Ulcer sinus fistula

dr sunil negi

1. ULCER SINUS FISTULA

2. Definition A break in the epithelial continuity Discontinuity of the skin or mucous membrane which occurs due to the microscopic death of the tissues

3. Aetiology Venous Disease (Varicose Veins) Arterial Disease ; Large vessel (Atherosclerosis) or Small vessel (Diabetes) Arteritis : Autoimmune (Rheumatoid Arthritis, Lupus) Trauma Chronic Infection : TB/Syphilis Neoplastic : Squamous or BCC, Sarcoma

4. Wagner’s Grading of ulcers Grade 0 - Preulcerative lesion/healed ulcer Grade 1 - Superficial ulcer Grade 2 - Ulcer deeper to Subcutaneous tissue exposing soft tissue or bone Grade 3 - Abscess formation or osteomyelitis Grade 4 - Gangrene of part of tissues/limb/foot Grade 5 - Gangrene of entire one area/foot

5. Classification A. Clinical B. Pathological

6. A. Clinical Spreading : ( Edge - Inflamed & Edematous) Healing : ( Edge is sloping with healthy red granulation tissue & serous discharge) Callous : ( Floor contains pale unhealthy granulation tissue with indurated edge )

7. B.Pathological 1. Nonspecific 2. Specific 3. Malignant

8. 1. Non specific Traumatic Ulcer Arterial Ulcer Venous Ulcer Neurogenic Ulcer Infective Ulcer

9. 1. Non specific contd. Diabetic Ulcer Tropical Ulcer Cryopathic Ulcer Martorell’s Ulcer Bazin’s Ulcer

10. Traumatic ulcer Mechanical- Dental ulcer on tongue ( jagged tooth ) Physical- Electrical burn Chemical- Application of caustics Acute, Superficial, Painful, Tender

11. Arterial Ulcer Caused due to peripheral vascular disease LL : Atherosclerosis & TAO UL : Cervical Rib, Raynauds Chief complaint : Severe Pain Toes, Feet, Legs & UL Digits

12. Venous ulcers Medial aspect of lower 3 rd of lower limb Ankle ( Gaiters Zone ) : Chronic Venous HTN Ulcers are Painless Varicose Veins or Post Phlebitic limb ( PTS )

13. Trophic Ulcer Pressure Sore or Decubitus Ulcer Punched out edge with slough on the floor Ex: Bed Sores & Perforating ulcers Develop as a result of Prolonged Pressure Sites : Ischial Tuberosity > Greater Trochanter > Sacrum > Heel > Malleolus > Occiput

14. Tropical ulcer Tropical regions : Africa, India, S.America Trauma or Insect Bite Fusobacterium fusiformis & Borrelia vincentii Abrasions, Redness, Papules & Pustules Severe Pain

15. Diabetic Ulcer It may be caused due to Diabetic Neuropathy Diabetic Microangiopathy Increased Glucose : Increased Infection Foot ( Plantar ), Leg, Back, Scrotum, Perineum Ischemia, Septicemia, Osteomyelitis,

16. 2. Specific Tuberculosis Syphilis Actinomycosis Meleney’s ulcer Soft sore

17. 3. Malignant Squamous cell ca Basal cell ca Malignant melanoma

18. Examination Inspection Palpation Examination of lymph nodes Vascular insufficiency Nerve lesions

19. INSPECTION Location, size, shape, floor, edge, discharge, surround­ing area. PALPATION Tenderness, local rise of temperature, bleeding on touch, consistency of the ulcer, edge, surrounding area - oedema , mobility. REGIONAL LYMPH NODES SENSATIONS PULSATIONS FUNCTION OF THE JOINT SYSTEMIC EXAMINATION

20. INSPECTION LOCATION OF THE ULCER FLOOR OF THE ULCER DISCHARGE FROM THE ULCER EDGE SURROUNDING AREA

21. LOCATION OF THE ULCER Arterial ulcer Tip of the toes, dorsum of the foot Long saphenous varicosity with ulcer Medial side of the leg. Short saphenous varicosity with ulcer Lateral side of the leg. Perforating ulcers Over the sole at pressure points. Nonhealing ulcer Over the shin

