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ULCER SINUS
FISTULA
Definition
A break in the epithelial continuity
Discontinuity of the skin or mucous membrane
which occurs due to the mic...
Aetiology
 Venous Disease (Varicose Veins)
 Arterial Disease ; Large vessel (Atherosclerosis) or Small
vessel (Diabetes)...
Wagner’s Grading of ulcers
 Grade 0 - Preulcerative lesion/healed ulcer
 Grade 1 - Superficial ulcer
 Grade 2 - Ulcer d...
Classification
A. Clinical
B. Pathological
A. Clinical
Spreading : (Edge - Inflamed & Edematous)
Healing : (Edge is sloping with healthy red
granulation tissue & s...
B.Pathological
1. Nonspecific
2. Specific
3. Malignant
1. Non specific
Traumatic Ulcer
Arterial Ulcer
Venous Ulcer
Neurogenic Ulcer
Infective Ulcer
1. Non specific contd.
Diabetic Ulcer
Tropical Ulcer
Cryopathic Ulcer
Martorell’s Ulcer
Bazin’s Ulcer
• Traumatic ulcer
1. Mechanical- Dental ulcer on tongue ( jagged tooth )
2. Physical- Electrical burn
3. Chemical- Applica...
• Arterial Ulcer
• Caused due to peripheral vascular disease
• LL : Atherosclerosis & TAO
• UL : Cervical Rib, Raynauds
• ...
• Venous ulcers
 Medial aspect of lower 3rd of lower limb
 Ankle ( Gaiters Zone ) : Chronic Venous HTN
 Ulcers are Pain...
• Trophic Ulcer
• Pressure Sore or Decubitus Ulcer
• Punched out edge with slough on the floor
• Ex: Bed Sores & Perforati...
• Tropical ulcer
• Tropical regions : Africa, India, S.America
• Trauma or Insect Bite
• Fusobacterium fusiformis & Borrel...
• Diabetic Ulcer
It may be caused due to
• Diabetic Neuropathy
• Diabetic Microangiopathy
• Increased Glucose : Increased ...
2. Specific
Tuberculosis
Syphilis
Actinomycosis
Meleney’s ulcer
Soft sore
3. Malignant
Squamous cell ca
Basal cell ca
Malignant melanoma
Examination
Inspection
Palpation
Examination of lymph nodes
Vascular insufficiency
 Nerve lesions
 INSPECTION
Location, size, shape, floor, edge, discharge, surrounding area.
 PALPATION
Tenderness, local rise of temper...
INSPECTION
LOCATION OF THE ULCER
FLOOR OF THE ULCER
DISCHARGE FROM THE ULCER
EDGE
SURROUNDING AREA
LOCATION OF THE ULCER
Arterial ulcer Tip of the toes, dorsum of
the foot
Long saphenous varicosity
with ulcer
Medial side ...
FLOOR OF THE
ULCERDEF : This is the part of the ulcer which is exposed or seen.
Red granulation tissue Healing ulcer
Necro...
DISCHARGE FROM THE ULCER
Serous discharge Healing ulcer
Purulent discharge Spreading ulcer
Bloody discharge Malignant ulce...
EDGE
DEF: This is between the floor of the ulcer and the margin.
The margin is the junction between the normal epithelium ...
A. Sloping edge All healing ulcers like
traumatic ulcers, venous
Ulcers
B. Punched out
edge
Gummatous
ulcers and trophic
ulcers.
C. Undermined
edge
Tuberculous
ulcers
D. Raised edge
(beaded edge)
Rodent ulcers or
basal cell
carcinoma .
E. Everted edge
(Rolled out)
Squamous cell
carcinoma.
SURROUNDING AREA
Thick and
pigmented
Varicose ulcer.
Thin and dark Arterial ulcer.
Red and
oedematous
Spreading ulcers
lik...
PALPATION
EDGE
BASE
MOBILITY
BLEEDING
SURROUNDING AREA
EDGE
Induration (hardness) of the edge is very char-
acteristic of squamous cell carcinoma.
It is said to be a host defe...
BASE
It is the area on which ulcer rests.
Marked induration at the base is diagnostic of
squamous cell carcinoma.
INDURATION
• The edge, base and the surrounding area should be examined for
induration.
Maximum induration Squamous cell c...
MOBILITY
Gentle attempt is made to move the ulcer to
know its fixity to the underlying tissues.
