anal fistula a surgical approach including treatments , drugs used in anal fistulas and surgical procedures and emergencies . the difference between anal fistulas and anal fissures pharmacological approach to treatment counselling points , education , theory , mechanism of action of the drugs and side effects

1. ANAL FISTULA
PRESENTATION BY: APPLEH SEDEM
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2. OUTLINE
 INTRODUCTION
 DEFINITION
 AETIOLOGY AND RISK FACTORS
 EPIDEMIOLOGY
 CLASSIFICATION
 PATHOPHYSIOLGY
 CLINICAL PRESENTATION
 MANAGEMENT/TREATMENT
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3. INTRODUCTION
 A fistula is an abnormal communication or connection between two
epithelial surfaces.
Types of fistulas
 Obstetric fistulas: an epithelial lined tract between a woman’s genital
tract and her urinary tract or rectum. Major cause: Obstructed/prolonged
labour
• Vesicovaginal fistula
• Rectovaginal fistula
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4. INTRODUCTION
 Intestinal fistula : an abnormal
connection between the intestine
and skin and another internal
organ.
 Commonly caused by
complication of abdominal
surgery, intra-abdominal
inflammation (15-25%)
• Enterocutaneous fistula
• Enterovesical
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5. INTRODUCTION
 Arteriovenous fistula: an
abnormal communication or
connection causing shunting
of blood from the high
pressure arterial side to the
low pressure venous side.
 Developmental errors that
occur between weeks 4 and 10
of embryogenesis.
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6. ANAL FISTULA
An anal fistula is an epithelial-
lined tract connecting the anal
cavity to the perianal skin.
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7. AETIOLOGY AND RISK FACTORS
 Previous anorectal abscess
 Tuberculosis
 Crohn disease
 Radiation therapy
 Trauma (Rectal foreign bodies)
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8. EPIDEMIOLOGY
 The prevalence is greater in men than in women. In men, prevalence
is 12.3 cases per 100,000 population and in women, 5.6 cases per
100,000 population.
 Commonly occurs between the ages of 20-40 years; the mean
patient age at diagnosis is 38 years.
 Approximately 30-50% of patients with anorectal abscess form an
anal fistula
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9. PATHOPHYSIOLOGY
 Infection and inflammation of the anal gland
 Abscess formation
 Spread of the infection through all layers of the wall of the anal
canal
 Perianal abscess formed
 Abscess raptures to the exterior of the perianal skin
 Connection between anal canal and perianal skin formed
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10. ANAL CANAL
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11. CLASSIFICATION
Park’s classification system
 Intersphincteric :
• dentate line
• tracks via the internal sphincter to
the intersphinteric space
 Trans sphincteric:
• Dentate line
• both the internal and external
sphincters into the ischiorectal
fossa.
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12. CLASSIFICATION
 Suprasphincteric:
• dentate line to the intersphincteric
space
• tracks superiorly to above the
puborectalis, down to the external
anal sphincter into the ischiorectal
fossa
 Extrasphincteric:
• begins at the rectum
• extends downward and opens
around the anus.
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13. CATEGORIES
 Simple anal fistulas
 A single tract
 Less than 30% of the external
sphincter
 Complex anal fistulas
 Multiple tracts
 Recurrent fistulas
 More than 30% of the external
sphincter
 Predisposing factors: Crohn’s
disease, radiation treatment
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14. GOODSALL’S RULE
 External opening anterior to a
plane passing transversely
through the centre of the anus
will follow a straight radial
course to the dentate line,
 Fistulas with their openings
posterior to this line will
follow a curved course to the
posterior midline.
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15. CLINICAL PRESENTATION
 Perianal discharge; purulent
 Pruritis
 Perianal pain
 Swelling
 Bleeding
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16. DIAGNOSIS
 Physical examination: Digital rectal exam
 Anoscopy
 MRI
 CT scan
 Fistulography
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17. GOALS OF THERAPY
 Draining abscess
 Eradicating the fistulous tract
 Prevent recurrence
 Preserving anal sphincter function
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18. TREATMENT
• Fistulotomy
-simple fistulas
• Fibrin plugs and glue
-Simple fistulas
-less complications
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19. TREATMENT
• Seton method
- Incontinence
• Anorectal Advancement flaps
-Low recurrence rates
-reduced complications
• Video-assisted anal fistula
treatment
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20. CONCLUSION
 A fistula is an abnormal connection between two epithelial surfaces.
Types include obstetric fistulas, intestinal fistulas etc.
 An anal fistula has a primary opening in the anal canal and a
secondary opening in the perianal skin.
 Parks classification system : Intersphincteric, trans sphincteric,
suprasphincteric and extrasphincteric fistulas.
 Management/Treatment: Fistulotomy, seton method, fibrin plug and
glue.
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21. REFERENCES
 Dudukigan H, Abcarian H. (2011).Why do we have so much trouble
treating anal fistula? World journal of gastronenterology.
Baishideng publishing group inc.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3160532/
 Porter R., Kaplan J.(2011).The merck manual of diagnosis and
Therapy. 19th Edition. Whitehouse station, NJ. Pp 248-249
 Poggio J. (2020). Fistula-in-ano. Department of Surgery, Drexel
University College of Medicine.
https://emedicine.medscape.com/article/190234-overview?
 Gupta P.J.(2005). Ano-perianal tuberculosis-solving a clinical
dilemma. Makerere medicacal school, Uganda.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1831950/
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22. REFERENCE
 Vogel J D, Johnson E K et al (2016). Clinical Practice Guidelines
for the management of anorectal abscess, Fistula-in-ano and
rectovaginal fistula. The American Society of Colon and rectal
surgeons,
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