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CHAPTER I CASE REPORT

1.1 PATIENT’S PROFILE 1. Name 2. Gender 3. Age 4. Address 5. Occupation 6. Marriage Status 7. Date Admitted : Mr. Darto : Male : 36 years old : Bangodua, Indramayu : Gangster : Married : June 10, 2013

1.2 ANAMNESIS ( AUTOANAMNESA on the 12nd June 2013) A. The main Complaint : ulcers on the area around anus that feels pain and when it

rupture contain pus and blood B. Additional Complaint look like a “cauliflower” C. Present Health History : Patients come to the Arjawinangun hospitals with complaints are ulcers on the area around anus since 2 year ago. Patients admitted theulcers rupture since 1 years ago, contains pus and arise again. According to patients, the ulcers usually breaks every 1 week, contains pus (+), blood (+). Currently the patient denied pain but felt pain when the patient has not ruptured ulcer. Patients say no distractions while eating and : small bumps on the genitals of patients that feels itch and

Bump no pain. Moreover. Lump measuring 0. not satisfied / bladder emptying during urination (-). no pus. urination normal jets. pain during urination (-) urinating blood mixed (-). the same color as the skin.3 PHYSICAL ASSESSMENT A.5 cm.5 x 0. E. hypertension and the patient have trauma history. often waking night to urinate denying patients. no blood. there are some bumps incorporated into one that resembles a cauliflower. objective General Status    general state : being sick Awareness GCS : compos mentis : E4V5M6 .drinking as well as nausea and vomiting. D. straining / difficult urination (-). soft. The patient denied having the disease of diabetes mellitus. Patients admitted no interference during defecation. urinate discontinuous (-). defecation 1x/day. History of fever (-). Family Health History : The patient admitted that in family never experienced anything like this 1. no difficult / hard during bowel movements and no straining during defecation. Patients say no disturbance during urination. uneven surfaces. Past Health History : Patient admitted to multiple sexual partners and the use of tattoos. no bleeding or mucus during defication. cough cough old (-). diarrhea(-).

Thyroid not palpable enlarged  Thorax LUNGS o Inspection : no presence of scars and lessions. Rh -/-.) : no masses and swelling noted . symmetric during inspiration and expiration o Palpation lung fields o Percussion : sonor in both of lung fields : Fremitus tactile and fremitus vocal symmetric in both of o Auscultation : vesicular + . Wh -/- COR o Inspection o Palpasion o Percussion : Ictus Cordis is not visible : Ictus Cordi is palpable : cardiac borders easily assessed .) SI ( -/.7o C o Blood pressure o Pulse rate o Respiration rate o Temperature    Head Eyes Neck : normochepal : CA ( -/. Vial sign : : 120 /70 mmHg : 80 bpm : 20 bpm : 36. enlargement of lymphonodes (-).

no tender : Timpani whole abdominal field o Auscultation : bowel sounds (+)  Upper & lower extremities Superior Inferior :warm akral.o Auscultation : regular cor sound. rounded : soft. G (-)  Abdomen o Inspection o Palpation o Percussion : Flat. edema (-/-). M (-). cyanosis (-/-) 1. edema (-/-). cyanosis (-/-) : warm akral.4 WORKING DIAGNOSTIC   Anal fistula Condyloma 1.5 DIAGNOSA BANDING    Sinus pilonidalis Fistula proktitis Hidranitis supurativa   Verucca vulgaris Carcinoma cel squamosal .

9 (31 .0 (2-10 %) o GRA% : 70.6.2 (50 .6 (1 .35.1 103 /μL) o GRA : 6.1 (0.100 µm3) o MCH : 30.6 (35 . LABORATORY EXAMINATIONS (on June 10.8 (11 .8 %) o LYM%: 18.1 . 2013)  Hematology report o WBC : 8.5 103 /μL) o MON : 1.17 g/dl) o HCT : 49.56 (4 .2 (26 . Moloscum contangiosum 1.6 PEMERIKSAAN PENUNJANG A.55%) o MCV : 89.5 (10 – 16 %) .80 %) o RBC : 5.2 (80 .2 (2 .50 %) o MON%: 11.9 (4 .2 103 /μL) o HGB : 16.0 (25 .5 g/dl) o RDW : 11.12 103 /μL) o LYM : 1.34 pg) o MCHC : 33.

pharmacology : excision : hypobach 2 x 1 Dolac 2 x 1 1.7 TREATMENT 1.500 %) o PDW : 14.o PLT : 179 (150 – 400 103 /μL) o MPV : 7.200 .8 (7 – 11 μm3) o PCT : 0.6 (10 – 18 %)  Random Blood Glucose : 113 mg/dl 1.140 (0.8 PROGNOSIS    Ad vitam Ad functionam Ad sanactionam : dubia at bonam : dubia at bonam : dubia at bonam .0. Surgery 2.

