*Jakub Kropieniewicz1, Marcin Adamiecki2, Michał Nycz1, Anita Owczarska3, Zbigniew Lorenc1
A foreign body leading to anal fistula – case reports
Ciało obce powodujące rozwój przetoki odbytu – opis przypadku
1Department of General, Colorectal and Multiple-Organ Surgery, Faculty of Health Sciences, Medical University of Silesia
Head of Department: Professor Zbigniew Lorenc, MD, PhD
2School of Medicine with Division of Dentistry in Zabrze, Medical University of Silesia
Head of School: Professor Przemysław Jałowiecki, MD, PhD
3School of Medicine in Katowice, Medical University of Silesia
Head of School: Professor Przemysław Jałowiecki, MD, PhD
Przetoka odbytu jest patologicznym kanałem wysłanym ziarniną zapalną łączącym dno krypty odbytu ze skórą okolicy odbytu. W większości przypadków jest konsekwencją ropnia wywołanego infekcją gruczołów odbytowych. Najczęstszymi objawami przetoki są nawracające stany zapalne okolicy odbytu, świąd oraz sącząca się wydzielina ropna. W leczeniu przetok stosowane są przede wszystkim metody operacyjne, jednak podejmuje się również próby leczenia zachowawczego (kleje tkankowe lub tzw. zatyczki). Kluczowym celem leczenia jest wybranie takiej metody, która będzie cechować się wysoką radykalnością przy jak najmniejszym ryzyku powikłań. Literatura podaje kilka przypadków przetok odbytu spowodowanych przez ciało obce. W artykule przedstawiony został opis przypadku 57-letniego mężczyzny, u którego zdiagnozowano przetokę spowodowaną przez ciało obce niewiadomego pochodzenia. Pacjent skarżył się na występowanie ropnej wydzieliny od dłuższego czasu. Leczenie chirurgiczne polegało na wycięciu przetoki z późniejszym niepowikłanym wyzdrowieniem obserwowanym podczas kontroli ambulatoryjnych. Przetokę odbytu zdiagnozowano na podstawie wywiadu i badania fizykalnego, natomiast jej przyczynę wykryto pooperacyjnie. Omówiono również przyczyny i konsekwencje perforacji przewodu pokarmowego wskutek połknięcia ciała obcego.
Anal fistula is pathological tract lined by inflammatory granule connects bottom of the anal crypt with perianal skin. In most cases, anal fistula is a consequence of abscess developed due to infection of anal the glands. The most common symptoms of anal fistula are recurrent inflammation around the anus, pruritus and purulent leakage. In the treatment of fistulas mainly surgical methods are used, however, attempts of conservative treatment (tissue adhesives glues or plugs) are also undertaken. The goal of treatment is to choose a method that will be characterized by high radicality with the lowest possible risk of complications. Literature describes only few cases of perianal fistula caused by a foreign body. The paper presents a case of a 57-year-old man who was diagnosed with fistula-in-ano caused by a foreign body of unknown origin. The patient reported long-term purulent discharge only. Surgical treatment involved resection of the foreign body and fistula with subsequent uneventful recovery during outpatient follow-up. Anal fistula was diagnosed by anamnesis and physical examination, but its cause was detected post-operatively. The reasons and consequences of gastrointestinal perforation as a result of swallowing a foreign body are also discussed.
Anal fistula is a pathological hollow tract or cavity which usually connects the anal canal or the rectum with perianal skin or perineum. In 90-95% of cases, it forms secondary to anal abscess, which is most often caused by cryptoglandular infections (1). The content of abscess can break through the tissue to the rectal canal or, most commonly, penetrate through the skin, leading to anal fistula, which is a chronic stage of this disease. Less often, fistulas can be caused by proctologic surgeries, Crohn’s disease, ulcerative colitis, trauma, malignant tumours of the rectum, anus, prostate or bladder, radiotherapy, tuberculosis or actinomycosis (2). Depending on the location of the internal opening, we classify fistulas as either anterior or posterior (Tylicki’s classification). Another, more popular classification was described by Parks et al. It divides fistulas into intersphincteric, trans-sphincteric, suprasphincteric, and extrasphincteric, depending on the relation to the anal sphincter muscles (3). Some studies report a possible link between a foreign body and perianal fistula.
