HEMORRHOIDS. RECTAL FISSURES.
PARAPROCTITIS. RECTAL FISTULAS.
CROHN’S DISEASE. UNSPECIFIC ULCEROUS COLITIS.
HEMORRHOIDS
Hemorrhoids from Greek mean bleeding.
Nowadays hemorrhoids are volume increase or dilation of cavernous bodies in
rectum.
Etiology
and Pathogenesis
Appearance of hemorroids is connected
with such factors as functional insufficiency of connective tissue, increase of
venous pressure at constipation, hard physical work, low-active life style,
pregnancy, alcoholism, spicy food. Mechanism of hemorrhoids’ development is
connected with disorder of blood outflow by venules from cavernous bodies and
their hyperplasia in distal part of rectum. Cavernous bodies are usually
situated in basal part of anal columns (Morgagni’s). Presence of direct
arteriovenous anastomoses conditions in hemorrhoids bleeding of arterial
character.
Pathomorphology
External hemorrhoids have their origin from veins of lower
hemorrhoidal plexus, internal – from upper. External hemorrhoids are soft, of
bluish color, they have not smooth surface and are filled with blood. Sometimes
they are dense and filled with thrombs. Sometimes external hemorrhoids are
prolapsed internal nodes. They have long leg deeply in anal canal.
Histologically they observe wall atrophy, anomalies of
development, often – signs of thrombophlebitis.
Classification
Hemorrhoids by etiological signs are
divided onto innate and acquired, by localization – internal (submucosal),
external and mixed (combined).
By clinical course hemorrhoids are: acute
and chronic, not complicated and complicated (thrombosis, strangulation of
hemorrhoids). There also define primary and secondary hemorrhoids (at liver
cirrhosis, diseases of circulatory system, tumors).
Symptoms
and clinical course
Early signs of hemorroids are rush
feeling in asnal region that appears due to skin maceration by mucous
excretions from rectum. This sign is increased in diet violations that may be a
consequence of constipation or diarrhea.
There define three degrees of
hemorrhoids. At I degree nodes prolabe from anus during defecation, but they
replace independently and are painful during palpation. At II degree there is a
need to replace nodes. There is edema in perianal region and pain. At III
degree nodes prolabe at very low physical loading, edema and pain are severe.
The speciality of chronic hemorrhoids is that there are conditions for
appearance of mucosal fissures, polipes and paraproctitis.
Variants
of clinical course and complications
Initial part of hemorrhoids is
characterized by gradual beginning and low reflected clinical signs – presence
of hemorrhoidal nodes. Duration of this period may be different – from several
months to years. Chronic course of hemorrhoids is characterized by periodical
acute conditions and remissions. Difference of clinical course of hemorrhoids
is only in complications.
Bleeding from hemorrhoids appears mostly
during or after defecation and may be as profuse as moderate. Blood is bright
red (arterial).
Acute thrombosis of hemorrhoidal nodes is
mostly seen in III degree of hemorrhoids. Thrombosis is a complication of as
external as internal nodes. At this there appear edema
of bluish color, severe pain. Progress of disease course sometimes may be
conditioned by thrombosis of inferior vena cava.
Such complication as prolapse and
strangulation in anal sphincter of internal hemorrhoidal nodes appear not so
often. Nodes swell, become bluish, sometimes there occur necrosis that spreads
on external nodes. Edema of anal region spreads to
Diagnostic
program
1.
Anamnesis and physical data.
2.
Examination of anal region.
3.
Finger investigation of
rectum.
4.
Examination of rectum by
rectal mirror.
5.
Rectoromanoscopia.
6.
General analysis of blood and
urine.
7.
Coagulogram.
8.
Sedimentation reactions
(Reaction of Wassermann).
Differential
diagnostics
Anal fissure is characterized by
severe pain during of after defecation, spasm of sphincter and small bleeding
during defecation.
The cancer of rectum at
the beginning of disease, usually, is painless, a blood in the first portions
of excrement appears. At the examination of rectum hard formation or ulcers
with a dense bottom is observed. Histological examination of biopsy specifies a
diagnosis.
Single or multiple polyps
of rectum may be combined with polyposis of colon. Revealed symptoms are
disorder of defecation and blood in feces. Examination of rectum lets us verify
the diagnosis.
