dr sunil negi

1. ULCER SINUS
FISTULA

2. Definition
A break in the epithelial continuity
Discontinuity of the skin or mucous membrane
which occurs due to the microscopic death of
the tissues

3. Aetiology
 Venous Disease (Varicose Veins)
 Arterial Disease ; Large vessel (Atherosclerosis) or Small
vessel (Diabetes)
 Arteritis : Autoimmune (Rheumatoid Arthritis, Lupus)
 Trauma
 Chronic Infection : TB/Syphilis
 Neoplastic : Squamous or BCC, Sarcoma

4. Wagner’s Grading of ulcers
 Grade 0 - Preulcerative lesion/healed ulcer
 Grade 1 - Superficial ulcer
 Grade 2 - Ulcer deeper to Subcutaneous tissue exposing soft
tissue or bone
 Grade 3 - Abscess formation or osteomyelitis
 Grade 4 - Gangrene of part of tissues/limb/foot
 Grade 5 - Gangrene of entire one area/foot

5. Classification
A. Clinical
B. Pathological

6. 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)

7. B.Pathological
1. Nonspecific
2. Specific
3. Malignant

8. 1. Non specific
Traumatic Ulcer
Arterial Ulcer
Venous Ulcer
Neurogenic Ulcer
Infective Ulcer

9. 1. Non specific contd.
Diabetic Ulcer
Tropical Ulcer
Cryopathic Ulcer
Martorell’s Ulcer
Bazin’s Ulcer

10. • Traumatic ulcer
1. Mechanical- Dental ulcer on tongue ( jagged tooth )
2. Physical- Electrical burn
3. Chemical- Application of caustics
 Acute, Superficial, Painful, Tender

11. • Arterial Ulcer
• Caused due to peripheral vascular disease
• LL : Atherosclerosis & TAO
• UL : Cervical Rib, Raynauds
• Chief complaint : Severe Pain
• Toes, Feet, Legs & UL Digits

12. • Venous ulcers
 Medial aspect of lower 3rd of lower limb
 Ankle ( Gaiters Zone ) : Chronic Venous HTN
 Ulcers are Painless
 Varicose Veins or Post Phlebitic limb ( PTS )

13. • 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

14. • Tropical ulcer
• Tropical regions : Africa, India, S.America
• Trauma or Insect Bite
• Fusobacterium fusiformis & Borrelia vincentii
• Abrasions, Redness, Papules & Pustules
• Severe Pain

15. • 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,

16. 2. Specific
Tuberculosis
Syphilis
Actinomycosis
Meleney’s ulcer
Soft sore

17. 3. Malignant
Squamous cell ca
Basal cell ca
Malignant melanoma

21. Examination
Inspection
Palpation
Examination of lymph nodes
Vascular insufficiency
 Nerve lesions

22.  INSPECTION
Location, size, shape, floor, edge, discharge, surrounding area.
 PALPATION
Tenderness, 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

23. INSPECTION
LOCATION OF THE ULCER
FLOOR OF THE ULCER
DISCHARGE FROM THE ULCER
EDGE
SURROUNDING AREA

24. 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

25. 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 ulcer
Wash-leather slough Gummatous ulcer

26. 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

27. EDGE
DEF: 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.

28. A. Sloping edge All healing ulcers like
traumatic ulcers, venous
Ulcers

29. B. Punched out
edge
Gummatous
ulcers and trophic
ulcers.

30. C. Undermined
edge
Tuberculous
ulcers

31. D. Raised edge
(beaded edge)
Rodent ulcers or
basal cell
carcinoma .

32. E. Everted edge
(Rolled out)
Squamous cell
carcinoma.

33. SURROUNDING AREA
Thick and
pigmented
Varicose ulcer.
Thin and dark Arterial ulcer.
Red and
oedematous
Spreading ulcers
like diabetic ulcer.

34. PALPATION
EDGE
BASE
MOBILITY
BLEEDING
SURROUNDING AREA

35. 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.

36. BASE
It is the area on which ulcer rests.
Marked induration at the base is diagnostic of
squamous cell carcinoma.

37. 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.

38. 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.

39. BLEEDING
Malignant ulcer is friable like a cauliflower. On
gentle palpation, it bleeds.
 Granulation tissue as in a healing ulcer also
causes bleeding.

40. SURROUNDING AREA
Thickening and induration is found in
squamous cell carcinoma.
Tenderness and pitting on pressure
indicates spreading inflammation
surrounding the ulcer.

41. 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.

42. MANAGEMENT

43. Investigations
1) Complete blood picture: Hb%, TC, DC, ESR, PS
2) Urine and blood examination to rule out diabetes
3) Chest X-ray - PA. view to rule out P.TB
4) Pus for culture/sensitivity
5) Lower limb angiography in cases of arterial diseases
6) X-ray of the part to see for Osteomyelitis
7) Biopsy: Non-healing/malignant ulcers

44. Treatment
Address cause
Correct deficiencies
Control pain, infection
Debridement, dressing
Closure of defect

45. TREATMENT OF THE ULCERS
Treatment of Spreading Ulcers
Treatment of Healing Ulcers
Treatment of Chronic Ulcers
Treatment of The Underlying Disease

46. TREATMENT OF SPREADING ULCERS
 Pus 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,

47. TREATMENT OF HEALING ULCER
 Regular dressings are done for a few days
 Antiseptic 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

48. 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.

