Anal Fissure & Fistula in Ano

Anal Fissure & Fistula In Ano
Department Of Shalyatantra
Anal Canal Anatomy
Anal Canal
 Length = 3.8 to 4 cm
 Zona Columnaris : Upper ½ - Line by Simple columnar
 Zona Hemorrhagica : Upper Part of Lower half
( hilton’s white line) - Stratified squamous non
keratinizing epithelium
 Zona Cutanea : Lower part of lower half ( below the
Hilton’s white line) – Stratified squamous keratinizing
epithelium.
Anorectal Bundle or Ring
Demarcating line b/w the
Rectum And Anal canal.
Can be felt posteriorly-

Thickened edge
Formed by- Puborectalis, Deep

Ext. Sphincter, Conjoined Long
muscle & Internal Sphincter
Puborectalis Muscle
 Maintain The angle b/w
Rectum and anal canal
 Gives off fiber to the longitudinal
Muscle layer.
 Position, length as well as
angle of the anorectal juntion
integrity & strength of the
Puborectalis muscle sling.
Development of Anal Canal.
 Fusion of post- allantoic gut ( upper) with the
proctodeum ( lower part)
 Pectinate or Dentate line is the junction pf these two.
 Anal Valves of Ball - Remnants of the pectodeal

membrane
 Column of Morgagni – Mucosa at Dentate line folded in

longitudinal column.
Anal Sphincter:
External & Internal Sphincter:
External Sphincter Internal Sphincter
Muscle Single muscle k/ as Goligher Continue of the circular

Muscle muscular coat of the rectum
Colour Red Pearly white
Nerve Pudendal Nerve Autonomic nervous system

– intrinsic non- adrenergic &
non- cholinergic fiber
Type Of Muscle Somatic voluntary muscle Non – Striated Involuntary
Muscle
Parts Deep, Superficial and Always lie in the tonic state
Subcutaneous portion of contraction
Blood Supply of Anal Canal
 Superior Rectal artery Right and Left branch
 Middle Rectal Artery
 Inferior Rectal Artery

Venous Drainage:
 Upper half – Superior Rectal Vein IMV Porto
mesenteric venous system -
middle rectal vein Internal rectal vein
 Lower half – inferior rectal vein & Subcutaneous Peri-
Anal plexus of vein Internal Iliac Vein.
LYMPHATIC DRAINAGE:
Upper half – Post rectal LN Para Aortic nodes
Lower Half – Superficial Deep Inguinal LN

Venous System Of Anal Canal
Anal Canal
Above the Dentate Line Below the Dentate Line

Devlopment Post – Allantoic gut Proctodeum
Epithelium Cuboidal/ Columnar Squamous without Sweat
and hair glands
Name Surgical Anal canal Anatomical Anal Canal
Colour Pink Skin colour
Nerve Parasympathetic - painless Spinal Nerve – Very painful
Venous Drainage Portal System Systemic – Ext iliac vein
Lymphatic Drainage Para – Aortic Superficial & Deep inguinal
LN
Examination of Anal Canal
 Relaxed Patient
 Informed Consent
 Private Environment
 Good Light Source
 Position: Left Lateral Position/ Sim’s position- most

commonly used.
Image of Different position
P/R Examination : Inspection
 Skin Lesion - Psoriasis
Lichen planus
Warts
Candidiasis & Herpes simplex
 Whether anus is closed or patulous
 Position of anus/ perineum
 Evidence of piles/Sentinel tag
(Anal fissure)
P/R : Gloves , jelly etc.......
 Sling of puborectalis – Posteriorly at the apex
 Posterior surface of the prostate gland with median
sulcus(male) and Uterine Cervix(in Female) – Anteriorly.
 Intrarectal , Intraanal or extraluminal mass.
 Sphincter length
 Resting tone
 Voluntary squeeze
 Examining finger – Mucus, Blood, Pus
 Stool Color.
Proctoscope :
Proctoscopy:
 Position : Left lateral position
 Inspection of the distal rectum and anal canal
 Injection in Hemorrhoids
 Banding of Piles mass
 Biopsy of mass
Sigmoidoscopy:
 Mainly used for Rectal
examination
 But also recommended
in fissure & Hemorrhoids
 Cos Colitis & Rectal

