Fistola anorettale
Definizione
Consiste nella presenza di tragitto infiammatorio avente un
orifizio al livello del canale anale e uno a livello della cute perianale. L’orifizio interno si trova in genere a livello della
linea dentata, dove le ghiandole anali penetrano nel canale
anale. Compare spontaneamente o in conseguenza di un ascesso perianale. È classificata in base alla relazione con gli sfinteri
anali:
♦ Intersfinterica (70%)
♦ Trans- sfinterica (23%)
♦ Sovrasfinterica (5%)
♦ Extrasfinterica (2%)
Epidemiologia
L’incidenza e la prevalenza sono simili a quelle degli ascessi
anorettali.
♦ Rapporto maschi femmine 3:1.
♦ Picco di incidenza nella terza-quinta decade di età (media 38 anni).
♦ Incidenza di 8,6 x 100000 in uno studio epidemiologico finlandese
Fattori di rischio
☖ Ascessi anorettali
☖ Il 10% delle fistole è associato a:
♦ Malattie infiammatorie intestinali
♦ Tubercolosi
♦ Neoplasia
♦ Danno da radiazione
♦ Ragade anale
Eziologia
♦ Gli ascessi anorettali sono causati da infezione delle ghiandole che circondano il canale anale.
♦ Il 30- 40% degli ascessi anorettali si complica con una fistola.
♦ La maggior parte è di origine cryptoghiandolare.
♦ Nel 90% dei casi non si identifica una causa specifica.
♦ Le restanti cause sono: trauma, complicanze postoperatorie,
ragadi anali, malattie infiammatorie intestinali e tubercolosi.
Sintomi e segni
♦ Possibile febbre
♦ Dolore perianale
♦ Drenaggio costante della regione perianale
♦ Aumenta durante la defecazione
♦ Rende difficile il mantenimento dell’igiene perianale
♦ Drenaggio mucopurulento dall’orifizio interno o esterno
♦ Tramite fistoloso spesso indurite e palpabile
Diagnosi differenziale
♦ Malattia di Crohn
♦ Neoplasie anorettali
♦ Malattia pilonidale
♦ Idrosadenite suppurativa
♦ Ascesso delle ghiandole di Bartolini
♦ Tubercolosi anale
♦ Actinomicosi
♦Trauma
♦ Ragade anale
♦ Danno da radiazione
♦ Diverticolite
♦ Clamidiasi
Diagnosi
L’esplorazione in anestesia è il modo migliore per valutare una fistola. In alternativa può essere seguita una RM con bobina endoanale.
La fistola con orifizio esterno posteriore penetra nel canale anale a livello della linea mediana posteriore.
La fistola con orifizio esterno anteriore penetra nel canale anale a livello della cripta più vicina.
Se l’orifizio fistoloso è posto a più di 3 cm dalla rima anale.
Esami di laboratorio
♦ Leucocitosi
Procedure diagnostiche
☖ Anoscopia in anestesia
♦ Per individuare l’orifizio interno
Terapia
Immediatamente dopo la diagnosi, la fistola deve essere trattata al fine di ridurre l’infiammazione in preparazione all’intervento chirurgico.
☖ Mantenere il paziente in terapia con:
♦ Agenti emollienti delle feci
♦ Antidolorifici non narcotici
♦ Semicupi
☖ L’intervento chirurgico è in genere il trattamento di scelta, con l’eccezione delle fistole in associazione alla malattia di Crohn,
per le quali è indicata, ove possibile, la terapia medica.
Terapia specifica
☖ Il trattamento ottimale è il posizionamento di un setone (in seta di tipo elastico o tipo vessel loop) tramite attraverso il tramite fistoloso
♦ Mantiene il tramite aperto
♦ Riduce l’infiammazione circostante.
☖ Una volta che si è attenuata la riduzione della flogosi locale, valutare l’esatta definizione anatomica della fistola e programmare l’intervento chirurgico.
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