Incomplete prolapse or prolapse of rectal mucosa
differs from hemorrhoids of III degree by combination with low reflected
incontinention.
Tactics
and choice of treating method
Conservative treatment is provided in
patients with not complicated hemorrhoids (I degree of disease). Treatment must
be complex and include diet therapy, remedies and physioprocedures.
For treatment of such patients they use massage
through Diet therapy means excluding from ration spicy and salty food. rectum,
recommend carrying of bandages. They also prescribe enemas (micro enemas with
warm water, oils, antiseptics), warm as sitting bath, perineal shower, warming
compresses.
In acute period they use bandages with
cold water, cooling bandages with plumbum water or furacilinum.
Medicamentous therapy includes
prescription of anti bleeding remedies and analgetics, antiseptics,
anti-inflammatory remedies (orally, intravenously and locally as rectal
suppositoria).
They also use physiotherapeutic methods
(UHF, darsonvalization), treating physical training for strengthening of
abdominal muscles and diaphragm, pelvis, spa treatment (H2S baths, mud and
radon sanatoria).
Indications for surgical treatment are
frequent bleedings from hemorrhoidal nodes that are accompanied with anemia,
big nodes that worsen defecationm inflammation, prolapse and strangulation of
nodes.
There are known more than 30 methods of
hemorrhoids’ extraction. The main moments of operation are divulsion of
sphincter, extraction and ligation of hemorrhoidal nodes situated in zones on
3, 7, and 11 hours at position of patient on back. Hemorrhoidal nodes are cut
from external area to internal, leg is ligated by silk ligature and extracted.
The most wide spread method is by Milligan-Morgan – extraction of nodes with
renewal of mucosa in anus.
In patients with complication of
secondary hemorrhoids by bleeding that may not be treated by conservative
therapy as a rule there is provided only ligation of bleeding areas.
Milligan-Morgan operation
After operation hemorrhoidectomy may
appear early (bleeding from the wound) and later (stricture of anal canal)
complications. With the aim of prevention of bleeding at hemorrhoidectomy leg
is ligated with silk ligation, and the wound – by node ligations to bottom. For
prevention of stricture of anal canal there makes sense to extract nodes not
more than in 4 places. During this between extracted nodes there must stay not
injured mucosa. When indicated, if after operation surgeon revealed the
stricture of entrance into anal canal, hemorrhoidectomy is finished by dosed
sphincterectomia.
During appearance of stricture of anal
canal by posterior comissure scar in extracted, there is provided dosed
sphincterectomia, and then mucosa is connected with perianal skin with further
fixation by separate ligations.
RECTAL
FISSURES
Rectal fissures are linear or triangle
shaped defects of anal mucosa. This disease takes 3rd place after hemorrhoids
and paraproctitis by frequency.
Etiology
and pathogenesis
The most wide spread theories of
appearance of fissures are mechanic and infectious. Due to the first,
appearance of fissures is conditioned by injury of anal mucosa by dense feces
in combination with constipation and diarrhea. Diseases that promote formation
of fissures are proctosigmoiditis, enterocolitis and hemorrhoids. Often
fissures accompany gastritis, gastric and duodenal ulcers.
By infectious theory fissures appear at
inflammation of anal glands (criptitis) that lead to tissue fibrosis and
decrease of their elasticity. Appearance of disease also may be promoted by
syphilis, tuberculosis, homosexualism.
Classification
Rectal fissures by clinical course are
divided onto acute and chronic. They may be complicated (paraproctitis,
malignization, bleeding, pectenosis) and combined with other diseases of anal
canal (hemorrhoids, criptitis, polypus).
Symptoms
and clinical course
Such disease is seen mostly in women of
middle age. Fissures are mostly situated in area of posterior comissure on 6
hours by clock dial in patient’s position laying on back. More rarely fissures
are situated on anterior and lateral walls. On posterior wall of anal canal
conditions of bleeding are worse, that’s why there is more danger of mucosal
injury during defecation, it is connected with pressure of feces during their
motion onto posterior and anterior commissures. Fissure mostly has longitudinal
direction and hides between skin folds in anal area. In chronic course near
external edge of fissure there appear skin fold with undermined edges, so
called terminal tuberculum. On internal edge of fissure there is tuberculum of
smaller size. In rare cases there are seen two fissures at the same time.
