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CHAPTER I CASE REPORT

1.1 PATIENTS PROFILE 1. Name 2. Gender 3. Age 4. Address 5. Occupation 6. Marriage Status 7. Date Admitted : Mr. Darto : Male : 36 years old : Bangodua, Indramayu : Gangster : Married : June 10, 2013

1.2 ANAMNESIS ( AUTOANAMNESA on the 12nd June 2013) A. The main Complaint : ulcers on the area around anus that feels pain and when it

rupture contain pus and blood B. Additional Complaint look like a cauliflower C. Present Health History : Patients come to the Arjawinangun hospitals with complaints are ulcers on the area around anus since 2 year ago. Patients admitted theulcers rupture since 1 years ago, contains pus and arise again. According to patients, the ulcers usually breaks every 1 week, contains pus (+), blood (+). Currently the patient denied pain but felt pain when the patient has not ruptured ulcer. Patients say no distractions while eating and : small bumps on the genitals of patients that feels itch and

drinking as well as nausea and vomiting. Patients admitted no interference during defecation, defecation 1x/day, no difficult / hard during bowel movements and no straining during defecation, no bleeding or mucus during defication. Moreover, there are some bumps incorporated into one that resembles a cauliflower. Bump no pain, no blood, no pus. Lump measuring 0.5 x 0.5 cm, soft, uneven surfaces, the same color as the skin. Patients say no disturbance during urination, urination normal jets, often waking night to urinate denying patients, urinate discontinuous (-), not satisfied / bladder emptying during urination (-), straining / difficult urination (-), pain during urination (-) urinating blood mixed (-). History of fever (-), cough cough old (-), diarrhea(-). D. Past Health History :

Patient admitted to multiple sexual partners and the use of tattoos. The patient denied having the disease of diabetes mellitus, hypertension and the patient have trauma history. E. Family Health History :

The patient admitted that in family never experienced anything like this

1.3 PHYSICAL ASSESSMENT A. objective General Status general state : being sick Awareness GCS : compos mentis : E4V5M6

Vial sign

: : 120 /70 mmHg : 80 bpm : 20 bpm : 36.7o C

o Blood pressure o Pulse rate o Respiration rate o Temperature Head Eyes Neck : normochepal

: CA ( -/- ) SI ( -/- ) : no masses and swelling noted , enlargement of lymphonodes (-),

Thyroid not palpable enlarged Thorax LUNGS o Inspection : no presence of scars and lessions, symmetric during

inspiration and expiration o Palpation lung fields o Percussion : sonor in both of lung fields : Fremitus tactile and fremitus vocal symmetric in both of

o Auscultation : vesicular + , Rh -/-, Wh -/-

COR o Inspection o Palpasion o Percussion : Ictus Cordis is not visible : Ictus Cordi is palpable : cardiac borders easily assessed

o Auscultation : regular cor sound, M (-), G (-)

Abdomen o Inspection o Palpation o Percussion : Flat, rounded : soft, no tender : Timpani whole abdominal field

o Auscultation : bowel sounds (+)

Upper & lower extremities Superior Inferior :warm akral, edema (-/-), cyanosis (-/-) : warm akral, edema (-/-), cyanosis (-/-)

1.4 WORKING DIAGNOSTIC Anal fistula Condyloma

1.5 DIAGNOSA BANDING Sinus pilonidalis Fistula proktitis Hidranitis supurativa

Verucca vulgaris Carcinoma cel squamosal

Moloscum contangiosum

1.6 PEMERIKSAAN PENUNJANG A. LABORATORY EXAMINATIONS (on June 10, 2013) Hematology report o WBC : 8.9 (4 - 12 103 /L) o LYM : 1.6 (1 - 5 103 /L) o MON : 1.1 (0.1 - 1 103 /L) o GRA : 6.2 (2 - 8 %) o LYM%: 18.0 (25 - 50 %) o MON%: 11.0 (2-10 %) o GRA% : 70.2 (50 - 80 %)

o RBC

: 5.56 (4 - 6.2 103 /L)

o HGB : 16.8 (11 - 17 g/dl) o HCT : 49.6 (35 - 55%)

o MCV : 89.2 (80 - 100 m3) o MCH : 30.2 (26 - 34 pg) o MCHC : 33.9 (31 - 35.5 g/dl) o RDW : 11.5 (10 16 %)

o PLT

: 179 (150 400 103 /L)

o MPV : 7.8 (7 11 m3) o PCT : 0.140 (0.200 - 0.500 %)

o PDW : 14.6 (10 18 %)

Random Blood Glucose

: 113 mg/dl

1.7 TREATMENT 1. Surgery 2. pharmacology : excision : hypobach 2 x 1 Dolac 2 x 1

1.8 PROGNOSIS Ad vitam Ad functionam Ad sanactionam : dubia at bonam : dubia at bonam : dubia at bonam

definition An anal fistula is a tiny, tubular, fibrous tract that extends into the anal canal from anopening beside the anus. Fistulas usually result from an infection. They may develop fromtrauma, fissures, or regional enteritis. Pus or stool may leak constantly from the cutaneousopening. Untreated fistulas may cause systemic infection with related symptoms.

