Diagnostic Procedures in Fistula-In-Ano : Diagnostic Procedures in Fistula-In-Ano - presentation by
Dr T.Divakar Rao , M.S ( Ay) B.H.U,
Senior Medical Officer,
CGHS(sushruta) Ayurvedic Hospital,
Lodhi Road, New Delhi-110003. : Acharya sushruta Acharya Sushruta : Acharya Sushruta Acharya sushruta - the father of surgery
Author of sushruta samhita
First one to describe about surgical instruments and techniques
Dissection and dead body preservation
First one to perform plastic surgery
(Rhino-plasty),ocular surgery, Ano-rectal surgery and various abdominal surgeries
Elaborate description regarding types of fractures and its management, also described types of bandages for different fractures
Elaborate description reg. fistula-in-Ano haemorrhoids and sinus etc. Torch bearer and path breakers : Torch bearer and path breakers CGHS (sushruta) Ay Hospital Lodhi Road New Delhi-03 : CGHS (sushruta) Ay Hospital Lodhi Road New Delhi-03 This is the only Ayurvedic Hospital having 50 beds( for CGHS beneficiaries) in India and is under the control of Min. of health &family welfare and AYUSH. Expertise being in panchakarma and kshar sutra therapy. Fistula-in-Ano (Bhagandar) : Fistula-in-Ano (Bhagandar) It’s a Chronic inflammatory condition, a tubular structure opening in the Ano-rectal canal at one end and surface of perineum or peri-anal skin on the other end.
Classical fistula has two openings, one internal and other external
Chronic on/off pus discharge
Deep seated abscess is the source of pus
Some times Passing of stool from external opening Causes of Fistula-in-Ano : Causes of Fistula-in-Ano Abscess in one or more potential spaces
Source of infection in Anal fissure
An ulcer at the root of the pile mass
Inflamed anal crypt
Infection from hair follicle
Infected sebaceous gland
Infected sweat gland
Foreign body injury
Inflamed /thrombosed pile mass
Retained sutures after haemorrhoidectomy
Foreign body penetrating from out side
Radiation burns from x-rays and radio therapy Systemic diseases can also cause Fistula-in-Ano : Systemic diseases can also cause Fistula-in-Ano Tuberculosis of Intestine
Osteo-myelitis of pelvic bones FIA with sys tuberculosis : FIA with sys tuberculosis CLASSIFICATION OF FISTULA : CLASSIFICATION OF FISTULA 2.ARVACHINA (ANTARMUKHA) 1.PARACHINA
(BAHIRMUKHA) I. ACCORIDING
TO ITS OPENING II.ACCORDING TO THE DOSHA 2.PAITTIK
(USHTRA GRIVA) 1.VATIK (SATAPONAK) 5.AGANTUJ (UNMARGI) 3.SHLESHMIK (PARISRAVI) 4.SANNIPATAJ (SAMBUKAVART) III.ACCORDING TO THE DIRECTION OF PUS DICHARGE 1.RIJU (DIRECT) 2.VAKRA (CURVED) Slide 11: Standard classification Pelvi-rectal High-anal Sub-cutaneous Sub-mucous Low-anal Types of fistula-in-ano : Types of fistula-in-ano complicated Fistula-In-Ano : complicated Fistula-In-Ano Problems in diagnosing and treating Fistula-in-ano : Problems in diagnosing and treating Fistula-in-ano Late diagnosis
lack of advanced diagnostic modalities
Avoidance of timely surgical intervention
Patient hesitation (esp. females)
Non-availability of kshar-sutra and surgical experts for timely intervention
Natural& routine infection with urine stool etc.
Surgical technique limitations.
lack of awareness about the disease among the people
use of heavy Anti-biotics Anti-Biotics :Have their proper use : Anti-Biotics :Have their proper use Diagnosis procedures for fistula-in-ano : Diagnosis procedures for fistula-in-ano Trividha pariksha : darshana, sparsana and prashna
Astanga pariksha :Nadi,mala,mootra,jiwha sabdam,sparsham,drik and akriti.
DRE : int.opening can be felt as a nodule
Dye injection (methylene blue or Indigo carmine
Procto-scopy :may reveal internal opening
Probing : useful in exploring tracts. painful sometimes. false passage one may create in fibrosed tracts Method of dye injection : Method of dye injection : Radio-Imaging Techniques Fistulo-graphy CT Scan MRI (Endo-anal) USG (TPUS,TRUS,TVS,EAUS) A first class surgeon can operate/cure any type of fistula in any theatre and in any OUTFIT…!!!! : A first class surgeon can operate/cure any type of fistula in any theatre and in any OUTFIT…!!!! anatomy of rectum : anatomy of rectum Reservoir of feaces?