Clinical picture of anal fissure includes
triad of symptoms: pain during or after defecation, spasm of sphincter,
and low bleeding during defecation.
Pain in patients with rectal fissures has burning character connected with
moving of volumatic dense feces through anal canal. It depends also on degree
of reflection of sphincter spasm, irradiates into perineum, genitalia, urinary
bladder, back, and conditions disuric signs in males and dysmenorrhea in
females.
Sphincter spasm during the onset of the disease may be small. In chronic course it may
lead to proliferation of connective tissue.
Blood in feces appears during or after defecation, it has bright red color and is
excreted mostly in small quantity.
After examination of patient with such
pathology you should ask him to exert himself in relaxed sphincter, it is like
defecation. In such conditions anus lowers and deep areas of skin, terminal
fold and mucosa become visible. It lets us examine external area of fissure. In
incredible spasm of sphincter patient is moved onto table in position on side
with legs near abdomen or in “knee-elbow” position, with the help of napkins
they carefully move tissues of anus toward different sides. During this in that
region of anal ring where is predicted localization of fissure they examine
deep skin folds. In careful investigation there may be found fissure without
severe pain for patient.
Variants of
clinical course and complications
Acute fissure is characterized by
acute onset, presence in anal area of linear longitudinal wound with soft
bottom and length 1-
Chronic fissures may disturb
patients from two months to 1 year and more. In prolonged existence fissure
transforms into chronic ulcer with dense sclerozing bottom. In patients with
chronic fissures there may appear complications.
Bleeding at rectal fissures is mostly low. There is
observed excretion of bright red blood during or after defecation. In
extraordinary cases even low but frequent bleeding from rectal fissures leads
to revealed anemia.
Pectenosis is revealed in chronic fissures. At this
pathology sphincter muscles are replaced by connective tissue and the patient
gets coprostasis. Any examination of rectum is impossible because of narrowing
of rigid anal ring.
At paraproctitis as a complication of fissure the entrance
for infection is crypt through which inflammatory process is spreaded. The
patient suffers from pain of pulsing character in area of rectum and perineum,
fever. During palpation of perianal region there appear severe pain. Punction
lets reveal purulent focus.
Malignization is characteric for prolonged fissure. In such
cases pain decreases, there is observed ulcer with dense bottom with grey
covering. In first portions of feces there appears blood with bad smell.
Excisional biopsia with further histological investigation helps to find out
the malignization of fissure.
Diagnostic
program
1.
Anamnesis and physical data.
2.
Examination of canal by
stretching of anal tissues.
3.
Finger examination of rectum.
4.
investigation of rectum by
rectal mirror.
5.
Rectoromanoscopia
(contraindicated in pectenosis).
6.
General analysis of blood and
urine.
7.
Coagulogram.
8.
Sedimentation reactions
(reaction of Wassermann).
Differential
diagnostics
Chronic fissures of rectum should be often differentiated
with other diseases that may have the same local signs.
Proctalgia. Pain is
localized in the area of rectum. Consider, that the reason of proctalgia is
pathology of the higher nervous system (neuroses, hysteria). At objective
examination the visible organic changes are not exposed.
The anal form of non specific ulcerous colitis is characterized
by the superficial damage of rectum – hyperemia and edema of mucus, formation
of shallow ulcers and erosions. As a rule, non specific ulcerous colitis with
all its signs begins from the distal part of rectum.
Kron’s disease of rectum begins from submucosal layer,
ulcers do not spread much, they mostly are like fissures that penetrate onto
all depth of intestinal wall, have longitudinal and transversal directions, and
may cause formation of fistules and abscesses. At histological investigation
during Kron’s disease there is revealed granuloma.
Cancer of rectum. Presence in anal canal of formation with
not smooth edges and additions of blood in feces gives a possibility to suspect
malignization of fissure. Morphological investigation of bioptates with
presence of atypical cells proves malignant process.
Tactics
and choice of treating method
Acute fissures are treated
conservatively.
Treatment includes diet therapy,
prescription of remedies and physiotherapeutic procedures.
Diet therapy means excluding from ration
spicy and salty food, introduction of oral-oil substances that regulate feces.
They use warm procedures (baths, hot
water bottles), physiotherapeutic measures (darsonvalization, UHF, diathermia).
