Updated: 5/22/2019

Fistula-in-Ano / Perianal Fistula

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Snapshot
  • A 39-year-old man with inflammatory bowel disease presents to his primary care physician due to concern of anal discharge. He reports that he has been compliant with his inflammatory bowel disease medications and has an upcoming appointment with a surgeon for drainage of a perianal abscess. On exam, an abnormal communication to the perianal skin is visualized.
Introduction
  • Clinical definition
    • pathological tract lined with granulation tissue between the anal canal and perianal skin (usually within 3 cm of the anal margin)
    • demographics
      • more common in men
    • risk factors
      • anal abscess
  • Pathogenesis
    • infection of the anal gland and abscess development that tracts to the skin surface
    • inappropriate wound healing leading to persistent tract (FRIENDS mnemonic)
      • foreign body
      • radiation therapy
      • inflammation or infection
      • epithelization
      • neoplasm
      • distal obstruction
      • steroids
  • Associated conditions
    • Crohn disease
    • diverticulitis
    • human immunodeficiency virus
Presentation
  • Symptoms
    • perianal drainage
    • tenderness or pain
    • bleeding
    • itching
  • Physical exam
    • perianal fistula with induration, erythema, purulence, and fecal discharge
    • elevated skin with underlying granulation tissue
Studies
  • Diagnostic testing
    • direct visualization of the fistula with anoscopy or proctoscopy is diagnostic
      • probe fistula to identify both openings
      • under anesthesia, if necessary
Differential
  • Pilonidal cyst
    • distinguishing factor
      • does not communicate with anal canal
  • Hidradenitis suppurativa
    • distinguishing factor
      • does not communicate with anal canal
Treatment
  • Fistulotomy
  • Infliximab for Crohn disease-associated fistula
Complications
  • Persistent fistula

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