Case Study Fistulectomy
Case Study Fistulectomy
Case Study Fistulectomy
Fistulectomy
Group 6:
Bulatao, Lesley Charmaine C.
Cabudoc, Maricar G.
Comilang, Janielle Lyn M.
Constante, Quolette M.
Dela Cruz, Rhealyn N.
Ebuenga, Allyssa O.
Espanueva, Gaylen C.
Fabon, Yvette Stephanie Nichol B.
Franco, Ma. Eliza Joy L.
Fuentes, Raquel F.
Introduction
An anal fistula is an abnormal connection
between the epithelialised surface of the anal
canal and (usually) the perianal skin. Anal
fistulae originate from the anal glands, which
are located between the two layers of the
anal sphincters and which drain into the anal
canal. If the outlet of these glands becomes
blocked, an abscess can form which can
eventually point to the skin surface. The tract
formed by this process is the fistula.
Abscesses can recur if the fistula seals
over, allowing the accumulation of pus. It then
points to the surface again, and the process
repeats. Anal fistulas do not generally harm
and they often do not hurt, but they can be
irritating because of the pus-drain (and, it is
not unknown for formed stools to be passed
through the fistula); additionally, recurrent
abscesses may lead to significant short term
morbidity from pain, and create nudes for
systemic spread of infection. A fistula is a
tiny channel or tract that develops in the
presence of inflammation and infection. It
may or may not be associated with an abscess,
but like abscesses, certain illnesses such as
Crohn’s disease can cause fistulas to develop.
The channel usually runs from the rectum
to an opening in the skin around the anus.
However, sometimes the fistula opening
develops elsewhere. For example, in women
with Crohn’s disease or obstetric injuries, the
fistula could open into the vagina or bladder.
Since fistulas are infected channels, there is
usually some drainage. Often a draining fistula
is not painful, but it can irritate the skin
around it. An abscess and fistula often occur
together. If the opening of the fistula seals
over before the fistula is cured, an abscess
may develop behind it.
An anal fistula is almost always the result of a
previous abscess. Just inside the anus are small
glands. When these glands get clogged, they may
become infected and an abscess can develop. A
fistula is a small tunnel that forms under the skin
and connects a previously infected anal gland to
the skin on the buttocks outside the anus. After
an abscess has been drained; a tunnel may persist
connecting the anal gland from which the abscess
arose to the skin. If this occurs, persistent
drainage from the outside opening may indicate
the persistence of this tunnel. If the outside
opening of the tunnel heals, recurrent abscess
may develop. Symptoms related to the fistula
include irritation of skin around the anus,
drainage of pus (which often relieves the pain),
fever, and feeling poorly in general.
Surgery is necessary to cure an anal
fistula. Although fistula surgery is usually
relatively straightforward, the potential for
complication exists, and is preferably
performed by a specialist in colon and rectal
surgery. It may be performed at the same
time as the abscess surgery, although fistulas
often develop four to six weeks after an
abscess is drained, sometimes even months or
years later.
Fistula surgery usually involves opening up
the fistula tunnel. Often this will require
cutting a small portion of the anal sphincter,
the muscle that helps to control bowel
movements. Joining the external and internal
openings of the tunnel and con-verging it to a
groove will then allow it to heal from the
inside out. Most of the time, fistula surgery
can be performed on an outpatient basis.
Treatment of a deep or extensive fistula may
require a short hospital stay. Discomfort
after fistula surgery can be mild to moderate
for the first week and can be controlled with
pain pills.
The amount of time lost from work or
school is usually minimal. Treatment of an
abscess or fistula is followed by a period of
time at home, when soaking the affected area
in warm water (sitz bath) is recommended
three or four times a day. Stool softeners or
a bulk fiber laxative may also be
recommended. It may be necessary to wear a
gauze pad or mini-pad to prevent the drainage
from soiling clothes. Bowel movements will not
affect healing.
CASE
ABSTRACT
This is the case of Patient X, a 34 year old
male who was admitted last September 3,
2009, under the service of Dr. R. Lopez of
Valuecare. He came to the hospital with a
chief complaint of hematochezia and painful
bowel elimination.
