Inflammatory diseases of the anus

Proctitis

It is an acute or chronic disease of anus characterized by bloody and thin stools. In the acute stage, proctitis is accompanied by fever and transient sphincter insufficiency with incontinence may be present.

Causes

M. Crohn, proctitis ulcerosa, post-radiation proctitis, Lymphogranuloma venereum, Gonorrhea, AIDS, carcinoma.

Diagnosis

Red hemorrhagic mucosa with superficial defects to ulcerations. Diagnosis requires rectoscopy with biopsy of the mucosa and bacteriological examination.

Therapy

Diet modification, chamomile infusions, corticosteroids.

Anal a periproctal abscess

Patogenesis

Classification

• subcutaneous (5-10%) - on the sides of the anus, usually located further away from the anus;
• submucosal (5%) - located between the mucosa and the internal sphincter, often perforating into the rectum;
• intersphincteric (upper and lower) (40-50%) - the upper one propagates over the m. levator ani (supralevator), the lower one is more common;
• transsphincteric (30-40%) - affects the fossa ischiorectalis, forming a so-called horseshoe-shaped abscess;
• pelvirectal - rarely occurring around the rectum, above the levators and below the pelvic peritoneum, usually the infection originates from the gynaecological organs, prostate, seminal vesicles, or urinary bladder.

Symptoms

Anal abscesses usually present with pressure in the anorectal area and significant pain, which increases after defecation. Increased temperature, shivering and chills can be expected in patients with anal abscess. The abscess may also cause a septic condition with subsequent alteration' of the organism.

Diagnosis

• Superficial abscesses - inspection and palpation with two fingers (one finger inside the rectum, the other externally), sometimes it is necessary to perform the examination under anaesthesia because of the great pain.
• Deep abscesses - examination by CT and endosonography.

Therapy

The mainstay of therapy is early incision followed by drainage of the abscess. The radical, T-shaped and cross incisions are used. The abscess can also be opened transanally, but care must be taken to preserve the m. puborectalis because of possible incontinence.

Anorectal fistulas

Anorectal fistulas - classification

Pathogenesis

Classification

• submucosal and subcutaneous - run inward from the sphincters;
• extrasphincteric - bypassing the sphincters;
• intersphincteric - between the two sphincters;
• transsphincteric - pass through different parts of the sphincters.

Diagnosis

On inspection, we can see a secreting ostium of the fistula in the perianal area or in the perineal region. Palpation reveals a rigid band corresponding to a fistula under the skin. A fistulography can also be performed - spraying the fistula with methylene blue.

Therapy

The therapy is surgical and is performed:

• dissection of the fistula and subsequent healing per secundam;
• fistulectomy - excision of the fistula wall and subsequent healing per secundam;
• procedural sphincter pruning - a thread is pulled through the fistula and tightened at the anus, followed by gradual tightening over 2 to 3 weeks. Ligature begins to prune through the sphincter with simultaneous fibrous healing immediately behind the fiber. This procedure is called Hippocratic elastic ligature. If a radical excision is resorted to, incontinence could result.

Atypical fistulas

Atypical fistulas in the anorectal region are typical for, for example, m.Crohn', venereal disease and leukosis. These are fistulas: extrasphincteric fistulas; pelvirectal fistulas; recto-organ fistulas.

Therapy

Therapy consists of wide opening and drainage. Sometimes a temporary colostomy is needed due to advanced disease.

Fistulating pyoderma

It is a skin anomaly manifested by the formation of retention cysts. It occurs in the perianal and inguinal areas, as well as on the abdomen, popliteal and axillae. The disease often occurs in obese people with a metabolic disorder and a tendency to form acne.

Clinical picture

These are subcutaneous abscesses with formation of fistulas and secretion of pus, which, by their chronicity, lead to the formation of indurations and livid discoloration of the skin.

Therapy

In the early stages, conservative therapy with antibiotics may be resorted to. However, treatment with antibiotics is often unsuccessful. It is therefore important to perform excision of the affected skin sections with opening of the communicating abscesses. After excision, the skin is allowed to heal per secundam, or plastic surgery may be used.

Links

Related articles

• Periproctal fistula
• Rectum
• Abscess
• Fistula

Used literature

• ZEMAN, Miroslav – KRŠKA, Zdeněk. Speciální chirurgie. 3. edition. Galén, 2014. 511 pp. ISBN 978-80-7492-128-5.

• ZEMAN, Miroslav – KRŠKA, Zdeněk. Chirurgická propedeutika. 34. edition. Grada, 2011. ISBN 978-80-247-3770-6.

• POVÝŠIL, Ctibor – ŠTEINER, Ivo – BARTONÍČEK, Jan. Speciální patologie. 2. edition. Galén, 2007. 430 pp. ISBN 978-807262-494-2.