Recto-sigmoid junction 3rd sacral vertebra
Ant-posterior curvature is known as sacral flexure, after passing pelvic diaphragm it passes downwards backwards. This curvature is known as perineal flexure.
3 lat. curvatures 2 in right 1 in left.
posteriorly :3rd sacra vertebra, coccyx median sacral vessels and coccygeal vessels
Anteriorly : in male: bladder ,seminal vesicles, prostate
in female :uterus, upper part of vagina, recto uterine pouch.
Laterally :para-rectal fossa, pelvic sym.plexuses,
sup. rectal vessels. Anal canal : Anal canal The anal canal is the terminal portion of the intestinal tract it begins at the ano-rectal junction (the point passing through the levator-ani muscles), is about 4 cm long, and terminates at the anal verge.
Anatomical : that extends from the dentate line to the anal verge.
Anteriorly Male : bulb of urethra
Female : perineal body and vagina
Posteriorly : Coccyx and pubo-rectalis muscle
Laterally : Ischio-rectal fossa containing inferior haemorrhoidal vessels and pudendal nerve surrounded below by external and internal sphincter muscles. cont. : cont. mucous membrane folds are called crypts of morgagni. columns join to form anal valves below and sinuses above usually get infected.
anal glands form crypts at dentate line (crypts of morgagni).
imaginary line where the anal valves are situated is known as dentate line (pectinate line).
INTERNAL SPHINCTER : thickened cont. of the muscle coat of the rectum.3 cm long.
EXT ANAL SPHINCTER: 3 parts
1.sub cutaneous part
SPACES ON THE LATERAL SIDE OF RECTUM AND ANAL CANAL:
2.ischio rectal space
3.pelvirectal space Anatomy of Anal canal : Anatomy of Anal canal Anatomy of Anal canal : Anatomy of Anal canal Illustration of anal canal anatomy in
the coronal plane. EAS :external anal sphincter,
IAS :internal anal sphincter, IS:inter-sphincteric
space, LA :levator-ani, LM : longitudinal
muscle, PR : pubo-rectalis muscle Anal canal with anal glands : Anal canal with anal glands fistulo-graphy : fistulo-graphy Fsitulo-graphy is a technique where catheterization and radiographic contrast x-ray examination of a cutaneous opening to see whether there is any communication to mucosal surface not.
It’s aim here to visualize
The direction of primary and secondary tracts
The External and Internal openings and their relative positions
The relation of the fistulous tract with ano-rectal canal ano-rectal ring and other structures
To confirm the diagnosis of fistula
Ramifications of the tracts Indications for fistulo-graphy : Indications for fistulo-graphy Longer duration
High anal fistula
Horse-shoe shaped fistula
When origin lies else where
Last but not the least, when the treating surgeon is a rookie Exploring Fistula-in-Ano is just like watching this clip ….. : Exploring Fistula-in-Ano is just like watching this clip ….. PARAPHERNALIA REQUIRED FOR PERFORMING FISTULOGRAPHY : PARAPHERNALIA REQUIRED FOR PERFORMING FISTULOGRAPHY Procedure for fistulo-graphy : Procedure for fistulo-graphy Patient is placed on a table in the prone or supine on the position
insertion of Foleys catheter with condom (tied) in to the rectum and condom should be inflated by cuff attached to the catheter
Local dressing with 2% tincture iodine, a blunt probe is introduced in to the external orifice of the fistula to estimate roughly its depth and principally
Another rubber catheter should be inserted in the ext. opening
The contrast material is injected through the rubber catheter by an ordinary syringe.
After resistance to the plunger of the syringe has been felt, the rubber tube connecting the syringe to the connecting piece is clamped near the syringe.