definition An anal fistula is a tiny. Anal Fistulas and Fissures ) Pathofisiology and etiology Most anal fistulas originate in anal crypts. tuberculosis.actinomycosis. Tgl akses 12 juni 2013. chlamydia. rectovaginal fistulas are found only in women. particularly Crohn disease. Fistulas are also found in patients with inflammatory bowel disease. FACEP.[7] and approximately 80% of anal fistulas arise from anorectal infection. Other causes of anal fistulas include opened perianal or ischiorectal abscesses. An anal fistula can have multiple accessory tracts complicating its anatomy. MPH. fibrous tract that extends into the anal canal from anopening beside the anus.( http://emedicine. Perianal activity often parallels abdominal disease activity.com/article/776150-overview#a0156: Bruce M Lo. Pus or stool may leak constantly from the cutaneousopening.[6] The incidence of fissures in Crohn disease is 30-50%. For reasons of intrinsic anatomy. or regional enteritis. with ensuing abscess formation. syphilis. which drain spontaneously through these fistulous tracts. which become infected. MD. lymphogranuloma venereum (LGV). . which are more common in women than in men. Fistulas usually result from an infection. fissures. Approximately 30-50% of patients with an anorectal abscess form an anal fistula. 2012. a fistula is formed. RDMS. MD. tubular. When the abscess is opened or when it ruptures. Untreated fistulas may cause systemic infection with related symptoms. but it may occasionally be the primary site of active disease. Anal fistulas can also be associated with diverticulitis. foreign-body reactions. Chief Editor: Robert E O'Connor. Epidemiology Anal fistulas are a complication of anorectal abscesses. They may develop fromtrauma.medscape.

ending in the perianal skin. Account for about 5% of all fistulae. Accounts for about only 1% of all fistulae . encompassing a portion of the internal and external sphincter.Through the anal crypt and encircling the entire sphincter. ending in the skin overlying buttocks. Classification Anal fistulas are classified into the following 4 general types:  Intersphincteric .  Extrasphincteric . tracking along the intersphincteric plane. encompassing the entire sphincter and ending in the skin overlying the buttocks.Through the dentate line to the anal verge.radiation exposure. Account for about 70% of all fistulae  Transsphincteric . and HIV disease.Starting high in the anal canal. ending in the ischiorectal fossa. Approximately 30% of patients with HIV disease develop anorectal abscesses and fistulas. Account for about 25% of all fistulae  Suprasphincteric .Through the external sphincter into the ischiorectal fossa.

either bloody or purulent Pruritus ani– itching around the anus Systemic symptoms if abscess becomes infected .Clinical manifestation SYMPTOMS OF FISTULA Anal fistulae can present with many different symptoms such as:     Pain Discharge .

(2) evidence of sepsis or a large abscess. Possible findings:      The opening of the fistula onto the skin may be seen The area may be painful on examination There may be redness A discharge may be seen It may be possible to explore the fistula using a fistula probe (a narrow instrument) and in this way it may be possible to find both openings of the fistula Treatment Treatment of anal fistulas depends on (1) the location of the fistula. intravenous fluids or a pressor may be necessary. or (3) worrisome findings on physical examination. The examination can be an Anoscopy. and analgesics are provided as needed. Surgical therapy is often indicated for healing of an anal fistula. as well as the risk of complications such as incontinence. A gastroenterologist should be consulted if inflammatory bowel disease is suspected. antipyretics. Asymptomatic anal fistulas from Crohn disease are not . However. simple rectal abscesses do not typically need antibiotics. The surgical approach is dependent on whether the fistula is simple or complex.Diagnosis Diagnosis is by examination. either in an outpatient setting or under anaesthesia. If an abscess is present. Depending on the presence of systemic symptoms and the condition of the patient. Intravenous antibiotics. outpatient follow-up with a surgeon is indicated if consultation did not take place at the time of presentation. drainage is indicated. surgery may be necessary.[13] If the patient also has sepsis. For anal fistulas.

symptomatic treatment with analgesics should be considered. Prognosis . Although it has a relatively low success rate.[13] Likewise.[13] In the presence of an abscess with anal fistula.001) but increased risk of continence disturbance.7% with the use of the Gore Bio-A fistula plug. 95% confidence interval. However. incision and drainage along with fistulotomy may be considered.09-0.[28] Fibrin glue has also been studied. debridement and fibrin glue or fistula plug may be used. In some cases. Surgical Treatment For simple anal fistulas. One small trial described a success rate of 72.17. Otherwise. fistulotomy with or without marsupialization is recommended. success rates have been reported lower than those for fistulotomy (41.7%). staged surgery is needed to repair an anal fistula. 0. This is associated with decreased recurrence (relative risk. For complex fistulas. surgical management should be considered.[29] Endoanal advancement flaps also have variable success rates for the treatment of complex fistulas. recent guidelines suggest that fibrin glue may be used as first-line therapy. if the patient is symptomatic. P < . Antibiotics should be reserved for those with overlying cellulitis or those with sepsis. However.managed by surgery. variable success has been reported with fistula plugs. Success rates for fibrin glue range from 10-67%.32. 0. with the advantage of less risk of incontinence.

. 8]Use of fibrin glue or fistula plug has variable success rates.[9.Prognosis for fistulas is excellent after surgery. with recurrence rates around 7-21% depending on the complexity and location of the fistula.