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Crohn's Disease Forum » Surgery » Fistulas, Fissures and Abscesses » Beginners guide to Fistulas and Abscesses



 
08-01-2011, 08:07 PM   #1
Jennifer
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Beginners guide to Fistulas and Abscesses

Please note this was not written by Jennifer but a member who decided to leave the community. Due to the important nature of this post, we needed to save it so he took it over in his name.

Crohnsforum/fistula/abscess veterans, if you have any tips to go into this (there's a tips section later), please post it in a reply. Also, any extra information is welcome. The section on treatment for abdominal fistulas needs aid, and any experience sharing would be great.

Introduction


Abscess: a collection of pus/fluid in a cavity formed of the surrounding tissue. Can appear in the perineum/anal area (perianal abscess), intestines (intestinal abscess), or on organ/skin surfaces/under teeth. Sometimes, abscessing is a defensive reaction to foreign matter existing in tissue. IBD patients sometimes develop perianal or intestinal abscesses as a result of the disease (not as a result of any foreign matter). Unlike a cyst (which is filled with a variety of liquids), an abscess is filled with body mucous intended to destroy foreign material/organisms and is an infection, however in patients with IBD, there is often no underlying foreign material/organism: the abscess is mostly a result of hyperactive immune responses. Abscesses MUST be attended to by a doctor: the infections fluid contained therein can be deadly.

tl;dr: Abscesses are like chronic pimples in uncomfortable areas, almost always requiring medical intervention.

Fistula: Abnormal communication (tunnel) between two tissue walls. Fistulas can exist between intestines (enteroenteral fistula), between intestines/skin surfaces/organs (ex: biliary fistula), between the anal walls and the exterior perianal area (perianal fistula/anorectal fistula), between the anal walls and the vaginal walls (recto-vaginal fistulas) or between anal walls and the bladder (vesicointestinal fistula). Fistulas sometimes seep fluids or gasses, sometimes because of where the fistula originates (ex: stool seeping into bladder), and sometimes because the fistula will bleed or create pus like an abscess. Fistulae (plural) are usually caused by microperforations or ulcers that have tunneled through one surface to another, without abscessing.

tl;dr: Fistulae are connective tubes/holes between two surfaces (imagine a tunnel or an ear piercing)


How to tell if you have an abscess/fistula



Abdominal Abscesses and Lower Abdominal Abscesses: Acute (local) symptoms include abdominal pain and swelling (distention), lack of appetite, nausea, diarrhea, feeling of "fullness", vomiting. Lower abdominal (colon) abscesses can push on the bladder, causing urgency. Fever, chills, weakness or delirium are signs that the infection is beginning to spread. Get to a doctor, or go to the hospital.

Anal Abscesses: Acute symptoms include rectal/anal pain, foul discharge, swelling, redness, warm to touch, problems sitting, constipation, feeling of fullness, induration (hardening of skin). An anal abscess will usually feel better after a BM. Fever, chills, weakness and delirium are signs that the infection is beginning to spread. Get to a doctor, or go to the hospital.

Is it a cyst? : Many people have trouble differentiating between an abscess and a cyst: An abscess is an infection, and will display appropriate symptoms which would not indicate a cyst. These symptoms include systematic infection, fever, fatigue or delirium, warmth/heat at the area affected. While a pilonidal cyst (a cyst near the tailbone) or an anal cyst will be painful and swollen, they should not be inflamed or hot to the touch unless they are infected. A cyst which has become infected is an abscess.

Abdominal Fistulas : Abdominal fistulas (small and large intestine) can connect from the bowels to the skin (enterocutaneous fistulas), from one section of bowel to another (enteroenteral fistulas), or from the bowels to the stomach (gastrocolic or gastrojenjunocolic fistulas). Enterocutaneous fistulae symptoms include an obvious sore that discharges potential foul fluids. The sore may resemble an ingrown hair. Enteroenteral fistulas can sometimes be completely symptom free, but often are accompanied with pain, malabsorption, dehydration and diarrhea. Fistulas leading to the stomach can also cause pain, diarrhea and other diarrhea associated problems.

