The Chronic paraproctitis (rectum fistula) is a chronic inflammatory process in the anal crypt, milfinternal space and adrectal fiber with formation of a fistulous. Infected crypt is thus the internal opening of the fistula. Also rectal fistulas can be traumatic, post-surgical (eg after anterior resection of the rectum).
The majority of patients with fistulas of the rectum is related to the beginning of the disease with a history of acute paraproctitis. Approximately one third of patients with acute paraproctitis go to the doctor after the spontaneous opening of the abscess, after which they often formed a fistula of the rectum, another third of patients do not seek medical help until after they have an acute paraproctitis appears fistula. Only the remaining one-third of patients with acute paraproctitis go to the doctor in a timely manner, but not all of them, for different reasons, operate radically. Approximately half of the patients in this group carry out only opening and drainage of the abscess without the elimination of the entrance gate of infection that often leads to the formation of a fistula of the rectum. There is a constant infection from the lumen of the intestine, purulent the course surrounded by a wall of connective tissue — this is the fistulous course. External opening of the fistula usually opens on the skin of the perineum, its diameter often exceeds 1 mm, in the course of the fistula in the tissue with lack of good drainage can be formed infiltrates and purulent cavities.
Complaints. Usually patients concerned about the presence of fistulous openings (wounds) on the skin in the anus, discharge of pus, ichor, which he is forced to wear a spacer, to make washing of the perineum or sitz baths 1-2 times a day. Sometimes allocations are abundant, cause skin irritation, itching.
Pain with good drainage complete fistula rarely bothers, as is typical for incomplete internal fistula. It is due to chronic inflammatory process in the thickness of the internal sphincter, milfinternal space and inadequate drainage at the closed back door. Usually the pain is worse at the time of defecation and gradually subsides, because the stretching of the anal canal at the time of passage of the fecal bolus incomplete internal fistula is better drained.
The course of the disease. Very often the disease occurs in waves, on the background of the existing fistula can be an acute inflammation in the perianal tissue. This occurs when blockage of the fistulous purulent-necrotic masses or granulation tissue. This can result in abscess, after opening and emptying of which acute inflammation subsides, the amount of discharge from the wound decreases, pain disappears, the General condition improves, but the wound is not completely healed, the wound remains not more than 1 cm in diameter, which continue to be sukrovichnye-purulent discharge, is the external opening of the fistula. In short the course of the fistulous discharge is usually scant, if the discharge copious purulent nature likely, in the course of the fistula is purulent cavity. Spotting needs to guard against the malignancy fistula.
During periods of remission pain for a fistula of the rectum are uncommon. The General condition of the patient at this time is satisfactory. With careful observation of hygienic measures, the patient for a long time may not particularly suffer from the presence of the fistula. But the periods of exacerbations greatly disrupt the quality of life. The emergence of new foci of inflammation, involvement of anal sphincter lead to the emergence of new symptoms of the disease, long-term inflammatory process affects the General condition of the patient, there are asthenia, headache, poor sleep, decreased performance, suffers psyche, reduced potency.
The presence of a fistula of the rectum, especially complex, with infiltrates and purulent cavities, accompanied by frequent exacerbations of the inflammatory process, may lead to a significant deterioration of the General condition of the patient. In addition, there may be severe local changes causing a significant deformation of the anal canal and the perineum, scarring of the muscle compresses the anus, resulting in the development of insufficiency of the anal sphincter. Another complication of chronic paraproctitis is pectins — cicatricial changes in the wall of the anal canal, leading to reduced elasticity and scar stricture. At long existence of the disease (over 5 years) in some cases, there is a malignancy fistula.
Diagnosis of chronic paraproctitis
Diagnosis of chronic abscess is not so difficult. Typically, patients turn to the doctor complaining of the presence of fistula in the perineum or pus from the anus. At external examination, if it is a complete fistula of the rectum, you can see the outer hole. When incomplete internal fistula is only the internal opening, external opening on the skin there.