Malignant ulcers are usu...
BLEEDING
Malignant ulcer is friable like a cauliflower. On
gentle palpation, it bleeds.
 Granulation tissue as in a heal...
SURROUNDING AREA
Thickening and induration is found in
squamous cell carcinoma.
Tenderness and pitting on pressure
indic...
RELEVANT CLINICAL EXAMINATION
 REGIONAL LYMPH NODES
Tender and enlarged Acute secondary
infection.
Non-tender and
enlarge...
MANAGEMENT
Investigations
1) Complete blood picture: Hb%, TC, DC, ESR, PS
2) Urine and blood examination to rule out diabetes
3) Ches...
Treatment
Address cause
Correct deficiencies
Control pain, infection
Debridement, dressing
Closure of defect
TREATMENT OF THE ULCERS
Treatment of Spreading Ulcers
Treatment of Healing Ulcers
Treatment of Chronic Ulcers
Treatmen...
TREATMENT OF SPREADING ULCERS
 Pus Culture/Sensitivity report,
 Appropriate Antibiotics
 Solutions to treat the Slough ...
TREATMENT OF HEALING ULCER
 Regular dressings are done for a few days
 Antiseptic creams like Liquid Iodine, Zinc Oxide ...
TREATMENT OF CHRONIC ULCERS
 These do not respond to conventional methods of treatment.
The following are tried:
 Infrar...
DEFINITION
SINUS:
 Blind track lined by granulation tissue leading from
epithelial surface down into the tissues.
 Latin...
CAUSES
CONGENITAL ACQUIRED
Preauricular sinus TB sinus
Pilonidal sinus
Median mental sinus
Actinomycosis
FISTULA:
 ABNORMAL communication between lumen of one viscus
and lumen of another (INTERNAL FISTULA)
(or)
between lumen o...
Latin : flute (or) a pipe (or) a tube
.
CAUSES
CONGENITAL
 Branchial fistula
 Tracheo-esophageal
 Umbilical
 Congenital AV fistula
 Thyroglossal fistula
ACQU...
ACQUIRED
I. TRAUMATIC:
(A) following surgery : eg., intestinal fistulas
(faecal,biliary,pancreatic)
(B) following instrume...
II. INFLAMMATORY:
Intestinal actinomycosis, TB
III. MALIGNANCY:
when growth of one organ penetrates into the
nearby organ....
FISTULA
EXTERNAL
 Orocutaneous
 Enterocutaneous
 Appendicular
 Thyroglossal
 Branchial
INTERNAL
 Tracheo-esophageal
...
.
Causes for persistence of sinus (or) fistula
 Presence of a foreign body. e.g., suture material
 Presence of necrotic ti...
 Epithelialisation (or) endothelisation of the track. e.g.,
AVF
 Malignancy.
 Dense fibrosis
 Irradiation
 Malnutriti...
CLINICAL FEATURES
Usually asymptomatic but when infected manifest as-
• Recurrent/ persistent discharge.
• Pain.
• Constit...
CLINICAL EXAMINATION
INSPECTION:
1. Location: usually gives diagnosis in most of the cases.
SINUS: pre-auricular- root of ...
2. Number: usually single but multiple seen in HIV
patients (or) actinomycosis.
3. Opening:
a) sprouting with granulation ...
5. Discharge:
 White thin caseous, cheesy like- TB sinus
 Faecal- faecal fistula
 Yellow sulphur granules- actinomycosi...
Palpation:
a) Temperature and tenderness:
b) Discharge: after application of pressure over the
surrounding area.
c) Indura...
INVESTIGATIONS
 CBP- Hb, TLC, DLC, ESR.
 Discharge for C/S , AFB, cytology, Gram staining.
 X-RAY of the part to rule o...
 FISTULOGRAPHY/ SINUSOGRAPHY:
• For knowing the exact extent/origin of sinus (or)fistula.
• Water soluble or ultrafluid l...
TREATMENT
BASIC PRINCIPLES:
 Antibiotics
 Adequate rest
 Adequate excision
 Adequate drainage.
 After excision specimen SHOULD be sent for HPE.
 Treating the cause.
e.g., ATT for TB sinus.
removal of any foreign bod...
TUBERCULAR SINUS OF NECK
Causative organism: mostly M.tuberculosis
but also M.bovis
Site and mode of infection:
a) lymph n...