50. DEFINITION
SINUS:
 Blind track lined by granulation tissue leading from
epithelial surface down into the tissues.
 Latin: Hollow (or) a bay

51. CAUSES
CONGENITAL ACQUIRED
Preauricular sinus TB sinus
Pilonidal sinus
Median mental sinus
Actinomycosis

52. 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

53. Latin : flute (or) a pipe (or) a tube
.

54. CAUSES
CONGENITAL
 Branchial fistula
 Tracheo-esophageal
 Umbilical
 Congenital AV fistula
 Thyroglossal fistula
ACQUIRED
I. Traumatic
II. Inflammatory
III. Malignancy
IV. Iatrogenic

55. 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

56. 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

57. FISTULA
EXTERNAL
 Orocutaneous
 Enterocutaneous
 Appendicular
 Thyroglossal
 Branchial
INTERNAL
 Tracheo-esophageal
 Colovesical
 Rectovesical
 AVF
 Cholecystoduodenal

58. .

59. 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.]

60.  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

61. CLINICAL FEATURES
Usually asymptomatic but when infected manifest as-
• Recurrent/ persistent discharge.
• Pain.
• Constitutional symptoms if any deep seated origin.

62. CLINICAL EXAMINATION
INSPECTION:
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.

65. 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- TB
4. Surrounding area:
erythematous- inflammatory
bluish- TB
excoriated- faecal
pigmented- chronic sinus/fistulae.

66. 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

67. 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

68. 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

69.  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.

70. TREATMENT
BASIC PRINCIPLES:
 Antibiotics
 Adequate rest
 Adequate excision
 Adequate drainage.

71.  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.

73. TUBERCULAR SINUS OF NECK
Causative organism: mostly M.tuberculosis
but also M.bovis
Site 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.

74. Clinical stages:

75. 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

76. 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.

77. 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.

78. Collar stud abscess

79. 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.

80. 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

81. Sometimes, USG neck to detect cold abscess.
 Hypoechoeic lesions with internal echoes S/O debris
within.
 Guided aspiration of cold abscess.

82. TREATMENT
 ATT
 Excision of sinus tract with excision of diseased lymph
nodes.

83. FISTULA-IN-ANO
Chronic 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)

84. AETIOPATHOGENESIS
 Cryptoglandular (90% cases)
 Non cryptoglandular (10% cases)
TB
Diabetes mellitus
Crohn’s disease
Carcinoma rectum
Trauma
Lymphogranuloma venereum
Radiotherapy
Immunocompromised patients (HIV etc.,)

85. CRYPTOGLANDULAR HYPOTHESIS

86. CLASSIFICATION
PARK’S CLASSIFICATION:
(relation of primary tract to external sphincter)
• Inter sphincteric (45%)
• Trans sphincteric (40%)
• Supra sphincteric
• Extra sphincteric

88. STANDARD CLASSIFICATION
 Sub cutaneous
 Sub mucous
 Low anal
 High anal
 Pelvi rectal

89.  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

90. 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

91. 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.

92. 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.

93. IMAGING
 Fistulography
 Endoanal ultrasound
 MRI

94. Fistulography:
 Reveals primary and secondary
tracts.
 Useful if extra sphincteric fistula
suspected.

95. END0 ANAL ULTRASOUND
• Determines sphincter
integrity.
• Complexity of fistula.
horse-shoe fistula

96. MRI
“GOLD STANDARD” for fistula-in-ano imaging.
high variety supra horse-shoe fistula.
sphincteric fistula.

97. MRI
Abscesses and contralateral
extensions disease

98. PRINCIPLES OF TREATMENT
 Control sepsis
EUA
Laying open abscesses and secondary tracts
Adequate drainage – seton insertion
 Define anatomy
• Openings and tracts
 Internal and External
 Single –v- multiple
 Extensions / Horseshoe
• Relation to sphincter complex
 High –v- Low
 Exclude co-existent disease

99. SURGICAL MANAGEMENT
 Fistulotomy (The laying open technique)
 Fistulectomy
 Seton techniques
 Fibrin glue sphincter preserving
 Anal fistula plug techniques.
 Advancement flap
 LIFT procedure.

100. 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.

101. 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.

102. 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.

103. 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

105. 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.

106. 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.

107. FISTULA PLUG

108. FISTULA PLUG:

109. ADVANCEMENT FLAPS
Endorectal
 Fistula tract probed
 Flap raised
• Mucosa + Int. Sphincter
 Internal opening excised/closed
 Flap advanced & sutured

110. ADVANCEMENT FLAP
Anodermal
 Fistula tract probed
 Flap raised
• Anodermal
 Flap advanced & sutures
 External defect closed

111. LIFT PROCEDURE
Ligation of Inter sphincteric
Fistula Tract
 Trans sphincteric fistula
 Draining seton – 6 weeks
 Tract prepared with fistula brush
 Debrides
 De-epithelializes

112. FOLLOW UP
As with most anorectal disorders, follow-up care
includes:
 Perianal baths,
 analgesics for pain,
 stool bulking agents, and
 good perianal hygiene