Proctology

Paraproctitis

The acute abscess — an acute inflammation of coloramerican tissue, caused by spread of inflammation of the anal crypts and anal glands.

The causative agent of the infection when the abscess is in most cases a mixed microflora. Often found staphylococci and streptococci in combination with E. coli, Proteus. Often (especially in ulcers pelviorectal space) detected the presence of Bacteroides, peptococcus, Fusobacterium related to nonspore anaerobes. Acute abscess caused by mixed microflora, usually called simple, banal. Specific infection (tuberculosis, actinomycosis, Clostridium) — very rare — 1-2%.

In 40-60-ies of XX century it was believed that when the abscess, especially chronic, it is necessary to exclude tuberculosis. The accumulation of knowledge on the etiology and pathogenesis of abscess this question was revised. To completely eliminate the role of the tubercle Bacillus in the development of the inflammatory process in pararectal tissue, of course, impossible. Cases of acute abscess on the background of generalized tuberculosis in the lungs and intestines, when the destruction of the intestinal wall leading to infection of the tissue of the intestinal microflora. Currently, there is a sharp jump in the incidence of tuberculosis, so be aware of this infection and conduct a survey of every patient, to the extent that will allow you to exclude specific process.

When abscess often present all the signs of acute inflammation: pain, swelling, redness, pus. If the abscess is caused by Association of microorganisms, but the main role is played nonspore anaerobes, there is a putrid abscess that affects the tissue over a large area; but can develop and present non-clostridial anaerobic paraproctitis with the defeat of not only fiber, but also the fascia and muscles. Such paraproctitis is characterized by rapid spread with severe swelling of tissues, necrosis, pus is secreted foul-smelling fluid with detritus. Sometimes the abscess is caused by clostridia — pathogens of gas gangrene.

The value of viruses, chlamydia, Gardnerella, Mycoplasma, etc. in acute abscess is unclear, but, given the relatively high prevalence of these infections and negative effects on the immune system, it can be assumed that they are playing not the last role in the development of the abscess.

Predisposing factors in the occurrence of purulent process in pararectal tissue are: the weakening of local and humoral immunity with exhaustion, alcoholism, due to acute or chronic infection (tonsillitis, influenza, sepsis); vascular changes in diabetes, atherosclerosis; functional disorders (constipation, diarrhea); the presence of hemorrhoids, fissures of the anus, criptica etc.

Causes

The anatomical border between the rectum and the anal canal passes through the anorectal line. At this level are morganeve crypts — pockets, the bottom of which is located approximately on the border of upper and middle thirds of the anal canal. At the bottom of the crypts open the excretory ducts of the anal glands. Themselves glands in the bulk are localized in the thickness of the internal sphincter, for which they called more intramuscular glands. Anal glands and crypts morganii is a very important elements in the pathogenesis of abscess. Intramuscular glands are laid in utero, and the child is born with them, but they begin to function with the period of puberty. For this reason, the abscess is associated with inflammation of the crypts and glands, occurs more often in adults. Have younger children the infection is in the tissue falls, as a rule, through maseribane the skin and newborns, the abscess often is a local source of infection when septicopyemia, which is confirmed by the fact that when abscess in children is usually planted monomicrobial staphylococcal flora, while in adult polymicrobial flora with the indispensable participation of pathogenic intestinal microorganisms.

Anal glands have the form of cones, or bunches, the size of which ranges from 0.75 to 2.9 mm, the excretory ducts are very thin, convoluted. Each crypt opened the ducts of several glands, and crypts in the rear of their more than 10, a little less in the crypts at the front of the semicircle, even less in the crypts on the side walls. Anal glands are ready-made channels into which penetrates the infection from the lumen of the rectum. If there is a blockage of duct of the gland due to swelling of the mucous membrane of the rectum (diarrhea), microtrauma, scarring of the excretory ducts of glands (moved cryptic), etc., may develop an acute inflammation of the groups the anal glands that open into the crypt (the crypt), and thus there is microabscess in the wall of the anal canal.

Outwards from the internal sphincter, separating it from the outer pulp is a longitudinal muscle layer, which is fan-shaped split at the bottom edge of the internal sphincter, fascial partition that separates the split fibers of longitudinal muscle distally to divide the space between the inner and outer sphincter (misfunction) on several layers:

  • inner space which leads to the submucosal layer of the rectum;
  • the space between the inner and intermediate layers of longitudinal muscle (directly communicates with clutchers pelviorectal space);
  • the space between the inner and outer layer of longitudinal muscles, communicating with the upper part ileorectal cellular spaces of space;
  • outdoor space, connecting with ileorectal space by fibrous septa passing through the surface portion of the external sphincter.

