Fistula in ano - Large Biopsy 3-6 cm

Biopsy

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Histopathology of fistula tract.

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Fistula in ano - Large Biopsy 3-6 cm

Why is it done?
- To obtain tissue samples from anal fistulas (abnormal connections between the anal canal and skin surface) measuring 3-6 cm in diameter for histopathological examination
- To rule out malignancy, inflammatory bowel disease (Crohn's disease), or other serious underlying pathology in fistulous tracts
- To diagnose infectious or granulomatous conditions affecting the fistula
- Typically performed when fistulas are persistent, recurrent, complex, atypical in presentation, or fail to respond to standard treatment
- Often performed during surgical excision or drainage procedures as a diagnostic adjunct
Normal Range
- Normal Result: Benign fibro-granulation tissue without evidence of malignancy, dysplasia, or systemic infection
- Pathological Components: Non-specific chronic inflammation consistent with simple anal fistula
- Tissue Composition: Presence of fibrosis, epithelialization, and inflammatory infiltrate composed of lymphocytes and macrophages
- Negative Indicators: Absence of malignant cells, granulomas, acid-fast bacilli, or atypical features
- Microorganism Culture: May be negative or show normal flora; negative for tuberculosis and atypical mycobacteria
Interpretation
- Simple Anal Fistula: Histology shows benign chronic inflammation with fibrosis and granulation tissue; represents typical idiopathic fistula-in-ano
- Squamous Cell Carcinoma: Malignant epithelial cells with nuclear pleomorphism, increased mitotic activity, and invasion into deeper tissues; requires urgent oncologic evaluation
- Adenocarcinoma: Malignant glandular differentiation; may arise from mucoid metaplasia or remnants of embryologic structures
- Crohn's Disease: Non-caseating granulomas, transmural inflammation, fissuring ulcers, and prominent lymphoid aggregates; patchy discontinuous involvement
- Tuberculosis: Caseating granulomas with central necrosis; acid-fast bacilli positive on special staining (Ziehl-Neelsen or auramine-rhodamine)
- Atypical Mycobacterial Infection: Non-caseating granulomas with acid-fast positive bacilli; may include MAC or other environmental species
- Hidradenitis Suppurativa: Extensive inflammation, follicular involvement, sinus tract formation with keratinous material, and areas of suppuration
- Foreign Body Reaction: Presence of foreign material with associated multinucleated giant cells and chronic inflammatory response
- Dysplasia: Mild, moderate, or severe dysplastic changes within epithelium; indicates increased malignancy risk requiring close surveillance
Associated Organs
- Primary Site: Anal canal, rectum, and perianal skin; fistula typically originates from anal glands at the dentate line
- Associated Gastrointestinal Conditions: Inflammatory bowel disease (Crohn's disease, ulcerative colitis), diverticular disease, and rectal malignancy
- Infectious Diseases: Tuberculosis, atypical mycobacterial infections (MAC, M. marinum), syphilis, and fungal infections affecting remote organs
- Dermatologic Conditions: Hidradenitis suppurativa (chronic suppurative folliculitis), pilonidal sinus disease, and severe acne vulgaris
- Complications Associated with Abnormal Results: Perirectal abscess formation, necrotizing fasciitis, fecal incontinence, rectourethral/rectovaginal communication
- Malignancy Risk: Chronic fistulas have increased risk of squamous cell carcinoma (0.5-5%) and adenocarcinoma; risk increases with fistula duration >10-20 years
- Systemic Involvement: Tuberculosis or MAC findings suggest pulmonary or disseminated disease; may require investigation of lungs, lymph nodes, and other sites
Follow-up Tests
- If Malignancy Detected: Staging imaging (CT pelvis/abdomen, MRI), endoscopic ultrasound, inguinal lymph node assessment, and oncology consultation
- If Crohn's Disease Suspected: Full colonoscopy with ileoscopy, fecal calprotectin measurement, CT/MR enterography, and gastroenterology consultation
- If Tuberculosis Identified: Chest X-ray, tuberculin skin test (TST) or IGRA (QuantiFERON-TB Gold), sputum smear microscopy, and mycobacteriology culture
- If Atypical Mycobacteria Detected: Species identification by DNA probe or 16S rRNA sequencing, chest imaging, blood cultures (in immunocompromised patients), and infectious disease consultation
- If Dysplasia Present: Close endoscopic surveillance every 3-6 months, repeat biopsy of dysplastic areas, and consideration of more aggressive surgical management
- For Simple Fistula: Pelvic MRI or endorectal ultrasound to define fistula anatomy and assess for additional tracts; serial clinical examination for recurrence
- Microbiological Culture Results: Sensitivity-guided antibiotic therapy if pathogenic organisms identified; repeat cultures for treatment monitoring
- Immunocompromised Patients: HIV testing and CD4 count assessment if unexpected infections identified; opportunistic infection prophylaxis as indicated
- Long-term Monitoring: Clinical assessment at 2-4 weeks post-procedure; surveillance for recurrence over years; annual examination for chronic complex fistulas
Fasting Required?
- Yes, fasting is required
- Fasting Duration: NPO (nothing by mouth) for minimum 6-8 hours before procedure; ideally overnight fasting (8-12 hours)
- Bowel Preparation: Day before procedure - clear liquid diet only; may require osmotic laxative (GoLYTELY, miralax) or phosphate-based enema
- Fleet Enema: Perform 1-2 hours before procedure to clear rectum and lower colon of stool; may repeat if needed
- Medications to Avoid: Discontinue aspirin and NSAIDs 3-5 days before procedure; continue anticoagulants only if bleeding risk acceptable (consult provider)
- Antacids and Iron Supplements: Avoid 24 hours before procedure as they cloud visualization
- Anesthesia Considerations: May require general, regional, or local anesthesia depending on fistula complexity and patient factors; coordinate with anesthesia team
- Positioning: Patient positioned in prone jackknife, left lateral decubitus, or lithotomy position depending on fistula location and surgeon preference
- Post-procedure: Resume normal diet gradually starting with clear liquids; discharge with pain management instructions and wound care guidelines

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