A 32-year-old male presents with a yellowish discharge around his anus for two weeks. On examination, there is a small inflamed opening on the right side of the anal verge that discharges pus, and an elevated tract is seen. Based on these findings and the patient's history of a previous anal abscess, he is diagnosed with a low anal simple intersphincteric fistula. Surgical management options aim to drain infection, eradicate the fistulous tract, avoid recurrence, and preserve sphincter function, and may include techniques such as fistulotomy, fistulectomy, seton placement, fibrin plug, or mucosal flap.

1. Perianal Fistula
(CBD)
Saleh Hassan Alorainy
438020973
SN:24

2. Case Scenario
• AP a 32-year-old male, Medically free, presents to the
outpatient clinic complaining of a discharge around the anal
canal that started two weeks ago

3. History

4. Personal Data
• Name: AP
• Age: 32
• Gender: Male
• Marital Status: Recently Married
• Nationality: Saudi
• Route of admission: Referral to surgical ward

5. Chief Complaint
• A yellowish discharge around the area of the anus for two
weeks

6. History of presenting illness
• Site: Right to the anal cavity
• Onset: Intermittent gradual painful discharge for two weeks,
with increasing in discomfort.
• Character: Small amount of pus with foul odor
• Aggravating and Relieving factors: gets minimal relief after
the pus drains.
• Timing: No specific time
• Severity: Began to affect his daily life
• Constitutional symptoms: No hx of fever, fatigue, loss of
weight, loss of appetite, night sweats

7. History of presenting illness
• Associated Symptoms:
• GI: No hx of Dysphagia, abdominal pain, nausea and vomiting,
bloating, diarrhea, constipation, change in stool color.
• GU: No history of frequency, hematuria, dysuria

8. Past Medical and surgical history
• He was diagnosed with an anal abscess for about 2 months, no
history of Chronic illness.
• No hx of admissions
• No hx of conventional or herbal drugs
• No hx of surgical procedures, other than drainage of the
abscess
• No known allergies and vaccines are up to date
• No recent hx of blood transfusion or trauma

9. Social History
• He works at a desk job, living with his wife, with sedentary
lifestyle, he has a good socioeconomic status.
• Smokes Cigarettes for more than 12 Years (1 packs a day), no
Alcohol, no Illicit Drugs
• Denied any Extramarital Relationships.
• No Hx of recent travels and No Hx of Contact with animals or
Sick Person.
• No Hx of specific dietary habits.

10. Family history
• No Hx of similar or chronic illness.
• No Hx of Malignancy.
• No Hx of Recent deaths.

11. Systemic Inquiry
• CNS: -Headache , -Hearing loss, -Vision Loss -Dizziness, -
Convulsions, -Vertigo, -Motor or sensory abnormalities
• CVS: - Palpitations, -Chest Pain, -Cyanosis
• RESP: -Cough, -Dyspnea, -Wheezes
• Rheum: -Dry mouth, -Dry eyes, -Raynaud's
• MSK: -Joint Pain or Inflammation, -Muscle & bone Pain or
weakness.
• DERM: -Alopecia, -Skin Rash, -Nail Changes, - Photosensitivity
• PSYCH: -Ve

12. Differential Diagnosis
• Perianal Fistula
• Recurrent anorectal abscess
• Pilonidal cyst
• Anal tumor

13. Physical Examination

14. Vital Signs
• BP: 108/71
• HR: 70 bpm with normal rhythm
• RR: 14
• Temperature: 37.1
• Weight: 96 KG
• Height: 172 cm
• BMI: 32.4

15. General appearance
• The patients look well, oriented to time and place
• The patient is Mildly obese
• There is No skin discoloration
• The patient is not connected to any device

16. General Examination
• Hands:-Nails, -Finger discoloration or deformities -Muscle
wasting, -Nodules,-Discoloration. –Tremor, -Cyanosis
• Eyes: -Pallor, -Jaundice, -Xanthelasma
• Oral Cavity: Good dental hygiene -Cyanosis, -Oral Ulcers
• Head: Normal Hair distribution
• Lymph node: No palpable lymph nodes
• Neck: No visible JVP, No Mass, No palpable Thyroid, No
carotid Bruit

17. Local Examination
• Per rectal exam
 Inspection: There was a small inflamed opening that discharges a
pus, it is closely on the right side of the anal verge, from this opening
there is an elevated skin that represent a tract. Could not appreciate
any rash, fissures, abscesses and ulcers. Cough did not show any
signs of prolapse or hemorrhoids.
 Palpation: Prostate was symmetrical and normal in shape and
consistency; A small indentation is felt on the lower end of the anus
which represents the entry of the fistula, No rectal lumps were felt and
there was no tenderness. Anal tone was intact. There was no blood or
mucus

18. Park’s classification

19. Goodsall’s rule

20. Case Summary
• AP a 32-year-old male presents to the outpatient clinic
complaining of a discharge around the anal canal that started 2
weeks ago, the patient was diagnosed with anal abscess about
2 months ago. On examination There was a small inflamed
opening that discharges a pus, it is closely on the right side of
the anal opening.

21. Investigations

22. General Procedures
• Proctosigmoidoscopy: To evaluate the rectal mucosa for any
disease process.
• Probe insertion: Helps to identify the whole fistulous tract.
• Methylene blue: used if we cannot identify the entry of the
fistula.

23. Imaging techniques
• Endoanal US w/ hydrogen peroxide
• MRI (GOLD STANDARD)
• CT & Fistulography

24. Final Diagnosis
• Low anal simple Intersphincteric Fistula

25. Management

26. Goals of management
• Drain local infection
• Eradicate the fistulous tract
• Avoid recurrence
• Preserve sphincter function

27. Surgical management
• Conventional techniques:
 Fistulotomy
 Fistulectomy
• Sphincter preserving techniques:
 Seton
 Fibrin plug
 Mucosal flap

28. Questions?

29. Thank You!