Roentgenography is then carried out in antero-posterior and lateral projections. Dis-advantages of fistulography : Dis-advantages of fistulography Hypersensitivity reactions can occur
Regurgitation of contrast in fibrosed tracts Aim of our treatment should be economical like Tata Nanobut not like a Mercedes BENZ…. : Aim of our treatment should be economical like Tata Nanobut not like a Mercedes BENZ…. f-i-a with multiple openings : f-i-a with multiple openings Fistulogram showing Fistula-in-anO (High-Anal)with anal communication : Fistulogram showing Fistula-in-anO (High-Anal)with anal communication Fistula-In-ano with multiple extensions Courtesy: halligan&stoker : Fistula-In-ano with multiple extensions Courtesy: halligan&stoker several high extensions (arrows) surrounding the ano-rectal junction; however, the exact anatomic location of these is unclear because the pelvic floor (ie, levator -ani in this case) cannot be directly visualized. FISTULOGRAPHY OF A MALE PATIENT SHOWING FISTULA-IN -ANO WITH ANAL OPENING : FISTULOGRAPHY OF A MALE PATIENT SHOWING FISTULA-IN -ANO WITH ANAL OPENING EXT.OPENING OF THE SAME PATIENT AT GLUTEAL REGION : EXT.OPENING OF THE SAME PATIENT AT GLUTEAL REGION INTERNAL OPENING AT 7 ‘o’ CLOCK POSITION : INTERNAL OPENING AT 7 ‘o’ CLOCK POSITION PRIMARY THREADING : PRIMARY THREADING Sometimes finding god is easier than exploring a Fistula : Sometimes finding god is easier than exploring a Fistula Endo-anal ultra-sonography : Endo-anal ultra-sonography The main indication : faecal incontinence
To assess the completeness of sphincter repair following surgery.
Fistula-in-Ano Endo-anal sonogram : Endo-anal sonogram Transducer is introduced in to the anal canal to visualize tracts (minimal invasive technique)
Advantage being it is more accurate than fistulography
Contra-indicated in peri-anal inflammation Ac.Fissure-in-ano and in anal stenosis
Visual field is less
Supra-levator extensions cannot be visualized Normal endo-anal usg of anal canal and rectum : Normal endo-anal usg of anal canal and rectum Normal appearance of the male anal canal at the level of the pubo-rectalis muscle. a, pubo-rectalis; b, circular muscle of the rectum; c, prostate. endo-anal sonogram : endo-anal sonogram Fistula with hypo-echoic tract located in inter-sphincteric plane between external (EAS) and internal (IAS) anal sphincters.
Internal sphincter is markedly hypo-echoic. Internal opening
was at 6 ‘o’ clock position endo-anal sonogram showing trans-sphincteric fistula (in the transverse plane at the mid–anal canal level) c ourtesy :JAMA : endo-anal sonogram showing trans-sphincteric fistula (in the transverse plane at the mid–anal canal level) c ourtesy :JAMA The fistula has penetrated the external anal-sphincter (EAS). The internal opening was at 7-o’clock position. Internal sphincter is relatively thinned here, but there is no tract extending to the anal canal. Endo-Anal sonogram showing horse-shoe shaped Fistula courtesy :JAMA : Endo-Anal sonogram showing horse-shoe shaped Fistula courtesy :JAMA shows extensive hypo-echoic horse-shoe extension . Because endo-sonography is limited to the transverse plane, It is difficult
to determine whether this extension infra or supra-levator. Advantages & dis-advantages of TRANCUTANEOUS PERIANAL USG (TPUS) : Advantages & dis-advantages of TRANCUTANEOUS PERIANAL USG (TPUS) Blocked primary and secondary tracts can be assessed
Muscles mobility can be visualized which is a unique quality for this procedure
It can be performed in peri-anal inflammation
Painless procedure. No specialised equipment needed
Can be performed in patients with anal stenosis
Can be used intra-operatively to delineate the tracts, Rapid evaluation
Levator-ani and external sphincter are well evaluated..
Supra-sphincteric type can be easily identified
Real time visualization (CT, MRI lack this).
Ideal tool for follow-up cases
differentiation between internal and external sphincter and inter-sphincteric collections was less satisfactory than endo-anal ultrasound
Internal openings are not always adequately demonstrated. transcutaneous peri-anal ULTRA-sonography (method) : transcutaneous peri-anal ULTRA-sonography (method) Latex glove filled with ultrasound contact gel was used to cover the probes for hygienic reasons (A).
The examinations were performed in the left lateral position with the probe placed above the anus (B) Trans-cutaneous Peri-anal Ultra-sonogram in Fistula- In-Ano : Trans-cutaneous Peri-anal Ultra-sonogram in Fistula- In-Ano Trans-sphincteric fistula : Internal opening shown with the use of a trans-vaginal (endo-cavitary) probe in a coronal section. A tract (arrow) is shown opening in the anal canal (arrowhead). transcutaneous peri-anal Ultra-sonography in fistula- in-ano (oblique/sagittal view) courtesy: Domkundwar and Shinagare : transcutaneous peri-anal Ultra-sonography in fistula- in-ano (oblique/sagittal view) courtesy: Domkundwar and Shinagare Oblique sagittal images showing a branching tract (black arrows). One branch (arrowhead) is shown entering the anal canal (white dot).