Microabscess caused by inflammation of the glands, at first localized in the crypt and does not go beyond the internal sphincter and under favorable circumstances may be emptied through the crypt. At this stage the disease can be regarded as cryptic. But if the abscess extends deep into, i.e. misfunction space, then it is abscess. The partitions milfinternal space pus can go in different directions, causing the formation of ulcers in the wider adrectal cellular spaces spaces.

Localization of the abscess are distinguished: subcutaneous, submucosal, intermuscular (when the abscess is located between the inner and outer sphincter), the ischial-rectal (ileorectal), pelvic-rectal (pelviorectal) and as a pelvic recto — rectal behind.

On the localization of crypts involved in the process of inflammation, abscess can be rear, front or side. In the first place in frequency is back abscess, on the second front, less often marvel at the crypt on the side walls. The more frequent the defeat of the crypts along the back wall can be explained by the fact that the rear of the crypts deeper and worse drained, they are most frequently injured solid feces due to the more rigid fixation of the bowel wall at the rear of the semicircle, and that in the rear the crypts opens much more of the ducts of the anal glands.

Another important element in the pathogenetic chain of acute paraproctitis is a purulent passage through which the pus from milfinternal space gets to more distant areas. The localization of this move is crucial when choosing the method of operation. The fact that the pus from the intermuscular space may fall into different cellular spaces space, bypassing the outer sphincter of the anus, or passing through it. The following options are available: course is located inwards from the outer pulp, the course goes through the subcutaneous portion of the sphincter, through the deeper layers — the superficial and deep portion of the muscle, the course goes around the sphincter with the lateral side — extrasphincter move.

Symptoms

The disease usually begins acutely. Following a short prodromal period with malaise, weakness, headache appears increasing pain in the rectum, perineum or pelvis, accompanied by fever and chills. The severity of symptoms of acute paraproctitis depends on the localization of the inflammatory process, its prevalence, the nature of the causative agent, the reactivity of the organism. The localization of the abscess in the subcutaneous tissue of the clinical manifestations are expressed more clearly and definitely: painful infiltration in the area of the anus, skin flushing, increased body temperature forcing, usually to go to the doctor in the first days after onset of the disease.

Ileorectal abscess in the first days of the disease manifested General symptoms: chilling, malaise, a dull ache in the pelvis and rectum, aggravated by defecation; local changes in the asymmetry of the buttocks, infiltration, hyperemia of the skin — appear in the late stage (5-6 day).

The most difficult runs pelviorectal paraproctitis, in which the abscess is situated deep in the pelvis. In the first days of the disease is dominated by General symptoms of inflammation: fever, chills, headache, joint pain, in the pelvis, in the abdomen. Often the patient goes to a surgeon, urologist, female gynecologist. Often they are treated for acute respiratory illness, influenza. The length of this period sometimes reaches 10-12 days. Further notes the increased pain in the pelvis and rectum, constipation, urine and severe intoxication.

If there is purulent fusion of the wall of the rectum, the pus breaks through into the rectum, women could be a breakthrough pus from pelviorectal space in the vagina. Complicated course pelviorectal abscess with evacuation of the abscess into the rectum or vagina often lubricates the picture of the disease, as it reduces pain and decreases temperature. In these cases, the allocation of pus and blood from the gut and the vagina may give the impression of dysentery, gynecological diseases, etc.

Symptoms such as constipation, tenesmus, dysuric disorders, lower abdominal pain, especially often in the localization of abscess in pelviorectal space, but can be any type of abscess.

Complications

The most severe complications of acute abscess — spread of inflammation at cellular spaces of the space of the pelvis, and purulent fusion of the rectal wall above the level of the anorectal line. In this case, intestinal contents flow into adrectal tissue and opens the possibility of widespread infection. Cases of purulent fusion of the urethra. Given its proximity to the pelvic peritoneum, pelvic cellular tissue message with a retroperitoneal, can not exclude the possibility of the breakout of pus in the abdominal cavity and retroperitoneal space. Such complications usually occur when late treatment to the doctor elderly, debilitated patients, in the presence of diabetes, vascular disorders, etc. late presentation of patients and when not performed the operations, the development of putrefactive process in the background of the abscess that started as trivial.

In addition, there are other possible complications of acute abscess: pus breakthrough cellular spaces from one space to another, the breakout of abscess (pelviorectal) in the rectum or vagina, a breakthrough of pus from the abscess cavity through the skin of the perineum (spontaneous opening).

