Anal fistula

FISTULA –IN –ANO OR ANAL FISTULA

Anal fistula is an abnormal connection that develops between two cavities or between a body cavity and the external environment.
Anal fistula originates 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.
CAUSES
1. Anal Fistula occurs as a result of; subsequent infection with Escherichia coli, staphylococci, or streptococci.
2. Trauma, fissures etc.
3. from a previous anu-rectal abscess.
4. Carcinomas of the rectum and anal canal
5. Hemorrhoids
6. Inflammatory bowel disease e.g. Colitis.
7. Certain systemic illness e.g. Chrohn’s disease.
8. Previous surgical obstetric operations with infected with badly healed perianal wounds.
CLASSIFICATIONS OF ANAL FISTULA.
Fistulas are classified according to their position related to the anorectal ring.
They are divided into two
1. Low level variety: the internal opens or lies below the anorectal ring
Three types may be identified
a.submucutaneous
b.submucous
c.intermuscular
2. The high level variety: these are uncommon and are commonly iatrogenic or secondary to colo-rectal or pelvic conditions. The internal opening passes through or lies above the anorectal .the types which may be identified are
a.pelvic-rectal (supralevator )
b. high interspincteric
c. high sub mucosa 

Pathophysiology
A localized infection, anorectal abscess appears as a collection of pus due to inflammation of the soft tissues. The inflammatory process that heads to abscess may begin with an abrasion or tear in the lining of the anal canal, rectum. As the abscess produces more pus, a fistula may form, creating an abnormal opening in the anal skin.


SIGNS AND SYMPTOMS.
1. Perianal pain which is worsened by defecation.
2. Discharge of watery, blood stained or purulent material or occasionally faeces and flatus through the external orifice in the perianal region.
3. Pruritus (anal itching). The discharge makes the perianal skin wet and softens and causes pruritus ani.   
4. Irritation of the skin around the perianal region.
5. General body weakness.
6. Perianal discharge either bloody or purulent.
7. Extra External opening.
8. Systemic Symptoms if abscess becomes infected eg. Septicemia, fever etc.
9. Perianal tenderness that is worsened by bowl movement.

DIAGNOSTIC INVESTIGATION
1. Physical Examination which include Digital Rectal Examination (DRE) to reveal a fibrous tract beneath the skin.
2. Anoscopy; may reveal
The opening of the fistula unto the skin may be seen
There may be redness.
An area of indurations (an abnormal hardening of a tissue) may be felt – thickening due to chronic infection, and a discharge maybe seen.
3. Fistulography; injection of a contrast solution into the fistula followed by an x-ray of the affected area.
4. Sigmoidoscopy, barium enema and colonoscopy maybe performed to rule out other conditions like ulcerative colitis.

TREATMENT
Aims:
1. To stop it from recurring.
2. To treat and prevent complications.
SURGICAL TREAMENT

1. Fistulotomy is a surgical opening of the fistulous tract. They can be performed by excision of the tract and surrounding tissue.

2. Fistulectomy – total removal of the fistulous tract to create larger wound followed insertion of drains, to remain in place for 48 hours.
3. Fistula plug; involves plugging the fistula with a device made from small intestinal submucosa. The fistula plug is positioned from the inside of the anus with sutures.
Fibrin glue injection; is a method explored in recent years, with variable success. It involves injecting the fistula with a biodegradable glue which should close the fistula from the inside out and let it heals naturally.
Cutting Section
If the fistula is in a high position and it passes through a significant portion of the sphincter muscle, a cutting section maybe used. This involves inserting a thin tube through the fistula tract, and fighting the ends together outside of the body minimizing scarring.
4. Colostomy
This is an opening of the colon to the surface of the abdomen. The purpose of bowel ostomies is to divert and drain feacal matter.

Pre-Operational Preparation

This includes all general pre-operative preparation including the following additions;
                                                                                                                                                                                                                                                                                                                                                                                                                             
Reassure client on competence of staff.                                                                                                                                                     
Explain procedure to alley fear and anxiety.                                                                                                                                                                                                                                                                                                                                                                                              
Provide diversional therapy.                                                                                                                                                                                   
Introduce client to successful recovering patient                                                                                                                                     
Orient patient on operating theatre and equipment
Give laxatives to the patient to take for a few days before the operation to help empty the bowels.
Maintain Nil per os 6 hours before surgery.
There should be a thorough bowel washout (enema).

Post operation management
Patient should be put to rest until the effect of the anesthesia has passed.

Put patient in the lateral position and change position from right to left lateral frequently.
Serve prescribed pain relief to help with any discomfort as the anesthesia wears off.
Encourage patient to drink and start with clear fluid when he/she feels good.
Maintain personal hygiene on the morning after the surgery.
Dress wound daily and examine the wound frequently to assess proper healing.
Dispose of solid dressing properly.
Serve prescribed antibiotics and laxatives such as psyllium.
Serve nutritious food to aid wound healing.
Serve stool softeners to enable patient to pass stool easily.