Carcinoma is frequently
A/W Fissure & Hemorrhoids.
Physiology
 Structural Integrity of the – Endoluminal USG
 Neuromuscular Function – (a) Assessment of
conduction velocity along with the Pudendal nerve or
(b) Needle Electromyogram (EMG) – Slightly Painful.
 Evacuation Proctography or Dynamic Proctography:
- In Rectal Sensorimotor dysfunction (Overflow of
rectal content)
Dynamic Proctography
 Radio – opaque pseudo – stool is inserted into the
rectum
 Rest , Squeeze and than bear down to evacuate the

rectal contents under real – time imaging
 Can be combined with EMG & Pressure studies

Dynamic Magnetic Resonance
Proctography: DMRP
 More popular
 More expensive
 Less physiological
Anal Fissure:
 Longitudinal tear in the anal canal
 Site : Posterior midline (90%) and Anterior midline in 10%
case especially in female
Etiology & Predisposing factors
Anal fissure:
 Age : Young adult & middle aged man
 Gender : male > Female
 Posterior midline is the commonest site because –
- Maximum stretching on this site
- Less tissue here
- Minimal tissue perfusion
Etiology of Anal Fissure
 Main cause – Trauma – Strained evacuation of hard Stool
or
 Less commonly – Repeated passage of stool ( diarrhea)
 Anterior anal Fissure in 10% cases – Mostly in Women that

occurs following vaginal delivery
Predisposing Factors : Fissure
 Faces – hard
 Ischemia
 Surgical procedure
 Sphincter hypertonia
 Underlying Diseases – Crohn’s , TB , Syphilis etc.
 Repeated Childbirth
 Enthusiastic Usage of Ointments and abuse of
laxatives.
Clinical findings in Anal Fissure:
 Severe Anal pain during defecation
 Blood Streak Outside the stool
 Bleeding P/R – Bright
 Mucous Discharge
 Constipation
 Itching
 Burning Sensation
Chronic Anal Fissure Findings:
 Hypertrophied Anal papilla: Proximally

 Sentinel Tag Distally
 Thickened edge
 Exposed Internal Sphincter i.e. Ulcer Overlying the
fibers of internal Sphincter.
Treatment: Conservative & Surgical
 Main Objective to treat constipation.

- add the Fiber Rich Diet
- Encourage water intake
- Laxative to make the stool soft
 Application of local Anesthetic –Lignocaine jelly
 Antibiotics
 Hot Seitz bath
Conservative : Hot Seitz bath
Surgical procedure:
 Lord’s Anal Dilatation
 Lateral Anal Sphincterotomy
 Anal Advancement Flap

Fistula – in - Ano
 Chronic abnormal communication
 Between the Internal Opening ( Anorectal lumen)
External opening on the Perineum Or Buttock
 Lining is granulation tissue
 Commonest cause : non- specific, idiopathic & crypto
glandular And inter- Sphincteric Anal gland Infection.
Pathogenesis:
Persistent Anal Gland
infection
Anorectal Abscess
Rupture inside as well as

outside
Fistula
Fistula- in - ano : Underlying
Conditions
 Carcinoma
 Crohn’s
 Schistosomiasis
 Tuberculosis
 Ulcerative Colitis
 L. Venereum
 Anal Fissure
 Abscess
 Actinomycosis
 Renal Duplication
 Foreign Body
Fistula – in – ano: clinical features
 Intermittent purulent discharge
 Pain
 External Opening as sinus or Ulcer
 Bleeding/PR(sometimes)
Types of Fistula in ano:
 Low anal Fistula: Internal opening below the anorectal ring
 High anal Fistula: Internal Opening above the anorectal ring
 Importance : Low type fistula - Fistulotomy without damage to

