Fistula-In-Ano

Identifying InformationAR, 36/M, married, Filipino, Roman Catholic, high school graduate, driver, residing in Pasig City

CC: Perianal discharge

Date admitted: 10/20/14 under Dr. Mallari

Date of operation: 10/21/14 by Dr. Ong

Date discharged: 10/23/14 4:10pm

HPI5 years PTA

(+) pain on the anal area, frequently during difficult defacationassociated with swelling and pruritus, no discharge(+) occasional blood in stoolSought consult, prescribed with unrecalled antibiotics which provided temporary relief

HPIInterim

Self-medicated with Amoxicillin 500mg OD and Mefenamic acid, unrecalled dose, PRN

1 month PTA

plastic-like sac protruding from the anus draining with yellowish fluid, pus-like

poking the sac causes extreme pain

PMHDengue Fever, November 2013

No allergies to food and drugs

No history of transfusions, surgeries

No HTN, diabetes, liver, kidney and lung diseases

Family HistoryHTN, motherStroke, grandmother, maternalNo history of DM, asthma, cancer, blood dyscrasias and allergies

Personal, Social HistoryHighschool graduate, currently a driver

works 8 hours/day from 5am to 1pmSmokes 10 sticks/day for 10 years (5-pack years)Alcohol beverage drinker, 2x/week, Emperador, 1/4 bottle

ROSGENERAL

no weight changes, no fever, no anorexia, no weakness, no fatigue, no insomnia

SKINno itchiness, no color changes, no pigmentation, no rashes, no vasomotor change, no photosensitivity, no hair, nail changes, no suspicious-looking moles

EYEno visual dysfunction, no redness, no itchiness, no pain, no scotoma, no lacrimation

EARno deafness, (+) tinnitus, rarely, no discharge

NOSEno epistaxis, no discharge, no obstruction, no smell changes, no postnasal drip, no sinusitis

MOUTH(+) dental carries, with dentures, no bleeding gums, no sores, no fissures, no tongue abnormalities

THROATno soreness, no tonsillitis

NECKno stiffness, no limitation of motion, no masses, no adenopathy, no sensation of lump in the throat

BREASTno masses, no discharge, no trauma

ROSPULMONARY

no dyspnea, no shortness of breath, no cough, no sputum production, no hemoptysis, no wheezing, no back pain, no chest wall abnormality

CARDIACno chest pain, no easy fatigability, no orthopnea, no nocturnal dyspnea, no palpitations, no syncope, no edema, no hypertension

VASCULARno phlebitis, no varicosities, no claudication

GASTRO-INTESTINALno nausea, no vomiting, no hematemesis, no melena, no hematochezia, no dysphagia, no belching, no indigestion, no food intolerance, no flatulence, no abdominal pain, no distention, no diarrhea, no constipation, no anal lesion

GENITO-URINARYno urinary frequency, no urgency, no hesitancy, no dysuria, no hematuria, no nocturia, no urine stream flow abnormality, no flank pain, no stones, no urethral discharge, no genital lesions, no testicular masses, no perineal pain

MUSCULOSKELETALno joint stiffness, no pain, no swelling, no cramps, no muscle pain, no weakness, no wasting, no trauma, no abnormal posture

ENDOCRINEno heat-cold intolerance, no thyroid problems, no poluria, no polyphagia, no polydipsia

HEMATOPOIETICno abnormal bleeding, no bruising, no anemia, no adenopathy

NEUROLOGICno headache, no seizure, no sensory perversion, no motor dysfunction, no speech disturbances, no mental changes, no head trauma

PSYCHIATRICno anxiety, no depression, no interpersonal relationship difficulties, no illusions, no delusions, no hallucinations, no paranoia

Physical ExaminationVITALS

Wt: 77kgHt: 170.18cmBMI: 26.59kg/m2

GENERAL SURVEY

Patient is awake, alert, coherent, not in cardiorespiratory distress, oriented to three spheres