22. FLOOR OF THE ULCER DEF : This is the part of the ulcer which is exposed or seen. Red granulation tissue Healing ulcer Necrotic tissue, slough Spreading ulcer Pale, scanty granulation tissue Tuberculous ul­cer Wash-leather slough Gummatous ulcer

23. DISCHARGE FROM THE ULCER Serous discharge Healing ulcer Purulent discharge Spreading ulcer Bloody discharge Malignant ulcer Discharge with bony spicules Osteomyelitis Greenish discharge Pseudomonas infection

24. EDGE DEF: This is between the floor of the ulcer and the margin. The margin is the junction between the normal epithelium and the ulcer. These two parts represent areas of maximum activity. 3 STAGES Stage of ex-tension. Stage of transition. Stage of repair.

25. Sloping edge All healing ulcers like traumatic ulcers, venous Ulcers

26. B. Punched out edge Gummatous ulcers and trophic ulcers.

27. C. Undermined edge Tuberculous ulcers

28. D. Raised edge (beaded edge) Rodent ulcers or basal cell carcinoma .

29. E. Everted edge (Rolled out) Squamous cell carcinoma.

30. SURROUNDING AREA Thick and pigmented Varicose ulcer. Thin and dark Arterial ulcer. Red and oedematous Spreading ulcers like dia­betic ulcer.

31. PALPATION EDGE BASE MOBILITY BLEEDING SURROUNDING AREA

32. EDGE Induration (hardness) of the edge is very char­acteristic of squamous cell carcinoma . It is said to be a host defense mechanism. Tenderness of the edge is characteristic of infected ulcers and arterial ulcers.

33. BASE It is the area on which ulcer rests. Marked induration at the base is diagnostic of squamous cell carcinoma.

34. INDURATION The edge, base and the surrounding area should be examined for induration. Maximum induration Squamous cell carcinoma Minimal induration Malignant melanoma. Brawny induration Abscess. Cyanotic induration Chronic venous congestion as in varicose ulcer.

35. MOBILITY Gentle attempt is made to move the ulcer to know its fixity to the underlying tissues. Malignant ulcers are usually fixed , benign ulcers are not.

36. BLEEDING Malignant ulcer is friable like a cauliflower. On gentle palpation, it bleeds. Granulation tissue as in a healing ulcer also causes bleeding.

37. SURROUNDING AREA Thickening and induration is found in squamous cell carcinoma. Tenderness and pitting on pressure indicates spreading inflammation surround­ing the ulcer.

38. RELEVANT CLINICAL EXAMINATION REGIONAL LYMPH NODES Tender and enlarged Acute secondary infection. Non-tender and enlarged Chronic infection. Non-tender and hard Squamous cell carcinoma. Non-tender, large, firm, multiple Malignant melanoma.

39. MANAGEMENT

40. Investigations Complete blood picture : Hb %, TC, DC, ESR, PS Urine and blood examination to rule out diabetes Chest X-ray - PA. view to rule out P.TB Pus for culture/sensitivity Lower limb angiography in cases of arterial diseases X-ray of the part to see for Osteomyelitis Biopsy : Non-healing/malignant ulcers

41. Treatment Address cause Correct deficiencies Control pain, infection Debridement, dressing Closure of defect

42. TREATMENT OF THE ULCERS Treatment of Spreading Ulcers Treatment of Healing Ulcers Treatment of Chronic Ulcers Treatment of The Underlying Disease

43. TREATMENT OF SPREADING ULCERS Pus Culture/Sensitivity report, Appropriate Antibiotics Solutions to treat the Slough : H₂O₂ & EUSOL - Edinburgh University Solution (Hypochlorite solution) Excessive Granulation Tissue (Proud Flesh) : Excision or Application of Copper Sulphate or Silver Nitrate Repeated Dressings,