Medicamentous therapy means prescription
of anti-spasmatic (spasmalginum, no-spa, spasmolytinum) and analgetics
(promedolum, baralginum).
Rectally they use micro enemas (oily,
antiseptic), rectal suppositoria (with belladonna, anaesthesinum and their
standard forms – proctosedylum, G preparation). Under the fissure by injection
they introduce hydrocortizonum with novocainum.
Indications for surgical treatment are chronic ulcer
complicated by pectenosis, fistule, bleeding, and also non effective
conservative treatment. From radical methods we recommend cutting of fissure in
longitudinal direction including all the fissure into deleted part. Operation
is added by dosed sphincterectomia. Defect of mucosa is closed in transversal
direction by ligation of rectal mucosa to perianal skin.
POLYPS
OF COLON AND RECTUM
Polyps are non malignant tumors on legs
that grow from mucosa.
Etiology
and pathogenesis
Reasons of polyp’s appearance are
disorders in embryonal development , inflammatory processes of mucosa and also
viral infection.
Pathomorphology
Polypus of inflammatory origin differ from adenomatous ones
by their incorrect form and size variety. They are soft, filled with blood,
often with ulceration and hematomas. Such polypus usually combine with other
signs of inflammation in intestine.
Adenomatous polypus are often part of syndromes. Thus,
combination with non malignant tumors of bones, skin and soft tissues is
characteric for Gardner’s syndrome, combination with focal melanosis of mucosa
– for Peitz-Eggers’ syndrome, combination with brain tumors – for Turco’s
syndrome.
Classification
By etiology:
· Innate (hereditary, family)
· Acquired (at inflammatory processes)
Separately they define also children
(juvenile, innate and acquired).
By process’ spreading:
· Single
· Multiple
· Total (injury of all intestines).
By external appearance and microscopic
structure:
· True (glandular, fleesy, from multi layer epithelium)
· False (hypertrophic at ulceric colitis, fibrose).
Symptoms
and clinical course
Men get this disease in 2-3 times more
than women. Single polypus of colon and rectum have usually latent course and
are often revealed accidentally.
Multiple polypus may lead to diarrhea,
bleeding, changes in morphological and biochemical blood composition. At this
children do not devlop properly. At distal localization in some patients
polypus prolapse and strangulate in anal ring causing pain. Low situated
polypus irritate rectum and cause tenesmas, sometimes they cause prolapse of
intestinal wall.
Among disease’s symptoms first palce belongs
to disorders of defecation and blood in feces with further anemia,
hypoproteinemia, decrease of workability. Fleesy polypus leads to disorders of
water-salt and protein metabolism, because mucus’ excretion at defecation may
achieve
At multiple polyposis they define triad
of symptoms:
1.
Pigment spots (on the face,
lips, mucosal membranes of cheeks, fingers, and other areas of covering
epithelium).
2.
Polyposis of digestive tract.
3.
Hereditary character of
disease.
Finger examination of rectum and observation with rectal
mirror give a possibility to investigate its lower part. During this procedures
you can reveal polypus of different size situated on jucosa of rectum and also
polypus prolapsed with invaginate of sygmoid colon.
Irigography reveals single and multiple defects of filling,
so called symptom of “shooted aim” that may be seen in different parts of
colon. At presence of invaginate as complication of polypus there is
charactering defect of filling.
With the help of rectoromanoscope you can
examine rectum and sigmoid colon on average height
Variants of
clinical course and complications
Polypus of small size at the onset have latent course. With
their growth during moving of feces may occur disorder of their completeness
with further possible complications. More often is bleeding that in most cases
occur defecation. Depending on the height of polypus’ localization in intestine
blood may be dark red to bright red color. Blood loss may be from small, light
to severe, with signs of small and incredible anemia.
In most patients polypus have a tendense to malignization.
Provided biopsia in pre operation period with morphological investigation
reveals malignant transformation of tissues and proves this diagnosis not in all
cases. It depends on that in what part polypus becomes malignant. Final
diagnosis may be put after the operation during histological investigation of
all polypus.
Polypus of big size situated in rectum usually strangulate.
During this strangulation takes place on the level of anal ring and is
accompanied with severe pain. Not reducible polypus may necrotize.