Clinical stages:
Stage of cold abscess:
due to caseating necrosis.
non-tender, cystic, fluctuant swelling not
adherent to overlying skin.
S...
TREATMENT:
 Zig-zag aspiration by wide bore needle in non-dependent
area to avoid a persistent sinus.
 Instillation of 1...
Stage of collar stud abscess:
cold abscess ruptures through deep fascia forming an
another swelling in sub-cutaneous plane...
Collar stud abscess
Stage of sinus:
 collar stud abscess bursts out leading to a persistent
discharging sinus.
 Can be multiple, wide openin...
INVESTIGATIONS
• Hematocrit, ESR , S.albumin , S.globulin
• FNAC of lymph nodes and smear for AFB and C/S
• Open node biop...
Sometimes, USG neck to detect cold abscess.
 Hypoechoeic lesions with internal echoes S/O debris
within.
 Guided aspirat...
TREATMENT
 ATT
 Excision of sinus tract with excision of diseased lymph
nodes.
FISTULA-IN-ANO
Chronic abnormal communication usually lined to some
degree by granulation tissue, which runs outwards from...
AETIOPATHOGENESIS
 Cryptoglandular (90% cases)
 Non cryptoglandular (10% cases)
TB
Diabetes mellitus
Crohn’s disease
Car...
CRYPTOGLANDULAR HYPOTHESIS
CLASSIFICATION
PARK’S CLASSIFICATION:
(relation of primary tract to external sphincter)
• Inter sphincteric (45%)
• Trans ...
STANDARD CLASSIFICATION
 Sub cutaneous
 Sub mucous
 Low anal
 High anal
 Pelvi rectal
 Can be
low level fistula- open into anal canal below
the internal ring.
high level fistula- at/ above the internal ring....
CLINICAL PRESENTATION
• Intermittent discharge
(sero-purulent/ bloody)
• Pain
(which increases until temporary relief
occu...
CLINICAL ASSESMENT
 HISTORY: full medical history incl. obstetric,anal,
gastrointestinal, surgical, continence
 DRE: are...
GOODSALL’S RULE
• If external opening in anterior half of anus, fistula
usually runs directly into anal canal.
• If extern...
IMAGING
 Fistulography
 Endoanal ultrasound
 MRI
Fistulography:
 Reveals primary and secondary
tracts.
 Useful if extra sphincteric fistula
suspected.
END0 ANAL ULTRASOUND
• Determines sphincter
integrity.
• Complexity of fistula.
horse-shoe fistula
MRI
“GOLD STANDARD” for fistula-in-ano imaging.
high variety supra horse-shoe fistula.
sphincteric fistula.
MRI
Abscesses and contralateral
extensions disease
PRINCIPLES OF TREATMENT
 Control sepsis
EUA
Laying open abscesses and secondary tracts
Adequate drainage – seton insertio...
SURGICAL MANAGEMENT
 Fistulotomy (The laying open technique)
 Fistulectomy
 Seton techniques
 Fibrin glue sphincter pr...
FISTULOTOMY
 In inter-sphincteric and low trans-sphincteric fistulas.
 Identification of tract with probe followed by di...
Advantages
least chance of recurrence
relatively easy procedure
minor degree of incontinence.
Risks
results in large and d...
FISTULECTOMY
• All chronic (low) and also for posterior horse-shoe shaped
fistulas.
• Excision of entire fibrous tissue an...
SETON SUTURE PLACEMENT
• Preferable surgical option for high variety.
• Setons are usually made from rubber slings
• 2 typ...
FIBRIN GLUE
 Multi component system containing mainly human
plasma fibrinogen and thrombin.
 Injected into fistula track...
ANAL FISTULA PLUG
 The Anal fistula plug is a minimally invasive and
sphincter-preserving alternative to traditional fist...
FISTULA PLUG
FISTULA PLUG:
ADVANCEMENT FLAPS
Endorectal
 Fistula tract probed
 Flap raised
• Mucosa + Int. Sphincter
 Internal opening excised/clo...
ADVANCEMENT FLAP
Anodermal
 Fistula tract probed
 Flap raised
• Anodermal
 Flap advanced & sutures
 External defect cl...
LIFT PROCEDURE
Ligation of Inter sphincteric
Fistula Tract
 Trans sphincteric fistula
 Draining seton – 6 weeks
 Tract ...
FOLLOW UP
As with most anorectal disorders, follow-up care
includes:
 Perianal baths,
 analgesics for pain,
 stool bulk...