Naturally, the examination of the patient should precede the collection of anamnesis, which specifies the duration of the disease, especially the beginning and duration of the process, the frequency of exacerbations, the nature of previous treatment, revealed the presence of concomitant diseases. During the interview, also pay attention to the General condition of the patient (weight loss, pallor, etc.) his mental status. Information on the nature and amount of discharge from the fistula can help in the diagnosis of other diseases also characterized by the appearance of fistulas (actinomycosis, teratogeny education, Crohn’s disease), to suggest the presence of purulent streaks and cavities, with abundant secretion of pus. It is important to ask about bowel function (constipation, diarrhea, bleeding) and anal sphincter, particularly if the patient previously had surgery on the anal canal.
The examination of the patient with they hiss of the rectum is best done after cleansing of the colon content (enema, laxative). It is more convenient to examine the patient in the gynecological chair in the position of the patient on the back with extended feet. During the inspection pay attention to the condition of the skin of the perineum and buttocks, estimate the distance from the outer hole of the fistula to the anus, note the localization of holes around the circumference of the fistula of the anus, etc. the localization of the external fistulous openings, you can roughly assume the location of the internal opening of the fistula. Thus it is necessary to Orient the line connecting the ischial tuberosity. If the outer fistulous opening in the position of the patient on the back is below this line, often internal opening is found in the back of the crypts, if the external opening of the fistula is above this line, in the first place to look for the inner hole, it should be in the crypts at the front of the semicircle. But there are exceptions to the rule. The distance of the external opening from the anus can sometimes judge the depth of the fistulous relative to the outer sphincter. Of course, this is not a major benchmark, but the move nevertheless located inwards from the outer pulp or pass through a small portion, often has an external opening near the anus.
For fistulas of the rectum due to acute abscess is characterized by the presence of one external opening, upon detection of holes right and left of the anus, you should think about a horseshoe fistula. The presence of multiple outer holes is more typical for a specific process. During the inspection assess the number and nature of the discharge from the fistula. Ordinary (banal) abscess is characterized by hoevenii secretions of yellowish color, odorless. If when pressing on the affected area pus is secreted abundantly, so in the course of the fistula is a cavity (and).
The tuberculous process is accompanied by abundant liquid discharge from the fistula. Lumpy the allocation of scarce, sometimes roscovitine, fistulous openings, as a rule, several fistulous passages can be long and well palpable under the skin of the perineum and buttocks, the skin in the outer circle of holes with a bluish tint. Quite rarely malignancy. The nature of the discharge from the fistula is changing: they become bloody with mucus.
The outside of the vehicle also pay attention to the presence of deformation of the perineum, scars, closed do anus whether the hiatus it, Yes or no maceration of the perianal skin, traces of scratching, etc. If the patient complains of the holding of gases and feces, mandatory verification of reflex with perianal skin and cremasteric reflexes by drawing strokes on the skin with a mild probe or needle. This is done before palpation and finger study of the rectum.
Palpation of the perianal region and perineum to determine the presence of cicatricial process in the course of the fistula. When the location of fistulous in the subcutaneous submucosal layer, i.e. intersphincteric or when the course goes through a small portion of the anal sphincter, it can be easily identified in the form of a strand from the outer hole of the fistula to the rectum. When the fistulous course is not determined by palpation it is safe to say that the fistula is transsphincteric or even extrasphincter. PAL-Paterno in the course of the fistula is sometimes possible to detect infiltrates and purulent streaks.
When digital examination of the rectum is primarily determined by the tone of the sphincter of the rectum without volitional effort during volitional compression patients the anus. These data will make the Protocol of examination of the patient. The continued existence of the fistula with exacerbations of the inflammatory process often lead to the development of insufficiency of the anal sphincter prior to surgical intervention can also have consequences, so we need to treat this kind of study very seriously. When digital examination is determined by the localization of the internal opening of the fistula, usually located in one of morganeve crypts. Localization of the inner hole there are the following types of fistulae: posterior, anterior, side. Most often, the fistulas come back.