Polypus are situated in caecum, colon and sigmoid colon. In
the most motile areas they may lead to intestinal invagination. In this case
there appear spastic pain, blood excretion with feces. During abdominal
palpation they reveal painful infiltrate. Invagination may prolapse into rectal
lumen.
Diagnostic
program
1.
Anamnesis and physical data.
2.
Finger investigation of
rectum.
3.
Investigation by rectal mirror.
4.
Rectoromanoscopy.
5.
Irigography.
6.
Fibrocolonoscopy.
7.
General analysis of blood and
urine.
8.
Coagulogram
Differential diagnosis
Polypus of colon and rectum should be differentiated with
malignant and non epithelial tumors, non specific ulcer colitis and rectal
fissures.
Cancer of right part of colon ahs a course with incredible
anemia (toxicoanemic form) due to absorption of tumor’s toxic products, their
action on hemopoetic organs.
Cancer of left part of colon is usually accompanied with
signs of obturative intestinal impassability. Additional examination (finger
rectal examination, irigography, endoscopic methods) give a possibility to
prove the diagnosis.
At chronic course of non specific ulcer colitis there is
injured mucosa of intestine, and little islands of not injured mucosa between
multiple big ulcers look like polypus, so called pseudopolyposis. Detailed
anamnesis, specialities of clinical course of the disease, irigography and
colonoscopy exclude presence of true polypus.
Not epithelial tumors (leyomyoma, lipoma) are situated
under intestinal mucosa and at their small size do not cause any symptoms. With
their growth mucosa is injured, there occurs bleeding with its signs. X-ray and
endoscopic methods of investigation, and also histological investigation prove
the final diagnosis.
Chronic fissure of rectum with not smooth edges and
terminal tuberculum often simulates true polypus. Removal of this formation
both with fissure and provided histological investigation help in proving of
diagnosis.
Tactics
and choice of treating method
Conservative method of
treatment is rarely used. For this is used solution of green greater celandine
for its introduction in enemas (3-
Because
of polypuses of small intestine and rectums are inclined
to malignization, the basic
method of its treatment is surgical .
Methods of operative treatment at polypus
are divided into two groups:
1.
Local operations (endoscopic
electrocoagulation, polypus’s removal). Indication for electrocoaguclation is
presence of single polypus on narrow leg, rarely – multiple polypus. Depending
on the localization polypus on wide leg are removed through rectum of by
laparotomy with further colotomy.
2.
Radical operations as
resection of separate segments of colon, right-side, left-side, subtotal
colectomy or coleproctectomy are provided at multiple polypus.
PARAPROCTITIS
Acute paraproctitis is acute inflammation
of pararectal cellular tissue. They take near 30% of all diseases of rectum.
Etiology
and pathogenesis
In most cases paraproctitis is caused by
polymicrobial flora. During inoculation of purulent content there are usually
revealed staphylococci, E. coli, Gram positive and Gram negative rods.
Causative agents of tuberculosis, actinomycosis, syphilis are rare causative
agents of paraproctitis. Clostridial infection causes occurance of gas gangrene
of pelvis cellular tissue. In etiology of paraproctitis the great role belongs
to penetration of infection into pararectal cellular tissue, status of
organism’s immunity, presence of additional diseases (diabetes mellitus).
Infection may penetrate through ana glands, injured rectal mucosa, and also by
hematogenic and lymphogenic way from neighbour organs injured by inflammatory
process. Every anal crypt collects openings from 6-8 anal glands. Thus, anal
crypt is opened gate for infection. After that follow swelling and obturation
of duct connecting anal gland with anal crypt. Due to that there forms purulent
cyst that opens and infection gets into perianal and perirectal spaces.
Pathomorphology
Morphologically there is defined purulent inflammation of crypts
with further spreading to perirectal, ischiorectal and pelvis cellular tissue.
Purulent inflammation usually is as phlegmone or (rarely) abscess.
Classification
1.
By etiology – usual,
anaerobic (gangrenous-putrefactive, ascendent anaerobic lymphangitis, anaerobic
sepsis), specific, traumatic paraproctitis.
2. By localization – submucosal, subcutaneous, oschiorectal, pelviorectal,
retrorectal paraproctitis
Separately there is
defined secondary paraproctitis at which inflammatory process spreads to pararectal
cellular tissue from prostate gland or female genitalia.
