Rectum fistulas – the chronic form of a paraproktit which is characterized by formation of deep pathological channels (fistulas) between a rectum and skin or pararectal cellulose. Fistulas of a rectum are shown by bloody and purulent or bloody allocations from an opening on skin near back pass, a local itch, pains, maceration and irritation of skin. Diagnosis of fistulas of a rectum includes carrying out sounding of the pathological courses, anoskopiya, fistulografiya, rektoromanoskopiya, irrigoskopiya, ultrasonografiya, sfinkterometriya. Treatment is surgical, the including various methods of excision of fistula of a rectum depending on its localization.
The chronic inflammation of an anal crypt, mezhsfinkterny space and pararectal cellulose leading to formation of the svishchevy course is the cornerstone of formation of fistula of a rectum. At the same time the struck anal crypt at the same time serves as an internal svishchevy opening. The course of fistula of a rectum recuring, exhausting the patient, which is followed by both local reaction, and the general deterioration in a state. Long existence of fistula can lead to deformation of an anal sphincter, and also increase probability of development of cancer of rectum.
Classification of fistulas of a rectum
By quantity and localization of openings fistulas of a rectum can be full and incomplete. At full fistula the entrance opening is located on a rectum wall; an exhaust outlet – on the surface of skin around an anus. Quite often at full fistula is available several entrance openings merging in the depth of pararectal cellulose to the uniform canal which exhaust outlet opens on skin.
Incomplete fistula of a rectum is characterized by existence only of an entrance opening on and blindly comes to an end in pararectal cellulose. However as a result of the purulent processes happening at a paraproktita, incomplete fistula quite often breaks outside, turning into full. In the place of localization of an internal opening on a wall of a rectum distinguish fistulas of forward, back and side localization.
On an arrangement svishchevy to the course of rather anal sphincter fistulas of a rectum can be intrasfinkterny, transsfinkterny and ekstrasfinkterny. Intrasfinkternye (regional hypodermic and submucous) rectum fistulas, as a rule, have direct svishchevy the course with the external opening leaving near an anus, and internal, located in one of crypts. At fistulas of transsfinkteralny localization svishchevy the channel can be located in a hypodermic, superficial or deep portion of a sphincter. The Svishchevy courses at the same time often happen branched, to the existence of purulent pockets in cellulose expressed by cicatricial process in surrounding fabrics.
Ekstrasfinkteralno the located fistulas of a rectum bend around an external sphincter, opening an internal opening in the field of crypts. Usually they are an outcome of a sharp paraproktit. Svishcheva the course long, wavy, with purulent zateka and hems, can have the horseshoe form and several svishchevy openings.
Ekstrasfinkterny fistulas of a rectum differ on complexity degree. Fistulas of the 1st degree have a narrow internal opening and rather forward stroke; hems, infiltrates and abscesses in cellulose are absent. At fistulas of the 2nd degree of complexity the internal opening is surrounded with hems, but inflammatory changes are absent. Ekstrasfinkterny fistulas of the 3rd degree are characterized by a narrow internal opening without hems, but existence in cellulose of pyoinflammatory process. At the 4th degree of complexity the internal opening of fistula of a rectum is expanded, surrounded with hems, inflammatory infiltrates, purulent zateka in cellulose.
Reasons of fistulas of a rectum
In a proktologiya about 95% of fistulas of a rectum are an outcome of a sharp paraproktit. An infection, getting deep into walls of a rectum and surrounding cellulose, causes formation of perirektalny abscess which is opened, forming fistula. Formation of fistula of a rectum can be connected with inopportuneness of the address of the patient to the proctologist, not radicalism of surgery at a paraproktita.
Rectum fistulas can also have a post-traumatic or post-operational origin (owing to a rectum resection). The fistulas connecting a rectum and a vagina are a consequence of patrimonial injuries more often (at pelvic prelying of a fruit, ruptures of patrimonial ways, application of obstetric grants, long childbirth and so forth) or the complicated gynecologic interventions.
Formation of fistulas of a rectum often occurs at patients with a disease Krone, a divertikulyarny disease of intestines, rectum cancer, rectum tuberculosis, actinomycosis, clamidiosis, syphilis, AIDS.
Symptoms of fistulas of a rectum
At rectum fistula the patient notices on skin of perianalny area existence of a wound – the svishchevy course from which the ichor and pus soiling linen is periodically allocated. In this regard the patient is forced to change often laying, to wash a crotch, to do sedentary bathtubs. Plentiful allocations from the svishchevy course cause an itch, maceration and irritation of skin, are followed by a fetid odor.
If fistula of a rectum is well drained, the pain syndrome is expressed poorly; severe pain usually arises at incomplete internal fistula owing to a chronic inflammation in the thickness of a sphincter. Strengthening of pain is noted at the time of defecation, when passing a kalovy lump on a rectum; after long sitting, during the walking and cough.