After opening the abscess, either spontaneously or surgically without the elimination of suppurative the speed and the affected crypts in the future, as a rule, formed fistula of the rectum. If the fistula is not formed, but remained a focus of inflammation in the anal glands and milfinternal space, then after some time there is a relapse of acute paraproctitis.

Diagnosis

The first and main task of diagnosis of acute abscess — on the basis of complaints of patient, clinic and examination to identify the presence and localization of an abscess in the cellular spaces the space surrounding the rectum.

Simple enough diagnosis of subcutaneous abscess. Abscess localized in the subcutaneous tissue of the perianal area, is shown quickly and clearly: pain, redness of the skin on the affected side, flattening the folds of the perianal skin. When the location of the abscess close to the anus it can acquire slit-like shape. Palpation in the area of inflammation sharply painful, but fluctuations in the beginning may not be is late symptom. Despite the fact that the diagnosis seems certain already at external examination and palpation, it is necessary to perform a finger examination of the rectum and anal canal. Thus it is necessary not only to establish communication of the abscess with the rectum, amazed to find the crypt, but also to remember that the pus in the subcutaneous tissue can occur due to breakthrough from other cellular spaces, most of ileorectal. The introduction of the finger into the rectum should be done carefully on the wall of the anal canal, opposite the location of the abscess. In subcutaneous paraproctitis upper border of the abscess is determined below the anorectal line. Above this zone the wall of the colon elastic.

Thus, the diagnosis of acute subcutaneous paraproctitis can be put on the basis of clinical, external inspection, palpation, and digital research of a rectum. ANO, sigmoidoscopy, sfinkterami and other studies are not usually carried out due to the fact that instrumental investigations in acute abscess is very painful.

Ileorectal abscess may produce changes that are visible in a late stage, when there are pronounced asymmetry of the buttocks, smoothing the perianal folds. Therefore, if the patient asked about chilling, deterioration of health, sleep and a constant dull pain in the rectum and the pelvis, aggravated by defecation, but without visible changes in the anus, you should run a finger examination of the rectum. Already in the very early stages of the disease can detect the flattening of the wall of the rectum above the anal canal, flattening the folds of the mucous membrane on the affected side. By the end of the 1st week of disease infiltration bulges into the lumen of the rectum, locally, the temperature increases. The inflammatory infiltrate may spread to the prostate and the urethra, in this case palpation them painful to urinate.

Characteristic signs of acute ileorectal abscess — the presence of an infiltrate in the anal canal at and above the anorectal line (the finger fails to reach the upper limit of the infiltration), increased pain in jerky study of the perineum. If the diagnosis is clear, instrumental methods of research as well as in subcutaneous paraproctitis, do not apply.

Submucosal paraproctitis is diagnosed by digital examination of the rectum. Usually the bulging of the abscess into the lumen of the intestine is severe, pus may spread down into the subcutaneous cellular spaces space or to go up otslaivaya nijneangarsk mucosa of the rectum. Submucosal abscess often revealed themselves in the lumen of the intestine, and if the drainage is adequate, there may come a recovery.

Pelvic-rectal (pelviorectal) abscess is most difficult and is often diagnosed late. The inflammatory process is localized deep in the pelvis. The upper limit pelviorectal space of the pelvic peritoneum, lower border of the muscle that lifts the anus. From the skin of the perineum to pelviorectal fiber two cellular spaces of space — subcutaneous and ileorectal, so an external examination of the perineum usually not possible to diagnose pelviorectal paraproctitis. Signs pelviorectal paraproctitis, visible at external examination of the patient, only appear if the purulent process extends to ileorectal region and in the hypodermis, i.e. in a late stage.

During the initial stages pelviorectal paraproctitis when digital examination can determine the tenderness of one of the walls of medium – or verneinung of the rectum, it is possible to detect testovatoj intestinal wall infiltration or abroad. At a later stage in the intestinal wall thickens, there is a compression from the outside, and later bulging in the lumen of the intestine elastic tumor masses, sometimes is determined by the fluctuation. It should be noted that when pelviorectal paraproctitis upper pole of the ulcer with your finger usually is not achieved even when the patient squatting. Pelviorectal abscess, as a rule, it is possible to recognize, using only finger examination of the rectum. It is often necessary to use instrumental methods of diagnosis no. But if the diagnosis is unclear, you need to use a sigmoidoscopy and ultrasonography.