Ulcer sinus fistula
Ulcer sinus fistula
Ulcer sinus fistula
Ulcer sinus fistula
Ulcer sinus fistula
Ulcer sinus fistula
Ulcer sinus fistula
Ulcer sinus fistula
Ulcer sinus fistula
Ulcer sinus fistula
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Ulcer sinus fistula

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Ulcer sinus fistula

  1. 1. ULCER SINUS FISTULA
  2. 2. Definition A break in the epithelial continuity Discontinuity of the skin or mucous membrane which occurs due to the microscopic death of the tissues
  3. 3. Aetiology  Venous Disease (Varicose Veins)  Arterial Disease ; Large vessel (Atherosclerosis) or Small vessel (Diabetes)  Arteritis : Autoimmune (Rheumatoid Arthritis, Lupus)  Trauma  Chronic Infection : TB/Syphilis  Neoplastic : Squamous or BCC, Sarcoma
  4. 4. Wagner’s Grading of ulcers  Grade 0 - Preulcerative lesion/healed ulcer  Grade 1 - Superficial ulcer  Grade 2 - Ulcer deeper to Subcutaneous tissue exposing soft tissue or bone  Grade 3 - Abscess formation or osteomyelitis  Grade 4 - Gangrene of part of tissues/limb/foot  Grade 5 - Gangrene of entire one area/foot
  5. 5. Classification A. Clinical B. Pathological
  6. 6. A. Clinical Spreading : (Edge - Inflamed & Edematous) Healing : (Edge is sloping with healthy red granulation tissue & serous discharge) Callous : (Floor contains pale unhealthy granulation tissue with indurated edge)
  7. 7. B.Pathological 1. Nonspecific 2. Specific 3. Malignant
  8. 8. 1. Non specific Traumatic Ulcer Arterial Ulcer Venous Ulcer Neurogenic Ulcer Infective Ulcer
  9. 9. 1. Non specific contd. Diabetic Ulcer Tropical Ulcer Cryopathic Ulcer Martorell’s Ulcer Bazin’s Ulcer
  10. 10. • Traumatic ulcer 1. Mechanical- Dental ulcer on tongue ( jagged tooth ) 2. Physical- Electrical burn 3. Chemical- Application of caustics  Acute, Superficial, Painful, Tender
  11. 11. • Arterial Ulcer • Caused due to peripheral vascular disease • LL : Atherosclerosis & TAO • UL : Cervical Rib, Raynauds • Chief complaint : Severe Pain • Toes, Feet, Legs & UL Digits
  12. 12. • Venous ulcers  Medial aspect of lower 3rd of lower limb  Ankle ( Gaiters Zone ) : Chronic Venous HTN  Ulcers are Painless  Varicose Veins or Post Phlebitic limb ( PTS )
  13. 13. • Trophic Ulcer • Pressure Sore or Decubitus Ulcer • Punched out edge with slough on the floor • Ex: Bed Sores & Perforating ulcers • Develop as a result of Prolonged Pressure • Sites : Ischial Tuberosity > Greater Trochanter > Sacrum > Heel > Malleolus > Occiput
  14. 14. • Tropical ulcer • Tropical regions : Africa, India, S.America • Trauma or Insect Bite • Fusobacterium fusiformis & Borrelia vincentii • Abrasions, Redness, Papules & Pustules • Severe Pain
  15. 15. • Diabetic Ulcer It may be caused due to • Diabetic Neuropathy • Diabetic Microangiopathy • Increased Glucose : Increased Infection • Foot ( Plantar ), Leg, Back, Scrotum, Perineum • Ischemia, Septicemia, Osteomyelitis,
  16. 16. 2. Specific Tuberculosis Syphilis Actinomycosis Meleney’s ulcer Soft sore
  17. 17. 3. Malignant Squamous cell ca Basal cell ca Malignant melanoma
  18. 18. Examination Inspection Palpation Examination of lymph nodes Vascular insufficiency  Nerve lesions
  19. 19.  INSPECTION Location, size, shape, floor, edge, discharge, surrounding area.  PALPATION Tenderness, local rise of temperature, bleeding on touch, consistency of the ulcer, edge, surrounding area - oedema, mobility.  REGIONAL LYMPH NODES  SENSATIONS  PULSATIONS  FUNCTION OF THE JOINT  SYSTEMIC EXAMINATION
  20. 20. INSPECTION LOCATION OF THE ULCER FLOOR OF THE ULCER DISCHARGE FROM THE ULCER EDGE SURROUNDING AREA
  21. 21. LOCATION OF THE ULCER Arterial ulcer Tip of the toes, dorsum of the foot Long saphenous varicosity with ulcer Medial side of the leg. Short saphenous varicosity with ulcer Lateral side of the leg. Perforating ulcers Over the sole at pressure points. Nonhealing ulcer Over the shin
  22. 22. FLOOR OF THE ULCERDEF : This is the part of the ulcer which is exposed or seen. Red granulation tissue Healing ulcer Necrotic tissue, slough Spreading ulcer Pale, scanty granulation tissue Tuberculous ulcer Wash-leather slough Gummatous ulcer
  23. 23. DISCHARGE FROM THE ULCER Serous discharge Healing ulcer Purulent discharge Spreading ulcer Bloody discharge Malignant ulcer Discharge with bony spicules Osteomyelitis Greenish discharge Pseudomonas infection
  24. 24. EDGE DEF: This is between the floor of the ulcer and the margin. The margin is the junction between the normal epithelium and the ulcer. These two parts represent areas of maximum activity. 3 STAGES  Stage of ex-tension.  Stage of transition.  Stage of repair.
