Anal fistula medical therapy: Difference between revisions

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__NOTOC__
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{{Template:Anal fistula}}
{{Template:Anal fistula}}
{{CMG}}
{{CMG}}, {{AE}}{{MKK}}
==Overview==
==Overview==
==Workup==
Pharmacotherapy used in anal fistula depends upon the location and symptoms of patient. [[Antibiotics]] are used in patient with comorbities like [[immunosuppression]], [[diabetes]], extensive [[cellulitis]], [[Prosthetic devices|prosthetic]] devices and high risk [[cardiac]] patients. [[Antipyretics]] and [[analgesic]] for symptomatic relief of [[pain]] and [[fever]]. Treatment of underlying causes is important to treat recurrent anal fistulas.
There are several stages to treating an anal fistula:


===Treating active infection===
==Pharmocotherapy==
Some patients will have active [[infection]] when they present with a fistula, and this requires clearing up before definitive treatment can be decided.  
*Empiric therapy for anal fistula depends on following factors:<ref name="urlwww.fascrs.org">{{cite web |url=https://www.fascrs.org/sites/default/files/downloads/publication/clinical_practice_guideline_for_the_management_of_anorectal_abscess_fistula-in-ano_and_rectovaginal_fistula.pdf |title=www.fascrs.org |format= |work= |accessdate=}}</ref>
 
**Location of anal fistula.
[[Antibiotics]] can be used as with other infections, but the best way of healing infection is to prevent the buildup of pus in the fistula, which leads to abscess formation. This can be done with a [[Seton stitch|seton]] - a length of [[suture]] material looped through the fistula which keeps it open and allows [[pus]] to drain out.  In this situation, the [[Seton stitch|seton]] is referred to as a draining seton.
**If the patient shows signs and symptoms of [[abscess]].
 
*Main stay of therapy is surgical management but [[antibiotics]] are given in the following condition:<ref name="pmid15933794">{{cite journal |vauthors=Whiteford MH, Kilkenny J, Hyman N, Buie WD, Cohen J, Orsay C, Dunn G, Perry WB, Ellis CN, Rakinic J, Gregorcyk S, Shellito P, Nelson R, Tjandra JJ, Newstead G |title=Practice parameters for the treatment of perianal abscess and fistula-in-ano (revised) |journal=Dis. Colon Rectum |volume=48 |issue=7 |pages=1337–42 |year=2005 |pmid=15933794 |doi=10.1007/s10350-005-0055-3 |url=}}</ref><ref name="pmid9236458">{{cite journal |vauthors=Dajani AS, Taubert KA, Wilson W, Bolger AF, Bayer A, Ferrieri P, Gewitz MH, Shulman ST, Nouri S, Newburger JW, Hutto C, Pallasch TJ, Gage TW, Levison ME, Peter G, Zuccaro G |title=Prevention of bacterial endocarditis. Recommendations by the American Heart Association |journal=Circulation |volume=96 |issue=1 |pages=358–66 |year=1997 |pmid=9236458 |doi= |url=}}</ref>
===Definitive Treatment===
**[[Immunosuppression]]
Definitive treatment of a fistula aims to stop it recurring.  Treatment depends on where the fistula lies, and which parts of the[[Anus|anal sphincter]] it crosses.
**[[Diabetes]]
 