Symptoms
and clinical course
Paraproctitis has as local as general
symptoms. The most often are pain in anal region of rectum, swelling,
hyperemia, fluctuation, constipation, sometimes - disuria, increase of body
temperature, loss of appetite and workability.
During general blood analysis there are
leukocytosis with left disposition of leukocyte formula, SES increase. If
in-time operative treatment shouldn't be provided, period of disease may
increase to 10 days and more. After that there comes independent opening of
abscess into rectum (chronic paraproctitis), formation of recurrent
paraproctitis or reconvalescense.
Variants of
clinical course and complications
Subcutaneous, submucoal and ischiorectal paraproctitis ar
characterized mostly by typical course, there usually are no difficulties in
putting of diagnosis. Pelviorectal paraproctitis as the most severe form is not
revealed exactly. At first pain in inflammated area is not felt, disease starts
from headache, fever, increase of body temperature. Sometimes on this stage of
disease there is put such diagnosis as influenza. After that appears pain in
lower part of pelvis that irradiates into uterus, urinary bladder causing
disorders of urination. Patients get treatment in urologist, gynecologist and
therapeutist for a long time. If inflammatory infiltrate of pelviorectal
cellular tissue transforms into abscess, disease becomes acute. External signs
are revealed at spreading of purulent process onto ischiorectal and
subcutaneous cellular tissue. It lasts in limits of one place. At the same
time, processes may spread onto other pelvis part and form horseshoe shaped
paraproctitis. Retrorectal paraproctitis as a kind of pelviorectal from the
very beginning is accompanied with pain. During this pain is concentrated in
rectum, coccygeal area, it is increased in sitting position of patient and
during defecation. At this localization of abscess there may be two-side horseshoe
shaped injury. Paraproctitis with clostridial infection is characterized from
the beginning with sever intoxicaton, high temperature.
Palpatory in this regions there is
felt crepitation. Acute paraproctitis may be complicated by fistulas, phlegmones,
lymphangitis, sepsis. At clostridial infection not in time and incomplete
treatment may lead to death.
Diagnostic
program
1.
Anamnesis and physical data.
2.
Examination of anal area and
anal canal.
3.
Finger examination.
4.
Investigation by rectal
mirror.
5.
Rectoromanoscopy.
6.
X-ray examination of ischial
areas in lateral position.
7.
Bacteriogram of purulent
content.
8.
General analysis of blood and
urine.
9.
Biochemical analysis of
blood.
10.
Coagulogram.
11.
Sedimental reactions
(reaction of Wassermann).
Differential
diagnosis
Paraproctitis is differentiated with hemorrhoids, purulent
dermoid cysts, suppuration of epithelial paracoccygeal canals, cancer of
rectum, tumors and inflammatory diseases of sacral bone.
Acute hemorrhoids are accompanied with severe pain,
swelling of perianal area, formation of thrombs in nodes, nodes’ necrosis.
Suppurated presacral dermoid cyst has no connection with
rectum, and paraproctitis usually does. Pararectal abscess is always connected
with rectum in area of anal crypts. If suppurated cyst empties into intestine,
then fistula's direction is beyond the linea dentate.
Suppurated epithelial pericoccygeal canals are
characterized by presence of point openings on coccygeal level, fistula's
direction is beyond rectum.
Cancer of rectum at the onset of the disease is usually
accompanied with no pain. During examination of rectum there is revealed dense
formation. Data of punctional biopsia help to prove the diagnosis.
Diseases of sacral bone as tumoral as inflammatory of the
basis of osteomyelitis with injury of bone tissue structure are revealed by
X-ray examination.
Tactics
and choice of treating method
Method of choice for treatment of acute
paraproctitis is surgical. But on early stages of pelviorectal paraproctitis
with deep infiltration of tissues surrounding rectum, without signs of
softening there is indicated conservative treatment (warming compress on area
of perineum with 20% spiritus aethylicus, antibioitics of wide spectrum of
stion, lumbal novocainum blocade, strict bed regime, exclusion of cellulose
from food, usage of cleaning enemas). Surgical treatment means early operation
by opening of abscess by semilunar incision with dreanging and liquidation of
its inner opening (removal of crypt) through which abscess’ cavity is connected
with rectum.
