ORIGINAL ARTICLE
Tubercular Fistula-in-Ano
Iram Bokhari, Syed Sagheer Hussain Shah, Inamullah,
Zahid Mehmood, Syed Umer Ali* and Asadullah Khan
ABSTRACT
Objective: To determine the frequency of tuberculosis in recurrent fistula-in-ano.
Study Design: Case series.
Place and Duration of Study: This study was conducted in Surgical Ward-3, Jinnah Postgraduate Medical Centre,
Karachi, Pakistan, from 1998 to 2007.
Patients and Methods: The study included 100 cases of recurrent fistula-in-ano not responding to conventional surgery.
Patients with other co-morbidities such as diabetes mellitus, bleeding disorders or with the evidence of pulmonary,
abdominal or intestinal tuberculosis were excluded from this study. Fistulogram was performed in all patients. All the
patients were subjected to fistulectomy followed by histopathology of the resected specimen. Thereafter, confirmation of
the disease, anti-tuberculous treatment was immediately started and response to treatment was observed after 6 months.
Results: Out of the 100 studied patients, 11 cases had biopsy proven tuberculosis in the fistula. All the patients were male.
The fistulae were low type, single and usually located posteriorly (n=9) with everted margins. Ten were located within
3 cm of anus. Fistulogram revealed single internal opening. Comparative statistics of tuberculous fistula-in-ano with fistulas
due to specific inflammation revealed no major differences. The diagnosed patients of tubercular fistulae-in-ano were
observed for at least 6 months after starting anti-tuberculous treatment. They all responded well to anti-tubercular
treatment and the fistulae healed without any complication such as recurrence or anal stenosis within 6 months.
Conclusion: Tuberculosis should be suspected in case of recurrent fistulae-in-ano, so as to avoid unusual delay in the
treatment and miseries to the patient. Appropriate anti-tuberculous therapy leads to healing within 6 months.
Key words:
Tuberculosis. Fistula-in-ano. Recurrence.
INTRODUCTION
Pakistan ranks sixth in the world in terms of tuberculosis
(TB) burden, with an estimated incidence of 181 per
100000, or 286000 new cases annually.1 Majority of the
cases present either as pulmonary, abdominal or
cervical tuberculosis. Although it is described as one of
the cause of granulomatous diseases within the
anorectal region,2 yet perianal TB, without the presence
of any previous or active pulmonary infection, is
extremely rare.3 Resurgence in tuberculosis during the
HIV era produces a new spectrum of presentations for
the surgeon4 and, therefore, invasion by tubercle bacilli
is often seen at unusual sites of the gut and reported in
literature.5 The distinct features, which include anal pain
or discharge, multiple or recurrent fistulae-in-ano and
inguinal lymphadenopathy, are not characteristically
distinct from other anal lesions. Undiagnosed cases are
associated with high recurrence rates. Due to the varied
Department of General Surgery, Jinnah Postgraduate Medical
Centre, Karachi.
* Medical Student, The Aga Khan University Hospital, Karachi.
Correspondence: Dr. Iram Bokhari, A-17, Sea Breeze Super
Star Apartments, Block No. 7, Kehkashan, Clifton, Karachi.
E-mail: [email protected]
Received February 8, 2008; accepted April 16, 2008.
presentation of anal TB, it should be suspected in all
lesions not responding to the conventional approaches.
All such recurrent or complex fistulae i.e. those with
more than one external opening should undergo
histopathological examination to exclude tuberculosis.
When confirmed, the treatment options are surgical for
the suppuration and medical for the tuberculosis.
The purpose of this study was, therefore, to determine
the frequency of tubercular fistulae-in-ano in recurrent or
complex fistula, with no evidence of tuberculous foci
elsewhere in the body and not responding to
conventional surgical treatment.
PATIENTS AND METHODS
This study was carried out at the Surgical Ward-3,
Jinnah Postgraduate Medical Centre, Karachi, from
1998 to 2007, on 100 patients, admitted through surgical
OPD with signs and symptoms suggestive of recurrent
fistula-in-ano, not responding to conventional surgical
treatment i.e. fistulectomy and developed recurrence
within 3 months. Those with diabetes mellitus, bleeding
disorders, age below 12 years and evidence of
pulmonary or systemic tuberculosis were excluded from
this study. Type of fistula, low or high, site of fistula,
anterior or posterior, number of fistulas, number of
external opening, nature of margins and distance from
Journal of the College of Physicians and Surgeons Pakistan 2008, Vol. 18 (7): 401-403
401
Iram Bokhari, Syed Sagheer Hussain Shah, Inamullah, Zahid Mehmood, Syed Umer Ali and Asadullah Khan
the anus were noted in all cases. A fistulogram was
performed in all the patients. All patients underwent
standard fistulectomy and the resected specimen was
sent for histopathological evaluation of tuberculosis.