Endoscopic picture of the pelvic-rectal paraproctitis has the features: the mucous membrane of the ampullar Department of the colon above the area of infiltration hyperemic vascular pattern is reinforced, net. In a later stage, when the infiltration bulges into the lumen of the intestine, the mucous membrane over them is smooth, bright red color, contact bleeding. If there is a breakthrough of pus in the lumen of the intestine, when pressure is applied the tube proctoscope into the intestinal wall at the site of infiltration of pus. To see the hole in the gut when this is not always possible.

Ultrasonography has opened great opportunities in the diagnosis of abscess. The study allows to establish the localization, the size of the ulcer, the nature of the changes in the surrounding tissues, the use of a rectal probe helps in topical diagnosis of purulent stroke and diseased crypts.

And still main in the diagnosis of acute pelviorectal paraproctitis are currently evaluating the clinical picture and the data of the finger study of the rectum.

Kind of pelviorectal paraproctitis is considered basedirectory, or retrorektalny. The peculiarity of the clinical picture in the localization of inflammation in retrorektalny space is severe pain from the onset. In this form of abscess the most important diagnostic method is finger examination of the rectum. The abscess is located behind the rectum above the anal-coccygeal ligament, the study is usually very painful. Often in this form of abscess are clearly defined struck back crypt.

Intermuscular abscess caused by spread of pus in the space between the inner and outer sphincter. It is diagnosed less frequently. The fact that the outside of the vehicle visible changes do not happen, the process is localized in the wall of the anal canal. The location and extent of infiltration can be determined by palpation with the thumb from the perianal skin and the forefinger introduced into the rectum. Dense and very painful infiltration indicates the presence of an intermuscular abscess. Often in such a situation, the diagnosis of infiltrative abscess and conservative treatment begins. Usually, the next day the pus spreads to other cellular spaces of space and the patient operated on abscess.

Of course, it so happens that conservative therapy is effective and infiltrative abscess resolves. But experience shows that if inflammation was involved misfunction space, soon the disease will reassert themselves.

So, we discussed diagnosis of a purulent process in adrectal cellular spaces spaces: subcutaneous, submucosal, ileorectal, pelviorectal and retrorektalny, intermuscular. Found that often well-conducted digital research enables timely diagnosis. Only in some cases, especially in advanced and complicated inflammatory processes, it is necessary to resort to instrumental methods of research.

It was already mentioned that the abscess is only part of the pathological process in acute paraproctitis. There are still amazed at the crypt, where open the ducts of the anal glands are inflamed, and there is purulent passage through which the pus has spread to the cellular spaces of space. Sometimes already during the first examination with digital examination of the rectum unable to palpate the affected crypt. But more reliable data get in the operating room, when you can not only palpate the scope of all of the crypts, but also by entering the dye solution (methylene blue with addition of hydrogen peroxide) into the cavity of the abscess, to see the staining of the interested crypts. Purulent is also often detected during surgery. If the process is acute, no scars, evidence of previous inflammation, to palpate even the surface course is not always possible. Most purulent the course passes through the subcutaneous portion of the external sphincter, and sometimes through the perianal skin to palpate the cord, extending from the subcutaneous abscess to the rectum. Very rarely purulent course is strictly inwards from the outer pulp.

If purulent the course passes through the superficial and the deeper portion of the anal sphincter, to palpate it, as a rule, impossible. In acute abscess, the progress is still not surrounded by scar tissue, the diameter of its small — 1-2 mm, the probe could pass on it if the move is fairly superficial. With the high location of the speed probe can be done about the course.

Conducted after the initial inspection we can formulate a diagnosis of acute abscess, indicating the localization of an abscess in the cellular spaces space, roughly in some cases, to assume the localization of the affected crypts and festering moves relative to the outer sphincter: intersphincteric, extrasphincter and transsphincteric. Intersphincteric purulent course happens very rarely, most often we are dealing with transsphincteric course, it can permeate into the sphincter at different levels. In the clinical picture we can judge the causative agent of the abscess. As a rule, the process is called Association of micro-organisms and there is the classic symptoms of inflammation: pain, swelling, redness, pus.

The information we receive during the first examination of the patient, supplemented by the further operation. But there can be difficulties. So, if the localization of the ulcer and the prevalence of inflammation in adrectal cellular spaces is indeed possible to set the above-described methods, that the localization of purulent speed to determine can be very difficult. The use of Doppler-, contrast abscessography did not give the desired effect. Most promising for the detection of purulent move proved to be ultrasound using a rectal probe.

