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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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