  25. 25. A. Sloping edge All healing ulcers like traumatic ulcers, venous Ulcers
  26. 26. B. Punched out edge Gummatous ulcers and trophic ulcers.
  27. 27. C. Undermined edge Tuberculous ulcers
  28. 28. D. Raised edge (beaded edge) Rodent ulcers or basal cell carcinoma .
  29. 29. E. Everted edge (Rolled out) Squamous cell carcinoma.
  30. 30. SURROUNDING AREA Thick and pigmented Varicose ulcer. Thin and dark Arterial ulcer. Red and oedematous Spreading ulcers like diabetic ulcer.
  31. 31. PALPATION EDGE BASE MOBILITY BLEEDING SURROUNDING AREA
  32. 32. EDGE Induration (hardness) of the edge is very char- acteristic of squamous cell carcinoma. It is said to be a host defense mechanism. Tenderness of the edge is characteristic of infected ulcers and arterial ulcers.
  33. 33. BASE It is the area on which ulcer rests. Marked induration at the base is diagnostic of squamous cell carcinoma.
  34. 34. INDURATION • The edge, base and the surrounding area should be examined for induration. Maximum induration Squamous cell carcinoma Minimal induration Malignant melanoma. Brawny induration Abscess. Cyanotic induration Chronic venous congestion as in varicose ulcer.
  35. 35. MOBILITY Gentle attempt is made to move the ulcer to know its fixity to the underlying tissues. Malignant ulcers are usually fixed, benign ulcers are not.
  36. 36. BLEEDING Malignant ulcer is friable like a cauliflower. On gentle palpation, it bleeds.  Granulation tissue as in a healing ulcer also causes bleeding.
  37. 37. SURROUNDING AREA Thickening and induration is found in squamous cell carcinoma. Tenderness and pitting on pressure indicates spreading inflammation surrounding the ulcer.
  38. 38. RELEVANT CLINICAL EXAMINATION  REGIONAL LYMPH NODES Tender and enlarged Acute secondary infection. Non-tender and enlarged Chronic infection. Non-tender and hard Squamous cell carcinoma. Non-tender, large, firm, multiple Malignant melanoma.
  39. 39. MANAGEMENT
  40. 40. Investigations 1) Complete blood picture: Hb%, TC, DC, ESR, PS 2) Urine and blood examination to rule out diabetes 3) Chest X-ray - PA. view to rule out P.TB 4) Pus for culture/sensitivity 5) Lower limb angiography in cases of arterial diseases 6) X-ray of the part to see for Osteomyelitis 7) Biopsy: Non-healing/malignant ulcers
  41. 41. Treatment Address cause Correct deficiencies Control pain, infection Debridement, dressing Closure of defect
  42. 42. TREATMENT OF THE ULCERS Treatment of Spreading Ulcers Treatment of Healing Ulcers Treatment of Chronic Ulcers Treatment of The Underlying Disease
  43. 43. TREATMENT OF SPREADING ULCERS  Pus Culture/Sensitivity report,  Appropriate Antibiotics  Solutions to treat the Slough : H₂O₂ & EUSOL - Edinburgh University Solution (Hypochlorite solution)  Excessive Granulation Tissue (Proud Flesh) : Excision or Application of Copper Sulphate or Silver Nitrate  Repeated Dressings,
  44. 44. TREATMENT OF HEALING ULCER  Regular dressings are done for a few days  Antiseptic creams like Liquid Iodine, Zinc Oxide or Silver Sulphadiazine.  Culture swab is taken to rule out Streptococcus Haemolyticus ( contraindication for skin grafting )  Ulcer is small - Heals by itself ( Epithelialization ) Large - Free Split Skin Graft applied
  45. 45. TREATMENT OF CHRONIC ULCERS  These do not respond to conventional methods of treatment. The following are tried:  Infrared radiation, short-wave therapy, ultraviolet rays decrease the size of the ulcer.  Amnion helps in epithelialization.  Chorion helps in granulation tissue.  These ulcers ultimately may require skin grafting.
