODUCTION

Both abscess and fistula-in-ano can be Both abscess and fistula-in-ano can be considered simultaneously.considered simultaneously.

The abscess is an acute manifestation, and The abscess is an acute manifestation, and the fistula is a chronic condition.the fistula is a chronic condition.

ETIOLOGYETIOLOGY

Nonspecific :Nonspecific : Cryptoglandular in origin.Cryptoglandular in origin.

Specific :Specific : Crohn’s Crohn’s Ulcerative colitis Ulcerative colitis TB TB Actinomycosis Actinomycosis Carcinoma Carcinoma Trauma Trauma Radiation Radiation Foreign body Foreign body Lymphoma Lymphoma Pelvic inflammation Pelvic inflammation LeukemiaLeukemia

PATHOGENESISPATHOGENESIS

The The cryptoglandularcryptoglandular hypothesis states that hypothesis states that infection of the anal glands associated with infection of the anal glands associated with the anal crypts is the primary cause of anal the anal crypts is the primary cause of anal fistula and abscess. fistula and abscess.

CLASSIFICATIONCLASSIFICATION

TREATMENTTREATMENT

Incision and drainage.Incision and drainage.

Determine the most tender point, a 2 cm Determine the most tender point, a 2 cm area of skin is injected with local freezing.area of skin is injected with local freezing.

Eliptical or cruciate incision.Eliptical or cruciate incision.

Drainage of pus. Destroy all loculations.Drainage of pus. Destroy all loculations.

ANTIBIOTICSANTIBIOTICS

Immunosuppression.Immunosuppression.

Valvular disease.Valvular disease.

Diabetics.Diabetics.

Extensive diseaseExtensive disease

Systemic manifestation.Systemic manifestation.

CLASSIFICATIONCLASSIFICATION

Intersphincteric fistulaIntersphincteric fistula

Transsphincteric fistulaTranssphincteric fistula

Suprasphincteric fistulaSuprasphincteric fistula

Extrasphincteric fistulaExtrasphincteric fistula

Evaluation of Anal FistulaEvaluation of Anal Fistula An accurate preoperative assessment of the An accurate preoperative assessment of the anatomyanatomy of an anal fistula of an anal fistula

is very important.is very important.

Five essential points Five essential points of a clinical examination of an anal fistula :of a clinical examination of an anal fistula : (1) location of the (1) location of the internalinternal opening. opening. (2) location of the (2) location of the externalexternal opening. opening. (3) location of the (3) location of the primaryprimary track . track . (4) location of any (4) location of any secondarysecondary track. track. (5) determination of the presence or absence of underlying disease .(5) determination of the presence or absence of underlying disease .

Goodsall’s ruleGoodsall’s rule

TREATMENTTREATMENT

The objective is to cure with lowest possible The objective is to cure with lowest possible recurrence rate and minimal, if any, alteration inrecurrence rate and minimal, if any, alteration in continence, shortest period. continence, shortest period.

The principles are:The principles are:

1- Identification of the primary opening.1- Identification of the primary opening. 2- Relationship to puborectalis2- Relationship to puborectalis 3- Least amount of muscles should be divided.3- Least amount of muscles should be divided. 4- Side tracts should be sought,4- Side tracts should be sought, 5- Presence of underlying disease. 5- Presence of underlying disease.

Fistulotomy/fistulectomyFistulotomy/fistulectomy

The laying-open technique (fistulotomy) is The laying-open technique (fistulotomy) is useful for 85-95% of primary fistulae .useful for 85-95% of primary fistulae .

Curettage is performed to remove Curettage is performed to remove granulation tissue.granulation tissue.

Marsupialization of the edges to improve Marsupialization of the edges to improve healing times.healing times.

Setons in the Management of Setons in the Management of Difficult FistulasDifficult Fistulas