**Extensive [[cellulitis]]
There are several options:
**[[Prosthetic devices]]
*'''Doing nothing''' - a drainage seton can be left in place long-term to prevent problems.  This is the safest option although it does not definitively cure the fistula.
**High-risk cardiac patient
*'''Conversion to a cutting seton''' - this involves a similar process to a draining seton but the suture is tied tightly.  This gradually cuts through the muscle and skin involved, leaving behind a small area of [[Scar|scarring]].  This cures the fistula in most cases, but can cause [[Fecal incontinence|incontinence]] in a small number of cases, mainly of [[Flatulence|flatus]] (wind).
*Other drugs used for symptomatic relief of anal fistula are:
*'''Lay-open of fistula-in-ano''' - this option involves an operation to cut the fistula open and let it heal naturally. This cures the fistula but leaves behind a scar, and can cause problems with [[Fecal incontinence|incontinence]]. This option is not suitable for complex fistulae, or those that cross the entire [[Anus|anal sphincter]].
**[[Antipyretics]] and [[analgesics]] like [[acetaminophen]], and [[Ibuprofen]].
*'''Fibrin glue injection''' is a method explored in recent years, with variable success. It involves injecting the fistula with a biodegradable glue which should, in theory, close the fistula from the inside out, and let it heal naturally. This method is perhaps best tried before all others since, if successful, it avoids the risk of incontinence, and creates minimal stress for the patient.
==Treatment of underlying cause==
*'''Fistula plug''' is an "advanced" version of the fibrin glue method. It involves "plugging" the fistula with a "plug" made of porcine small intestine submucosa (sterile, biodegradable), fixing the plug from the inside of the anus with suture, and, again, letting the fistula heal "naturally" from the inside out. According to some sources, the success rate with this method is as high as 80%.
*Treatment of anal fistula with [[Crohns disease|Crohn's]] diseases:
*'''Endorectal advancement flap''' is a procedure in which the internal opening of the fistula is identified and a flap of mucosal tissue is cut around the opening. The flap is lifted to expose the fistula, which is then cleaned and the internal opening is sewn shut. After cutting the end of the flap on which the internal opening was, the flap is pulled down over the sewn internal opening and sutured in place. The external opening is cleaned and sutured. Success rates are variable and high recurrence rates are directly related to previous attempts to correct the fistula.
**Anti-[[TNF-α|tumour necrosis factor α]] antibody, [[infliximab]] is the first line of treatment.<ref name="pmid16611273">{{cite journal |vauthors=Sands BE, Blank MA, Diamond RH, Barrett JP, Van Deventer SJ |title=Maintenance infliximab does not result in increased abscess development in fistulizing Crohn's disease: results from the ACCENT II study |journal=Aliment. Pharmacol. Ther. |volume=23 |issue=8 |pages=1127–36 |year=2006 |pmid=16611273 |doi=10.1111/j.1365-2036.2006.02878.x |url=}}</ref><ref name="pmid14985485">{{cite journal |vauthors=Sands BE, Anderson FH, Bernstein CN, Chey WY, Feagan BG, Fedorak RN, Kamm MA, Korzenik JR, Lashner BA, Onken JE, Rachmilewitz D, Rutgeerts P, Wild G, Wolf DC, Marsters PA, Travers SB, Blank MA, van Deventer SJ |title=Infliximab maintenance therapy for fistulizing Crohn's disease |journal=N. Engl. J. Med. |volume=350 |issue=9 |pages=876–85 |year=2004 |pmid=14985485 |doi=10.1056/NEJMoa030815 |url=}}</ref><ref name="pmid19750568">{{cite journal |vauthors=Taxonera C, Schwartz DA, García-Olmo D |title=Emerging treatments for complex perianal fistula in Crohn's disease |journal=World J. Gastroenterol. |volume=15 |issue=34 |pages=4263–72 |year=2009 |pmid=19750568 |pmc=2744181 |doi= |url=}}</ref>
*'''Anal Fistula Plug''' is a recently developed method known as AFP. This treatment requires placement and fixing of a plug in the anal fistula by a special technique. The plug is made of highly sophisticated absorbent material; it provides a scaffold over which body’s collagen gets deposited and closes the fistula. Comparative studies have shown this method to be very effective. One advantage of this method is that it involves no cutting, so there is no post operative wound and pain. AFP plugs can sometimes be inserted under local anesthesia. This method can be used successfully to treat high fistula without colostomy. It does not carry any risk of bowel incontinence. As opposed to the staged operations, which may require multiple hospitalizations, AFP requires hospitalization for only about 24 hours. The success rate of AFP is better than the other procedures. AFP was approved for clinical use by the [[FDA]] in May 2005 and hundreds of procedures have been done since then.
*Treatment of anal fistula with [[tuberculosis]]:<ref name="pmid18760061">{{cite journal |vauthors=Bokhari I, Shah SS, Inamullah, Mehmood Z, Ali SU, Khan A |title=Tubercular fistula-in-ano |journal=J Coll Physicians Surg Pak |volume=18 |issue=7 |pages=401–3 |year=2008 |pmid=18760061 |doi=06.2008/JCPSP.401403 |url=}}</ref><ref name="pmid19623062">{{cite journal |vauthors=Donoghue HD, Holton J |title=Intestinal tuberculosis |journal=Curr. Opin. Infect. Dis. |volume=22 |issue=5 |pages=490–6 |year=2009 |pmid=19623062 |doi=10.1097/QCO.0b013e3283306712 |url=}}</ref>
**If the patient is having recurrent [[fistula]] and fail to respond to standard therapy then, [[tuberculosis]] should be suspected.
**Anti-[[tuberculous]] drugs are the first line treatment.