Differential diagnosis

Acute abscess basically have to be differentiated from teratoma festering adrectal fiber, abscess Douglas space, tumors of the rectum and pararectal region. Usually this need arises when, isio-, pelviorectal paraproctitis, i.e. with the high location of the abscess. In subcutaneous paraproctitis sometimes the question arises: is this a boil abscess abscessed, festering atheroma? If the abscess in the subcutaneous tissue is determined by the cord, reaching the anus, because the infection comes from the bowel lumen.

To distinguish the banal from the festering abscess teratoma (dermoid and epidermoid cyst, solid teratoma with presence of cystic cavities) is not easy. It should be borne in mind that festering, but not revealed a cyst has no communication with the lumen of the rectum, cysts often have a pronounced shell, clear boundaries. The contents of the cysts (except pus) unusual to the banal ulcers — it studneobraznogo, cheesy or Zamoskvorechie. If the cyst is emptied into the lumen of the intestine, it is a hole, usually above the level of the crypts, whereas, when abscess has affected the crypt, which is the entry of infection from the lumen of the intestine.

Differential diagnostic differences between pelvirectal the abscess and the abscess of Douglas space are found in the history collection. Abscess Douglas space occurs as a complication of diseases of the abdominal cavity or after surgery about them. Helps in correct diagnosis of bimanual and budgetline research through the rectum and vagina. According to the observations of Professor A. M. Amineva, “by bimanual examination through the rectum and the abdominal wall in patients with abscess of the pelvis be reduced to match the ends of the fingers through the thickness of fabrics never fails. If bimanual examination through the rectum in men and through vagina in women could be reduced to match the ends of the fingers, at least not in the midline and in the lateral parts of the pelvis, we must assume that the patient has no abscess Douglas space, and pelvic-rectal abscess”. In modern conditions the most often used ultrasound, allowing precisely enough to determine the localization of the abscess. Topical diagnosis is extremely important because the surgical approach for drainage of the abscess if the abscess is different from that of abscess of the Douglas pocket.

Acute abscess occurs as a complication of the decaying malignant tumors of the rectum. To recognize it is possible, using a finger examination of the rectum.

If the inflammatory process in pararectal tissue is induratum nature, it is necessary to exclude malignancy. While it is appropriate to apply all the necessary methods of research: fractography and x-ray sacrum and coccyx, ultrasonography, biopsy.

Treatment for abscess

Treatment of abscess surgery only. The operation should be performed immediately after diagnosis, as it belongs to the category of urgent. The type of anesthesia plays an important role. Requires full anesthesia and good relaxation. The most commonly used intravenous anesthesia, epidural and sacral anesthesia mask anesthesia. Local anesthesia in operations for acute paraproctitis impractical because of the risk of infection during the injection of anesthetic, inadequate analgesia and complications of the orientation due to infiltration of tissues with an anesthetic solution.

The main task of radical surgery — the obligatory opening of the abscess, draining it, finding the affected crypts and festering turn, the elimination of the crypt and stroke. If you eliminate the connection with the gut, you can count on full recovery of the patient.

In the conditions of specialized hospitals most often run only opening and drainage of abscess, radical surgery is mainly performed in coloproctological units. Aspiration in that whatever was to immediately perform a radical intervention without diagnostic skills and sufficient knowledge of anatomy of the anal sphincter and the adrectal cellular spaces can cause together with purulent course would cut part of the external sphincter and there it is insufficient.

Radical surgery for acute paraproctitis can be grouped as follows:

  • opening and drainage of abscess, excision of the diseased crypts and dissection of purulent move in the lumen of the intestine;
  • opening and drainage of abscess, excision of the diseased crypts and sphincterotomy;
  • opening and drainage of abscess, excision of the diseased crypts, holding the ligature;
  • opening and drainage of abscess, delayed excision of the diseased crypts and moving the flap of the intestinal mucosa to interrupt pathways of infection from the lumen of the rectum.

Treatment of patients with acute paraproctitis is an arduous task that requires good knowledge of anatomy and experience. The most easy to solve the problem of treatment of subcutaneous abscesses, and purulent superficial location of the stroke, when applicable, the operation of incision of purulent move in the lumen of the intestine by excision of the diseased crypts. With the high location of the purulent it usually happens when ishio and pelviorectal abscess, the choice of method operation is hindered and is determined not only by the complexity of the situation in a specific patient, but also experience and knowledge operating.

The forecast: When timely and properly performed radical surgery for acute paraproctitis (urgently or in a delayed order) the prognosis is favorable. When a simple operation of opening the abscess without addressing his connection with the lumen of the intestine recovery is unlikely, most likely, will form a fistula, or after some time there will be a relapse of acute paraproctitis.

Reviewed by the QSota Medical Advisory Board