44. TREATMENT OF HEALING ULCER Regular dressings are done for a few days Antiseptic creams like Liquid Iodine , Zinc Oxide or Silver Sulphadiazine . Culture swab is taken to rule out Streptococcus Haemolyticus ( contraindication for skin grafting ) Ulcer is small - Heals by itself ( Epithelialization ) Large - Free Split Skin Graft applied

45. TREATMENT OF CHRONIC ULCERS These do not respond to conventional methods of treatment. The following are tried: Infrared radiation, short-wave therapy, ultraviolet rays decrease the size of the ulcer. Amnion helps in epithelialization. Chorion helps in granulation tissue. These ulcers ultimately may require skin grafting.

46. DEFINITION SINUS: Blind track lined by granulation tissue leading from epithelial surface down into the tissues. Latin: Hollow (or) a bay

47. CAUSES CONGENITAL ACQUIRED Preauricular sinus TB sinus Pilonidal sinus Median mental sinus Actinomycosis

48. FISTULA: ABNORMAL communication between lumen of one viscus and lumen of another (INTERNAL FISTULA) (or) between lumen of one hollow viscus to the exterior (EXTERNAL FISTULA) (or) between any two vessels

49. Latin : flute (or) a pipe (or) a tube .

50. CAUSES CONGENITAL Branchial fistula Tracheo-esophageal Umbilical Congenital AV fistula Thyroglossal fistula ACQUIRED Traumatic Inflammatory Malignancy Iatrogenic

51. ACQUIRED TRAUMATIC: (A) following surgery : eg., intestinal fistulas (faecal,biliary,pancreatic) (B) following instrumental delivery (or) difficult labour e.g., vesicovaginal,rectovaginal, ureterovaginal fistula

52. II. INFLAMMATORY: Intestinal actinomycosis , TB III. MALIGNANCY: when growth of one organ penetrates into the nearby organ. e.g., Rectovesical fistula in carcinoma rectum IV. IATROGENIC: Cimino fistula- AVF for hemodialysis ECK fistula- to treat esophageal varices in portal HTN

53. FISTULA EXTERNAL Orocutaneous Enterocutaneous Appendicular Thyroglossal Branchial INTERNAL Tracheo-esophageal Colovesical Rectovesical AVF Cholecystoduodenal

54. .

55. Causes for persistence of sinus (or) fistula Presence of a foreign body. e.g., suture material Presence of necrotic tissue underneath. e.g.,sequestrum Insufficient (or) non-dependent drainage. e.g., TB sinus Distal obstruction. e.g., faecal (or) biliary fistula Persistent drainage like urine/faeces/CSF Lack of rest [contd.]

56. Epithelialisation (or) endothelisation of the track. e.g., AVF Malignancy. Dense fibrosis Irradiation Malnutrition Specific causes. e.g., TB, actinomycosis Ischemia Drugs. e.g., steroids Interference by the patient

57. CLINICAL FEATURES Usually asymptomatic but when infected manifest as- Recurrent/ persistent discharge. Pain. Constitutional symptoms if any deep seated origin.

58. CLINICAL EXAMINATION INSPECTION: Location: usually gives diagnosis in most of the cases. SINUS: pre-auricular- root of helix of ear. median mental- symphysis menti. TB- neck. FISTULA: branchial- sternomastoid ant border. parotid- parotid region thyroglossal- midline of neck below hyoid.

59. 2. Number: usually single but multiple seen in HIV patients (or) actinomycosis. 3. Opening: a) sprouting with granulation tissue-foreign body. b) flushing with skin- TB 4. Surrounding area: erythematous- inflammatory bluish- TB excoriated- faecal pigmented- chronic sinus/fistulae.

