ULCER SINUS FISTULA
DefinitionA break in the epithelial continuity
Discontinuity of the skin or mucous membrane which occurs due to the microscopic death of the tissues
AetiologyVenous Disease (Varicose Veins)Arterial Disease ; Large vessel (Atherosclerosis) or
Small vessel (Diabetes)Arteritis : Autoimmune (Rheumatoid Arthritis, Lupus)TraumaChronic Infection : TB/SyphilisNeoplastic : Squamous or BCC, Sarcoma
Wagner’s Grading of ulcers
Grade 0 - Preulcerative lesion/healed ulcerGrade 1 - Superficial ulcerGrade 2 - Ulcer deeper to Subcutaneous tissue
exposing soft tissue or boneGrade 3 - Abscess formation or osteomyelitisGrade 4 - Gangrene of part of tissues/limb/footGrade 5 - Gangrene of entire one area/foot
Classification A. ClinicalB. Pathological
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)
B.Pathological 1. Nonspecific 2. Specific 3. Malignant
1. Non specificTraumatic UlcerArterial UlcerVenous UlcerNeurogenic UlcerInfective Ulcer
1. Non specific contd.Diabetic UlcerTropical UlcerCryopathic UlcerMartorell’s UlcerBazin’s Ulcer
• Traumatic ulcer
1. Mechanical- Dental ulcer on tongue ( jagged tooth )2. Physical- Electrical burn3. Chemical- Application of caustics
Acute, Superficial, Painful, Tender
• Arterial Ulcer
• Caused due to peripheral vascular disease• LL : Atherosclerosis & TAO• UL : Cervical Rib, Raynauds• Chief complaint : Severe Pain• Toes, Feet, Legs & UL Digits
• Venous ulcers
Medial aspect of lower 3rd of lower limbAnkle ( Gaiters Zone ) : Chronic Venous HTNUlcers are PainlessVaricose Veins or Post Phlebitic limb ( PTS )
• 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
• Tropical ulcer
• Tropical regions : Africa, India, S.America• Trauma or Insect Bite• Fusobacterium fusiformis & Borrelia
vincentii• Abrasions, Redness, Papules & Pustules• Severe Pain
• 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,
2. Specific TuberculosisSyphilis Actinomycosis Meleney’s ulcerSoft sore
3. Malignant Squamous cell caBasal cell caMalignant melanoma
Examination Inspection PalpationExamination of lymph nodesVascular insufficiency Nerve lesions
INSPECTIONLocation, size, shape, floor, edge, discharge, surround ing area.
PALPATIONTenderness, 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
INSPECTIONLOCATION OF THE ULCERFLOOR OF THE ULCER DISCHARGE FROM THE ULCEREDGESURROUNDING AREA
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
FLOOR OF THE ULCERDEF : 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 ul cer
Wash-leather slough Gummatous ulcer
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
EDGEDEF: 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.
A. Sloping edge All healing ulcers like traumatic ulcers, venous Ulcers
B. Punched out edge
Gummatous ulcers and trophic ulcers.
C. Undermined edge
Tuberculous ulcers
D. Raised edge (beaded edge)
Rodent ulcers or basal cell carcinoma .
E. Everted edge (Rolled out)
Squamous cell carcinoma.
SURROUNDING AREAThick and
pigmented Varicose ulcer.
Thin and dark Arterial ulcer.
Red and oedematous
Spreading ulcers like dia betic ulcer.
PALPATIONEDGEBASEMOBILITYBLEEDINGSURROUNDING AREA
EDGE
Induration (hardness) of the edge is very char acteristic 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.
BASEIt is the area on which ulcer rests.
Marked induration at the base is diagnostic of squamous cell carcinoma.
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.
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.
BLEEDING
Malignant ulcer is friable like a cauliflower. On gentle palpation, it bleeds.
Granulation tissue as in a healing ulcer also causes bleeding.
SURROUNDING AREAThickening and induration is found
in squamous cell carcinoma.
Tenderness and pitting on pressure indicates spreading inflammation surround ing the ulcer.
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.
MANAGEMENT
Investigations 1) Complete blood picture: Hb%, TC, DC, ESR, PS2) Urine and blood examination to rule out diabetes3) Chest X-ray - PA. view to rule out P.TB4) Pus for culture/sensitivity5) Lower limb angiography in cases of arterial
diseases6) X-ray of the part to see for Osteomyelitis 7) Biopsy: Non-healing/malignant ulcers
Treatment Address causeCorrect deficienciesControl pain, infectionDebridement, dressingClosure of defect
TREATMENT OF THE ULCERS
Treatment of Spreading UlcersTreatment of Healing UlcersTreatment of Chronic UlcersTreatment of The Underlying Disease
TREATMENT OF SPREADING ULCERSPus 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,
TREATMENT OF HEALING ULCERRegular dressings are done for a few daysAntiseptic 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
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.