Fistula in ano (anal fistulas) : connections from the anus or rectum to outside anus. Can be painful, and usually discharge some form of fluid. Usually caused by a previous abscess, but sometimes the body will fistulize faster than it can abscess. External openings can look like ingrown hairs or needle wounds. The internal opening may feel like a fissure in the lining of the rectum. Some people may confuse their fistula with an ingrown hair or pimple, but unlike a pimple or ingrown hair, fistula discharge and discomfort are chronic until medical attention is sought. Furthermore, pain from fistulas will reach further than a simple skin problem, and will have an opposing opening which may hurt.

Recto-vaginal fistulas: Fistulas between the rectum and lining of the vagina usually present themselves similar to a fistula in ano, except usually with more stinging around the exit wound. Recto-vaginal fistulas can present themselves as a simple infection, as they may not be visible.

Colovesical/Enterovesical Fistulas: Fistulas between the colon and bladder, or small bowel and bladder, respectively. Symptoms include recurrent urinary tract infections (UTI's), symptoms of a UTI without actual infection, bladder urgency and frequency, pain in pelvic area/pain when passing urine, cloudy or bubbly urine and debris in urine.

Abscesses and Fistulas should ALWAYS be examined by a doctor…


Procedures

A note from butt surgery experts: try your hardest to see a colorectal surgeon, as opposed to a general surgeon!


Observation:

Abscess and fistula observation can be a pain, as most patients want the issue solved immediately, as opposed to examined and scanned. However, doctors usually start by performing a visual observation, sometimes feeling the problem area for indications. Abscess can usually be felt by touch, or in the case of intestinal abscess, viewed VIA colonoscopy/laproscopy/fluoroscopy (a moving x-ray, in which the patient ingests a contrast, or a contrast is administered VIA enema). Fistulas can often be determined by viewing the opposing openings with nothing more than the eye. However, many doctors opt to see the entirety of the fistula, and perform a fistulagram, in which a contrast is injected into a fistular opening, and the area is x-ray’d. Fistulas can also be viewed via an MRI (such as a pelvic MRI for perianal fistulas) with the added bonus that you get to keep your underwear on! MRI's however, are expensive, so don't be surprised if your doctor first opts for a simpler route of examination.

tl;dr: if you are uncomfortable about your body, then i'd suggest getting over it. Your doc is gonna want to look at parts of you you've never even seen.


Treatment:

Abdominal Abscesses/Lower Abdominal Abscesses: Antibiotics to fight infection. Surgery to remove or drain the abscess is likely. Biologics, such as Remicade, cannot be used when abscesses are present, as they have a chance of closing them.

Anal Abscesses: Antibiotics to fight infection. Anal abscesses almost always require surgical drainage via lancing or incision. In non-IBD patients, the abscess may heal over properly, or form a fistula (because of the lancing). In IBD patients, abscess drainage is almost always followed up by a fistula. Because of the complications of IBD, abscesses in patients with IBD may not drain entirely, thus forming a new abscess every time the ends heal over. This is rectified by something called a seton. A seton is a thread that goes through the newly fistula'ed abscess, and out the other opening. It is then tied on the outside of the abscess. More on setons in the fistula in ano section. Like abdominal abscesses, anal abscesses prevent the use of biologics until they are turned into a fistula.

Abdominal Fistulas: Can be treated with antibiotics, or biologics. Surgery usually involves resection of the connecting piece(s) of bowel.

Fistula in ano/Recto-vaginal Fistulas: Fistula in ano/Recto-vaginal Fistulas are often the result of setons, a thread like apparatus meant to create a non-healing fistula, preventing recurrent abscesses.

These types of fistulas are usually fixed by invasive surgury, in patients without IBD. However, because it is very dangerous to cut the sphincters in a patient WITH IBD (think of the diarrhea), medical professionals prefer initially to try medicinal therapy, followed by surgical therapy. Antibiotics (often Cipro + Flagyl) are usually the first line of attack. Medicinal therapies can then progress to immunomodulators (such as imuran), which have a slight chance of healing fistulae in these areas. From there, biologics are chosen, because they tend to have a healing effect on fistulas in the anal/genital region. Surgical removal of fistulae can involve the use of cutting setons (tight setons, meant to slowly lay open the fistula, allowing it time to heal from the back forward, and hopefully preventing incontinence), mucosal plugs (which plug the fistula and stimulate permanent healing) or flap procedures (which close the fistula from the inner opening (preventing bowel discharge and abscessing).