Three weeks prior to admission, Patient X
experienced hematochezia. He noted painful
defecation, however describes having
constipation or diarrhea. He decided to seek
consult and was admitted to undergo
proctosigmoidoscopy.
He was initially diagnosed with an anal
fistula and was to be forwarded to the OR for
proctosigmoidoscopy and fistulectomy on
September 4, 2009 at 7 a.m. Meanwhile,
Patient X was hooked to a liter of D5LR which
was to run for 8 hours. He was also advised
to be on NPO and for urine collection. His
attending physician ordered CBC, urinalysis
and x-ray.
The following morning, at 6:35 a.m.,
Patient X was wheeled to the OR table,
inducted with spinal anesthesia and was placed
on lithotomy for proctosigmoidoscopy. At
7:35, Dr. Lopez confirmed the anal fistula. At
8:00 a.m., Dr. Lopez and Dr. Publico started
the fistulectomy, the procedure was well
tolerated and Patient X was brought to the
Recovery Room for further management.
At the Recovery Room, Patient X was
inserted with a Foley Catheter for urine
collection and was transferred to room. He
was hooked to a liter of D5NM + Ketorolac 60
mg to run for 6 hours and was placed on diet
as tolerated. A few hours later, the foley
catheter was removed and he was able to void
freely. The sack on the surgical site was
removed later on.
On September 5, 2009 at 5:40 a.m. the
IVF was discontinued upon request and on
September 6, 2009, Patient X was discharged
ambulatory.
Physical
Assessment
GENERAL DATA
1. General Information
Name: D.Y. Age: 34 y/o
Gender: Male
VALSALVA MANEUVER
INTRA-ABDOMEN PRESSURE
↑ WBC NEUTROPHILS
PAIN FEVER
Clinical presentation
History (in order of prevalence)
• Perianal discharge-intermittent or constant
• Perianal pain-worse during defecation, may be
constant
• Swelling /lump in the perianal area
• Bleeding in the perianal area
• Diarrhea
• Discoloration of skin surrounding the fistula
• External opening in the perianal discharging
• Fever
Past medical history
Important points in the history that may suggest
a complex fistula include the following:
Inflammatory bowel disease
Diverticulitis
History of trauma
Previous radiation therapy for prostate or
rectal cancer
Tuberculosis
Immune suppression-Steroid therapy, HIV
infection
Review of symptoms
• -Abdominal pain
• -Weight loss
• -Change in bowel habits
Physical examination
• Physical examination findings remain
the mainstay of diagnosis
Classification of fistula in-ano
• Parks classification system (all are in
relation to the sphincters)
• The Parks classification system defines
4 types of fistula-in-ano that result
from cryptoglandular infections.
1.Intersphincteric-commonest-70%
Common course - Via internal sphincter to the
intersphincteric space and then to the perineum.
They result from perianal abscesses
2. Transsphincteric -25%
Common course - Low via internal and external
sphincters into the ischiorectal fossa and then to
the perineum. Originate from ischiorectal
abscesses
3.Suprasphincteric -5%
Common course - Via intersphincteric space
superiorly to above puborectalis muscle into
ischiorectal fossa and then to perineum. Result
from supralevator abscesses
4. Extrasphincteric-1%
• Bypass the anal canal and sphincter
mechanism, passing through the ischiorectal
fossa and levator ani muscle, and open high in
the rectum
Current procedural terminology
codes classification
1.Subcutaneous
2.Submuscular (intersphincteric, low
transsphincteric)
3.Complex, recurrent (high transsphincteric,
suprasphincteric and extrasphincteric,
multiple tracts, recurrent)
Laboratory
Examination Date Result Normal Significance
done Values
Urinalysis Sept. 3, 2009
Color Yellow Yellow Normal
Transparency Turbid Clear Turbid is a
manifestation of
pus in the urine.
Reaction (pH) 6.0 4.8-7.8 Normal
Pus cells 10-15 0-8 Indicates UTI
anywhere from
the kidneys to
the urethra.
RBC 8-12 0-5 Hematuria
potentially a sign
of a bladder
infection.
Amorp. Urates Few
Bacteria Few Negative or Bacteria in urine
rare sediment reflect
genito urinary
tract infection or
contamination of
external genitalia.
Examination done Date Result Normal Values Significance