60. 5. Discharge: White thin caseous, cheesy like- TB sinus Faecal- faecal fistula Yellow sulphur granules- actinomycosis Bony granules- osteomyelitis Yellow purulent- staph. infections Thin mucous like- brachial fistula Saliva- parotid fistula

61. Palpation: Temperature and tenderness: Discharge: after application of pressure over the surrounding area. Induration: present in chronic fistulae/sinus as in actinomycosis, OM TB Sinus induration absent. d) Fixity: e) Palpation at deeper plane: lymph nodes- TB Thickening of bone underneath- OM

62. INVESTIGATIONS CBP - Hb, TLC, DLC, ESR. Discharge for C/S , AFB, cytology, Gram staining. X-RAY of the part to rule out OM, foreign body. X-RAY KUB and USG abdomen in cases of lumbar fistula to rule out staghorn calculi. MRI BIOPSY from edge of sinus CT Sinusogram

63. FISTULOGRAPHY/ SINUSOGRAPHY: For knowing the exact extent/origin of sinus (or)fistula. Water soluble or ultrafluid lipoidal iodine dye is used. Lipoidal iodine is poppy seed oil containing 40% iodine.

64. TREATMENT BASIC PRINCIPLES: Antibiotics Adequate rest Adequate excision Adequate drainage.

65. After excision specimen SHOULD be sent for HPE. Treating the cause. e.g., ATT for TB sinus. removal of any foreign body. sequestrectomy for OM.

66. TUBERCULAR SINUS OF NECK Causative organism: mostly M.tuberculosis but also M.bovis Site and mode of infection: a) lymph nodes in anterior triangle from tonsils. b) lymph nodes in posterior triangle from adenoids. c) supraclavicular nodes from apex of the lung.

67. Clinical stages:

68. Stage of cold abscess: due to caseating necrosis. non-tender, cystic, fluctuant swelling not adherent to overlying skin. Sternocleidomastoid contraction test- present deep to deep fascia trans illumination negative

69. TREATMENT: Zig-zag aspiration by wide bore needle in non-dependent area to avoid a persistent sinus. Instillation of 1g streptomycin +/- INH in solution with closure of wound without placing a drain. ATT NOTE: I&D not done-persistent TB sinus.

70. Stage of collar stud abscess: cold abscess ruptures through deep fascia forming an another swelling in sub-cutaneous plane. Fluctuant, adherent to skin. Treated like a cold abscess.

71. Collar stud abscess

72. Stage of sinus: collar stud abscess bursts out leading to a persistent discharging sinus. Can be multiple, wide opening, undermined edges, non-mobile. Bluish discoloration around the edges. NO INDURATION.

73. INVESTIGATIONS Hematocrit, ESR , S.albumin , S.globulin FNAC of lymph nodes and smear for AFB and C/S Open node biopsy of lymph nodes. Edge biopsy of sinus- granuloma. mantoux test Chest X ray Sputum for AFB

74. Sometimes, USG neck to detect cold abscess. Hypoechoeic lesions with internal echoes S/O debris within. Guided aspiration of cold abscess.

75. TREATMENT ATT Excision of sinus tract with excision of diseased lymph nodes.

76. FISTULA-IN-ANO Chronic abnormal communication usually lined to some degree by granulation tissue, which runs outwards from anorectal lumen (internal opening) to skin of perineum or the buttocks (external opening)

77. AETIOPATHOGENESIS Cryptoglandular (90% cases) Non cryptoglandular (10% cases) TB Diabetes mellitus Crohn’s disease Carcinoma rectum Trauma Lymphogranuloma venereum Radiotherapy Immunocompromised patients (HIV etc.,)

78. CRYPTOGLANDULAR HYPOTHESIS

79. CLASSIFICATION PARK’S CLASSIFICATION: (relation of primary tract to external sphincter) Inter sphincteric (45%) Trans sphincteric (40%) Supra sphincteric Extra sphincteric

80. STANDARD CLASSIFICATION Sub cutaneous Sub mucous Low anal High anal Pelvi rectal

81. Can be low level fistula- open into anal canal below the internal ring. high level fistula- at/ above the internal ring. Can be Simple- without any extensions Complex- with extensions Can be single multiple- TB, ulcerative colitis, crohn’s, HIV, LGV

82. CLINICAL PRESENTATION Intermittent discharge (sero-purulent/ bloody) Pain (which increases until temporary relief occurs when pus discharges) Pruritus ani Previous h/o anal gland infection

83. CLINICAL ASSESMENT HISTORY: full medical history incl. obstetric,anal, gastrointestinal, surgical, continence DRE : area of induration, fibrous tract and internal opening may be felt ( “button-hole” defect in Ca rectum) PROCTOSIGMOIDOSCOPY: To evaluate rectal mucosa for any underlying disease process.

