Anal fistula: Difference between revisions
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==Background== | ==Background== | ||
*Inflammatory tract originating from infected anal gland connecting anal canal | [[File:Rectum anatomy en.png|thumb|Anatomy of the anus and rectum.]] | ||
[[File:Fistula diag 01.png|thumb|Different types of anal fistulas.]] | |||
*Inflammatory tract originating from infected anal gland connecting anal canal with skin | |||
**May be intersphincteric, suprasphincteric, transsphincteric, or extrasphincteric | **May be intersphincteric, suprasphincteric, transsphincteric, or extrasphincteric | ||
*Goodsall's Rule | *Goodsall's Rule | ||
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***If external opening is anterior to this line fistula runs directly into the canal | ***If external opening is anterior to this line fistula runs directly into the canal | ||
***If external opening is posterior to this line fistula curves to post midline of canal | ***If external opening is posterior to this line fistula curves to post midline of canal | ||
* | ===Causes=== | ||
*[[perianal Abscess|Perianal]]/ischiorectal abscess | |||
*[[Crohn's]] | |||
*[[Ulcerative colitis]] | |||
*Malignancy | |||
*[[STI]] | |||
*[[Anal fissure]] | |||
*[[Rectal foreign body|foreign bodies]] | |||
*[[TB]] | |||
==Clinical Features== | ==Clinical Features== | ||
*Fistulous tract open: Persistent, painless, blood-stained, mucous, malodorous discharge | *Fistulous tract open: Persistent, painless, blood-stained, mucous, malodorous discharge | ||
*Fistulous tract blocked: Bouts of inflammation that are relieved by spontaneous rupture | *Fistulous tract blocked: Bouts of inflammation that are relieved by spontaneous rupture | ||
*Abscess | *[[perianal Abscess|Abscess]] | ||
**Throbbing pain that is constant and worse | **Throbbing pain that is constant and worse with sitting, moving, defecation | ||
**May be only sign of fistula | **May be only sign of fistula | ||
*Fistulous opening | *Fistulous opening | ||
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{{Anorectal DDX}} | {{Anorectal DDX}} | ||
== | ==Evaluation== | ||
*Endocavitary | *Endocavitary [[ultrasound]] with 3% hydrogen peroxide for definitive diagnosis | ||
==Management== | ==Management== | ||
#Ill-appearing | #Ill-appearing | ||
##Analgesia | ##[[Analgesia]] | ||
##IVF | ##[[IVF]] | ||
## | ##[[Antibiotics]] | ||
##Urgent surgical consultation | ##Urgent surgical consultation | ||
#Well-appearing | #Well-appearing | ||
## | ##Antibiotics | ||
###Ciprofloxacin 750mg PO BID AND metronidazole 500mg QID x7d | ###[[Ciprofloxacin]] 750mg PO BID AND [[metronidazole]] 500mg QID x7d | ||
## | ##Outpatient surgery referral | ||
###Improperly excised fistulas may result in permanent fecal incontinence | ###Improperly excised fistulas may result in permanent fecal incontinence | ||
##Spasm treatment | ##Spasm treatment | ||
###Nitroglycerin, Lidocaine | ###[[Nitroglycerin]], [[Lidocaine]] | ||
###Sitz baths | ###Sitz baths | ||
==See Also== | ==See Also== | ||
[[Anorectal Disorders]] | *[[Anorectal Disorders]] | ||
==References== | |||
<references/> | |||
[[Category:GI]] | [[Category:GI]] | ||
[[Category:Surgery]] | |||
Latest revision as of 21:50, 7 July 2021
Background
- Inflammatory tract originating from infected anal gland connecting anal canal with skin
- May be intersphincteric, suprasphincteric, transsphincteric, or extrasphincteric
- Goodsall's Rule
- Draw imaginary line horizontally through the anal canal
- If external opening is anterior to this line fistula runs directly into the canal
- If external opening is posterior to this line fistula curves to post midline of canal
- Draw imaginary line horizontally through the anal canal
Causes
- Perianal/ischiorectal abscess
- Crohn's
- Ulcerative colitis
- Malignancy
- STI
- Anal fissure
- foreign bodies
- TB
Clinical Features
- Fistulous tract open: Persistent, painless, blood-stained, mucous, malodorous discharge
- Fistulous tract blocked: Bouts of inflammation that are relieved by spontaneous rupture
- Abscess
- Throbbing pain that is constant and worse with sitting, moving, defecation
- May be only sign of fistula
- Fistulous opening
- Adjacent to anal margin suggests superficial connection (e.g. intersphincteric region)
- Distant from anal margin suggests deeper, more superior abscess
Differential Diagnosis
Anorectal Disorders
- Anal fissure
- Anal fistula
- Anal malignancy
- Anal tags
- Anorectal abscess
- Coccydynia
- Colorectal malignancy
- Condyloma acuminata
- Constipation
- Crohn's disease
- Cryptitis
- GC/Chlamydia
- Fecal impaction
- Hemorrhoids
- Levator ani syndrome
- Pedunculated polyp
- Pilonidal cyst
- Proctalgia fugax
- Proctitis
- Pruritus ani
- Enterobius (pinworms)
- Rectal foreign body
- Rectal prolapse
- Syphilitic fissure
Non-GI Look-a-Likes
Evaluation
- Endocavitary ultrasound with 3% hydrogen peroxide for definitive diagnosis
Management
- Ill-appearing
- Analgesia
- IVF
- Antibiotics
- Urgent surgical consultation
- Well-appearing
- Antibiotics
- Ciprofloxacin 750mg PO BID AND metronidazole 500mg QID x7d
- Outpatient surgery referral
- Improperly excised fistulas may result in permanent fecal incontinence
- Spasm treatment
- Nitroglycerin, Lidocaine
- Sitz baths
- Antibiotics