When dealing with Crohn’s and Colitis there are some complications that are more common than others, and fistulas are one of them. In fact, 1 in 3 people with Crohn’s and 1 in 35 with UC will experience this complication at some point in their life. A fistula is a small narrow tunnel-like structure that forms, connecting to other parts of the bowel, other organs, or skin. These are more often found in Crohn’s patients as inflammation in CD radiates throughout the entire digestive system and penetrates all layers of the bowel walls. This can lead to abscesses, leakage, and ulcers. From these a hole can form, thus becoming a tunnel, and making a fistula. There are several different types, which we will cover, as well as symptoms, diagnosis, treatments, and managing everyday life while recovering.
Let’s start with the types of fistulas, as there are quite a few.
- The first up, and most common is the anal or perianal fistula. These connect from the anal canal or rectum and attach to skin near the surface of the anus. While the exact cause of fistulas is not known, perianal fistulas often occur after an abscess in the rectal area.
- Next up is Enterovesicular fistulas. This type of fistula starts in the bowel and connects to the bladder.
- Then we have Enterovaginal fistulas, meaning they connect from the bowel to the vagina. Enterocutaneous is next. This means the fistula connects from the bowel to the skin, but somewhere other than the rectum. Most commonly, this type is found in the abdominal area.
- Second to last, we have,Enteroenteric or enterocolic. This connects one part of the bowel to another, bypassing some sections in between.
- Lastly, we have Ileo-anal pouch fistulas. These often only affect those with UC and only after Ileo-anal pouch surgery. This particular type of fistula can connect from the pouch formation and can link to the bladder, vagina, bowel, or skin.
Since anal or perianal fistulas are the most common, I want to discuss the main types. There are internal anal sphincter fistulas, and external anal sphincter fistulas. An internal will affect the muscle you cannot control, and the external is the muscle you can control. In addition to these placements these fistulas can be simple or complex. Simple perianal fistulas occur below these sphincter muscles, and only have one pathway. Complex, may have several pathways, involve the sphincter muscles, and can come with abscesses and connect to other areas like the bladder.
Now that we know the basics, let’s discuss symptoms, diagnosis, and treatments. All of these will vary based on the fistula’s location.
- Some common symptoms of perianal fistulas include; pain, tenderness, swelling, or a lump in the rectal area, irritation and pain after using the bathroom, coughing, or sitting. You may also notice puss, stool, or blood at the opening of the fistula. Diagnosis usually includes an examination of the area followed by a pelvic MRI or high-powered ultrasound. Common treatments include; medication like antibiotics, biologics, and immune suppressants. Surgery is also another option, and 1 in 3 will require it. The two types of surgery include a seton and a Fistulotomy. A seton is a type of surgical thread that passes through the opening and out the anus. It will stay there to help drain and heal the fistula, and is usually removed after several weeks. Fistulotomy is a surgery in which the fistula is cut open lengthwise to flatten the tunnel. This promotes healing, and is often the most successful surgery of the two.
- Enterovesicular fistulas can cause UTIs. Other symptoms include pain, and passing air, urine, or feces through the urinary tract. These are usually diagnosed after using a cystoscope to look inside of the bladder. Treatment also includes medication such as antibiotics, steroids, and immunosuppressants, along with bowel rest.
- Next is Enterovaginal fistulas. Symptoms of these include; pain (mild to severe), pain during sex, and passing puss, blood or feces through the vagina. For diagnosis, Pelvic MRI and ultrasound are used in addition to a blue dye test that will show the fistula’s connection. If medication doesn’t treat this type of fistula, there are several operations they can do as well including a vaginal advancement flap.
- Some common symptoms of perianal fistulas include; pain, tenderness, swelling, or a lump in the rectal area, irritation and pain after using the bathroom, coughing, or sitting. You may also notice puss, stool, or blood at the opening of the fistula. Diagnosis usually includes an examination of the area followed by a pelvic MRI or high-powered ultrasound. Common treatments include; medication like antibiotics, biologics, and immune suppressants. Surgery is also another option, and 1 in 3 will require it. The two types of surgery include a seton and a Fistulotomy. A seton is a type of surgical thread that passes through the opening and out the anus. It will stay there to help drain and heal the fistula, and is usually removed after several weeks. Fistulotomy is a surgery in which the fistula is cut open lengthwise to flatten the tunnel. This promotes healing, and is often the most successful surgery of the two.
- Enteroenteric or enterocolic fistulas often lead to malnourishment from the stool being so quickly passed through the digestive system. In other words, because of extreme diarrhea. However, some people do not experience any symptoms. These can too be diagnosed with MRI, ultrasound, or during regular scopes. Oftentimes with these fistulas, biologics are used. If surgery is needed, they will cut out the affected bowel area, attach it to the rest of the bowel and close the fistulas opening in the bowel wall.
Being diagnosed and managing a fistula can be overwhelming. Know you’re not alone, and your health providers are there to help you through the diagnosis and treatment process. If you are struggling with pain and have an anal fistula regular and sitz baths can help. You can also sit on cushions and pads to make sitting more comfortably as well as wearing loose clothing. Don’t be afraid to ask your specialists any questions you have. You may feel that they are embarrassing, but it’s nothing they haven’t seen or heard before. Whichever course of treatment you may need to follow, trust that it is the best one for you, and if you have questions or concerns be sure to speak up! Now you’re armed with all the 101-fistula knowledge!
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