  46. 46. DEFINITION SINUS:  Blind track lined by granulation tissue leading from epithelial surface down into the tissues.  Latin: Hollow (or) a bay
  47. 47. CAUSES CONGENITAL ACQUIRED Preauricular sinus TB sinus Pilonidal sinus Median mental sinus Actinomycosis
  48. 48. FISTULA:  ABNORMAL communication between lumen of one viscus and lumen of another (INTERNAL FISTULA) (or) between lumen of one hollow viscus to the exterior (EXTERNAL FISTULA) (or) between any two vessels
  49. 49. Latin : flute (or) a pipe (or) a tube .
  50. 50. CAUSES CONGENITAL  Branchial fistula  Tracheo-esophageal  Umbilical  Congenital AV fistula  Thyroglossal fistula ACQUIRED I. Traumatic II. Inflammatory III. Malignancy IV. Iatrogenic
  51. 51. ACQUIRED I. TRAUMATIC: (A) following surgery : eg., intestinal fistulas (faecal,biliary,pancreatic) (B) following instrumental delivery (or) difficult labour e.g., vesicovaginal,rectovaginal, ureterovaginal fistula
  52. 52. II. INFLAMMATORY: Intestinal actinomycosis, TB III. MALIGNANCY: when growth of one organ penetrates into the nearby organ. e.g., Rectovesical fistula in carcinoma rectum IV. IATROGENIC: Cimino fistula- AVF for hemodialysis ECK fistula- to treat esophageal varices in portal HTN
  53. 53. FISTULA EXTERNAL  Orocutaneous  Enterocutaneous  Appendicular  Thyroglossal  Branchial INTERNAL  Tracheo-esophageal  Colovesical  Rectovesical  AVF  Cholecystoduodenal
  54. 54. .
  55. 55. Causes for persistence of sinus (or) fistula  Presence of a foreign body. e.g., suture material  Presence of necrotic tissue underneath. e.g.,sequestrum  Insufficient (or) non-dependent drainage. e.g., TB sinus  Distal obstruction. e.g., faecal (or) biliary fistula  Persistent drainage like urine/faeces/CSF  Lack of rest [contd.]
  56. 56.  Epithelialisation (or) endothelisation of the track. e.g., AVF  Malignancy.  Dense fibrosis  Irradiation  Malnutrition  Specific causes. e.g., TB, actinomycosis  Ischemia  Drugs. e.g., steroids  Interference by the patient
  57. 57. CLINICAL FEATURES Usually asymptomatic but when infected manifest as- • Recurrent/ persistent discharge. • Pain. • Constitutional symptoms if any deep seated origin.
  58. 58. CLINICAL EXAMINATION INSPECTION: 1. Location: usually gives diagnosis in most of the cases. SINUS: pre-auricular- root of helix of ear. median mental- symphysis menti. TB- neck. FISTULA: branchial- sternomastoid ant border. parotid- parotid region thyroglossal- midline of neck below hyoid.
  59. 59. 2. Number: usually single but multiple seen in HIV patients (or) actinomycosis. 3. Opening: a) sprouting with granulation tissue-foreign body. b) flushing with skin- TB 4. Surrounding area: erythematous- inflammatory bluish- TB excoriated- faecal pigmented- chronic sinus/fistulae.