At paraproctitis there may be observed
transsphincter and extrasphincter directions of fistulas, at pelviorectal and
retrorectal – extrasphincter. Important thing is choice of way of big abscess’
opening: through skin or mucosa from rectum. With this aim before opening of
abscess by thick needle you should provide punction of infiltrated area and if
exudates is got you should provide the incision. If pus of ischiorectal area is
spreaded on subcutaneous cellular tissue and there are changes in shape of
buttock, fluctuation, question of surgical operation has no doubt. At
retrorectal paraproctitis there makes sense to open the abscess from rectal
lumen. If in this case there functions inner fistule, it usually brings no
troubles for patients.
At signs of anaerobic infection they
provide wide multiple incisions, necrectiomia, wound cavity is washed by
solutions of oxidants (permanent washing), you should use antibiotics of wide
action spectrum, polyvalent anti-gangrenous serum (250-300,000 units 1 time per
2-3 days), desintoxicative therapy, oxygen barotherapy (10 procedures at
pressure 2 atmospheres), introduction of fresh blood blood, albumine, plasma,
hemodes, rheopolyglucinum. At diabetes mellitus they provide insulin therapy
and introduction of metrogilum.
After the operation there may appear
early complications: bleeding from wound bottom, especially at anaerobic
paraproctitis, and late – insufficiency of distal part of rectum, recidivum of
paraproctitis, formation of fistules. If bleeding occurs, they provide
tamponade of these areas, and if it does not stop – bleeding places are
ligated. At insufficiency of sphincter there should be provided one more
operation: renewal of sphincter completeness by Ï-like ligations.
RECTAL
FISTULAS
(CHRONIC
PARAPROCTITIS)
Rectal fistulas are tubular purulent
canals in cellular tissue surrounding rectum and anus.
Etiology
and pathogenesis
Rectal fistulas occur mostly on the basis
of acute paraproctitis. Reasons of chronic fistulas are:
-
opening of purulent
paraproctitis without cutting of crypt;
-
shortening of external anal
sphincter at which fistula's canal is pressed and excretion of its content
stops;
-
decreased resistance to
infection and low tissue regeneration;
-
epithelization of coccygeal
canals.
Classification
I.
By etiology and pathogenesis:
1.
Innate.
2.
Acquired (traumatic,
inflammatory, tumoral).
II.
By infection character:
1.
Vulgaric.
2.
Anaerobic.
3.
Specific (tuberculous,
syphilitic, actinomycotic etc.)
III.
By anatomical signs:
1.
Depending on connection with
intestinal lumen (complete, incomplete, internal, external).
2.
By correlation to external
sphincter (intrasphincter, extrasphincter, transsphincter).
3.
Depending on primary
localization of inflammatory process (subcutaneous, submucosal, ischiorectal,
pelviorectal).
4.
Depending on localization of
external and internal fistula's canals (cutaneous, marginal, on crypt level).
5.
By fistula's shape (simple –
direct, complex – curve and containing cavities).
There define 4 degrees of extrasphincter
fistulas:
I degree – scar and inflammatory changes
are absent.
II degree – scar process around inner
fistula’s opening without inflammatory changes in pararectal cellular tissue.
III degree – purulent cavities or
infiltrates in pararectal cellular tissue without scars around inner opening.
IV degree – incredible infiltrates or
pururlent cavities inpararectal cellular tissue and big scar process around
inner opening.
Symptoms
and clinical course
Self feeling and general status of
patient with chronic course of paraproctitis in most cases is satisfacting. At
long time existing inflammatory focus workability decreases, increased
irritability appears, sleep becomes worse. Depending on activity of
inflammatory process, character of excretions fro fistula changes. After abscess
opening pain decreases and may be back when process becomes acute. In most
patients with rectal fistulas there are observed signs of proctosigmoiditis and
chronic recurrent paraproctitis. When process becomes acute pain appears and
temperature increases. There is formed purulent focus with formation of new
fistula's canals.
In most patients fistula situated near
anal ring goes inside the sphincter. Fistula situated 4-
Variants of
clinical course and complications
Patients with fistulas feel rush and heaviness in areas of
rectum and anus. Long existing fistulas are accompanied with scar changes of
anal ring (pectenosis) that difficults defecation. After fistula’s closing
(between acute periods) patients have no troubles and feel healthy. In some
patients there stay painful infiltrates where inflammatory process may renew.
