Fistola anorettale
DefinizioneÂ
Consiste nella presenza di tragitto infiammatorio avente unÂ
orifizio al livello del canale anale e uno a livello della cute perianale. L’orifizio interno si trova in genere a livello dellaÂ
linea dentata, dove le ghiandole anali penetrano nel canaleÂ
anale. Compare spontaneamente o in conseguenza di un ascesso perianale. È classificata in base alla relazione con gli sfinteriÂ
anali:
♦ Intersfinterica (70%)
♦ Trans- sfinterica (23%)
♦ Sovrasfinterica (5%)
♦ Extrasfinterica (2%)
EpidemiologiaÂ
L’incidenza e la prevalenza sono simili a quelle degli ascessiÂ
anorettali.Â
♦  Rapporto maschi femmine  3:1.Â
♦  Picco di incidenza nella terza-quinta decade di età (media 38   anni).Â
♦  Incidenza di 8,6 x 100000 in uno studio epidemiologico   finlandese
Fattori di rischioÂ
☖  Ascessi anorettaliÂ
☖  Il 10% delle fistole è associato a:
♦ Malattie infiammatorie intestinaliÂ
♦ TubercolosiÂ
♦ NeoplasiaÂ
♦ Danno da radiazioneÂ
♦ Ragade analeÂ
EziologiaÂ
♦ Gli ascessi anorettali sono causati da infezione delle ghiandole che circondano il canale anale.Â
♦ Il 30- 40% degli ascessi anorettali si complica con una fistola.Â
♦ La maggior parte è di origine cryptoghiandolare.Â
♦ Nel 90% dei casi non si identifica una causa specifica.Â
♦ Le restanti cause sono: trauma, complicanze postoperatorie,Â
ragadi anali, malattie infiammatorie intestinali e tubercolosi.Â
Sintomi e segniÂ
♦ Possibile febbreÂ
♦ Dolore perianaleÂ
♦ Drenaggio costante della regione perianaleÂ
♦ Aumenta durante la defecazioneÂ
♦ Rende difficile il mantenimento dell’igiene perianaleÂ
♦ Drenaggio mucopurulento dall’orifizio interno o esterno
♦ Tramite fistoloso spesso indurite e palpabile
Diagnosi differenzialeÂ
♦ Malattia di CrohnÂ
♦ Neoplasie anorettaliÂ
♦ Malattia pilonidaleÂ
♦ Idrosadenite suppurativaÂ
♦ Ascesso delle ghiandole di BartoliniÂ
♦ Tubercolosi analeÂ
♦ ActinomicosiÂ
♦TraumaÂ
♦ Ragade analeÂ
♦ Danno da radiazioneÂ
♦ DiverticoliteÂ
♦ ClamidiasiÂ
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.Â
Se l’orifizio fistoloso è posto a più di 3 cm dalla rima anale.Â
Esami di laboratorioÂ
♦ LeucocitosiÂ
Procedure diagnosticheÂ
☖  Anoscopia in anestesiaÂ
♦  Per individuare l’orifizio internoÂ
TerapiaÂ
Immediatamente dopo la diagnosi, la fistola deve essere trattata al fine di ridurre l’infiammazione in preparazione all’intervento chirurgico.Â
☖ Mantenere il paziente in terapia con:
♦ Agenti emollienti delle feciÂ
♦ Antidolorifici non narcotici
♦ SemicupiÂ
☖ L’intervento chirurgico è in genere il trattamento di scelta, con l’eccezione delle fistole in associazione alla malattia di Crohn,Â
per le quali è indicata, ove possibile, la terapia medica.
Terapia specificaÂ
☖ Il trattamento ottimale è il posizionamento di un setone (in seta di tipo elastico o  tipo vessel loop) tramite attraverso il tramite fistolosoÂ
♦ Mantiene il tramite apertoÂ
♦ Riduce l’infiammazione circostante.Â
☖ Una volta che si è attenuata la riduzione della flogosi locale, valutare l’esatta definizione anatomica della fistola e programmare l’intervento chirurgico.Â
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