Physical ExaminationSKIN

Even brown skin, no signs of pallor, jaundice or cyanosis.HEENT

Abundant black hair without lice infestations or areas of baldnessSymmetric face, anicteric sclerae, pink palpebral conjunctiva, pupils equally brisk and reactive to light, pink buccal and oral mucosa, tongue midline

NECK

able to move >180 degrees to L and R, no cervical lymphadenopathies, thyroid not enlarged, jugular veins not distended

THORAX/LUNGS

Symmetric chest expansion, clear breath sounds, no wheezes, no crackles, no rhonchi

Physical ExaminationCARDIOVASCULAR

Adynamic precordium, no lifts, heaves or thrills, normal rate, regular rhythm, no murmurs

ABDOMEN

Abdomen is round, no scars nor excoriations, normative bowel sounds, tympanitic on all quadrants, no organomegaly, no direct and rebound tenderness

MUSCULOSKELETAL

5/5 on all extremities, no tenderness, no swelling, no limitation of motionDIGITAL RECTAL EXAMINATION, anesthesized

(+) 0.5cm fistula at the external anus(+) blood, induration at the posterior aspect of the anal canal, midline, 1.5cm from the anal verge(+) pus-like discharge

NEUROLOGICAL

grossly intact

Fistula-In-AnoDiagnosis

Fistula-In-Anousually originates from an infected crypt (internal opening) and tracts to an external opening

Main origin: cryptoglandular

Other causes: trauma, Crohn’s disease, malignancy, radiation or unusual infections (TB, actinomycosis, chlamydia)

DiagnosisHistory of persistent drainage from opening

usually a red elevation of granulation tissue with or without concurrent drainage

Indurated tract palpable during PE

Goodsall’s rule

anterior external opening —> short, radial tract

posterior external opening —> curvilinear to the posterior midline

Exemptions: anterior external opening >3cm from anal margin

Types of Fistulascategorized based on relationship with anal sphincter

Intersphincteric

distal internal sphincter and intersphincteric space to an external opening near the anal verge

Types of FistulasTranssphincteric

results from ischiorectal abscess and extends through both the internal and external sphincters

Types of FistulasSuprasphincteric

originates from the intersphincteric plane and tracts up and around the entire external sphincter

Types of FistulasExtrasphincteric

originates in the rectal wall and tracks around both sphincters to exit laterally, usually in the ischiorectal fossa

TreatmentGOAL

eradication of sepsis without sacrificing continence

Surgical treatment is dictated by the location of the internal and external openings and the course of the fistula

Hydrogen peroxide or dilute methylene blue - helpful in detecting the internal opening

TreatmentFISTULOTOMY

opening of the fistulous tract which involves opening and draining of the part outside of the sphincterA primary tract at the level of the dentate line may also be opened and drained if presentinvolves curettage and healing by secondary intention

SPHINCTEROTOMY

tx for fistulas involving 30% of the sphincter muscles, however, may sometimes lead to incontinence

TreatmentSETON PLACEMENT

tx for transsphincteric fistula and suprasphincteric fistulasit is a drain placed through a fistula to maintain drainage or induce fibrosis

FECAL DIVERSION

failure to heal of previously opened and drained fistulamay lead to Crohn’s disease, malignancy, radiation proctitis or unusual infectionsProtoscopy and biopsy may sometimes be indicated

FistulectomyIntersphincteric Fistula-in-ano, 10/21/2014

Operative TechniquePatient was placed in lithotomy position under spinal anaesthesia

Aseptic techniques observed

Sterile drapes placed

Fistula opening identified and isolated with probe

Internal opening identified

Fistula opened and lifted

Fistulectomy done

Hemostatis

Anal pack applied

External Opening 1.5cm from anal verge at posterior midline

Internal opening 1.5cm from anal verge at posterior midline

Postoperative diagnosis