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PERIANAL SUPPURATION ANAL ABSCESS-FISTULA. Anatomy anal glands.

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Presentation on theme: "PERIANAL SUPPURATION ANAL ABSCESS-FISTULA. Anatomy anal glands."— Presentation transcript:

1 PERIANAL SUPPURATION ANAL ABSCESS-FISTULA

2 Anatomy anal glands

3 anal glands  The average number of glands in a normal anal canal is six (range, 3–10)  Each gland is lined by stratified columnar epithelium with mucus-secreting or goblet cells interspersed within the glandular epithelial lining and has a direct opening into an anal crypt at the dentate line.  Occasionally, two glands open into the same crypt  Half the crypts have no communication with the glands

4 anal glands

5 Perianal spaces

6

7 Horseshoe-shaped connections of the anorectal spaces.

8 Etiology  Cryptogenic or cryptoglandular  Specific ones include the following: o Crohn’s disease, chronic ulcerative colitis o Actinomycosis, lymphogranuloma venereum tuberculosis (TB) o foreign body o carcinoma, lymphoma, leukemia o trauma (impalement, enemas, prostatic surgery, episiotomy, hemorrhoidectomy) o radiation

9 Cryptoglandular disease  The anal glands were found to arise in the middle of the anal canal at the level of the crypts and to pass into, the submucosa,  two-thirds continuing into the internal sphincter  one-half penetrating into the intersphincteric plane

10 Cryptoglandular disease Obstruction of these ducts, whether secondary to fecal material foreign bodies, or trauma, results in stasis and infection chronicity is due to persistence of the anal gland epithelium in the part of the tract joining the internal opening or to nonspecific epithelialization of the fistula tract from either the internal or external openings than to a chronically infected anal gland Destruction of the anal gland epithelium might explain the occasional spontaneous healing of a fistula

11 Acute phase (abscess) symptoms  acute pain and in the anal region. Pain occurs with sitting or movement and is usually aggravated by defecation and even coughing or sneezing.  Swelling  purulent anal discharge  preceding bout of diarrhea  bleeding  General symptoms include malaise and pyrexia

12 Bacteriology  Escherichia coli (22%)  Enterococcus spp. (16%)  Bacterioides fragilis (20%)

13 Acute phase (abscess) Findings  Tender induration  Pus may be seen exuding from a crypt  Examination under anesthesia is not only justified but also indicated  Supralevator abscess, a tender mass in the pelvis may be diagnosed by rectal or vaginal examination. Abdominal examination may reveal signs of peritoneal irritation

14 Acute phase (abscess) location

15 Avenues of extension for an anal fistula

16 chronic phase(fistula) history  the patient’s history will reveal an abscess that either  burst spontaneously or  required drainage  small discharging sinus

17 chronic phase(fistula)  External opening usually can be seen as a red elevation of granulation tissue with purulent serosanguinous discharge on compression.  Opening is sometimes so small that it can be detected only when palpation around the anus expresses a few beads of pus

18 chronic phase(fistula)  An external opening adjacent to the anal margin may suggest an intersphincteric tract  A more laterally located opening would suggest a transsphincteric one  The further the distance of the external opening from the anal margin, the greater is the probability of a complicated upward extension  increasing complexity and increasing laterality and multiplicity of external openings also has been observed

19 chronic phase(fistula)  palpate the skin since with a superficial fistula a cord structure can be felt just beneath the skin leading from the secondary opening to the anal canal  internal opening might be palpable  crypt of origin is often retracted into a funnel by pulling the fibrous tract leading to the internal sphincter; this state is called the funnel, or ‘‘herniation sign’’ of the involved crypt

20 Goodsall’s rule

21 Probing of the fistulous tract

22 INVESTIGATION  Anoscopy and sigmoidoscopy  Fistulography  Endoanal Ultrasonography  Endoanal Magnetic Resonance Imaging

23 Fistulography

24 Endoanal Ultrasonography

25 Drainage of a supralevator abscess

26 incision and drainage of a horseshoe abscess.

27 FISTULA-IN-ANO INCIDENCE  Men predominate in most series with a male- to-female ratio varying from 2:1 to 7:1  Age distribution is spread throughout adult life with a maximal incidence between the third and fifth decades

28 INCIDENCE  intersphincteric, 70%  transsphincteric, 23%;  suprasphincteric, 5%  extrasphincteric, 2%.

29 FISTULA-IN-ANO principles of management 1. the primary opening of a tract must be identified 2. the relationship of the tract to the pubrorectalis muscle must be established; 3. division of the least amount of muscle in keeping with cure of the fistula shouldbe practiced; 4. side tracts should be sought 5. the presence or absence of underlying disease should be determined

30 Intersphincteric fistula: simple low tract

31 Intersphincteric fistula: high blind tract

32 Intersphincteric fistula: high tract with a rectal opening

33 Intersphincteric fistula: secondary to pelvic disease

34 Transsphincteric fistula: uncomplicated type

35 Trans-sphincteric fistula: high blind tract

36 Suprasphincteric fistula: uncomplicated type

37 Suprasphincteric fistula: high blind tract

38 Extrasphincteric fistula: secondary to anal fistula

39 Fistulotomy vs fistulectomy

40 Seton insertion

41 Advancement rectal flap

42 Dermal Island Flap Anoplasty

43 Other procedures  Fistulectomy and Primary Closure  Fibrin Glue  Anal Plug

44 Necrotizing infection

45 Anal incontinence A. those continent of solid and liquid stool and flatus (i.e., normal continence) B. those continent of solid and usually liquid stool but not flatus C. acceptable continence of solid stool but no control over liquid stool or flatus D. continued fecal leakages

46 Jorge/Wexner Continence Grading Scale (0 = Perfect; 20 = Complete Incontinence )

47 Causes of anal incontinence PREVIOUS OPERATIVE PROCEDURES  Previous Anal Operations o Internal Sphincterotomy o Fistula Surgery o Hemorrhoidectomy o Manual Dilatation of Anus  Sphincter-Saving Procedures

48 Causes of anal incontinence  CHILDBIRTH  AGING  PROCIDENTIA  TRAUMA  PRIMARY DISEASE; Chronic inflammatory processes of the anorectal region, as ulcerative colitis, amebic colitis, lymphogranuloma venereuminfections, or laxative abuse  IRRADIATION  NEUROGENIC CAUSES  CONGENITAL ABNORMALITIES  PRIMARY; sphincter defects in 65%, pudendal neuropathy

49 Investigations  Anal Endosonography  The ‘‘Enema Challenge’’  Anorectal Manometry  Electromyography  Pudendal Nerve Terminal Motor Latency  Rectal Compliance  Magnetic Resonance Imaging

50 Endosonography

51

52

53 Endo MRI

54

55 management

56 NONOPERATIVE PROCEDURES  Medical Treatment  Continence Plugs  Biofeedback Training, exercise of the external sphincter muscle, training in the discrimination of rectal sensations, and training synchrony of the internal and external sphincter responses during rectal distention

57 OPERATIVE PROCEDURES  Anterior Anal Sphincter Repair  Postanal repair  Muscle Transposition  GRACILIS MUSCLE TRANSPOSITION  DYNAMIC GRACILOPLASTY  GLUTEAL MUSCLE TRANSPOSITION  FREE MUSCLE GRAFT

58 OPERATIVE PROCEDURES  Artificial Sphincter Implantation  Secca Procedure  Implantation of Silicone Biomaterial  Sacral Neuromodulation (SNM)  Colostomy

59 Anterior Anal Sphincter Repair

60 Artificial Sphincter


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