- 1 BHAGANDAR (FISTULA IN ANO)
- 1.1 Anorectal Fistula
- 1.2 Goodsall’s rule Classification of FIA
- 1.3 Possible findings:-
- 1.4 Kshar Sutra Chikitsa
- 1.5 Procedure of threading
BHAGANDAR (FISTULA IN ANO)
- A fistula is an abnormal communication between two epithelial/endothelial-lined surfaces.
- A fistula in ano has its external opening in the peri anal skin and its internal opening in the anal canal.
- Anorectal sepsis can be complicated by a fistula in ano in about 50% of patients during the acute phase of sepsis or within 6 months thereafter.
- A fistula in ano forms during the chronic stage of an acute inflammatory process that begins in the intersphincteric anal glands.
- The fistula tracts will follow the course of the original
abscess cavities and subsequent external drainage.
- Escherichia coli 60%
- Staphylococcus aureus 23%
- Streptococcus, B.Proteus 17%
- Always mixed infection
Source of Infection
- Cryptoglandular infection 90%
- Penetration of rectal wall
(bone piece, fish bone or any FB)
- Blood borne infection
(TB, Syphillis, AIDS, etc.)
- supralevator abscess, external, perianal abscess, intersphincteric abscess, ischiorectal abscess, internal sphincter
- An extension from a cutaneus boil
Other cause of FIA
- Crohn’s disease.
- diverticulitis with perforation and fistula to
- hydroadinitis suppurativa;
- pilonidal sinus;
- malignancies of the distal rectum, anal
canal or perianal
- skin tuberculosis;
- If the anus is bisected by a line in the frontal plane, an external opening inferior to that line connects to the internal opening via a short direct tract.
- if the external opening is posterior to this imaginary line, the fistula tract follows a curved route to the internal opening in the posterior midline.
Goodsall’s rule Classification of FIA
- Intersphincteric (the most common): The fistula track is confined to the intersphincteric plane.
- Trans-sphincteric: The fistula connects the intersphincteric plane with the ischiorectal fossa by perforating the external sphincter.
- Suprasphincteric: Similar to trans-sphincteric, but the track loops over the external sphincter and perforates the levator ani.
- Extrasphincteric: The track passes from the rectum to perineal skin, completely external to the sphincteric complex. Clinical classification
High anal fistula-
- these open into the anal canal at or above the anorectal ring.
Low anal fistula-
- these open into the anal canal blow the anorectal ring.
Sign and symptoms
- Anal fistulae can present with many
- Discharge – either bloody or purulent
- Pururitis- itching
- Systemic symptoms if abscess becomes infected
- Diagnosis is by examination, either in an outpatient setting The examination can be an anoscopy.
- The opening of the fistula onto the skin may be seen
- The area may be painful on examination
- there may be redness
- An area of induration may be felt – thickening due to chronic infection
- A discharge may be seen
- It may be possible to explore the fistula using a fistula probe (a narrow instrument) and in this way it may be possible to find both openings of the fistula
Digital Rectal examination Better after enema Find
- I. Sphincter tone
- II. Pain or Tenderness
- III. Palpable Mass
- IV. Internal opening of Fistula
- V. Temp
Internal opening of Fistula …… Digital examination
- vi. Male
- Prostate, Seminal vesicles, Base of bladder
- Uterus, Cervix, Vagina
- Male & Female
- Ischio Rectal Abscess
- Blood- RE
- Smear C & S
Kshar Sutra Chikitsa
Properity of kshar
- Distroys the unhealthy tissues.
- Deberides the wound.
- Promots the healing of healthy tissues.
- It distroys the fibrous tissues and acts as fibrolytic agent.
- I. Lithotomy table within a OT.
- II. Spot light
- III. Ksharsutra dressing trolley
- IV. Instrument box
Preparation of the patient
- Evacuation of bowel
- Shaving of local area
- Inj. T.T.
- Xylocane sensitivity test
- Swedan of local area
- Washing of local area by antiseptic lotion.
Procedure of threading
- • Patient should be keep in lithotomy position.
- • Cleaning by antiseptic lotion and covered by a sterile clothes.
- • Explain the major procedure to patient.
- • Instruct to patient to relax the anal sphincter.
- • Now probing should be done through the path of least resistance under L.A. guided by the finger inside the anal canal.
- • Tip of probe should come out through anal orifice.
- • Now threaded the plain thread of suitable length in the eye of probe. (Primary threading)
- • Pull the probe through the anal orifice to leave the thread behind fistulous track.
- • Now tight the two end of thread moderatly.
- • Finally dressing by Jatyaditail or Anu tail.
- • Chang the thread by kshar sutra at a regular interval of 7 days by rail and train method.
- Jatyaditail or anu tail basti
- Sitz bath
- Proper antibiotic
- Haritaki Churn or Panchsakar Churan HS
- Abhayarista 4 TSF BD.
- Analgesics and anti-inflmmatory drugs.
- Diet- nutritious vegetarian diet.
Sitz bath tub
- • After subsequent changing of thread, in a few week, ksahar sutra comes out with the knot intact from the tract. This is known as cut through. Cut through indicates complet division of track.
How does Kshar Shutra work!
- • Cutting due to pressure necrossis
- • Kshar helps in cleaning debris from track, sterilization of track
- • Quick and Good healing of track
- • Slow cutting and healing result in nil recurrence and minimal sphincter mechanism distrubances.
Problem during the therapy
- I. Duration of treatment- depend on the length of track.
- II. Allergic reaction
- III. Discharge
- IV. Incontinence- may be due to trauma to sphincter, so that never cross the ano rectal-ring.
- V. Foreign body sensation.
- VI. Anal stenosis.
Advantage of kshar sutra
- Minimal trauma and no tissue loss as compare to fistulectomy.
- Almost no bleeding as compare to fistulectomy.
- Anesthesia is seldom required.
- Minimal hospital stay.
- No dressing as compare to fistulectomy
- No anal stricture if properly treated.
- Nil recurrence 99.96%
- Very narrow and fine scare as compare to fistulectomy
- Therapy is cost effective.