Tag: Anal Fissure and Fistula

Anal Fissure and Fistula

Anal Fissure and Fistula


ANAL FISSURE (FISSURE-IN-ANO)

  • A longitudinal split in the distal anal canal; extends from the anal verge proximally towards dentate line
  • Posterior fissures (most common) – passage of hard stool
  • Anterior fissures – more common in women following vaginal delivery
  • Fissure away from midline – Crohn’s disease, tuberculosis, STDs, HIV, Kaposi’s sarcoma, squamous cell carcinoma
  • Severe anal pain associated with defaecation
  • Stools are hard, pellet like and there is a drop or streaks of fresh (bright red) blood
  • Mucus discharge
  • Sentinel pile – tag of skin at the outer end of chronic fissures
  • Per-rectal examination with lignocaine jelly – can demonstrate sphincter spasm
  • Proctoscopy is contraindicated

 Treatment

  • Conservative: stool softeners, high fibre diet, mild laxatives, sitz bath
  • Pharmacological
  • Topical Lignocaine gel
  • Topical 0.2% Glyceryl trinitrate – releases NO and relaxes internal sphincter (head ache is a complication)
  • Oral Nifedipine
  • Injection Botulinum A toxin

Surgery

  • Lateral sphincterotomy – gold standard
  • Fissurectomy and local advancement flap – for chronic, non-healing fissure 

ANAL FISTULA (FISTULA-IN-ANO)

  • An abnormal communication between anal canal and recto with exterior
  • Even though multiple openings are seen in perianal skin – the internal opening is always single
  • Causes: persistent anal gland infection, TB, Crohn’s disease, lymphogranuloma venereum, actinomycosis, rectal duplication, foreign body and malignancy
  • More common in men
  • Usual presentation – intermittent purulent discharge (may be bloody) and pain (which increases until temporary relief occurs when the pus discharges)
  • previous episode of acute anorectal sepsis that settled (incompletely) spontaneously or with antibiotics, or which was surgically drained 

Parks classification

  • Inter-sphincteric (45%) – do not cross external sphincter
  • Trans-sphincteric (40%) – have a primary track that crosses both internal and external sphincters, which then passes through the ischiorectal fossa to reach the skin of the buttock
  • Supra-sphincteric – rare; internal opening above anorectal bundle; usually result from pelvic disease or trauma
  • Goodsall’s rule (used to indicate the likely position of the internal opening according to the position of the external opening)
  • Fistula with external opening in the anterior half of the anus within 3.75 cm – direct type
  • Fistula with external opening in the posterior half of the anus– indirect, curved or horseshoe type

 Investigations

  • Endoanal ultrasound with hydrogen peroxide – to delineate fistulae
  • MRI – Gold standard for fistula imaging
  • Fistulography and CT – useful techniques if an extrasphincteric fistula is suspected

Exam Question

  • Intersphincteric fistula is the most common type of ‘fistula in ano’. 
  • Anal fissure is best diagnosed by characteristic history of bleeding PR and pain during defecation and clinical examination.
  • Treatment of acute fissure in ano : Conservative , Dilatation under GA  , Lateral sphincterotomy.
  • Fistula in ano  is not a cause of acute anal pain.
  • Sentinel pile indicates Anal Fissure.
  • Rectal examination should not be done in Anal Fissure.
  • The treatment of choice in fistula in ano is Fistulotomy.
  • Internal sphincterotomy is the treatment of choice for Fissure in Ano.
  • High or low fistula in ano is termed according to its internal opening present with reference to Anorectal ring.
  • Multiple fistula in ano commonly occurs in Tuberculosis and LGV.
  • Lateral internal sphincterotomy is useful for Anal Fissure.
Don’t Forget to Solve all the previous Year Question asked on Anal Fissure and Fistula

Anal Fissure and Fistula

Anal Fissure and Fistula

Q. 1

True statement regarding ‘Fistula in ano’ is:

 A

Posterior fistulae have straight tracks

 B

High fistulae can be operated with no fear of incontinence

 C

High and low divisions are made in relation to the pelvic floor

 D

Intersphincteric is the most common type

Q. 1

True statement regarding ‘Fistula in ano’ is:

 A

Posterior fistulae have straight tracks

 B

High fistulae can be operated with no fear of incontinence

 C

High and low divisions are made in relation to the pelvic floor

 D

Intersphincteric is the most common type

Ans. D

Explanation:

Intersphincteric fistula is the most common type of ‘fistula in ano’.

 
Ref: Bailey and Love’s Short Practice of Surgery, 25th Edition, Page 1263.

Q. 2

Anal fissure best diagnosed by:

 A

Anoscopy

 B

History and superficial clinical examination

 C

PR examination

 D

USG

Q. 2

Anal fissure best diagnosed by:

 A

Anoscopy

 B

History and superficial clinical examination

 C

PR examination

 D

USG

Ans. B

Explanation:

Anal fissure is best diagnosed by characteristic history of bleeding PR and pain during defecation and clinical examination.