After confirmation of the disease, antituberculous
treatment was started immediately. For atleast six
months after commencement of anti-tuberculous
treatment, responses like decrease in the discharge and
closure of the fistulae were observed. All these
observations were recorded on the prescribed proforma.
Descriptive statistics in terms of frequency and
proportions were used.
RESULTS
Out of the 100 patients, the majority were males (92%).
The median age was 35 years ranging from 15-65
years. Biopsy revealed non-specific inflammation in
majority of the cases. Only in 11 patients, the diagnosis
turned out to be tubercular fistula-in-ano. All of the
fistulas were low type, single in number and mostly
located posteriorly, usually within 3 cms of anal verge. In
one case of fistula, due to non specific inflammation, the
external openings were multiple. Table I shows the
comparative statistics of tubercular fistulas with fistulas
due to non-specific inflammation. There were no
significant major difference regarding age, gender, type,
site, number, external openings and distance from the
anus. Fistulogram revealed single internal opening in all
the tubercular cases. However, in only one case of nonspecific inflammation, external openings were multiple.
These patients were then kept under follow-up for at
Table I: Comparative statistics of tuberculous fistulas with
non-specific fistulas.
Tuberculosis
Non-specific
inflammation
Total no. of patients
11
89
Age (years) mean + SD
33.50 + 7.5
35.49 +12.27
11
81
Gender
Male
Female
0
8
11
89
High
0
0
Low
11
89
Recurrence*
Type of fistula
Site of fistula
Anterior
2
5
Posterior
9
84
Number of fistula
Multiple
Single
0
0
11
89
11
88
External openings
Single
Multiple
Margins everted
0
1
11
89
10
80
1
9
Distance from anus
Within 3 cms
More than 3 cms
*Recurrence within 3 months of previous operation
402
least 6 months and in all cases complete healing within
6 months after the start of antituberculous treatment was
observed.
DISCUSSION
Gastrointestinal tuberculosis represents 1% of
extrapulmonary tuberculosis and only sporadic cases of
anal tuberculosis have been reported in the literature.6,7
Tuberculosis is a neglected cause of anal sepsis.
Often it is not recognized and, therefore, is not treated
properly.8 This results in recurrence of fistulas after
routine surgical treatment.
The clinical features of anal tuberculosis, which include
anal pain or discharge, multiple or recurrent fistulaein-ano and inguinal lymphadenopathy are not
characteristically distinct from other anal lesions.9
Similarly in this study, there was no characteristic clinical
picture for tubercular fistulae-in-ano. This series showed
that there was no difference in the clinical picture
including age and gender distribution and clinical
features of anal lesions between the 11 cases of
tubercular fistula-in-ano or 89 cases of non-tubercular
fistula-in-ano. In one case of non-specific inflammation
fistulas, external openings were multiple. A case
reported by Gupta,10 showed multiple (eight) external
openings in tubercular anal fistulae with evidence of
tuberculosis in one of the tracts. Therefore, it seems that
histological examination of the excised fistula is
mandatory for the diagnosis of anal tuberculosis.11,12
As excised fistula-in-ano are not invariably subjected to
histopathological examination, it may also be agreed
that some cases of tubercular fistula-in-ano are missed
and the incidence of anal or perianal tuberculosis may
not be as low as reported in literature.11,13-14 However,
non-recurrent fistulas may also be tuberculous. So, to
prevent recurrence, all fistulas should be sent for
histology. It is also concluded that a tuberculous origin
must be considered when the cause of perianal lesion is
unclear to avoid undesirable delay in the diagnosis and
treatment.15
The main differential for gastrointestinal tuberculosis
remains the Crohn’s disease. Crohn's disease is a
debilitating expensive disease that is growing in
incidence in both developing and developed countries.16
Clinical manifestations varies from asymptomatic skin
tags to severe, debilitating perineal destruction and
sepsis. However, the histological differential diagnosis of
Crohn's disease and intestinal tuberculosis can be very
challenging, as both are chronic granulomatous
disorders with overlapping histological features.17 In this
study, none of the biopsy reports showed the evidence
of Crohn’s disease or malignancy. This may be
explained by the fact that malignancy is already
diagnosed because of its clinical features before the
development of fistulous communications at a later
Journal of the College of Physicians and Surgeons Pakistan 2008, Vol. 18 (7): 401-403
Tubercular fistula-in-ano
drugs in Pakistan. Int J Tuberc Lung Dis 2008; 12: 326-31.
stage. So, biopsy is seldom required in such patients
and fistulae usually assumed as their sequel. Similarly,
Crohn’s disease is not common in this country,
therefore, none of the patients were diagnosed with this
disease in the biopsy reports.
