Paraproctitis and rectal fistulas
Paraproctitis (adrectal abscess) - acute or chronic inflammation adrectal fiber. It accounts for about 30% of all cases, the process affects approximately 0.5% of the population. Men are affected 2 times more often than women, sick at the age of 30-50 years.
The etiology and pathogenesis. paraproctitis occurs as a result of contact with tissue adrectal microflora (Staphylococcus aureus, Gram-negative and gram-positive rods). In normal paraproctitis often identify polymicrobial flora. Inflammation involving anaerobes accompanied by a particularly severe manifestations of the disease - the gas phlegmon tissue of the pelvis, putrid paraproctitis, anaerobic sepsis. Specific agents of tuberculosis, syphilis, actinomycosis is very rare cause paraproctitis.
Ways of infection are very diverse. Germs get into adrectal tissue from the anal glands, anal opening in the sinuses. When inflammation in the anal gland of the duct is blocked, in the space formed mezhsfinkternom abscess, which erupts in the perianal or adrectal space. The transition process from the inflamed gland on adrectal fiber can also lymphogenous route.
In the development of paraproctitis may play a role trauma ¬ If zistoy shell rectal foreign bodies contained in the stool, hemorrhoids, anal fissures, ulcerative colitis, Crohn's disease, immunodeficiency states.
Paraproctitis may be secondary - in the propagation of the inflammatory process in adrectal tissue from the prostate, urethra, female genital mutilation. Injuries to the rectum is a rare cause of paraproctitis (traumatic).
The spread of pus in adrectal kletchatochnym spaces can go in different directions, which leads to the formation of various forms of paraproctitis. In this pus often breaks out through the skin to form a fistula.
By etiological principle: the traditional anaerobic specific, traumatic.
Localization of ulcers (infiltrates, streaks): subcutaneous, ishiorektalny, submucosal, pelviorektalny, retrorektalny.
Chronic paraproctitis (rectal fistula).
On anatomical grounds: full, partial, external, internal.
The position of the internal fistula opening: front, rear, side.
With respect to the fibers of the fistulous sphincter: intrasfinkterny, transsfinkterny, ekstrasfinkterny.
Degree of difficulty: simple, complex.
Acute paraproctitis characterized by a rapid development process.
The clinical picture and diagnosis. paraproctitis clinically manifested quite severe pain in the rectum or perineum, fever, accompanied by chills, a feeling of malaise, weakness, headaches, insomnia, appetite disappearance. Extensive cellulitis adrectal tissue leads to severe intoxication syndrome dysfunction of vital organs, threatening the transition to multi-organ failure and sepsis. Patients experience malaise, fatigue, headaches, insomnia, loss of appetite. Often appear delayed stool, tenesmus, dizuricheskie phenomenon. As the pain intensified accumulation of pus, become jerky, pulsating. If time does not make opening the abscess, he breaks out into adjacent kletchatochnye space, colon, out through the skin of the perineum.
The breakthrough of abscess in the rectum is the result of melting of the wall with pus pelviorektalnom paraproctitis. Formed an abscess cavity with a message lumen of the rectum (incomplete internal fistula).
A break of pus out (on the skin of the perineum), formed by the outer fistula. Pain subsides, the body temperature is reduced, improving the general condition of the patient.
The breakthrough of abscess in the lumen of the rectum or outside very rarely leads to complete recovery of patients. More often formed a fistula of the rectum (chronic paraproctitis).
Recurrent paraproctitis shows the presence of remission, when it seemed to fully recover the patient (pain disappear, normal body temperature, wound healing). Then there is the aggravation of the clinical picture of acute adrectal abscess.
Subcutaneous paraproctitis - the most common form of the disease (up to 50% of all patients paraproctitis). Characterized by sharp, jerking pain, aggravated by movement, straining, stool, there is dysuria. The body temperature reaches 39 "C, chills often occur. On examination reveals hyperemia, swelling and bulging of the skin in a limited area near the anus, anal canal deformation. Palpation of this area indicated a sharp pain, sometimes defined fluctuation. A digital rectal examination causes increased pain. However, under anesthesia, it is expedient to carry out, as it allows you to determine the extent of infiltration on one wall of the rectum near the anal canal and decide on the method of treatment.
Ishiorektalny paraproctitis occurs in 35-40% of patients. In the beginning there common symptoms of purulent process, characteristic of the syndrome a systemic reaction to inflammation with a sharp fever, chills, tachycardia, and tachypnea, high white blood cell count. In addition, the observed weakness, sleep disturbances, signs of intoxication. Dull pain in the depth of the perineum are sharp, throbbing. They are worse when coughing, physical exertion, defecation. With the localization of an abscess in front of the rectum occurs dysuria. Only after 5-7 days of onset of illness noted a moderate hyperemia and edema of the skin of the perineum in the zone where the abscess. Emphasis is placed on the asymmetry of the gluteal regions, flattening the semilunar fold on the affected side. Tenderness medially from the ischial tuberosity is moderate. Very valuable in the diagnosis of abscesses ishiorektalnyh a finger rectal examination. At the beginning of the disease can be determined soreness and induration bowel wall above the anal rectal-line, smoothed the folds of the mucous membrane of the rectum on the affected side.
Submucosal paraproctitis observed in 2-6% of patients with acute paraproctitis. Pain in this form of the disease is very mild, somewhat worse during defecation. The body temperature is low-grade. Palpable determine bulging in the intestinal lumen, in the area of abscess, sharply painful. After the spontaneous breaking of abscess in the lumen of the intestine begins recovery.
Pelviorektalny paraproctitis - the most severe form of the disease, occurs in 2-7% of patients with acute paraproctitis. Initially, there is a general weakness, malaise, fever up to subfebrile, chills, headache, loss of appetite, aching joints, aching in the abdomen.