Francesco Carelli, Professor of Clinical Medicine and elective courses in GP, University of Milan

Giotta Attilio, internship student in GP, University of Milan

Donatella Gambera, MD, University of Milan

This case shows how the doctor / patient relationship can be optimal: a relationship based on trust, understanding and dialogue between the two parties. This can be seen by the temporal sequence in which diagnostic tests recommended by the doctor were carried out.

Family medicine has the role of first contact between the patient and the healthcare system, having the opportunity to see a wide variety of diseases within their study, ranging from seasonal diseases, common diseases in more niche, to see that happen but seldom are reported immediately by the patient to the severity of symptoms that they manifest and create in the patient the need to find an immediate resolution. This case concerns  a  male patient  66 years who has made repeated accesses to the GP practice   referring pain in the anal region associated with itching and secretion of pus, that affect his daily live. This was not the first manifestation of disease being reported the onset  4 years earlier, with relapses in more or less regular intervals with variable intensity;  silent periods were not going to disrupt the quality of life and were not associated with  fecal incontinence. 

Thanks to specific questions made by the physician, the patient made a clear and detailed description of symptoms leading to diagnosis of recurrent perineal suppuration, will require lower abdomen MRI with and without contrast, examination that had been agreed with the patient after having made him understand the importance of a diagnostic assessment of the disease and with the same finding, the maximum availability to carry and faster.

The result of this examination has shown in the inner fold of the right buttock and left subcutaneous fluid collections, fistulas serpiginous confluent, especially, of variable length up to 10 cm. This situation has meant that the perianal skin was pushed upward, pushing up other adipose tissue. Also highlighted was the presence of numerous lymphadenopathy groin-crural, hernias with a maximum diameter of 15 mm. To the right of the subcutaneous adipose tissue is presented with an enhancement of the inflammatory type.

This has prompted the doctor to submit it to a series of tests: transrectal ultrasound scan, an endoscopic biopsy of terminal ileum and lower rectum and pancolonscopia ileoscopia associated with retrograde. A series of tests, also considering the anatomic location of the disorder, characterized by a degree of invasiveness and a certain reluctance on the part of patients’ performance. The family doctor, patiently, and highly aware of the risks that the disabling complications of this disease could lead, explained to the patient the reason for the request of these tests and what each of these could be detected.  It ‘was also very useful to indicate the usefulness of these tests in a therapeutic perspective: In the final analysis indicated a surgical approach, and what the patient has been very useful to have seen the doctor who was giving the doubts, he understood the reason for this reluctance, and had stressed on the other hand what would bring an inadequate treatment of the disease, the patient was able to find the correct explanation, the right questions in a climate of trust, mutual respect and understanding for the fundamental a good, if not great, compliance.

The findings prompted the suspicion were born during the visit:  trans rectal ultrasound  showed a severe inflammatory situation with multiple orifices perianal fistula perianal and gluteal region bilaterally. The sphincteric region appeared markedly subverted for the presence of variously collected inflammatory sinus and through communicating with each other. More caudal scans was evident disruption of the structure of the external anal sphincter for the presence of multiple areas of inflammation with signs of scarring especially in the posterior – the right side who were also responsible for the interruption of semicircle  back of the internal anal sphincter .

As suggested by the doctor performed an endoscopic biopsy was charged to the terminal ileum and rectum bottom.

Histopathology showed a mild chronic inflammation of the lamina propria with follicular hyperplasia of lymphoid tissue associated with it, with regard to the mucosa of the small intestine, while, at the expense of the large bowel, mild edema and chronic inflammation of the lamina propria. 

Pancolonscopy highlighted a sphincter tone,  a marked inflammation of the anal canal  but without identifiable endoscopically orifices there. The rectal ampulla was  covered by mucous membrane smooth and regular, with discrete inflammation to lower third where it was not identifiable the vascular pattern. 

The set of examinations performed by the patient, so very close, as indicated by the physician, both in the interest of patient’s health, either to give an acceptable quality of life, led to the decision taken by common agreement, resort to hospitalization for fistulectomy surgery. 

Probably without a proper explanation of the surgical procedure and the real seriousness for  the situation with the result that this bore, the patient, reluctant from the beginning, would have refused  surgery, even decisive, due to its invasiveness and immediate postoperative consequences. Also in this case, as in the explanation of swiftness in carrying out invasive diagnostic testing, it was critical the mediation role of family doctor who defended the patient’s interests, deciding a therapeutic strategy, by mutual agreement, without neglecting the problems, needs and fears, allowing an optimal resolution of the disease, not removing the patient’s centricity in favor of the disease. 

The examination of the operative part gave the diagnosis of abscess cavity in dermo-hypodermic, consisting of granulation tissue healthy and necrotic material extended up to the surface. 

The postoperative was held regularly without complications and at last visits to the our practice, performed a short distance from one another, the patient reported no complication, and, indeed, an improvement of symptoms. 

From all this, experience shows how the doctor/patient relationship may be the optimum: a relationship based on trust, understanding and dialogue between the two partners, so evident from the temporal sequence in which they diagnostic tests suggested by the doctor were carried out.

 

This experience shows how the doctor / patient relationship may be optimal: a relationship based on trust, understanding and dialogue between the two parties. This can be seen from the temporal sequence in which they were carried out diagnostic tests recommended by your doctor. Considering the disease has been fundamental to the timeliness with which they were carried out investigations with the intent to frame in an optimal way the disease: it was the sequence of events which occurred during visits / examinations of the suspected disease (later confirmed by the same) that if confirmed would have – as was – to be approached in a timely and decisive to avoid the loss of sphincter function, a result that would bring devastating consequences for the quality of life of the patient.

 

 

What is already known

Anal fistulas are communications between the anal canal and the skin that can be more or less large and take a route more or less long. In fact, in most cases the anal fistula  born as a perianal abscess, the latter being the acute phase of a suppuration of the glands of the anal canal and the chronicity of the abscess fistula instead of an expression, representing Therefore, abscesses and anal fistulas, a different phase of the same disease process.