  60. 60. 5. Discharge:  White thin caseous, cheesy like- TB sinus  Faecal- faecal fistula  Yellow sulphur granules- actinomycosis  Bony granules- osteomyelitis  Yellow purulent- staph. infections  Thin mucous like- brachial fistula  Saliva- parotid fistula
  61. 61. Palpation: a) Temperature and tenderness: b) Discharge: after application of pressure over the surrounding area. c) Induration: present in chronic fistulae/sinus as in actinomycosis, OM TB Sinus induration absent. d) Fixity: e) Palpation at deeper plane: lymph nodes- TB Thickening of bone underneath- OM
  62. 62. INVESTIGATIONS  CBP- Hb, TLC, DLC, ESR.  Discharge for C/S , AFB, cytology, Gram staining.  X-RAY of the part to rule out OM, foreign body.  X-RAY KUB and USG abdomen in cases of lumbar fistula to rule out staghorn calculi.  MRI  BIOPSY from edge of sinus  CT Sinusogram
  63. 63.  FISTULOGRAPHY/ SINUSOGRAPHY: • For knowing the exact extent/origin of sinus (or)fistula. • Water soluble or ultrafluid lipoidal iodine dye is used. • Lipoidal iodine is poppy seed oil containing 40% iodine.
  64. 64. TREATMENT BASIC PRINCIPLES:  Antibiotics  Adequate rest  Adequate excision  Adequate drainage.
  65. 65.  After excision specimen SHOULD be sent for HPE.  Treating the cause. e.g., ATT for TB sinus. removal of any foreign body. sequestrectomy for OM.
  66. 66. TUBERCULAR SINUS OF NECK Causative organism: mostly M.tuberculosis but also M.bovis Site and mode of infection: a) lymph nodes in anterior triangle from tonsils. b) lymph nodes in posterior triangle from adenoids. c) supraclavicular nodes from apex of the lung.
  67. 67. Clinical stages:
  68. 68. Stage of cold abscess: due to caseating necrosis. non-tender, cystic, fluctuant swelling not adherent to overlying skin. Sternocleidomastoid contraction test- present deep to deep fascia trans illumination negative
  69. 69. TREATMENT:  Zig-zag aspiration by wide bore needle in non-dependent area to avoid a persistent sinus.  Instillation of 1g streptomycin +/- INH in solution with closure of wound without placing a drain.  ATT NOTE: I&D not done-persistent TB sinus.
  70. 70. Stage of collar stud abscess: cold abscess ruptures through deep fascia forming an another swelling in sub-cutaneous plane.  Fluctuant, adherent to skin.  Treated like a cold abscess.
  71. 71. Collar stud abscess
  72. 72. Stage of sinus:  collar stud abscess bursts out leading to a persistent discharging sinus.  Can be multiple, wide opening, undermined edges, non-mobile.  Bluish discoloration around the edges.  NO INDURATION.
  73. 73. INVESTIGATIONS • Hematocrit, ESR , S.albumin , S.globulin • FNAC of lymph nodes and smear for AFB and C/S • Open node biopsy of lymph nodes. • Edge biopsy of sinus- granuloma. • mantoux test • Chest X ray • Sputum for AFB
  74. 74. Sometimes, USG neck to detect cold abscess.  Hypoechoeic lesions with internal echoes S/O debris within.  Guided aspiration of cold abscess.
  75. 75. TREATMENT  ATT  Excision of sinus tract with excision of diseased lymph nodes.
  76. 76. FISTULA-IN-ANO Chronic abnormal communication usually lined to some degree by granulation tissue, which runs outwards from anorectal lumen (internal opening) to skin of perineum or the buttocks (external opening)
  77. 77. AETIOPATHOGENESIS  Cryptoglandular (90% cases)  Non cryptoglandular (10% cases) TB Diabetes mellitus Crohn’s disease Carcinoma rectum Trauma Lymphogranuloma venereum Radiotherapy Immunocompromised patients (HIV etc.,)
  78. 78. CRYPTOGLANDULAR HYPOTHESIS
  79. 79. CLASSIFICATION PARK’S CLASSIFICATION: (relation of primary tract to external sphincter) • Inter sphincteric (45%) • Trans sphincteric (40%) • Supra sphincteric • Extra sphincteric
  80. 80. STANDARD CLASSIFICATION  Sub cutaneous  Sub mucous  Low anal  High anal  Pelvi rectal
  81. 81.  Can be low level fistula- open into anal canal below the internal ring. high level fistula- at/ above the internal ring.  Can be Simple- without any extensions Complex- with extensions  Can be single multiple- TB, ulcerative colitis, crohn’s, HIV, LGV
  82. 82. CLINICAL PRESENTATION • Intermittent discharge (sero-purulent/ bloody) • Pain (which increases until temporary relief occurs when pus discharges) • Pruritus ani • Previous h/o anal gland infection
  83. 83. CLINICAL ASSESMENT  HISTORY: full medical history incl. obstetric,anal, gastrointestinal, surgical, continence  DRE: area of induration, fibrous tract and internal opening may be felt (“button-hole” defect in Ca rectum)  PROCTOSIGMOIDOSCOPY: To evaluate rectal mucosa for any underlying disease process.
