A fistula-in-ano is a track , lined by granulation tissue resulting from a perianal abscess which has burst spontaneously or has been opened by an incision without removing the lining of the abscess cavity . the fistula continues to discharge , seldom if ever healing permanently with out surgical aid , because of constant re infection from the anal canal or the rectum , inadequate drainage and repeated movement of the related masculature . The majority of fistula – in – ano are complete , i.e., they have an opening or openings on the skin around the anus and an internal opening in the anal canal , or rarely the rectum a few have no internal opening is called a blind external fistula and a fistula with no external opening a blind internal fistula .
VARIETIES OF FISTULAE – IN –ANO
- ano-rectal ( usually blind internally )
- low level anal
- high level anal
- blind external ano-rectal , submucous
1. the principal symptom is a persistent purulent discharge that irritates the skin in the neighbourhood and causes discomfort
2.often the history dates back for years
3.as long as the opening is large enough for the pus to escape , pain is not a symptom
4. frequently there is a solitary external opening , usually situated with in 3.75 cm of the anus presenting as a small elevation with granulation tissue pouting from the mouth of the opening . sometimes superficial healing occurs ; pus accumulates and an abscess again forms and discharges through the same opening or a new opening .
So there may be present two or more external openings , usually grouped together on the right or left of the middle line but occasionally when both ischio –rectal forsae are involved , a horse shoe fistula results , as a rule there is much induration of the skin and subcutaneous tissues around the fistula , on rectal examination occasionally an internal opening can be felt as a nodule on the wall of the anal canal , irrespective of the number of external openings , there is almost invariably but one internally opening .
PROBING : the insertion of a probe affords valuable information as to the direction of the main canal and with a finger in the anal canal it may be possible to feel the naked end of the probe protruding through the internal opening of the fistula when an external opening is situated at a greater distance than 3.75 cm from the anus a high internal connection can usually be anticipated .
GOOD SALL’S RULE : fistulae with an external opening in relation to the anterior half of the anus usually have curving tracks and may be of the horse-shoe variety
RADIOGRAPHY : unless the course of a high level fistula can be defined clearly by probing , radiography after injecting lipiodol into the external opening provides valuable information concerning the extent and tortuosity of the main channel and will often reveal side branches , if such be present .
SPECIAL CLINICAL TYPES OF FISTULA IN ANO
1.that connected with an anal fissure unlike the usual fistula in ano , pain is a leading symptom , the fistula is very near the anal orifice , usually posterior and the opening is often hidden by the sentinel pile , it can be found only by probing
2.fistula with many external openings may arise from tuberculosis , ulcerative procto-colitis , bilharziasis , and lymphogranuloma venereum with a fibrous rectal stricture , mucoid carcinoma some times complicates long standing fistulae in ano
3.tuberculous : if induration around a fistula is lacking , if the opening is ragged and flush with the surface , if the surrounding skin is discolored and the discharge is watery it strongly suggests that the fistula is due to a tuberculous infection about 10%of fistulae in ano are tuberculous .
Treatment : keeping in view the nature of disease i.e., inflammation , granulations and tuberculous origin ledum and tubercuinum were considered for this long clinical trial . this study is continuous since 1990 –26 cases have been treated so far with one or more external fistululous openings , the duration of treatment is according to the standing of disease in a particular case .
One case report :
Mrs xx 55 years ,horse shoe fistulae with four openings presented in 1988 may with abscess and fissure , this patient was put on tuberculinun 10m –1 dose on first day followed by ledum 200 daily 3 times and Echinacea Q lotion wash . the progress was quick . abscess drained and fissure too healed . treatment was continued for 2.5 years and all the openings gradually closed . ( healing from inside of whole trank ) patient has no complaint , no discharge & discomfort .
All cases have reported better on this regime though there are many medicines for fistula . this study is disease oriented since the patients with such diseases comes with very scanty symptoms .
Tuberculinum in high potency has cleared the base for indicted pathological remedy to work more effectively
Ledum pal known for its healing power has shown best results on laying granulation tissue , thus healing the whole track gradually not closing the mouth merely when an abscess in the rectum adopts chronic form , it is termed as fistula , when pus collects , there is swelling it opens and pus is drained , this process is repeated again and again .
Belladonna : when the abscess forms
Mercurius vivus : after the opening of the access
Hepar sulphur this medicine hastens suppuration 200 and higher potencies heal and prevent recurrence . the same is the case with silicea in 1000and higher potencies cures
Calcarea sulph : may be used after the opening of the abscess to dry it up and heal . cal-flour , nitric acid and graphites are also indicated .