9 months old boy is suffering from Fistula in Ano with a history of 5 months chronicity. Multiple external Fistulous openings with 1 int. opening are present. 3 openings are in Rt side and 2 in left. What will be the possible etiopathology and line of management ? BCG was given.Please guide.
Dear Dwivedi,
In case of anorectal fistulae with multiple tracks in children you have to exclude the presence of associated Crohn's disease.
A fistula in ano in paediatric age usually occurs following perianal abscess. Initial treatment might begin with a long course of antibiotic (i.e.6 months). If not healed, a simple fistulotomy mostly gives satisfactory outcome.
even if the kid is vaccinated TB is still a likely diagnosis. Such complicated fistulas are unlikely to be due to simple perianal abscess. How is the kid doing in-terms of growth and development. a therapeutic trial with anti TB is a good idea
Thanks a lot for guidance Dr Khalid, Dr Surasak,Dr Engida & Lavekar Sir. Further I wish to add that Crohns is little uncommon in this age group. I put this Pt. on antibiotics for 15 days and response of the drugs will decide to continue further. Yes I am looking for possibilities of Tubercular origin, though the development of this child is good. Thanks again.
Fistula-in-ano in children is a congenital and there are several articles to support this. It can present initially as a perianal abscess which needs drainage or as a fistula from the start. There are people who will wait for spontaneous healing once the lining is destroyed from repeated infections. I prefer to treat it surgically either fisulotomy ot more preferably fistulectomy. It is seen in boys only. It can be unilateral, bilateral or sometimes multiple. Rarely, fistula in ano can be seen in children secondary to Crhons disease. These patients will have other related symptoms.
If the primary track is midline, then congenital is a possibility. However, there are a number of chronic or recurrent acute infectious and inflammatory conditions that could account for his condition. The cytology/microbiology/pathology - including a rectal biopsy would be an initial guide. I would suggest all conservative measures, including a nnon-cutting, loose seton and even a plug, once the track is mature. But, at this age, I would definitely not recommend any measure to incising either sphincter. The opinion of a good dermatologist would be very helpful...
It may be congenital, TB, Crohn's disease, immunocompamised host , DM, or less likely malignanat. i/v/o mutiple fistultale and chronicity better to do MRI or examoination under anaethesia to know the extension of tract. operate accordingly and send specimen for histopathology.
Daer Dwiivedi,
I agree with you that according to the literature, Crohn's disease is uncommon. However, there is some new demographic data suggesting that this notion is changing nowadays. I my self diagnosed 2 cases in the last year. Their main presentation recurrent multiple perianal fistulea.
please, I wonder if you could update us about your final diagnosis.
Dr.Pena publicised an article about this type of perineal abscess and advised conservative treatment until age of one year.
Dr Farid, Can you please either send a copy of the article or give some link please ? I wish to read that. Thanks
Please refer to my publication " a systematic review of the management of anal fistula in infants"
http://www.ncbi.nlm.nih.gov/pubmed/27663698
Have you investigated ano-rectal anomalies in newborn child by radiographic diagnosis procedure? Anorectal malformation in males; High: with recto prostatic uretral fistula; Intermediate: Rectobulbar urethral fistula; Low: Anocutaneous fistula.
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