        Follow up / patient teaching
Explain the disorder to the patient and emphasize that complete recovery take’s time.
Patient should be encouraged to frequently visit the hospital within the 1st 4weeks to ensure proper wound healing.
Teach the patient that a diet high in fiber and fluids promote regular bowel movement and prevent irritation on an existing abscess. Explain that straining during a bowel movement can increase abscess discomfort.
Stress the importance of perianal cleanliness at all times, especially after bowel movement or any contact with a foreign body.
Encourage regular exercise to help the patient to return to normal activity as soon as possible.

Complications
1. Perianal cellulitis(localize or diffuse inflammation of the connective tissue of the anal canal)
2. Scar tissue formation (as a result the tissue fibrosis)
3. Urinary Retention.
4. Hemorrhoid.(swollen an inflamed veins at the anus and lower rectum)
5. Incontinence: In some cases surgery can damage the anal sphincter muscle to diminish it opening and close functioning.
6. Infection


ANAL FISSURE (FISSURE- IN- ANO)
Is a longitudinal tear or ulceration in the lining of the anal canal
Incidence
The incidence of anal fissures is around 1 in 350 adult.it affect men more than women. acute ulcers are quite common in children who passes bulky stool very quickly.
Chronic ulcers are quite common patient between the ages of 20-40 years.The ulcers does not heal readily.
CAUSES
1. Trauma of passing a large, firm stool
2. Tightening of the anal canal with increase sphincter tension
3. Spasm of the anal sphincter
4. Anal sexual intercourse
5. Laceration by a foreign body
6. Child birth
7. Chronic infection and inflammation of the surrounding tissues of the anal canal
CLASSIFICATION OF ANAL FISSURE
Fissures may be classified as
1. Primary: they are idiopathic with non known cause
2. Secondary: they are associated with another disorders e.g. tuberculosis, chrohn disease, trauma e. g child birth or perirectal surgery
3. Acute fissure: an acute fissure occurs as a result of excessive tissue stretching and possibly from passage of a hard large stool through the anal canal
4. Chronic fissure: they are secondary to cystitis

PATHOPHYSIOLOGY
The tear of anal fissure is usually located at the posterior wall. An acute fissure occurs as a result of excessive tissue tissue stretching and possibly from of a hard or large stool through the area.
The skin tear is very tender and tends to reopen at subsequent period of defecation.
An acute tear is quite a common event and heals quickly.
If the tear reopens every time the patient defecates, because of constipation and has a high sphincter tone, its base becomes fibrous and does not heal. It becomes a chronic ulcer.
The underlying sphincter goes into spasm at the slightest stimulation and may become fibroses and contracted preventing healing of the fissure.
The base at the base of the fissure becomes edematous and indurated (hardened) forming a sentinel pile (a hemorrhoid-like thickening of the mucous membrane at the lower end of an anal fissure) 


CLINICAL MANIFESTATION
1. Extremely painful defecation
2. Bleeding as a result of the ulcer or abrasion in  the anal region.
3. Bright-red blood may be seen in the stool after bowl movement.
4. Severe irritation causes great distress, particularly at night.
5. Mucus discharge from the anus. This may due to local causes within the anus or rectum examples are lack of cleanliness, excessive sweating.
6. Dyspareunia (painful sexual intercourse)
7. Pruritus. The discharge makes the perianal skin wet and softens and causes pruritus ani.   


DIAGNOSTIC INVESTIGATION
1. A gentle digital examination of the anal canal using a small anoscope.
2. When painless or multiple fissures are present a barium enema and sigmoidoscope  are used to rule out an associated inflammatory bowel disease.
3. Inspection and stretching of the perianal skin.

MANAGEMENT
Dietary modification with addition of fiber supplement
Give stool softener to reduce trauma to the anal region example mist sennaco
Advice patient to increase intake of water
Give sitz bath
Give bulk producing agent example psyllium mucciloid to help minimize pain associated with defecation
Perianal or intra anal application of nitroglycerin ointment to help increase the rate of healing and lowers pain level in chronic anal fissure. The ointment also helps too increase blood supply to the wound and relaxes the anal sphincter.
A suppository combining and anesthetic with corticosteroids helps to relieve the discomfort.
SURGICAL MANAGEMENT
Sphincter stretching
Digital stretching of the anal sphincter under general anesthesia partially paralysis them thereby relieving the spasms and allowing the tissues to heal
Internal sphincterectomy
Is an incision into the internal sphincter to increase its diameter?