Fistulas of a rectum have a wavy current. The aggravation comes in case of obstruction of the svishchevy course granulyatsionny fabric and is purulent - necrotic weight. It can lead to formation of abscess after which spontaneous opening the sharp phenomena abate: decreases separated from a wound and pain. Nevertheless, full healing of an external opening of fistula does not happen and through some time the sharp symptomatology renews.
During remission the general condition of the patient is not changed, and at careful respect for hygiene quality of life strongly does not suffer. However the long course of fistula of a rectum and constant exacerbations of a disease can lead to astenisation, deterioration in a dream, a headache, periodic temperature increase, decrease in working capacity, nervousness, decrease in a potentiality.
The difficult fistulas of a rectum existing long time often are followed by heavy local changes – deformation of the anal channel, cicatricial changes of muscles and insufficiency of an anal sphincter. Quite often as a result of fistulas of a rectum develops – the scarring of walls of the anal channel leading to its striktura.
Diagnosis of fistulas of a rectum
Recognition of fistula of a rectum is based on the basis of complaints, clinical examination and tool inspection (sounding, performance of the painting test, a fistulografiya, an ultrasonografiya, a rektoromanoskopiya, an irrigoskopiya, etc.).
At full fistula of a rectum on skin of perianalny area the external opening for which when pressing slime and pus is emitted is noticeable. The fistulas arising after a sharp paraproktit, as a rule, have one external opening. Existence of two openings and their arrangement at the left and to the right of an anus allows to think of horseshoe fistula of a rectum. Multiple external openings are characteristic of specific processes.
At an allocation paraproktita from fistula usually putreform, yellow color, not having a smell. Tuberculosis of a rectum is followed by the expiration from fistula of plentiful liquid allocations. In case of actinomycosis of allocation have poor kroshkovidny character. Existence of bloody allocations can serve as a rectum fistula ozlokachestvleniye signal. At incomplete internal fistula of a rectum there is only an internal opening therefore existence of fistula is established at a rectal manual research. At women carrying out the gynecologic research allowing to exclude existence of fistula of a vagina is obligatory.
Sounding of fistula of a rectum helps to establish the direction of the svishchevy course, its branching in fabrics, existence of purulent pockets, the course relation to a sphincter. Determination of extent and a form of the pathological channel, and also localization of an internal svishchevy opening is specified when carrying out an anoskopiya and test with dye (solution of methylene blue). At negative test with dye or in addition to it the fistulografiya is shown.
To all patients with fistulas of a rectum the rektoromanoskopiya allowing to estimate a condition of a mucous rectum, to reveal new growths and inflammatory changes is carried out. Irrigoskopiya with a baric enema in diagnosis of fistula of a rectum has auxiliary differential value.
For assessment of a functional condition of an anal sphincter at recuring the existing rectum fistulas expediently carrying out a sfinkterometriya is also long. In complex diagnosis of fistula of a rectum the ultrasonografiya is extremely informative. Differential diagnosis of fistulas of a rectum is carried out with cysts of pararectal cellulose, osteomyelitis of pelvic bones, the epitelialny coccygeal course.
Treatment of fistulas of a rectum
Radical treatment of fistula of a rectum is possible only quickly. During remission, when closing svishchevy openings, performing operation is inexpedient in view of lack of accurate visible reference points, a possibility of not radical excision of fistula and damage of healthy fabrics. In case of an aggravation of a paraproktit opening of abscess and elimination of purulent is made: massive antibiotic treatment, physical therapy (an electrophoresis, Ural federal district) is appointed then in the "cold" period operation is performed.
At various types of fistulas of a rectum the section or excision of fistula in a rectum gleam, additional opening and drainage of purulent zatek, a sphincter ushivaniye, movement of a mucous or mucous and muscular rag for closing of an internal svishchevy opening can be carried out. The choice of a technique is defined by localization of the svishchevy course, extent of cicatricial changes, availability of infiltrates and purulent pockets in pararectal space.
The post-operational current can be complicated by a recurrence of fistula of a rectum and insufficiency of an anal sphincter. The adequate choice of a surgical technique, timeliness of rendering a surgical grant, the correct technical performance of operation and lack of errors under the authority of the patient after intervention allows to avoid similar complications.
Forecast and prevention of fistulas of a rectum
Intrasfinkterny and low transsfinkterny fistulas of a rectum usually give in to permanent treatment and do not involve serious complications. Deep transsfinkterny and ekstrasfinkterny fistulas often recur. It is long the existing fistulas complicated by scarring of a wall of a rectum and purulent zateka, can be followed by secondary functional changes.
Prevention of formation of fistulas of a rectum demands timely treatment of a paraproktit, an exception of factors of a travmatization of a rectum.