Finger examination of the rectum useful to Supplement palpation on the part of the perineum, i.e. to carry out bimanual examination. When digital examination can identify other diseases of the rectum and anal canal, prostate gland. Women conduct vaginal examination. About the presence of the fistulous going into the vagina, the condition of the recto vaginal septum are best judged in concurrent study through the rectum and vagina.
The sample with the dye should be applied in all patients with they hiss rectum. For this purpose most often used 1% solution of methylene blue. Paint marks internal opening of the fistula. Best seen staining of the crypts if anoscopy. The lack of staining of the inner hole even with the addition of hydrogen peroxide does not indicate that the connection with the intestine is not, and that in the region of the inner hole is an inflammatory process and the course was temporarily closed. In this situation, you should assign lavage of the fistulous antiseptic solutions for several days and then repeat the test with paint. The purpose of fistulography to identify the progress and the internal opening at negative sample paint is not recommended, as the study is only informative with good patency of the fistula.
Probing of the fistula gives you the opportunity to judge the direction of the fistulous, branching it into the tissues, the presence of purulent cavities with respect to the outer sphincter. It is better to use bellied metal probe. It gently injected into the outer fistulous opening and further promoted in the course of, controlling using the index finger of the free hand introduced into the rectum. Rough manipulation is misplaced, because it is not only very painful, but also dangerous because of the possibility to make a false move.
When the fistula is short and straight move the probe freely into the lumen of the intestine. If the course is tortuous, probe into the inner hole often fails. In the presence of a purulent cavity probe ballotine. When multiple external fistula openings usually probed all the moves.
In the presence of intersphincteric or superficial transsphincteric fistula probe goes toward the anal canal. If the fistulous course is high, the probe goes up, parallel to the rectum. The thickness of the bridge tissue between the finger introduced into the rectum, and the probe can be judged against fistulous to the outer sphincter of the anus.
For all patients with fistulas of the rectum obligatory sigmoidoscopy, which is needed to detect the condition of the mucous membrane of the rectum, the presence of other diseases (tumors, inflammatory diseases, etc.).
If, upon inspection of the impression that the patient has a TRANS – or extrasphincter fistulas of the rectum, it is necessary to Supplement the examination by fistulography. Radiographic study using barium enema is commonly used in the diagnosis of a fistula of the rectum as a helper when needed to differentiate the chronic abscess from other diseases.
Above was mentioned the necessity of evaluating the function of the anal sphincter, especially with long-term existence of the fistula and re-operations for him. The most informative method of research is synchromedia.
Of course, in patients with fistulas of the rectum is sometimes necessary to carry out additional research if you suspect the presence of competing diseases, and differential diagnosis for the detection of concomitant diseases of other organs and systems. But the main methods of diagnosis in the presence of a fistula of the rectum are: visual examination, palpation, finger examination of the anal canal and rectum, alloy with paint, probing stroke, ANO, sigmoidoscopy, fistulografiya at high fistulas, abundant secretions, and the balloting of the probe.
Great help in topical diagnosis of fistulous provides ultrasonography.
Classification of fistulas
Depending on the location of the fistulous relative to the outer sphincter of the anus secrete intra-, TRANS – and extrasphincter fistulas of rectum.
The most simple fistula is a fistula intersphincteric. They are also called subcutaneous submucosa boundary. Fistulous course, as a rule, is straight, scar the process is not marked, the disease duration is usually small. The outer hole of the fistula is most often localized near the anus, internal can be in any of the crypts.
Diagnosis of this type of fistula is simple: palpation of the perianal area allows you to define fistulous course in the submucosal and subcutaneous layers, is a tube inserted into the outer hole of the fistula, usually passes freely into the lumen of the intestine through an internal opening or approaches him in the submucosal layer. The sample with the dye in patients with so they hiss is usually positive. The function of the sphincter saved. Fistulografiya and other additional methods of research, as a rule, are not required.
Transsphincteric fistulas of the rectum are more common than extrasphincter. Moreover, the relation of the fistulous to the outer pulp can be different: the move can go through the subcutaneous portion of the sphincter, through the surface, i.e. deeper and deeper — through the deep portion.