Colovesical/Enterovesical Fistulas: Treated with the same steps as fistula in ano, or recto-vaginal fistulas. Because these fistulas involve the colon and small bowel, biologic and antibiotic therapies are not as successful, and the healing process usually involves surgical removal.

A bit about Biologics (and immunomodulators): These two types of drugs have shown some ability to heal lower-body fistulas (recto-vaginal, fistula in ano). Immunomodulators are relatively inexpensive, and work by suppressing the immune system entirely. They have a small chance of healing a fistula. Biologics are very expensive, and work by suppressing any damage the immune system tries to inflict. They block something called Tumor Necrosis Factor (the alpha variety, if you care), which are involved in destroying infection/foreign materials, as well as in ulcering and fistulizing (if you have IBD). Biologics have a fairly good chance of closing the fistula. Both of these will suppress your immune system, and will make you susceptible to infection or other illnesses, as well as increase your chance of cancer. Talk to your doctor.

tl;dr Abscesses and Fistulas usually take a while to heal and treat, so don’t assume you can go to the doctor for a band-aid. Also, they're going to be a pain in the arse, so you might wanna take up drinking.


What to do while you’re waiting for a doctor


This list is meant to be comprised of various forms of pain-relief/promotion of healing as recommended by Crohnsforum.com users.

Perianal Abscesses:
- Hot compresses (hot water + clean cloth) on affected area help to ease pain. Will also break down skin, and dilate openings, so as to let infectious fluid out. Don't compress too often, or you'll end up with burns.

Perianal Fistulas:
-Sometimes, after a seton is put in place, granulation tissue will appear. This is pre-healing tissue, and can be very sore. Sitz baths will help heal the granulation tissue (which is good), or alternatively, you can apply a mixture of water/epsom salts to the opening of the fistula with a cotton ball. Do this right before bed, as well as wear loose undies to bed, for best granulation tissue healing.
-Also, sometimes with a seton, the knot can move itself up into the fistula. This can be quite painful, and difficult to take care of. It is recommended that you first get into a hot bath, and soak for atleast five minutes. Then, you can reach down with one finger, and slowly slide your finger along the seton, towards your bum hole. The friction this causes will slowly pull the knot out of the fistula. It should be relatively painless.

Vesical Fistulas:
- Drink plenty of fluids - water, cranberry juice, lemon barley water are best.
- Avoid tea, coffee and fizzy drinks - they are diuretics.
- Try not to eat too much sweet, sugary food.
- Keep warm and a heating pad or hot water bottle might help with the pain and urgency.

Want more Info? Try:

http://www.fascrs.org/physicians/edu...stula_abscess/

http://www.fascrs.org/physicians/edu...s/2011/Crohns/

http://www.nacc.org.uk/downloads/factsheets/Fistula.pdf

Last edited by RFarmer; 11-07-2011 at 06:08 PM.
08-01-2011, 08:22 PM   #2
Entchen
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LOVE the tl;drs!!!!
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08-01-2011, 08:51 PM   #3
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It's very informative and it's a good guide. I've often wondered what a fistula is and how you can tell you have one
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08-01-2011, 09:02 PM   #4
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My son recently had a fistula and abscess in the ileum and was I was told by a number of different colorectal surgeons and GI's, Crohn's specialists included, that these type of fistula's will not respond to medicinal treatment and surgery is the only option. I think it is also worth pointing out that if you do have an abscess then that rules out using the biologics.

Dusty. xxx
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08-01-2011, 09:03 PM   #5
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My son recently had a fistula and abscess in the ileum and was I was told by a number of different colorectal surgeons and GI's, Crohn's specialists included, that these type of fistula's will not respond to medicinal treatment and surgery is the only option. I think it is also worth pointing out that if you do have an abscess then that rules out using the biologics.

