Agree that correct diagnosis is crtiical. Atypical multiple perianal fistula in the elderly male patient must exclude malignancy and Crohn's disease. Active current infection needs to be controlled while undergoing evaluation and diagnostic tests (cultures, sigmoidoscopy, biopsy, etc). I do not know the extent of mycoplasma complications in perianal fistula conditions. A useful recent review of complex perianal fistula in Crohn's disease appeared in World J Gastroenterol. 2009 September 14; 15(34): 4263–4272 by Taxonera et al: Emerging treatments for complex perianal fistula in Crohn’s disease" full article on the internet at:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2744181/

tough case Dr Dwivedi,

Tuberculosis in the developing world is worth considering like you suggested, but i am not sure if treatment for 15 days with antitubercular therapy is the right approach..

Likewise, in the western world, crohn's disease should be considered for such fistulas..

I think an MRI will help a lot in delineating the fistula before taking him back for another surgical exploration..

I am not sure if you are planning a biopsy of the ulcer felt on digital examination or the fistula tract itself.. kindly explain..

regards, raza

Thanks Dr Raza & Dr James, This ATT is empirical and if the clinical symptoms & signs are reduced after 15 days, ATT can be prescribed even for a long period.Though I advised him for an MRI but as you might be aware that in India (we dont have MRI facility at our center) a common man is unable to afford costlier investigations. Specimen for HPE will be taken from track only as these are well connected with the ulcer (Internal opening).Thanks

Dr. Dwivedi, you certainly must have seen his blood sugar, and as did not mention it it must be normal... And I agree with Dr. Bowman and Sayyed that you have to check him for Tbc, Crohn's and malignancy... Would transrectal or simply superficial USG be cheaper in India, it could give you some opinion on configuration of fistulas... If it's Crohn's a good consultation of gastroenterologist would be crucial with, if appropriate, a diversion colostomy. Of course, Tbc should be excluded once and forever... Good luck to you and your patient!

Dr Sarsenov, i think it is a great idea to perform an ultrasound.. i'm not sure if it is feasible but maybe hydrogen peroxide can be used as contrast to better delineate the fistula tract on ultrasound..

Dr Dwivedi, my only reservation in empiric use of Antituberculous therapy is that we often keep in mind only two scenarios that either the patient has tuberculosis that will get better on ATT or it won't be tuberculosis in which case it won't be affected..

In real life, however, there are many more scenarios that can exist, which this simple assumption will fail to recognize.. the patient, for example, can have multidrug resistant TB (an entity not uncommon these days, especially in southeast asia) in which case he won't get better even on ATT.. or the patient has a complex fistula that goes in temporary remission following discharge and some drainage, and we might attribute the response to ATT, thus subjecting the patient to a full course of therapy..

maybe i am being overcautious, but in this day and age (of antimicrobial resistance and its global permutations) empiric treatment of tuberculosis with a premise that if it gets better, then it is TB might not be in overall benefit of the community..

attempts to diagnose TB can be made by sending the pus from fistulas for acid fast bacilli, and pathology from the fistula tract for routine histopathology as well as mycobacterial PCR since the culture yields are not very high..

regards, raza

Of course all answers are true. But I want to ask HIV serology of the patient. Rarely multipl perianal fistulas can be the first presentation for AIDS

Thanks, Pt. is non diabetic, Pus culture is sterile, HIV negative. we planned Biopsy from fistulous tracks( multiple bites ), followed by Ksharsutra ligation ( a type of seton prepared by smearing some herbal ashes, latex of Commiphora mukul and turmeric powder- An ayurvedic technique) and if HPE reveal, tubercular fistula, will continue ATT.

Differential diagnosis includes tuberculosis, actinomycosis, Crohn's disease, lymphogranuloma venereum.

in addition to Dr. Rakinic HIV is the other possibility in such cases!

Pt is HIV negative.In India Tuberculosis is most likely. we are waiting HPE reports.

Namaste Dr. Dwivedi i'm curious whats the HPE now & whats ur next step?

Thanks, Tubercular Fistula. we kept on AKT (3 drug regimen) for two months. After this we are planning to apply Kshar sutra.

Sir, continue with att & ligate with k.s., after few months it will heal

Very interested to hear more about the Kshar Sutra.. could you kindly give us more info

Thanks, Nuha !, Kshar sutra therapy is an ayurvedic technique for Fistula in Ano & some other ailments.It can be compared with Seton with some added benefits. Kshar sutra means Kshar- Alkali and Sutra-Thread. So it is a thread smeared with certain alkalies and latex of plants with turmeric powder. It is used like cutting seton but needs to replace usually on weekly intervals.Unlike conventional fistulectomy and some other procedures, post operative complications( anal stenosis, incontinence, recurrence etc) are almost nil in this technique. Please feel free to ask more. Thanks

Hello Dr. Dwiwedi, thank you for report us your case, it is very interesting. I would like to ask you how Kshar sutra works, cutting the sphinter or healing the fistula, it is a poultice or a seton. Kind regards.

Thanks Dr Manuel, It is similar to seton. It chemically debride the track with simultaneous healing. It cut the structures in its route including sphincters but this differs from fistulectomy because of more time it takes.you may compare it with staged Fistulectomy.