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