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/education/core_subjects/2009/anal_fistula_abscess/
http://www.fascrs.org/physicians/education/core_subjects/2011/Crohns/
http://www.nacc.org.uk/downloads/factsheets/Fistula.pdf
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/education/core_subjects/2009/anal_fistula_abscess/
http://www.fascrs.org/physicians/education/core_subjects/2011/Crohns/
http://www.nacc.org.uk/downloads/factsheets/Fistula.pdf
Last edited by a moderator:
Atleast, I'll try. I can't seem to edit it anymore, so I'll PM David.
