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 10 cm. Body temperature increases to 39 degrees centigrade, defecation and diuresis are disordered, patients cannot sleep due to severe pain, they lose appetite, general status incredibly worsens.

 

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 1-2 cm, width 0.3-0.5 cm, depth to 0.3 cm. Disease may have duration to two months. As a rule, acute fissures don’t cause complications.

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 1.5 liters,

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 30 cm, and fibrocolonoscope is to examine all parts of colon. This investigation method gives a possibility to reveal exact place of polypus’ localization, its appearance including leg width, to provide excisional byopsia and also electrocoagulation.

 

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 (3-4 grams of green mass for 1 kg of patient weight, on the average 50 g for adults). A celandine is ground down on a meat grinder, conduct in hot water in the ratio 1:10. A medical cycle includes 15–30 enemas. Per treatments course is conducted three cycles at intervals in one month. The low located polypuses from a stratified epithelium, pseudopolypuses and malignant polypuses are not treated by celandine.

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 4-5 cm from anus and deeper is situated mostly outside the sphincter and may be of IV degree.

 

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 1-1.5 cm and length to 4 cm). Inner fistula's opening is ligated with node catgut ligations. With this aim threads are knotted after removal of rectal mirror. Then there should be put several ligations between separated and partially cut pieces of mucosa and distal part of the wound. At the end of operation there is provided posterior dosed sphincterotomia.

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 1-1.5 cm width intestinal wall and sphincter fibers. Ligation is tightened again till complete cutting of tissues and sphincter with cellular tissue.

 

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.