Perianal Fistula

Clinical Scenario, Perianal Fistula

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!