The other branch is shown extending deep toward granulation tissue.
The external opening was at the 5-o’clockposition. What is ct scan? how does it work? : What is ct scan? how does it work? CT scan - is it useful? : CT scan - is it useful? Computerized axial tomography is of limited use in diagnosing FIA.
Dis-advantages : cannot visualize sphincters adequately
Subtle infections cannot be visualized
Can be used for visualizing peri-anal abscess How MRI works? Invented by Dr .Howard hart jr : How MRI works? Invented by Dr .Howard hart jr See the video Advantages of MRI : Advantages of MRI Can visualize minute details of tract, sphincters, ramfications.
Useful in assessing fistula with multiple openings
Useful in detecting peri-anal abscesses
Less feasible for follow-up
Needs specialised equipment and staff
Real time correlation not possible CT scan vs. MRI : CT scan vs. MRI We have to update ourselves regularly to avoid to become like this…….. : We have to update ourselves regularly to avoid to become like this…….. Dinosaur eggs (fossils) Mri of a male patient showing fia at perineal region with ext op. at 7,and int. op. at 6 ‘o’ clock position with fluid collection in it courtesy :cghs ay hospital : Mri of a male patient showing fia at perineal region with ext op. at 7,and int. op. at 6 ‘o’ clock position with fluid collection in it courtesy :cghs ay hospital Cont. courtesy :cghs ay hospital : Cont. courtesy :cghs ay hospital Cont. : Cont. The same Patient with fia, ext opening at 7 ‘o’ clock position & int .opening at 6 ‘o’ clock position. Courtesy : cghs ay hospital : The same Patient with fia, ext opening at 7 ‘o’ clock position & int .opening at 6 ‘o’ clock position. Courtesy : cghs ay hospital MRI showing inter-sphincteric fistula (transverse STIR image) : MRI showing inter-sphincteric fistula (transverse STIR image) lateral margin of external sphincter (long arrow) contrasts Ischio-anal fossa (*). Fistula (short arrow) is in the inter-sphincteric space posteriorly at 6 o’clock and is contained by the external sphincter. There is no tract in the ischio-anal fossa supra-sphincteric FIA (female) courtesy: CGHS Ay Hospital : supra-sphincteric FIA (female) courtesy: CGHS Ay Hospital (a) Primary tracts in right (long arrow) and left (short arrow) ischio-anal fossae are shown. (b) Image obtained just posterior to a shows that right-sided primary tract (white arrows) arches over Pubo-rectalis muscle (*) to reach a lower internal opening at the dentate line level (black arrow). FIA with left-sided trans-sphincteric tract (female) : FIA with left-sided trans-sphincteric tract (female) MRI shows large extension (long arrow) from apex of tract into roof of ipsi-lateral ischio-anal fossa. Fistulography required (out of 100 patients at CGHS Ay Hospital) ( From jan 08 to oct 09) : Fistulography required (out of 100 patients at CGHS Ay Hospital) ( From jan 08 to oct 09) mri required (out of 100 patients at CGHS Ay Hospital) ( period : as above) : mri required (out of 100 patients at CGHS Ay Hospital) ( period : as above) Anti-biotics : Anti-biotics Slide 67: Last but not the least
while treating Fistula-In-Ano
we must remember
our teachers and respect them…..
but do not follow them blindly
we must apply our own brains….
whenever situation demands…. Conclusion : Conclusion Most of the patients with Fistulae come to Ano-rectal OPD are mainly of low-anal type and doesn’t need any expensive and flashy diagnostic procedures to cure it.
Radio imaging techniques should be done in active phase of illness
Fistulo-graphy can be carried out in multiple and high-anal and complicated Fistulae
MRI and other above mentioned procedures still under evaluation and being expensive to the patient advice only when there is a proper need.
Trans-cutaneous peri-anal USG and MRI (Endo-anal) are the two imaging techniques with more adaptability and acceptability in future. Pledge : Pledge No more Fistulotomy or Fistulectomy No unnecessary
Investigations No Anti-biotics Any type of Fistula In Ano can be treated
by our own surgical procedures World is full of surprises IF HE CAN ??? WHY NOT WE?!!! : World is full of surprises IF HE CAN ??? WHY NOT WE?!!! THANK YOU FOR PATIENT LISTENING : THANK YOU FOR PATIENT LISTENING ALL OF U CAN TAKE A NAP NOW