AnoRectal Abscess and Fistula PowerPoint Presentation

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AnoRectal Abscess and Fistula Dino Mendez

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Anatomy Rectum (Retroperitoneal) Sigmoid colon to anorectal line Surgical Anal canal Anorectal line (or puborectalis) to anal verge Anatomical Anal canal Dentate line to anal verge Anal Margin Extends laterally from the anal verge all around for a distance of 5 cm

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Anatomy Dentate/Pectinate line Anorectal line Anal Columns of Morgagni Anal crypt/sinus *Anal gland*

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Anatomy – Muscles Internal sphincter External sphincter Intersphincteric groove Puborectalis (Levator ani)

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Anatomy Anorectal Ring Strong muscular ring that represents the upper end of the sphincter, formed by puborectalis, deep portion of external sphincter and upper border of internal sphincter Anorectal Angle Maintained by U-shaped sling of puborectalis around anorectal junction, supports rectum and aids in continence Anal sphincters are responsible for closure of the anal canal to retain gas and liquid stool. Puborectalis & anorectal angle are designed to maintain gross fecal continence

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Anatomy - Muscles

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Anorectal Angle

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Anatomy – Anorectal Spaces Perianal Ischioanal/Ischiorectal Intersphincteric Supralevator Deep postanal space (Space of Courtney)

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Anatomy – Anorectal Spaces Perianal and Perirectal Spaces

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Anorectal SuppurationEpidemiology Anorectal abscesses (“Acute phase”) 100,000 cases per year Age range 20-60, 2:1 ratio M:F 30% recurrence rate Anorectal fistula (“Chronic phase”) 25-40% of abscesses lead to fistula 10-20% recurrence rate

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Anorectal SuppurationEtiology *Cryptoglandular* (90%) Malignancy Infectious- actinomycosis, lymphogranuloma vernerum, HIV, Tb Crohn’s, diverticulitis, appendicitis, PID Trauma/Surgery

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Classification of Anorectal Abscesses

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Classification of Anorectal Abscesses Supralevator abscess MUST r/u intraabdominal process

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Anorectal AbscessClinical Presentation Hx Severe, constant pain Fevers/chill Malaise Drainage (relieves pain) Constipation, Urinary retention Exam Induration, fluctuance, erythema, warmth, purulent drainage DRE

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Anorectal AbscessTreatment I&D- cruciate or elliptical incision Antibiotics? Culture?

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Anorectal AbscessTreatment I&D- cruciate or elliptical incision Antibiotics? Culture? Indications: Immunosuppression Valvular heart dz Prosthetic devices Sepsis or Extensive cellulitis Crohn’s dz Prophylactic fistulotomy? Sitz Baths

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Perianal - ER Ischiorectal- ER or OR Intersphincteric - OR Supralevator- OR (solve etiology!) Horse-shoe- OR Anorectal AbscessI&D – ED vs OR

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I&D of the abscess Drainage of an abscess (especially, ischiorectal abscess) requires some planning, because the condition may well be associated with the subsequent development of a fistula. It is important, therefore, to drain the abscess by creating an external opening as close to the anal verge as is possible. If this is not considered, the subsequent fistulotomy may result in a larger wound that requires a long time to heal.

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Anorectal Fistula(Fistula-in-Ano) “Chronic form” of anorectal abscesses Connection/tract between two epithelial-line structures Internal opening- Anal crypt of the gland External opening- Perianal/Perineal skin Other: rectovesicular, rectovaginal, rectourethral fistula

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Park’s Classification of Anorectal Fistulas Type 1 – Intersphincteric, most common Type 2 – Transphincteric Type 3 – Suprasphincteric Type 4 - Extrasphincteric

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Park’s Classification of Anorectal Fistulas

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Anorectal FistulaClinical Presentation Hx Chronic drainage from “nonhealing abscess” Pain with defecation Pruritus Physical exam Draining pustule Erythema, induration, excoriated skin DRE- firm cord (fistula tract)

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Caution – Necrotizing Fasciitis

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Anorectal FistulaGoodsall’s Rule General guideline for position of internal opening and path of fistula tract, based off line drawn through ischial spines Note: applies to external openings within 3cm of anal verge Posterior- curved tract, travel curvilinear to posterior midline Anterior- straight tract, enter anterior anal canal in radial fashion Exception- if External opening > 3cm of anal verge then curved tract that travels curvilinear fashion to posterior midline

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Anorectal FistulaDiagnosis Exam under anesthesia (EUA)- anoscopy, proctoscopy; assess for internal opening and occult abscess Injection of Hydrogen peroxide or povidone iodine allows to visualize bubbles at internal opening(s) MRI- most sensitive Transrectal U/S (TRUS) Fistulogram, CT scan

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Anorectal FistulaManagement Goals of Therapy Drain local infection Eradicate fistulous tract Avoid recurrence while preserving native sphincter function

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Anorectal FistulaManagement Simple Fistula- minimal or no involvement of external sphincter or puborectalis e.g. Intersphincteric, low-lying Transsphincteric Complex Fistula Involvement of > 30% of external sphincter Suprasphincteric Extrasphincteric or high fistulas (proximal to dentate line) Fistulas with multiple tracts Recurrent fistulas Fistulas related to IBD, infection (TB, HIV), radiation

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Anorectal FistulasManagement Simple Fistulas *Fistulotomy*- lay open fistula tract, make incision over entire length of fistula using probe as guide Recurrence rate = 0-20% Fibrin plug > Fibrin glue Recurrence rate = 30-65% Advantage- preserve sphincter function