DEFINITION
SINUS: Blind track lined by granulation tissue
leading from epithelial surface down into the tissues.
Latin: Hollow (or) a bay
CAUSES
CONGENITAL ACQUIRED
Preauricular sinus TB sinus Pilonidal sinus Median mental sinus Actinomycosis
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
Latin : flute (or) a pipe (or) a tube.
CAUSESCONGENITAL Branchial fistula Tracheo-
esophageal Umbilical Congenital AV
fistula Thyroglossal fistula
ACQUIREDI. TraumaticII. InflammatoryIII. MalignancyIV. Iatrogenic
ACQUIRED
I. TRAUMATIC: (A) following surgery : eg., intestinal fistulas (faecal,biliary,pancreatic)
(B) following instrumental delivery (or) difficult labour e.g., vesicovaginal,rectovaginal, ureterovaginal fistula
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
FISTULA
EXTERNAL Orocutaneous Enterocutaneous Appendicular Thyroglossal Branchial
INTERNAL Tracheo-
esophageal Colovesical Rectovesical AVF Cholecystoduoden
al
.
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.]
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
CLINICAL FEATURES
Usually asymptomatic but when infected manifest as-• Recurrent/ persistent discharge.• Pain.• Constitutional symptoms if any deep
seated origin.
CLINICAL EXAMINATIONINSPECTION: 1. 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.
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- TB4. Surrounding area: erythematous- inflammatory bluish- TB excoriated- faecal pigmented- chronic sinus/fistulae.
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
Palpation:a) Temperature and tenderness:b) Discharge: after application of pressure
over the surrounding area.c) 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
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
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.
TREATMENTBASIC PRINCIPLES:
Antibiotics Adequate rest Adequate excision Adequate drainage.
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.
TUBERCULAR SINUS OF NECK
Causative organism: mostly M.tuberculosis but also M.bovisSite 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.
Clinical stages:
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
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.
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.
Collar stud abscess
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.
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
Sometimes, USG neck to detect cold abscess. Hypoechoeic lesions with internal echoes
S/O debris within. Guided aspiration of cold abscess.
TREATMENT ATT Excision of sinus tract with excision of
diseased lymph nodes.
FISTULA-IN-ANOChronic 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)
AETIOPATHOGENESIS Cryptoglandular (90% cases) Non cryptoglandular (10% cases) TB Diabetes mellitus Crohn’s disease Carcinoma rectum Trauma Lymphogranuloma venereum Radiotherapy Immunocompromised patients (HIV etc.,)
CRYPTOGLANDULAR HYPOTHESIS
CLASSIFICATION
PARK’S CLASSIFICATION:(relation of primary tract to external sphincter)
• Inter sphincteric (45%)• Trans sphincteric (40%)• Supra sphincteric• Extra sphincteric
STANDARD CLASSIFICATION Sub cutaneous Sub mucous Low anal High anal Pelvi rectal
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
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
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.
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.
IMAGING
Fistulography Endoanal ultrasound MRI
Fistulography: Reveals primary and secondary tracts.
Useful if extra sphincteric fistula suspected.
END0 ANAL ULTRASOUND• Determines sphincter integrity.• Complexity of fistula.
horse-shoe fistula
MRI“GOLD STANDARD” for fistula-in-ano imaging.
high variety supra horse-shoe fistula. sphincteric fistula.
MRI
Abscesses and contralateral extensions disease
PRINCIPLES OF TREATMENT Control sepsis
EUALaying open abscesses and secondary tractsAdequate drainage – seton insertion
Define anatomy• Openings and tracts
Internal and ExternalSingle –v- multipleExtensions / Horseshoe
• Relation to sphincter complexHigh –v- Low
Exclude co-existent disease
SURGICAL MANAGEMENT Fistulotomy (The laying open technique) Fistulectomy Seton techniques Fibrin glue sphincter
preserving Anal fistula plug
techniques. Advancement flap LIFT procedure.
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.
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.
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.
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
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.
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.
FISTULA PLUG
FISTULA PLUG:
ADVANCEMENT FLAPS
Endorectal Fistula tract probed Flap raised
• Mucosa + Int. Sphincter Internal opening excised/closed Flap advanced & sutured
ADVANCEMENT FLAPAnodermal Fistula tract probed Flap raised
• Anodermal Flap advanced & sutures External defect closed
LIFT PROCEDURELigation of Inter sphinctericFistula Tract Trans sphincteric fistula Draining seton – 6 weeks
Tract prepared with fistula brush Debrides De-epithelializes
FOLLOW UPAs with most anorectal disorders, follow-
up care includes: Perianal baths, analgesics for pain, stool bulking agents, and good perianal hygiene
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