 
Ref: Colon and Rectal Surgery By Marvin L. Corman; Bailey and Love’s Short Practice of Surgery, 24th Edition, Page 1252; Sabiston Textbook of Surgery, 18th Edition, Page 1444

 


Q. 3

True statement regarding ‘Fistula in ano’ is –

 A

Posterior fistulae have straight tracks

 B

High fistulae can be operated with no fear of incontinence

 C

High and low divisions are made in relation to the pelvic floor

 D

Intersphincteric is the most common type

Q. 3

True statement regarding ‘Fistula in ano’ is –

 A

Posterior fistulae have straight tracks

 B

High fistulae can be operated with no fear of incontinence

 C

High and low divisions are made in relation to the pelvic floor

 D

Intersphincteric is the most common type

Ans. D

Explanation:

Ans. ‘d’ Intersphincteric fistula is the most common type 

  • A fistula in ano is a track, lined by granulation tissue, that connects deeply in the anal canal or rectum and superficially on the skin around the anus.

It usually results from an anorectal abscess (cryptoglundular abscess)

  • Other causes are :

–       Crohn’s ds., malignancy, radiation, tuberculosis, actinomycosis, chalamydia inf.

  • It is divided into 2 types – high & low, according to whether their internal openings is below or above the anorectal ring
  • The importance of deciding whether a fistula is a low or a high type is that a low level can be treated by fistulotomy (opening the tract) without causing damage to the sphincter.
  • High level fistulas can be treated only by ‘staged’ operation as there is risk of incontinence.
  • Another and more used classification is based on relationship offistulous tract to the anal sphincters.  (a) Intersphincteric fistula (most common type)

– runs in the intersphincteric space

b) Transsphincteric fistula

extends through both internal & external sphincters

c) Suprasphincteric fistula

–  originates in the intersphincteric plane and tracks up & around the entire external sphincter.

d) Extrasphincteric fistula

originates in the rectal wall and tracks lateral to both sphincters.

Goodsall’s Rule

– is used to determine the location of internal opening

  • According to it : fistulas with external opening anterior to horizontal imaginary line drawn across the Transverse mid point of anus connect to the internal anal line opening by short straight tract. fistulas with external opening posterior to the horizontal line – run a curvilinear course and open internally into the posterior midline.
  • Exceptions to this rule often occur if an anterior external opening is greater than 3 cm from the anal margin. Such fistulas track to the posterior midline. Also remember : when there is an anterior and also a posterior opening of the same fistula, the rule of posterior opening applies.

Q. 4

Anal fissure best diagnosed by:

 A

Anoscopy

 B

History and superficial clinical examination

 C

PR examination

 D

USG

Q. 4

Anal fissure best diagnosed by:

 A

Anoscopy

 B

History and superficial clinical examination

 C

PR examination

 D

USG

Ans. B

Explanation:

Ans. is ‘b’ i.e. History and superficial clinical examination 

Anal fissure is a linear ulcer of the lower half of the anal canal, thus can he diagnosed by visually inspecting the anal verge with gentle separation of the gluteal cleft.

The history is typical of pain and bleeding with defecation.

Per rectal or proctoscopic examination may trigger severe pain and interfere with the ability to visualize the ulcer.


Q. 5

All are treatment of acute fissure in ano except one –

 A

Conservative

 B

Dilatation under GA

 C

Lateral sphincterotomy

 D

External sphincterotomy

Q. 5

All are treatment of acute fissure in ano except one –

 A

Conservative

 B

Dilatation under GA

 C

Lateral sphincterotomy

 D

External sphincterotomy

Ans. D

Explanation:

Ans is ‘d’ ie External sphincterotomy 

Treatment of Anal fissure

Object of all tit is to obtain complete relaxation of the internal sphincter.

Conservative tit

– Stool bulking agents and stool softners

Nitric oxide or Glyceryl trinitrate are applied as an ointment to the anal canal produce sufficient relaxation of the sphincter to allow the fissure to heal up in 2/3 of pts. (k/a chemical Sphincterotomy)

  1. Dilatation of the sphincter under GA
  2. Lateral anal sphincterotomy – the internal sphincter is divided away from the fissure itself – usually either in the right or the left lateral position.
  3. Anal advancement flap – this operation consists of excision of the edges of the fissure and mobilisation of a square, full thickness anal skin flap so that this can be slid forward over the fissure and sutured in place. This technique has become popular recently as there is little risk of damage to the underlying internal sphincter and incontinence is unlikely.