Dusty. xxx
Thanks for the info! I forgot to mention about abscees and biologics. I had no idea about the illeum abscesses.
08-04-2011, 04:33 AM   #6
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Oh, this is great, how did I miss this?? It would be really good to have a sticky, especially as we now have the Fistuls and Abscesses sub-forum ( thank you very much, you Admin guys xxx. )

Could I add a bit for Colovesical ( colon to bladder ) and Enterovesical ( bowel to bladder ) fistulae?
Signs that you may have one:
* recurrent urinary tract infections
* symptoms of a UTI without the actual infection
* bladder urgency and frequency
* pain in the pelvic area or when passing urine
* cloudy and/or bubbly urine
* debris such as food particles in the urine

Drs may prescribe antibiotics and possibly Remicade to see if the fistula(e) will heal, but it is highly likely that surgery will be required.
What to do? Must be treated by a doctor, but taking the steps that you would if it was a UTI might give some relief:
* drink plenty of fluids - water, cranberry juice, lemon barley water are best
* avoid tea, coffee and fizzy drinks - they are diurectics
* try not to eat too much sweet, sugary food
* keep warm and a heating pad or hot water bottle might help with the pain and urgency
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08-04-2011, 08:31 AM   #7
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Helen, I'll get right onto adding your info Atleast, I'll try. I can't seem to edit it anymore, so I'll PM David.
08-04-2011, 10:04 AM   #8
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Thanks very much I don't think this will freak people out. Well, fistulas are pretty freaky things anyway but I think, as I did, that you'd want to know if you had one and what if anything you could do about it, the implications etc. I really like the idea too that new posters/enquirers can get the information they need here on the forum rather than having to be redirected to other sites.
Thanks again.
08-04-2011, 12:13 PM   #9
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Thanks very much I don't think this will freak people out. Well, fistulas are pretty freaky things anyway but I think, as I did, that you'd want to know if you had one and what if anything you could do about it, the implications etc. I really like the idea too that new posters/enquirers can get the information they need here on the forum rather than having to be redirected to other sites.
Thanks again.
No problem! It's nice to be able to contribute something. BTW: When I mention freaking out, I mean people who suddenly have a large boil of pus or strange oozing hole and have no idea what to do with themselves :P The thread is now editable But any likes or subscriptions are reset because David had to move the thread, or something like that. Just in case you were confused

Last edited by RFarmer; 08-04-2011 at 03:33 PM.
08-06-2011, 03:18 AM   #10
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Looking good :-)
08-09-2011, 09:54 PM   #11
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this looks really helpful!!

you could maybe add about pelvic MRIs been used to see perianal fistula under the observation section?
i had an mri after my surgeon didn't see/find any fistulae during an EUA. it's just a normal mri, no weird prep or anything. i had most of my images taken without contrast and then the last few with contrast which was injected through an iv thingy in my arm. it was all very stress free and i even got keep my underwear on!! haha
08-10-2011, 07:59 AM   #12
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Lol, Kate. I've yet to have a colonoscopy and am hoping I can get through my whole Crohn's experience without one. Good point about the MRI. My enterovesical fistula didn't show up on ultrasound or Barium FT. It was confirmed by CAT scan i.e. signs of gas in the bladder.
Are you going to add that in, Ben my man?
08-13-2011, 07:41 PM   #13
RFarmer
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Sorry guys! I've been a little stoned lately. Painkillers <3


Yeah, I'll absolutely add that bit in

EDIT: Kate, can you clarify one thing: For your pelvic MRI, they did both non-contrast and contrast?

thanks,

Ben.
08-13-2011, 09:48 PM   #14
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yep, i had both. it was a bit weird, they put the iv cannula in but didn't inject anything into it in before my scans and then about the 3/4 of the way through actually taking them the lady paused everything came in, injected the contrast and then took a few more scans.

when i first arrived she said they would only use the contrast if it seemed like it would be helpful, so if nothing was showing up on the images without contrast i don't think i would had any contrast. (my fistula wasn't actually confirmed before my MRI, even after my abscess surgery and a second EUA, so i think that's why everyone was a little skeptical of it showing up on the MRI)

haha you asked one question so i gave you a huge story!!
kate
08-13-2011, 10:03 PM   #15
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Hey Kate,

Matt has had all his scans done that way. They cannulate and set up the pump, then they do a run without the IV contrast, so just with whatever you have taken orally if anything, and then they will come in and start the IV contrast and do another run of films.