84. GOODSALL’S RULE If external opening in anterior half of anus, fistula usually runs directly into anal canal. If external opening in posterior half of anus, fistula usually curves midline of the anal canal posteriorly.

85. IMAGING Fistulography Endoanal ultrasound MRI

86. Fistulography: Reveals primary and secondary tracts. Useful if extra sphincteric fistula suspected .

87. END0 ANAL ULTRASOUND Determines sphincter integrity. Complexity of fistula. horse-shoe fistula

88. MRI “GOLD STANDARD” for fistula-in-ano imaging. high variety supra horse-shoe fistula. sphincteric fistula.

89. MRI Abscesses and contralateral extensions disease

90. PRINCIPLES OF TREATMENT Control sepsis EUA Laying open abscesses and secondary tracts Adequate drainage – seton insertion Define anatomy Openings and tracts Internal and External Single –v- multiple Extensions / Horseshoe Relation to sphincter complex High –v- Low Exclude co-existent disease

91. SURGICAL MANAGEMENT Fistulotomy ( The laying open technique ) Fistulectomy Seton techniques Fibrin glue sphincter preserving Anal fistula plug techniques. Advancement flap LIFT procedure.

92. FISTULOTOMY In inter-sphincteric and low trans-sphincteric fistulas. Identification of tract with probe followed by division of all structures between external and internal openings. Secondary tracts laid open. +/- marsupialization.

93. Advantages least chance of recurrence relatively easy procedure minor degree of incontinence. Risks results in large and deep wounds that might take months to heal .

94. FISTULECTOMY All chronic (low) and also for posterior horse-shoe shaped fistulas. Excision of entire fibrous tissue and tract and wound kept open. Sphincter repair +/- advancement flap. High anal fistulas +/-colostomy.

95. SETON SUTURE PLACEMENT Preferable surgical option for high variety. Setons are usually made from rubber slings 2 types of seton suture can be placed Draining Seton Facilitates draining of sepsis Left loose and allows fistula to heal by fibrosis Cutting Seto Slowly "cheese-wires" though the sphincter muscle Allows fibrosis to take place behind as it gradually cuts through

96. FIBRIN GLUE Multi component system containing mainly human plasma fibrinogen and thrombin. Injected into fistula track which hardens in few minutes and fills the track.

97. ANAL FISTULA PLUG The Anal fistula plug is a minimally invasive and sphincter-preserving alternative to traditional fistula surgery. The plug is a conical device and is placed by drawing it through the fistula tract and suturing it in place. the plug, once implanted, incorporates naturally over time into the human tissue (human cells and tissues will 'grow' into the plug), thus facilitating the closure of the fistula .

98. FISTULA PLUG

99. FISTULA PLUG:

100. ADVANCEMENT FLAPS Endorectal Fistula tract probed Flap raised Mucosa + Int. Sphincter Internal opening excised/closed Flap advanced & sutured

101. ADVANCEMENT FLAP Anodermal Fistula tract probed Flap raised Anodermal Flap advanced & sutures External defect closed

102. LIFT PROCEDURE L igation of I nter sphincteric F istula T ract Trans sphincteric fistula Draining seton – 6 weeks Tract prepared with fistula brush Debrides De-epithelializes

103. FOLLOW UP As with most anorectal disorders, follow-up care includes: Perianal baths, analgesics for pain, stool bulking agents, and good perianal hygiene