==References==
==References==

Latest revision as of 20:46, 13 February 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1], Associate Editor(s)-in-Chief: Manpreet Kaur, MD [2]

Overview

Pharmacotherapy used in anal fistula depends upon the location and symptoms of patient. Antibiotics are used in patient with comorbities like immunosuppression, diabetes, extensive cellulitis, prosthetic devices and high risk cardiac patients. Antipyretics and analgesic for symptomatic relief of pain and fever. Treatment of underlying causes is important to treat recurrent anal fistulas.

Pharmocotherapy

Treatment of underlying cause

References

  1. ↑ "www.fascrs.org" (PDF).
  2. ↑ Whiteford MH, Kilkenny J, Hyman N, Buie WD, Cohen J, Orsay C, Dunn G, Perry WB, Ellis CN, Rakinic J, Gregorcyk S, Shellito P, Nelson R, Tjandra JJ, Newstead G (2005). "Practice parameters for the treatment of perianal abscess and fistula-in-ano (revised)". Dis. Colon Rectum. 48 (7): 1337–42. doi:10.1007/s10350-005-0055-3. PMID 15933794.
  3. ↑ Dajani AS, Taubert KA, Wilson W, Bolger AF, Bayer A, Ferrieri P, Gewitz MH, Shulman ST, Nouri S, Newburger JW, Hutto C, Pallasch TJ, Gage TW, Levison ME, Peter G, Zuccaro G (1997). "Prevention of bacterial endocarditis. Recommendations by the American Heart Association". Circulation. 96 (1): 358–66. PMID 9236458.
  4. ↑ Sands BE, Blank MA, Diamond RH, Barrett JP, Van Deventer SJ (2006). "Maintenance infliximab does not result in increased abscess development in fistulizing Crohn's disease: results from the ACCENT II study". Aliment. Pharmacol. Ther. 23 (8): 1127–36. doi:10.1111/j.1365-2036.2006.02878.x. PMID 16611273.
  5. ↑ Sands BE, Anderson FH, Bernstein CN, Chey WY, Feagan BG, Fedorak RN, Kamm MA, Korzenik JR, Lashner BA, Onken JE, Rachmilewitz D, Rutgeerts P, Wild G, Wolf DC, Marsters PA, Travers SB, Blank MA, van Deventer SJ (2004). "Infliximab maintenance therapy for fistulizing Crohn's disease". N. Engl. J. Med. 350 (9): 876–85. doi:10.1056/NEJMoa030815. PMID 14985485.
  6. ↑ Taxonera C, Schwartz DA, García-Olmo D (2009). "Emerging treatments for complex perianal fistula in Crohn's disease". World J. Gastroenterol. 15 (34): 4263–72. PMC 2744181. PMID 19750568.
  7. ↑ Bokhari I, Shah SS, Inamullah, Mehmood Z, Ali SU, Khan A (2008). "Tubercular fistula-in-ano". J Coll Physicians Surg Pak. 18 (7): 401–3. doi:06.2008/JCPSP.401403 Check |doi= value (help). PMID 18760061.
  8. ↑ Donoghue HD, Holton J (2009). "Intestinal tuberculosis". Curr. Opin. Infect. Dis. 22 (5): 490–6. doi:10.1097/QCO.0b013e3283306712. PMID 19623062.

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