The most dangerous and rare complication of chronic paraproctitis is malignant
transformation of rectal fistulas.
Diagnostic
program
1.
Anamnesis and physical data.
2.
Examination of anal area and
anal canal.
3.
Finger examination of rectum.
4.
Investigation by rectal
mirror.
5.
Rectoromanoscopy.
6.
Bacteriogram of purulent
content.
7.
General analysis of blood and
urine.
8.
Biochemical analysis of
blood.
9.
Sedimental reactions
(reaction of Wassermann).
10.
Contrast fistulography.
11.
Introduction of catheter into
fistula's canal.
Differential
disagnosis
Chronic paraproctitis are differentiated with suppuration
of epithelial paracoccygeal canals, diseases of sacral bone, fissures of rectum
and suppurated presacral dermoid cysts.
Suppurated epithelial paracoccygeal canals are primary
openings of fistulas in area of intergluteal folds, and fistula's canals are
situated behind the dental line and are not connected with rectum.
Diseases of sacral bone on the basis of osteomyelitis are
recognized by X-ray method. At this there are revealed disorders of bone structure.
Fissures of rectal mucosa are acaompanoed with severe pain,
bleeding and spasms of sphincter. Presence of wound mostly on posterior
comissure proves the diagnosis.
Suppurated presacral dermoid cyst has no connection with
rectum. Even if it empties into rectum, fistula's canal is always situated
beyond the linea dentata.
Tactics
and choice of treating method
At conservative treatment of chronic
paraproctitis (fistulas) they use sitting baths and warming compresses with 20%
spiritus aethylicus. They also prescribe physiotherapeutic procedures
(ultraviolet radiation, local darsonvalization, electrophoresis with 1%
solution of potassium iodide, 1% novocainum solution), lavage of fistula with
diluted solutions of antiseptics.
Operative treatment is indicated if
fistula is present for a long time or closes for some time and then opens again
after acute inflammatory period. In patients with intrasphincter fistulas there
is used operation by Gabriel. Its basis is that fistula is cut from inner to
external opening. Skin that covers the fistula is cut as triangle. Its peak
includes internal opening, and basis is situated outside.
In case of fistula going through inner
parts of sphincter (transsphincter fistula) during canal removal there are
injured fibers of sphincter. For renewal of cut sphincter there are used node
of Ï-like ligations. At extrasphincter fistulas there are used such operations:
Ryzhykh-I – they remove fistula's canal
in perineal wound to rectal wall and cut in basis. Stump of fistula's canal is
emptied with Folkmann’s spoon, cleaned with iodine solution and ligated with
two or three layers of catgut ligations. During this ligated stump of fistula's
canal is covered by surrounding tissues. Operaiton is finished with dosed
sphincterotomia of inner fibers. This method is used when inner fistula's
opening is localized in posterior crypt.
Ryzhykh-II (second variant) is used when
inner fistula's opening is localized in anterior crypt or on lateral wall.
Removal offistula in perineal wound is provided the same as in the first
variant. Further, upon the inner fistula's opening there is separated piece of
mucosa (width 1-
By Blinnitchev, opening in rectal mucosa
is closed by catgut ligations in two stairs. There is separated mucosa upon the
ligated opening, it should be fixed including submucosal layer to muscular
membrane and ligated by silk ligations to perianal skin. Sometimes mobilized
piece is moved downwards. Mobilized mucosal-muscular piece is ligated in such a
way that needle should go near the edge of terminal fold to the basis of
mobilized piece. After that by separate silk ligations they fix piece’s edge to
perianal skin.
Ligation method (by Hippocrates). On the
wall of anal canal there should be cut inner fistula's opening and perianal
skin together with narrow stripe of mucosa. Into this layer there are put
ligations No.6 and sphincter fibers are tightened. Thus, thread stretches with
1-
At extrasphincter fistulas of I degree there is used operation of Ryzhykh of Blinnitchev,
or removal of fistula with ligation of sphincter. At fistulas of II degree
fistulas are removed with ligation of sphincter, at III degree – operation of
Blinnitchev or ligation method. At fistulas of IV degree there is used ligation
method.