Fistula

Definition
Fistula is an abnormal connection between
the exterior and a hollow viscus or between
two hollow viscera.
Fistula in ano is track, lined by granulation
tissue, that conects deeply in the anal canal
or rectum and superficially on the skin
around the anus.

Aetiology
Inflammatory causes : ulcerative colitis,
Crohns disease etc, tuberculosis
Neoplastic causes : cancer rectum or anal
canal
Incidence
Common and may be simple or complex
Classified into high or low depending on
whether the track passes above or below the
anorectal ring

Pathophysiology
Inflammation ulceration penetration of
the ulcer through all layers of the wall of the
viscus involvement of the adjacent hollow
viscus in the ulceration connection
established. Or the ulceration may involve
the abdominal wall leading to openint of
the hollow viscus to the outside.

Fistula in ano
Pathophysiology
Fistula in ano usually starts as a perianal abscess
The abscess bursts open and discharges pus
A track between the perianal skin and the anal
canal is established
The infection and suppuration commonly starts in
an anal gland (glands found at the dentate line of
the anal canal) and spreads to the perianal region.

Clinical Features

Signs and symptoms (in order of prevalence)

Perianal discharge
Pain
Swelling
Bleeding
Diarrhea
Skin excoriation
External opening

Clinical features
purulent discharge and drainage of pus
and/or stool near the anus,
Irritation of the outer tissues
Itching and discomfort.
Pain occurs when fistulas become blocked
and abscesses recur.
Flatus (gas) may also escape from the
fistulous tract.

Investigations
Digital examination
Proctoscopy
Probing under anaesthesia
radiography X- ray Chest
Routine investigations like Hb, TC, DC, ESR

Differential diagnosis
Ulcerative colitis
Crohns disease of the anal canal and rectum
Anal tuberculosis (look for PT)
Actinomycosis
Cancer rectum

Complications
Branching of the fistulous track
Water can perineum

Treatment
Ordinary fistulae need laying the track open and
formation of a groove which will heal from the
bottom of the groove

Occasionally a high fistula may need a two stage

operation I stage of laying open as far as
possible then inserting a Setons suture II stage
laying the rest of the tract open

Evolution of a fistula

Low fistula in ano

A fistula-in-ano is diagnosed when a probe

has been passed between the opening on the
skin's surface and the interior opening

Perirectal abscess

Perirectal Abscess

Fistula in ano external opening

Other considerations

Past medical history

Important points in the history that may suggest a
complex fistula include the following:
Inflammatory bowel disease
Diverticulitis
Previous radiation therapy for prostate or rectal
cancer
Tuberculosis
Steroid therapy
HIV infection

Parks classification system

The Parks classification system defines 4 types of
fistula-in-ano that result from cryptoglandular
infections.
Intersphincteric
Common course - Via internal sphincter to the
intersphincteric space and then to the perineum
Seventy percent of all anal fistulae
Other possible tracts - No perineal opening; high blind
tract; high tract to lower rectum or pelvis

 Transsphincteric
Common course - Low via internal and external
sphincters into the ischiorectal fossa and then to the
perineum
Twenty-five percent of all anal fistulae
Other possible tracts - High tract with perineal opening;
high blind tract

 Suprasphincteric
Common course - Via intersphincteric space superiorly to
above puborectalis muscle into ischiorectal fossa and
then to perineum
Five percent of all anal fistulae
Other possible tracts - High blind tract (ie, palpable
through rectal wall above dentate line)

 Extrasphincteric
Common course - From perianal skin through levator ani
muscles to the rectal wall completely outside sphincter
mechanism
One percent of all anal fistulae

Ischiorectal
fossa

Anorectal musculature frontal section

1.intersphincteric 2.transsphincteric 3.supralevator