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| The cause of anal fistula |
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History
Rectal pain, usually described as burning, cutting, or tearing
Pain with bowel movements; spasm of the anus is very suspicious for an anal fissure.
Bloody stools
Typically, bright-red blood appears on the surface of stools. Blood usually is not mixed into stool.
Occasionally, blood is found on toilet paper after wiping.
Patient may report no bleeding.
Mucoid discharge
Pruritus
A patient with an anal fistula may complain of recurrent malodorous perianal drainage, pruritus, recurrent abscesses, fever, or perianal pain due to an occluded tract.
Pain occasionally resolves spontaneously with reopening of a tract or formation of a new outflow tract.
Pain occurs with sitting, moving, defecating, and even coughing.
Pain usually is throbbing in quality and is constant throughout the day.
Physical
Start by optimizing patient placement; place the patient in the left lateral decubitus position with knees drawn up toward the chest.
Examine the patient carefully to avoid infliction of further pain or sphincter spasm. Examination may be facilitated by application of a topical anesthetic, such as Lidocaine jelly, prior to digital rectal examination.
Most fissures are visible externally when the patient bears down as if having a bowel movement.
Note the depth of the fissure and its orientation to the midline, often described using clock orientation of the hour hand.
Most tears are found in the posterior midline.
Rectal examination is generally difficult to tolerate because of sphincter spasm and pain.
Acute fissures are erythematous and bleed easily.
With chronic fissures, classic fissure triad may be seen.
Deep ulcer
Sentinel pile, which forms when the base of the fissure becomes edematous and hypertrophic (a resolving sentinel pile can result in a permanent skin tag or may become associated with a fistulous tract)
Enlarged anal papillae
Bidigital rectal examination in a patient with a fistula-in-ano may reveal an indurated tract or cord.
Fistula can be identified by small circles of granulation tissue, which exude pus when compressed if tissue is patent.
A fistulous tract that opens internally can be visualized with aid of an anoscope.
Inguinal lymph nodes may be enlarged and painful.
In an acute fistulous abscess, cardinal signs of inflammation, rubor, dolor, calor, and tumor (eg, erythema, pain, increased temperature, edema) may be found.
Examination of the anus reveals a linear tear in fissure-in-ano.
Causes
Passage of hard stool
Chronic diarrhea
Ten percent of chronic anal fissures are caused by childbirth.
Habitual use of cathartics
Anal trauma (can occur with anal intercourse or a rectal examination using a speculum or digit)
Causes of anal fistula include opened perianal or ischiorectal abscesses, which drain spontaneously through these fistulous tracts.
Anal fissures can be observed in patients with syphilis and other sexually transmitted diseases, tuberculosis, leukemia, inflammatory bowel disease such as Crohn disease, previous anal surgery, HIV, and other conditions or diseases.
Incidence of anal fissures in patients with leukemia is approximately 24%.
Fistulas are also found in patients with inflammatory bowel disease, particularly Crohn disease. The incidence of fissures in Crohn disease is 30-50%. Perianal activity often parallels abdominal disease activity, but it may occasionally be the primary site of active disease.
Anal fistulas also are associated with diverticulitis, foreign body reactions, actinomycosis, chlamydia, lymphogranuloma venereum (LGV), syphilis, tuberculosis, radiation exposure, and HIV.
Approximately 30% of patients with HIV develop anorectal abscesses and fistulas.
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