Dusty. xxx
08-13-2011, 10:56 PM   #16
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I am glad to see this thread. I would be glad to do some research for the portion on abdominal fistulae. My experience in the area... I had one.
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08-14-2011, 04:06 AM   #17
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Kate, what's an EUA? I never heard of or had one of them.... I think!
Ben, honey, why are you on painkillers? Are you having a hard time? Well, a harder time than usual?
08-14-2011, 04:12 AM   #18
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EUA = Examination Under Anaesthetic?

Dusty.
08-14-2011, 06:43 AM   #19
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Kate, what's an EUA? I never heard of or had one of them.... I think!
oh sorry! too many acronyms haha!!

but like Dusty said EUA=Examination Under Anaesthetic.

kate
08-14-2011, 07:16 AM   #20
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Hiya Ben

It's great for someone to explain these in more simple terms for me.
Can I just say
I've read some threads by yourself and muppet about the importance of getting a colorectal specialist ( a bum surgeon) to do these procedures, and not a general surgeon who doesn't know a bum from his elbow!
I'm so glad this was mentioned in another thread, it's something that I will never forget if I ever have a fistula/abscess.
It's frightenng to think that some random doc in ER would conduct such an op and ball's it up!
xxx
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08-14-2011, 10:15 AM   #21
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Kate, what's an EUA? I never heard of or had one of them.... I think!
Ben, honey, why are you on painkillers? Are you having a hard time? Well, a harder time than usual?
My butt hurts, and I've run out of salofalk. I never thought it did anything, but now that I'm off it, I'm getting alot of cramping and blood. Plus, my seton stuff is finally starting to heal over with granulation tissue. Which hurts like heck. lololol...

Last edited by RFarmer; 11-07-2011 at 06:09 PM.
08-14-2011, 10:17 AM   #22
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I am glad to see this thread. I would be glad to do some research for the portion on abdominal fistulae. My experience in the area... I had one.
Any info you could share would be great. Especially with the surgery part. I've got no idea.
09-07-2011, 09:12 PM   #23
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Here are two links I found very helpful from the American Society of Colon and Rectal Surgeons.

http://www.fascrs.org/physicians/edu...stula_abscess/

http://www.fascrs.org/physicians/edu...s/2011/Crohns/
09-08-2011, 03:01 PM   #24
RFarmer
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Here are two links I found very helpful from the American Society of Colon and Rectal Surgeons.

http://www.fascrs.org/physicians/edu...stula_abscess/

http://www.fascrs.org/physicians/edu...s/2011/Crohns/
I'm going to include those links in the original post, if you don't mind. Thanks
11-02-2011, 04:01 PM   #25
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Thats brilliant..thanks for the information guys and gals...
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03-25-2012, 09:13 AM   #26
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Make sure you mention to your GI (or IR) if the product, TISSEEL, might be a good option to seal up your fistulas.
03-25-2012, 11:50 AM   #27
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Hi System X. I hadn't heard of it before, so Googled. Sounds very promising. Have you had experience of it?
03-25-2012, 05:49 PM   #28
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I've done a session of Tisseel. It sealed up one fistula. Unfortunately, at the time, they couldn't clearly see my other fistula. Remicade failed to close up the hidden fistula, and now it is another candidate for more Tisseel, once I get my abscess cleared out.
03-25-2012, 06:14 PM   #29
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Granted, my TISSEEL application was more off-label, as my fistula is internal without any external drainage.

<<>>

CONCLUSIONS: Fibrin-glue treatment of anal fistulas is successful in up to 69 percent of patients if initial failures are retreated. This sphincter-saving technique is associated with minimal complications and no functional detriment. Late recurrences are unusual.

http://www.springerlink.com/content/ltd4f1qwklfxx0u4/
04-24-2012, 06:19 PM   #30
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Floating around on the web, and being a 20 yer Crohnie, with advanced peri-anal-fistulas, I found something that is exciting for the cure and prevention of the before mentioned. Too bad from what I have read that it's been developed in India and the USA is now looking into the equipment and procedures safety that will prolly take ten years, lol but I wanted to share with you.


http://www.ncbi.nlm.nih.gov/pubmed/22002535

http://www.karlstorz.com/cps/rde/xch...s.xsl/8684.htm

http://up-surge.com/blog/2012/01/31/...ment-by-vaaft/

http://news.amrita.edu/news/2012/02/...med-at-amrita/

This is the best link detailing studies.....

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3226694/
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