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Anorectal FistulasManagement of Simple Fistulas Fistulotomy

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Anorectal FistulasManagement of Simple Fistulas Fibrin Plug

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Fibrin Glue Anorectal FistulasManagement of Simple Fistulas

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Complex Fistula *Cutting Seton (Staged Fistulotomy)*- tightening of seton at regular intervals allows for slow transection of muscle, minimizing sphincter dysfunction Recurrence = 0-18% Incontinence rate = 0-30% Mucosal advancement flap- mobilize flap that covers the internal fistulous opening Indication = recurrent fistula Recurrence = 0-36% Incontinence rate = 0-13% Anorectal FistulasManagement

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Cutting seton (staged fistulotomy) Thread silk suture through fistula tract, tie together on outside Incise SKIN ONLY over fistula tract Tighten seton at regular intervals, slowly cutting through sphincter Gradual cutting causes muscle scarring leaving muscle ends near usual location after being transected, thus minimizing disruption of sphincter and decreasing risk of incontinence Anorectal FistulasManagement of Complex Fistulas

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Anorectal FistulasManagement of Complex Fistulas Cutting Seton (Staged Fistulotomy)

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Mucosal advancement flap Anorectal FistulasManagement of Complex Fistulas

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Questions 45 y/o F with DM2 (HgbA1c = 6.2) presents with 2-day h/o acute perirectal pain. On exam, a tender fluctuant mass is present to the left of the anus. What treatment should be administered at this time? Broad spectrum antibiotics Abscess drainage and excision of fistulous tract Incision and drainage of abscess Continued observation Treatment of Crohn’s disease

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Questions 45 y/o F with DM2 (HgbA1c = 6.2) presents with 2-day h/o acute perirectal pain. On exam, a tender fluctuant mass is present to the left of the anus. What treatment should be administered at this time? Broad spectrum antibiotics Abscess drainage and excision of fistulous tract Incision and drainage of abscess Continued observation Treatment of Crohn’s disease

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Questions Regarding fistula in ano: The majority are intersphicteric They usually follow a curvilinear course to the midline if arising in anterior anal crypts Persistent drainage after fistulotomy indicates presence of Crohn’s disease Seton placement should be rarely required

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Questions Regarding fistula in ano: The majority are intersphicteric They usually follow a curvilinear course to the midline if arising in anterior anal crypts Persistent drainage after fistulotomy indicates presence of Crohn’s disease Seton placement should be rarely required

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Questions Anorectal abscesses are infections that typically: Originate within anal crypt glands Resolve completely without sequalae after I&D Form horseshoe extensions Occur in pts who are immunocompromised Can be treated early with antibiotics

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Questions Anorectal abscesses are infections that typically: Originate within anal crypt glands Resolve completely without sequalae after I&D Form horseshoe extensions Occur in pts who are immunocompromised Can be treated early with antibiotics

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Q: With regard to the anal sphincteric mechanism, which of the following statements is/are true? The teniae of the colon thicken to form the internal sphincter Internal sphincter is made up of smooth muscle and surrounds the distal two-thirds of the anal canal External sphincter is made up of striated muscle Puborectalis is responsible for the anorectal angle The anorectal ring is composed of the palpable deep portion of external sphincter

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Q: With regard to the anal sphincteric mechanism, which of the following statements is/are true? The teniae of the colon thicken to form the internal sphincter Internal sphincter is made up of smooth muscle and surrounds the distal two-thirds of the anal canal External sphincter is made up of striated muscle Puborectalis is responsible for the anorectal angle The anorectal ring is composed of the palpable deep portion of external sphincter

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Q: With regard to the anatomy of the anal canal, which of the following statements is/are true? The dentate line lies above the columns of Morgagni Anal gland ducts open into the anal crypts Anal glands never extend beyond the internal sphincter The columns of Morgagni overlie the internal hemorrhoidal plexus The epithelium above the dentate line is innervated by the autonomic nervous system

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Q: With regard to the anatomy of the anal canal, which of the following statements is/are true? The dentate line lies above the columns of Morgagni Anal gland ducts open into the anal crypts Anal glands never extend beyond the internal sphincter The columns of Morgagni overlie the internal hemorrhoidal plexus The epithelium above the dentate line is innervated by the autonomic nervous system

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Q: What is Goodsall’s rule?

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ANORECTAL FISTULA Goodsall’s Rule External opening anterior to this line and within 3 cms from anal verge will lead to a straight radial tract External opening posterior to the line will lead to a curved tract and an internal opening in the posterior midline Long anterior fistula (>3 cms from anal verge) has a curved tract and an internal opening in the posterior midline

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Q: With regard to the management of patients with fistula in ano, which of the following statements is/are true? All internal openings of fistulas are located posteriorly according to Goodsall’s rule The most common type of fistula is intersphincteric Excision of the entire fistulous tract is necessary for cure High fistulas are managed by seton suture A horseshoe fistula can be treated by posterior midline internal sphincterotomy combined with opening the deep postanal space

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Q: With regard to the management of patients with fistula in ano, which of the following statements is/are true? All internal openings of fistulas are located posteriorly according to Goodsall’s rule The most common type of fistula is intersphincteric Excision of the entire fistulous tract is necessary for cure High fistulas are managed by seton suture A horseshoe fistula can be treated by posterior midline internal sphincterotomy combined with opening the deep postanal space