Sphincter
High Type Fistula - Staged Operation
Park’s Classification:
 Based on Relationship Of Fistulous tract to the anal

Sphincter – 4 Types
 Intersphincteric fistula
 In vast majority of case
 Trans Sphinceteric Fistula
 Supra Sphincteric Fistula
 Extra Sphincteric Fistula

Park’s Classification:
Intersphincteric Fistula
 Most common type
 Incidence = 45%
 Don’t cross the external sphincter
Trans – sphincteric Fistula:
 Second Most Common type

 Incidence = 40%
 Its Track crosses both external & Internal sphincter
 Passes through the Ischio – rectal fossa to reach the skin

of the buttock
Supra- Sphincteric Fistula:
 Very Rare
 Cause – Iatrogenic
 Very similar to high level
T-S type
Extra- Sphincteric Fistula:
 Run without specific
relation to the sphincter
 Cause- Trauma or pelvic
Disease
 Originated in the Rectal
Wall
 Tracks Lateral to both
Sphicters
Clinical Assessment/Investigation:
 Obstetric History
 Gastrointestinal History
 Surgical History
 Continence History
 Proctosigmoidoscopy examination
 Site of the internal opening & External Opening.
 Course of the primary track
 Presence of the secondary extension
 Presence of other associated condition.
Goodsall’s Rule:
Clinical Assessment/Investigation
C. Hydrogen Peroxide Injection:
- Injection through the
External opening
- Find out the site of internal

opening
D. Gentle Use of Probe
 E. Maonmerty
- Resting anal tone
- functional anal sphincter length
- Voluntary squeeze
 F.Endoluminal USG
 G. MRI
 H. Fistulography
Management Of Fistula In Ano:
 Fistulotomy
 Fistulectomy
 Setons loose & Tight Setones
 Biological Agent: Fibrin Glue
 Advacement Flap: To preserve both anatomy & function
 VAFFT: Video Assisted Anal Fistula Treatment
Fistulotomy:
Fistulectomy: Excision of
whole Fistulous Tract
Setons : Bristle material
 Tread
 Wire
 Proline
 Infant Feeding Tube
 Ksharsutra
Ksharsutra Ligation
Thank You…….

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Anal Fissure & Fistula In Ano

Can be felt posteriorly-

Formed by- Puborectalis, Deep

 Pectinate or Dentate line is the junction pf these two.

 Anal Valves of Ball - Remnants of the pectodeal

 Column of Morgagni – Mucosa at Dentate line folded in

Muscle Single muscle k/ as Goligher Continue of the circular

Colour Red Pearly white

Nerve Pudendal Nerve Autonomic nervous system

 Middle Rectal Artery

 Inferior Rectal Artery

Lower Half – Superficial Deep Inguinal LN

Above the Dentate Line Below the Dentate Line

 Good Light Source

 Position: Left Lateral Position/ Sim’s position- most

 Inspection of the distal rectum and anal canal

 Banding of Piles mass

 Cos Colitis & Rectal

 Rest , Squeeze and than bear down to evacuate the

 Can be combined with EMG & Pressure studies

 Anterior anal Fissure in 10% cases – Mostly in Women that

 Hypertrophied Anal papilla: Proximally

 Main Objective to treat constipation.

 Lateral Anal Sphincterotomy

 Anal Advancement Flap

Rupture inside as well as

 Intermittent purulent discharge

 External Opening as sinus or Ulcer

 High anal Fistula: Internal Opening above the anorectal ring

 Importance : Low type fistula - Fistulotomy without damage to

 Based on Relationship Of Fistulous tract to the anal

 Supra Sphincteric Fistula

 Extra Sphincteric Fistula

 Second Most Common type

 Passes through the Ischio – rectal fossa to reach the skin

- Find out the site of internal

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