A 57-year-old man was admitted to the Department of General Surgery for a scheduled surgical treatment due to the diagnosed anal fistula with concomitant purulent discharge observed for the past few months. Patient’s history revealed surgical removal of anal fistula in 2013. The patient did not remember any situation when the foreign body could get through the anus, nor did he suffer from pain or any problems with defecation. Haemorrhoids and external opening of anal fistula at 8 o’clock were found on physical examination. Digital rectal examination did not reveal the presence of a foreign body. Laboratory tests were within normal limits. A surgical intervention was planned and the patient was taken to the operating room., A probe was inserted through the external opening of the fistula under regional anaesthesia to locate its internal opening. Next, the fistula was resected with a margin of healthy tissues using diathermy. The associated haemorrhoids were also dissected (fig. 1). This revealed a 3 cm long foreign body similar to bone, with sharp ends inside the fistula tract, which was evacuated (fig. 2). Local tissues were curetted and the wound was left for secondary healing (fig. 3). Hospitalisation was uneventful. The patient was discharged home in a good general condition, on the day after the operation. Ambulatory examination two weeks after the procedure showed proper wound healing and no problems with stool continence.
Fig. 1. Intraoperative view of the probe inserted into the fistula. The extracted foreign body is held in forceps
Fig. 2. The extracted foreign body
Fig. 3. Postoperative view
A swallowed foreign body is usually excreted from the digestive tract without any health complications. However, literature describes some rare cases of complications due to foreign body impaction and perforation of the wall of the digestive tract, leading to mediastinitis, peritonitis or intraperitoneal abscess (4).
A few studies report cases when a foreign body perforated rectal wall leading to anal abscesses and, subsequently, fistula formation. Paksoy et al. (2) described in their case report the consequences of a foreign body left in a patient after an orthopaedic surgery, leading to abscesses of gluteal and femoral region and, consequently, to anal fistula. The fistulous tract was opened; the foreign body was located in relation to the anal sphincter and extracted. Kocierz et al. (4) presented a case similar to the case of our patient, in which the patient developed a fistula as a result of a swallowed piece of bone. The treatment involved an incision of the fistula canal and an extraction of the foreign object. Aduful (5) reported two cases of consequences of a swallowed object. The first one lead to painful constipation caused by the object positioned transversely inside of the anus, which allowed the surgeons to extract the foreign body without anaesthesia. In the second case a fistula formed and the patient required fistulotomy.
The force with which the anal sphincter contracts during defecation may be a probable cause of the sharp object impaction into the anal wall. Risk factors predisposing to an ingested foreign body piercing the GI wall include decreased palatal sensitivity, previous anal surgery complicated by anal stenosis and alcohol abuse (6).
Patients diagnosed with fistula-in-ano usually present with similar symptoms related to the anal region: pain, oedema, purulent discharge or bleeding. Diagnostic methods used in perianal pathologies include digital examination, anorectoscopy, endorectal ultrasonography and MRI. Sometimes, abdominal or pelvic X-ray can help reveal or localize a foreign body, as well as exclude intestinal perforation (2, 4, 6). In the presented case, the diagnosis was made only postoperatively.
There are various treatment methods for patients diagnosed with perianal fistulas. Ideally, surgical management should lead to the healing of the tract while maintaining sphincter function and proper continence mechanism. Classical methods include fistulotomy, fistulectomy, cutting or loosing setons, mucosa advancement flaps, while modern strategies include fibrin glue, anal fistula plug, ligation of the intersphincteric fistula tract (LIFT), expanded adipose-derived stem-cells (ASCs), video-assisted anal fistula treatment (VAAFT) and Radial-emitting laser probe (FiLaCTM) (7).
Perianal fistulas usually manifest with a similar pattern of symptoms. However, it should be taken into consideration that some cases of fistulas can present with non-specific symptoms. Recurrent or nonhealing anal fistula should always be suspected of having a chronic background. It is worth noting that a foreign body may be one of the causes. In this case, it is crucial to completely remove the foreign body.
1. Sugrue J, Nordenstam J, Abcarian H et al.: Pathogenesis and persistence of cryptoglandular anal fistula: a systematic review. Tech Coloproctol 2017; 21: 425-432.
2. Paksoy M, Ozben V, Ayan F, Simsek A: An atypical etiology of suprasphincteric fistula: a forgotten surgical material. Case Rep Med 2010; 2010: 189846.
3. Parks AG, Gordon PH, Hardcastle JD: A classification of fistula-in-ano. Br J Surg 1976; 63(1): 1-12.
4. Kocierz L, Leung E, Thumbe V: An unusual cause of perianal fistula. J Surg Case Rep 2011; 2011(10): 4.
5. Aduful HK: Anal pain secondary to swallowed bone. Ghana Med J 2006; 40(1): 31-32.
6. Doublali M, Chouaib A, Elfassi MJ et al.: Perianal abscesses due to ingested foreign bodies. J Emerg Trauma Shock 2010; 3(4): 395-397.
7. Limura E, Giordano P: Modern management of anal fistula. World J Gastroenterol 2015; 21(1): 12-20.