REFERENCE
Prosper victor (2011). Modern surgery for professional nurses in Ghana, 3rd ed. Energy and design printing LTD, Tarkoradi
 SMELTZER ET AL (2010):   BRUNNER AND SADDARTH’S TEXT BOOK OF MEDICAL SURGICAL NURSING 12TH EDITION, NEWYORK; LIPINCOTT WILLIAMS AND WILKINS




HIRSCHSPRUNG’S DISEASE (MEGACOLON)

This is a congenital malformation of the large intestine. Hirschsprung’s disease (congenital mega colon) is characterized by the absence of marked production of parasympathetic ganglion cell of the colorectal wall. This disorder impairs intestinal motility and causes severe intractable constipation.
Hirschsprung’s disease is a blockage of the large intestine due to improper bowel muscle movement resulting from absence of parasympathetic ganglionic cells.
Or
It’s a disease of the large intestine that causes constipation or intestinal obstruction. This condition is named after Herald Hirschsprung’s; a Danish physician who first described the disease in 1888.
Incidence
Occurs in 1 in 2,000 to 1 in 5,000 live births
It occurs 5 times more often in males than in females.
It causes about 25% of all newborn intestinal blockages.
It usually occurs in blacks (non-whites) than whites.


Pathophysiology
Muscle contractions in the gut help digested material move through the intestine. This is called peristalsis. Nerves in between the muscle layers trigger the constriction. In Hirschsprung’s disease, the nerves are absent in the part of the bowel. Areas without such nerves cannot push materials through. This causes blockage and intestinal content buildup behind the blockage, causing a bowel and abdomen to become swollen.

Causes
Hereditary
Signs and symptoms
In newborns and infants.
Children always fail to have their first bowel movement (stools) within 24 – 48 hours after birth.
Infrequent but explosive stools after a doctor insert a finger into the rectum.
Swelling of the belly(abdomen)
Difficulty with bowel movement.
Jaundice (poor feeding).
Poor weight gain.

In toddlers and older children
Constipation that gradually gets worse.
Slow growth and development.
Feacal impaction (i.e. a collection of harden faeces in the rectum or sigmoid colon).
Swollen belly.
Children are not able to pass stool without laxatives.
Malnutrition.

Diagnosis and findings
Abdominal x-ray
If Hirschsprung’s disease is present, the last segment of the large intestine will look narrower than normal just before the narrow segment, the intestine will look bulged. The bulging is caused by blocked stools stretching the intestine.

Anal manometry;
During manometry, the doctor inflates a small balloon inside the rectum. Normally the rectal muscles will relax. If the muscles do not relax, Hirschsprung’s disease may be the problem. This test is often done in older children and adults.

Rectal biopsy;
This is the most accurate test for Hirschsprung’s disease. The doctor removes a tiny piece of large intestine and looks at it with a microscope. If nerve cells are missing, Hirschsprung’s disease is the problem.

Barium Enema;
This shows a narrow segment of distal colon with a saw tooth appearance and a funnel shaped segment above it.

Treatment
Treatment of Hirschsprung’s disease consists of surgical removal (resection) of the abnormal section of the colon, followed by re-anastomosis.
There are two steps typically used to achieve this goal;
The first stage is a colostomy
Later, when the child’s weight, age and condition are right, a pull through procedure is performed. In a pull through procedure, the Surgeon removes the segment of the large intestine lacking nerve cells and connects the healthy segment to the anus.

Pre-operative preparation
Provide psychological support to patient and family.
Bowel preparation with an anti-biotic, such as neomycin is necessary.
Daily colonic lavage with  toorm
Daily colonic lavage with normal saline to empty the bowel.
Post-operative
Monitor vital signs 4 hourly and record your findings. Monitor intake and output and maintain fluid and electrolyte balance.
Keep patient in an upright position.
Observe the patient for signs of complications such as tower, vomiting etc. and notify the doctor immediately if any of these occur.
Initiate and maintain IV therapy as ordered and administer antibiotics and monitor the patient for desired effect.
If ordered insert an N-G tube and note the colour, consistency and amount of drainage.

After colostomy or ileostomy;
Monitor us, watching for sepsis and Enterocolitis (increased respiratory rate) with abdominal distention.
Provide total parenteral nutrition as ordered
To prevent aspiration pneumonia and skin breakdown, turn and reposition the patient often.
Keep area around stoma clean and dry, and cover it with dressings or a colostomy appliance to absorbed drainage.
Begin oral feedings as ordered when bowel sounds resume.

After final corrective surgery
Keep the wound clean and dry, and check for significant inflammation.
Check the urine for blood, especially in a boy; because extensive surgical manipulation may cause bladder trauma.
Watch for signs of possible anastomotic leaks (sudden development of abdominal distension unrelieved by gastric aspiration, temperature spike, extreme irritability, which may lead to pelvic abscess.
Begin oral feedings when active bowel sounds resume and NG tube drainage decreases.

Patient teaching
Explain the disorder to the patient and the parents.
Teach the patient on colostomy or ileostomy care.
If the patient is a child, instruct the parents to watch for foods that increase the number of stools and to avoid offering these foods.

References

Springhouse Diseases(1997)  pennysylvania, second edition
www.digestive.niddk.nih.goddiseases/p.............
www.google.com