  84. 84. GOODSALL’S RULE • If external opening in anterior half of anus, fistula usually runs directly into anal canal. • If external opening in posterior half of anus, fistula usually curves midline of the anal canal posteriorly.
  85. 85. IMAGING  Fistulography  Endoanal ultrasound  MRI
  86. 86. Fistulography:  Reveals primary and secondary tracts.  Useful if extra sphincteric fistula suspected.
  87. 87. END0 ANAL ULTRASOUND • Determines sphincter integrity. • Complexity of fistula. horse-shoe fistula
  88. 88. MRI “GOLD STANDARD” for fistula-in-ano imaging. high variety supra horse-shoe fistula. sphincteric fistula.
  89. 89. MRI Abscesses and contralateral extensions disease
  90. 90. PRINCIPLES OF TREATMENT  Control sepsis EUA Laying open abscesses and secondary tracts Adequate drainage – seton insertion  Define anatomy • Openings and tracts  Internal and External  Single –v- multiple  Extensions / Horseshoe • Relation to sphincter complex  High –v- Low  Exclude co-existent disease
  91. 91. SURGICAL MANAGEMENT  Fistulotomy (The laying open technique)  Fistulectomy  Seton techniques  Fibrin glue sphincter preserving  Anal fistula plug techniques.  Advancement flap  LIFT procedure.
  92. 92. FISTULOTOMY  In inter-sphincteric and low trans-sphincteric fistulas.  Identification of tract with probe followed by division of all structures between external and internal openings.  Secondary tracts laid open.  +/- marsupialization.
  93. 93. Advantages least chance of recurrence relatively easy procedure minor degree of incontinence. Risks results in large and deep wounds that might take months to heal.
  94. 94. FISTULECTOMY • All chronic (low) and also for posterior horse-shoe shaped fistulas. • Excision of entire fibrous tissue and tract and wound kept open. • Sphincter repair +/- advancement flap. • High anal fistulas +/-colostomy.
  95. 95. SETON SUTURE PLACEMENT • Preferable surgical option for high variety. • Setons are usually made from rubber slings • 2 types of seton suture can be placed • Draining Seton Facilitates draining of sepsis Left loose and allows fistula to heal by fibrosis • Cutting Seto Slowly "cheese-wires" though the sphincter muscle Allows fibrosis to take place behind as it gradually cuts through
  96. 96. FIBRIN GLUE  Multi component system containing mainly human plasma fibrinogen and thrombin.  Injected into fistula track which hardens in few minutes and fills the track.
  97. 97. ANAL FISTULA PLUG  The Anal fistula plug is a minimally invasive and sphincter-preserving alternative to traditional fistula surgery.  The plug is a conical device and is placed by drawing it through the fistula tract and suturing it in place.  the plug, once implanted, incorporates naturally over time into the human tissue (human cells and tissues will 'grow' into the plug), thus facilitating the closure of the fistula.
  98. 98. FISTULA PLUG
  99. 99. FISTULA PLUG:
  100. 100. ADVANCEMENT FLAPS Endorectal  Fistula tract probed  Flap raised • Mucosa + Int. Sphincter  Internal opening excised/closed  Flap advanced & sutured
  101. 101. ADVANCEMENT FLAP Anodermal  Fistula tract probed  Flap raised • Anodermal  Flap advanced & sutures  External defect closed
  102. 102. LIFT PROCEDURE Ligation of Inter sphincteric Fistula Tract  Trans sphincteric fistula  Draining seton – 6 weeks  Tract prepared with fistula brush  Debrides  De-epithelializes
  103. 103. FOLLOW UP As with most anorectal disorders, follow-up care includes:  Perianal baths,  analgesics for pain,  stool bulking agents, and  good perianal hygiene

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