Fissure in Ano (or Anal fissure)

  • Most common site is —-> mid-line posterioly
  • MC symptom is –> pain associated with defecation
  • Fissure starts proximally at the dentate line. So whole of anal fissure lies in the pain sensitive part of the anal canal.
  • The bleeding of anal fissure occurs as streaks on the outside of the stool or spots noted on toilet paper.
  • There are 2 types of fissures – Acute & Chronic
  • Chronic fissure
  • is a deep canoe shaped ulcer with thick edematous margins
  • at the upper end there is hypertrophied papilla*
  • at the lower end there is a skin tag k/a sentinel pile*

Q. 6

Not a cause of acute anal pain is:

 A

Perianal abscess

 B

Thrombosed hemorrhoids

 C

Acute anal fissure

 D

Fistual in ano

Q. 6

Not a cause of acute anal pain is:

 A

Perianal abscess

 B

Thrombosed hemorrhoids

 C

Acute anal fissure

 D

Fistual in ano

Ans. D

Explanation:

Ans is`d’ i.e. Fistula in ano 

Patients with an anorectal fistula usually present with a “non-healing” anorectal abscess following drainage, or with chronic purulent drainage and a pustule-like lesion in the perianal or buttock area. Patients experience intermittent rectal pain, particularly during defecation, but also with sitting and activity. Patients may also experience intermittent and malodorous perianal drainage and pruritus.

Hemorrhoids cause painless bleeding, but when thrombosed cause acute pain.

Anal fissure patients describe severe anal pain following bowel movements that may persist for hours or even continue until exacerbation by the next bowel movement.

Perianal abscess patients most commonly present with severe anal pain. Walking, coughing, or straining can aggravate the pain. A palpable mass often is detected by inspection of the perianal area or by digital rectal examination. Occasionally, patients will present with fever, urinary retention, or life-threatening sepsis.


Q. 7

Sentinel pile indicates –

 A

Carcinoma rectum

 B

Internal haemorrhoids

 C

Perianal fistula

 D

Anal fissure

Q. 7

Sentinel pile indicates –

 A

Carcinoma rectum

 B

Internal haemorrhoids

 C

Perianal fistula

 D

Anal fissure

Ans. D

Explanation:

Ans. is ‘d’ i.e., Anal fissure 


Q. 8

Rectal examination should not be done –

 A

Anal fissure

 B

Fistual in ano

 C

Prolapsed piles with bleeding

 D

Anal stenosis

Q. 8

Rectal examination should not be done –

 A

Anal fissure

 B

Fistual in ano

 C

Prolapsed piles with bleeding

 D

Anal stenosis

Ans. A

Explanation:

Ans. is ‘a’ i.e., Anal fissure 


Q. 9

The treatment of choice in fistula in ano 

 A

Anal dilatation

 B

Fissurotomy

 C

Fistulectomy

 D

Fistulotomy

Q. 9

The treatment of choice in fistula in ano 

 A

Anal dilatation

 B

Fissurotomy

 C

Fistulectomy

 D

Fistulotomy

Ans. D

Explanation:

Ans. is ‘d’ i.e., Fistulotomy 


Q. 10

Internal sphincterotomy is the treatment of choice for –

 A

Piles

 B

Fistula

 C

Fissure-in-ano

 D

Carcinoma

Q. 10

Internal sphincterotomy is the treatment of choice for –

 A

Piles

 B

Fistula

 C

Fissure-in-ano

 D

Carcinoma

Ans. C

Explanation:

Ans. is ‘c’ i.e., Fissure-in-ano 


Q. 11

High or low fistula in ano is termed according to its internal opening present with reference to 

 A

Anal canal

 B

Dentate line

 C

Anorectal ring

 D

Sacral promontory

Q. 11

High or low fistula in ano is termed according to its internal opening present with reference to 

 A

Anal canal

 B

Dentate line

 C

Anorectal ring

 D

Sacral promontory

Ans. C

Explanation:

Ans. is ‘c’ i.e. Anorectal ring 


Q. 12

Multiple fistula in ano commonly occurs in ‑

 A

Tuberculosis

 B

Gonococcal protocolitis

 C

LGV

 D

a and c

Q. 12

Multiple fistula in ano commonly occurs in ‑

 A

Tuberculosis

 B

Gonococcal protocolitis

 C

LGV

 D

a and c

Ans. D

Explanation:

Ans. is ‘a’ i.e. Tuberculosis & ‘c’ i.e. LGV 


Q. 13

Lateral internal sphincterotomy is useful for:

September 2007

 A

Anal fistula

 B

Anal canal strictures

 C

Haemorrhoids

 D

Anal fissure

Q. 13

Lateral internal sphincterotomy is useful for:

September 2007

 A

Anal fistula

 B

Anal canal strictures

 C

Haemorrhoids

 D

Anal fissure

Ans. D

Explanation:

Ans. D: Anal fissure

Lateral internal sphincterotomy is the preferred method of surgery for persons with chronic anal fissures, and is generally used when medical therapy has failed.

It is associated with a lower rate of side effects than older techniques such as posterior internal sphincterotomy and anoplasty, and has also been shown to be superior to topical glyceryl trinitrate (GTN 0.2% ointment) in long term healing of fissures, with no difference in fecal continence.


Q. 14

Not a cause of acute anal pain

 A

Thrombosed hemorrhoids

 B

Acute anal fissure

 C

Fistula in ano

 D

Perianal abscess

Q. 14

Not a cause of acute anal pain

 A

Thrombosed hemorrhoids

 B

Acute anal fissure

 C

Fistula in ano

 D

Perianal abscess

Ans. C

Explanation:

Ans. c. Fistula in ano



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