University:
Michigan State University
Course:
MED 615 | Gastroenterology Clerkship
Academic year:

2020
Views:

486

Pages:

53
Author:

scallywallyjiq

PERIANAL SUPPURATION ANAL ABSCESSFISTULA Anatomy anal glands anal glands ◻ ◻ ◻ ◻ The average number of glands in a normal anal canal is six (range, 3–10) Each gland is lined by stratified columnar epithelium with mucus-secreting or goblet cells interspersed within the glandular epithelial lining and has a direct opening into an anal crypt at the dentate line. Occasionally, two glands open into the same crypt Half the crypts have no communication with the glands anal glands Perianal spaces Perianal spaces Horseshoe-shaped connections of the anorectal spaces. Etiology ❑ ❑ Cryptogenic or cryptoglandular Specific ones include the following: o o o o o o o Crohn’s disease, chronic ulcerative colitis Actinomycosis, lymphogranuloma venereum tuberculosis (TB) foreign body carcinoma, lymphoma, leukemia trauma (impalement, enemas, prostatic surgery, episiotomy, hemorrhoidectomy) Radiation Chronic anal fissure Cryptoglandular disease ◻ ◻ ◻ The anal glands were found to arise in the middle of the anal canal at the level of the crypts and to pass into the submucosa. two-thirds continuing into the internal sphincter one-half penetrating into the intersphincteric plane Cryptoglandular disease Obstruction of these ducts, whether secondary to fecal material foreign bodies, or trauma, results in stasis and infection chronicity is due to persistence of the anal gland epithelium in the part of the tract joining the internal opening or to nonspecific epithelialization of the fistula tract from either the internal or external openings than to a chronically infected anal gland Destruction of the anal gland epithelium might explain the occasional spontaneous healing of a fistula Acute phase (abscess) symptoms ◻ ◻ ◻ ◻ ◻ ◻ acute pain and in the anal region. Pain occurs with sitting or movement and is usually aggravated by defecation and even coughing or sneezing. Swelling purulent anal discharge preceding bout of diarrhea bleeding General symptoms include malaise and pyrexia Bacteriology ◻ ◻ ◻ Escherichia coli (22%) Enterococcus spp. (16%) Bacterioides fragilis (20%) Acute phase (abscess) Findings ◻ ◻ ◻ ◻ Tender induration Pus may be seen exuding from a crypt Examination under anesthesia is not only justified but also indicated Supralevator abscess, a tender mass in the pelvis may be diagnosed by rectal or vaginal examination. Abdominal examination may reveal signs of peritoneal irritation Acute phase (abscess) location Avenues of extension for an anal fistula Diagnosis and treatment ◻ ◻ ◻ ◻ ◻ Physical examination Examination under GA MRI Treatment by drainage Antibiotics if immuno-suppressed , SIRS, deep and local spread, Drainage of a supralevator abscess incision and drainage of a horseshoe abscess. chronic phase (fistula) history ❑ the patient’s history will reveal an abscess that either ▪ ▪ ❑ burst spontaneously or required drainage small discharging sinus chronic phase (fistula) ◻ ◻ External opening usually can be seen as a red elevation of granulation tissue with purulent serosanguinous discharge on compression. Opening is sometimes so small that it can be detected only when palpation around the anus expresses a few beads of pus chronic phase(fistula) ◻ ◻ ◻ ◻ An external opening adjacent to the anal margin may suggest an intersphincteric tract A more laterally located opening would suggest a transsphincteric one The further the distance of the external opening from the anal margin, the greater is the probability of a complicated upward extension increasing complexity and increasing laterality and multiplicity of external openings also has been observed chronic phase(fistula) ◻ ◻ ◻ palpate the skin since with a superficial fistula a cord structure can be felt just beneath the skin leading from the secondary opening to the anal canal internal opening might be palpable crypt of origin is often retracted into a funnel by pulling the fibrous tract leading to the internal sphincter; this state is called the funnel, or ‘‘herniation sign’’ of the involved crypt Goodsall’s rule Probing of the fistulous tract INVESTIGATION ◻ ◻ ◻ ◻ ◻ Anoscopy and sigmoidoscopy Fistulography Endoanal Ultrasonography Magnetic Resonance Imaging Endoanal Magnetic Resonance Imaging Fistulography Endoanal Ultrasonography MRI FISTULA-IN-ANO INCIDENCE ◻ ◻ Men predominate in most series with a male-to-female ratio varying from 2:1 to 7:1 Age distribution is spread throughout adult life with a maximal incidence between the third and fifth decades FISTULA-IN-ANO DEFINTIONS ◻ ◻ ◻ COMPLEX; more than one tract (branching) HIGH; the main tract or a branch passes to the level of anorectal ring HORSE-SHOE; the tract passes on both sides of the midline INCIDENCE ◻ ◻ ◻ ◻ Inter-sphincteric, 70% Trans-sphincteric, 23%; Supra-sphincteric, 5% Extra-sphincteric, 2%. FISTULA-IN-ANO types FISTULA-IN-ANO principles of management 1. 2. 3. 4. 5. the primary opening of a tract must be identified the relationship of the tract to the pubrorectalis muscle must be established; division of the least amount of muscle in keeping with cure of the fistula should be practiced; side tracts should be sought the presence or absence of underlying disease should be determined Intersphincteric fistula: simple low tract Intersphincteric fistula: high blind tract Inter- sphincteric fistula: high tract with a rectal opening Inter- sphincteric fistula: secondary to pelvic disease Trans- sphincteric fistula: uncomplicated type Trans- sphincteric fistula: high blind tract Supra- sphincteric fistula: uncomplicated type Suprasphincteric fistula: high blind tract Extrasphincteric fistula: secondary to anal fistula Fistulotomy Fistulotomy vs. fistulectomy Seton insertion Advancement rectal flap Dermal Island Flap Anoplasty Other procedures ◻ ◻ ◻ ◻ ◻ ◻ ◻ Fistulectomy and Primary Closure Video assisted anal fistula treatment Cutting Seton Fibrin Glue Anal Plug Lift Technique Ablation, LASER Fibrin Glue Video assisted anal fistula treatment Anal Plug Intersphincteric fistula tract removal Necrotizing infection

Perianal Suppuration Anal Abscess-Fistula

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