The higher in relation to the sphincter is the course, the more frequent are not straight, and branched passages, purulent cavities in the tissue, more pronounced scar process in the tissues surrounding the course, including the sphincter.
In 15-20 % of cases are marked extrasphincter fistulas in which the course is placed high, as if skirting the outer sphincter, but the inner hole is in the region of the crypts, i.e. below. Such fistulae are formed due to sharp isio, palvia and retrorektalny abscess. They are characterized by the presence of a long convoluted turn, often found purulent streaks, scars. Often, the regular exacerbation of the inflammatory process leads to the formation of a new sinus openings, sometimes the inflammatory process goes from the cellular spaces space one side to the other — there is a horseshoe fistula. Horseshoe fistula may be the back and front.
Extrasphincter fistulas are classified according to the degree of difficulty. At the first degree of complexity of the extrasphincter fistula the internal opening is narrow without scarring around it, there’s no pustules, and infiltrates in the tissue, the progress is quite straightforward. At the second degree of complexity in the field of internal holes are scars, but no inflammatory changes in the tissue. In the third degree extrasphincter fistulas characterizes the narrow inner hole without the scar process around, but in tissue a suppurative inflammatory process. At the fourth degree of complexity they have a wide inner hole surrounded by scarring, inflammatory infiltration or a purulent cavities in cellular spaces spaces.
When transsphincteric and extrasphincter fistulas of rectum examination of the patient should be supplemented with fistulography, ultrasonography, as well as the definition of the function of the sphincter of the anus. These studies are needed to distinguish chronic abscess from other diseases that can cause fistulas.
Fistulas of the rectum usually have to be differentiated from cysts adrectal fiber, osteomyelitis of the sacrum and coccyx, actinomycosis, tuberculous fistulas, fistulas in Crohn’s disease, pilonidal sinus disease.
Cysts adrectal tissue-specific teratomas, often abscess and emptied out. In this case, in the perianal region form a fistula, which should be distinguished from abscess. Palpation from the skin of the perineum and digital rectal exam in the presence of cystic masses allow the vast majority of cases to detect rounded education plotnoelasticheskoy consistency with clear boundaries. Most often cysts drained through a fistula on the skin and then no communication the external opening of the fistula with rectal lumen. The probe and the paint does not reveal this relationship — its just not there. But sometimes the cyst may be opened simultaneously on the skin and in the rectum — there is a complete fistula. In such cases the internal opening in the rectum is high, above the level of the crypts, while in the ordinary fistula it is usually localized in one of the crypts. Discharge from cryptogenic fistula of the rectum exacerbation of scarce hoevenii, cystic cavity of the discharge may be abundant, mucous character, with roscovitine inclusions, sometimes semasko – or jelly-like. In the presence of the cysts at rectoscopy marked a narrowing, bulging of one of the walls of the colon. If fistulography the cyst cavity is filled, the contour it is usually clear, smooth, in contrast to conventional abscess, when the filling of streaks and voids the outline is uneven, the course tortuous and narrow. On radiographs in the presence of teratomas revealed extension retrorektalny space. Great help in the diagnosis has ultrasound adrectal cellular spaces.
Osteomyelitis of the pelvic bones can also lead to the formation of fistulas of the perineum, Sacro-coccygeal and gluteal regions. In chronic abscess of the fistula outer hole is often one that osteomyelitis may be several, they are usually located far from the anus, their connection with the lumen of the intestine not. Radiography of the pelvis and spine allows you to make the correct diagnosis.
Fistula with actinomycosis usually multiple, the skin in the outer circle of holes with a bluish tint, fistulous passages can be long and well palpable under the skin of the perineum and buttocks, the relationship with the lumen of the intestine is not detected. Discharge from the fistula is scarce, sometimes roscovitine.
In tuberculosis of the lungs, intestines can be banal and fistula of the rectum. The suspicion of a specific process are the cases, when the fistula liberally liquid pus, while histological examination revealed numerous confluent granulomas with caseous necrosis.