Although abdominal and pulmonary tuberculosis is
commoner in women,11 but in this study, none of the
resected specimens from the females showed evidence
of tuberculosis. This reversal of the gender incidence is
difficult to explain unless it is a simple reflection of a
generally increased incidence of fistula-in-ano in males
compared to females in most series.18
In some cases, pulmonary or other tuberculosis is
accompanied with anal tuberculosis. However, in this
study, all of these fistulas were primary and there was no
evidence of any underlying systemic or gastrointestinal
causative factor. So, it further confirms that isolated
perianal tuberculosis can occur in the absence of any
tuberculous foci elsewhere in the body. Therefore, it
further concludes that primary tuberculosis of the
perianal region should always be kept in mind when
encountering a case of recurrent fistulae or multiple
fistulae not healing despite conventional surgical
treatment.
3.
Akgun E, Tekin F, Ersin S, Osmanoglu H. Isolated perianal
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Clarke DL, Thomson SR, Bissetty T, Madiba TE, Buccimazza I,
Anderson F. A single surgical unit's experience with abdominal
tuberculosis in the HIV/AIDS era. World J Surg 2007; 31:1087-96.
5.
Lax JD, Haroutiounian G, Attia A, Rodriguez R, Thayaparan R,
Bashist B. Tuberculosis of the rectum in a patient with acquired
immune deficiency syndrome: report of a case. Dis Colon Rectum
1988; 31: 394-7.
6.
Romelaer C, Abramowitz L. Anal abscess with a tuberculous
origin: report of two cases and review of the literature.
Gastroenterol Clin Biol 2007; 31: 94-6.
Myers SR. Tuberculous fissure-in ano. J R Soc Med 1994; 87:46.
8.
Kraemer M, Gill SS, Seow-Choen F. Tuberculous anal sepsis:
report of clinical features in 20 cases. Dis Colon Rectum 2000;
43:1589-91.
9.
Gupta PJ. Ano-perianal tuberculosis- solving a clinical dilemma.
Afr Health Sci 2005; 5:345-7.
10. Gupta PJ. A case of multiple (eight external openings)
tubercular anal fistulae: a case report. Eur Rev Med Pharmacol Sci
2007; 11:359-61.
11. Shukla HS, Gupta SC, Singh G, Singh PA. Tubercular fistula-inano. Br J Surg 1988; 75:38-9.
12. Ohse H, Ishii Y, Saito T, Watanabe S, Fukai S, Yanai N, et al. A
case of pulmonary tuberculosis associated with tuberculous
fistula of anus. Kekkaku 1995; 70:385-8.
13. Chung CC, Choi CL, Kwok SP, Leung KL, Lau WY, Li AK. Anal
and perianal tuberculosis: a report of three cases in 10 years.
J R Coll Surg Edinb 1997; 42:189-90.
14. Alvarez Conde JL, Gutiérrez Alonso VM, Del Riego Tomás J,
García Martínez I, Arizcun Sánchez-Morate A, Vaquero Puerta
C. Perianal ulcers of tubercular origin: a report of 3 new cases.
Rev Esp Enferm Dig 1992; 81:46-8.
15. Gupta PJ. Ano-perianal tuberculosis. Bratisl Lek Listy 2005; 106:
351-4.
CONCLUSION
16. Panés J, Gomollón F, Taxonera C, Hinojosa J, Clofent J, Nos P.
Crohn's disease: a review of current treatment with a focus on
biologics. Drugs 2007; 67:2511-37.
Tuberculosis was responsible for 11% cases in recurrent
fistula-in-ano responding standard surgery. Antituberculous therapy led to healing within 06 months. A
tubercular fistula-in-ano is seldom diagnosed preoperatively on the basis of clinical picture. Therefore- in
all cases of recurrent fistula-in-ano, histopathological
examination of the excised fistula is mandatory and
once tuberculosis is confirmed, antituberculous
treatment should be immediately started to ensure early
healing and cure of the disease.
17. Kirsch R, Pentecost M, Hall Pde M, Epstein DP, Watermeyer G,
Friederich PW. Role of colonoscopic biopsy in distinguishing
between Crohn's disease and intestinal tuberculosis. J Clin Pathol
2006; 59: 840-4.
18. Marks CG, Ritchie JK. Anal fistulas at St. Mark’s Hospital.
Br J Surg 1977; 64:84-91.
19. Puri AS, Vij JC, Chaudhary A, Kumar N, Sachdev A, Malhotra V,
et al. Diagnosis and outcome of isolated rectal tuberculosis.
Dis Colon Rectum 1996; 39:1126-9.
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7.
The treatment is two-fold in such patients of tubercular
anal fistulas i.e. surgical for the suppuration and medical
for the tuberculosis. Therefore, a good response was seen
when healing occurred in all of the cases of tubercular
fistulae-in-ano, after anti-tuberculous treatment was
started, following fistulectomy. Response to anti-tubercular
chemotherapy is uniformly good, and surgery is seldom
required in these patients,19 as shown in literature in such
cases of perianal tuberculosis.20 Recurrences are unusual
after the start of anti-tuberculous therapy. Therefore, an
early diagnosis is a must in such patients to prevent
recurrences as well as further surgeries of such an easily
curable disease.
1.
2.
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