Epidemiology Anal fistulas are a complication of anorectal abscesses, which are more common in women than in men. For reasons of intrinsic anatomy, rectovaginal fistulas are found only in women. Approximately 30-50% of patients with an anorectal abscess form an anal fistula.[7] and approximately 80% of anal fistulas arise from anorectal infection.( http://emedicine.medscape.com/article/776150-overview#a0156: Bruce M Lo, MD, RDMS, FACEP; Chief Editor: Robert E O'Connor, MD, MPH. 2012. Tgl akses 12 juni 2013. Anal Fistulas and Fissures )

Pathofisiology and etiology Most anal fistulas originate in anal crypts, which become infected, with ensuing abscess formation. When the abscess is opened or when it ruptures, a fistula is formed. An anal fistula can have multiple accessory tracts complicating its anatomy. Other causes of anal fistulas include opened perianal or ischiorectal abscesses, which drain spontaneously through these fistulous tracts. Fistulas are also found in patients with inflammatory bowel disease, particularly Crohn disease.[6] The incidence of fissures in Crohn disease is 30-50%. Perianal activity often parallels abdominal disease activity, but it may occasionally be the primary site of active disease. Anal fistulas can also be associated with diverticulitis, foreign-body reactions,actinomycosis, chlamydia, lymphogranuloma venereum (LGV), syphilis, tuberculosis,

radiation exposure, and HIV disease. Approximately 30% of patients with HIV disease develop anorectal abscesses and fistulas.

Classification Anal fistulas are classified into the following 4 general types:

Intersphincteric - Through the dentate line to the anal verge, tracking along the intersphincteric plane, ending in the perianal skin. Account for about 70% of all fistulae

Transsphincteric - Through the external sphincter into the ischiorectal fossa, encompassing a portion of the internal and external sphincter, ending in the skin overlying buttocks. Account for about 25% of all fistulae

Suprasphincteric - Through the anal crypt and encircling the entire sphincter, ending in the ischiorectal fossa. Account for about 5% of all fistulae.

Extrasphincteric - Starting high in the anal canal, encompassing the entire sphincter and ending in the skin overlying the buttocks. Accounts for about only 1% of all fistulae

Clinical manifestation SYMPTOMS OF FISTULA Anal fistulae can present with many different symptoms such as:

Pain Discharge - either bloody or purulent Pruritus ani itching around the anus Systemic symptoms if abscess becomes infected

Diagnosis Diagnosis is by examination, either in an outpatient setting or under anaesthesia. The examination can be an Anoscopy. Possible findings:

The opening of the fistula onto the skin may be seen The area may be painful on examination There may be redness A discharge may be seen It may be possible to explore the fistula using a fistula probe (a narrow instrument) and in this way it may be possible to find both openings of the fistula

Treatment Treatment of anal fistulas depends on (1) the location of the fistula, (2) evidence of sepsis or a large abscess, or (3) worrisome findings on physical examination. If an abscess is present, drainage is indicated. Intravenous antibiotics, antipyretics, and analgesics are provided as needed. However, simple rectal abscesses do not typically need antibiotics.[13] If the patient also has sepsis, intravenous fluids or a pressor may be necessary. Depending on the presence of systemic symptoms and the condition of the patient, surgery may be necessary. For anal fistulas, outpatient follow-up with a surgeon is indicated if consultation did not take place at the time of presentation. Surgical therapy is often indicated for healing of an anal fistula. The surgical approach is dependent on whether the fistula is simple or complex, as well as the risk of complications such as incontinence. A gastroenterologist should be consulted if inflammatory bowel disease is suspected. Asymptomatic anal fistulas from Crohn disease are not

managed by surgery. However, if the patient is symptomatic, surgical management should be considered. Antibiotics should be reserved for those with overlying cellulitis or those with sepsis. Otherwise, symptomatic treatment with analgesics should be considered.

Surgical Treatment For simple anal fistulas, fistulotomy with or without marsupialization is recommended.[13] In the presence of an abscess with anal fistula, incision and drainage along with fistulotomy may be considered. This is associated with decreased recurrence (relative risk, 0.17; 95% confidence interval, 0.09-0.32; P < .001) but increased risk of continence disturbance.[28] Fibrin glue has also been studied, with the advantage of less risk of incontinence. However, success rates have been reported lower than those for fistulotomy (41.7%). For complex fistulas, debridement and fibrin glue or fistula plug may be used. Success rates for fibrin glue range from 10-67%. Although it has a relatively low success rate, recent guidelines suggest that fibrin glue may be used as first-line therapy.[13] Likewise, variable success has been reported with fistula plugs. One small trial described a success rate of 72.7% with the use of the Gore Bio-A fistula plug.[29] Endoanal advancement flaps also have variable success rates for the treatment of complex fistulas. In some cases, staged surgery is needed to repair an anal fistula.

Prognosis

Prognosis for fistulas is excellent after surgery, with recurrence rates around 7-21% depending on the complexity and location of the fistula.[9, 8]Use of fibrin glue or fistula plug has variable success rates.

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