Fistulas in Crohn’s disease arise against the background of the underlying disease as its complications. Characteristic of Crohn’s disease is the presence in the gut ulcers-cracks, while under normal fistulas inflammatory changes in the mucous membrane of the rectum are absent or minimal.
Fistulas of the rectum occasionally have to be differentiated from fistulas caused by inflammation of the epithelial pilonidal sinus, when they open near the anus. Help the detection of primary holes pilonidal sinus and the lack of communication of these fistulas with rectal lumen.
Rarely malignancy fistula of the rectum; discharge become bloody with mucus. A reliable method of diagnosis is the cytological examination of scraping of the fistulous, and scraping it is better to make a deep portion of the stroke, and not from the external opening. If necessary subjected to histological study of the elements of the stroke.
Treatment of chronic paraproctitis
The only radical method of treatment of rectal fistulas is surgical, i.e., the presence of a fistula is a direct indication for surgery. Of course, there are contraindications for radical surgery, mostly for severe disease of various organs and systems in the stage of decompensation. If you are able to improve the status of conservative treatment, the operation becomes possible.
The timing of radical surgery and mainly determined by the clinical course of the disease. Exacerbation of chronic abscess with abscess formation it is necessary to open the abscess, and only after the elimination of purulent process to operate about fistula. It is impractical to defer radical treatment for long, as aggravation may be repeated inflammation with subsequent scarring of the wall of the anal canal, sphincter and perianal tissue may lead to deformation of the anal canal and the perineum and the development of anal sphincter insufficiency. In the presence of infiltrates in the course of the fistula is actively anti-inflammatory therapy, antibiotics, physiotherapy, after which the operation is performed. If the process flows are chronic and not of acute, surgery is performed in a planned manner. If a period of stable remission, the fistula orifice was closed, the operation should be postponed, since under these conditions there are no clear guidelines to perform a radical intervention, the operation might not only be ineffective in relation to whistle, but dangerous because of the possibility of tissue damage is not involved actually in the pathological process. Operation should be performed in the case where the fistula will reopen.
The most common types of operations for rectal fistula:
- dissection of the fistula into the rectal lumen;
- excision of fistula in the rectum (operation Gabriel);
- excision of the fistula into the rectal lumen with a dissection and drainage of streaks;
- excision of the fistula into the lumen of the rectum with closure of the sphincter;
- excision of the fistula with the ligature;
- excision of fistula is with moving of mucous membrane or Muco-muscle flap of the distal rectum for the elimination of the internal opening of the fistula.
The choice of method operation is determined by the following factors:
- localization of the fistulous relative to the outer sphincter of the anus;
- the degree of development of cicatricial process in the wall of the colon, the area of the inner openings and in the course of the fistula;
- the presence of purulent cavities and infiltrates in the pararectal tissue.
Operations about the rectum fistulas require knowledge of anatomy, physiology and clinical experience. Therefore, routine treatment of patients with fistulas of the rectum should be performed only in specialized hospitals and surgery needs specialist Coloproctology.
Emergency surgery in chronic abscess can occur in General surgical hospitals, but after calming down inflammation radical treatment should be undertaken from the experts. Too big a risk of complications of these interventions makes a cautious approach to surgical treatment of rectal fistulas.
The main complication is recurrence of the fistula and failure of the anal sphincter. Causes of relapse can be as errors in the selection of methods of procedure, and technical errors as well as defects in the postoperative management of the patient.
Forecast. Surgical treatment of regional, submucosal rectal fistula and low transsphincteric leads to permanent healing and is accompanied by some serious complications. High-level fistulas (high TRANS – and ex-transpondernye) can also be treated without functional disorders. In case of recurrent fistulas, long-existing inflammation, the presence of streaks and Scarring in the intestinal wall, the sphincter and the perianal tissue, the results are much worse. Hence the rule: surgery for fistulas of the rectum should be performed timely and professionally.