Loss of a rectum is a violation of anatomic position of a rectum at which there is a shift of its disteel part out of limits of an anal sphincter. Can be followed by pain, an incontience of intestinal contents, mucous and bloody allocations, feeling of a foreign matter in back pass, false desires on defecation. Diagnostics of loss of a rectum is based on data of survey, rectal manual inspection, a rektoromanoskopiya, irrigoskopiya, manometriya. Treatment is usually surgical, consists in performance of a resection and fixing of a rectum, plasticity of a sphincter.
Loss of a rectum
In a proktologiya understand an exit through back pass outside of all layers of disteel department of a thick gut as loss of a rectum (a rectal prolapse). Length of the dropping-out segment of a gut can make from 2 to 20 and more see. Quite often loss of a rectum occurs at children up to 3-4 years that is explained by anatomo-physiological specifics of a children's organism. Among adults loss of a rectum develops at men (70%) more often, than at women (30%), mainly at working-age (20-50 years). It is connected with hard physical work with which are engaged in the man's basic, and also the features of anatomy of a female small pelvis promoting deduction of a rectum in normal situation.
Reasons and risk factors
The contributing factors
The reasons causing loss of a rectum can be contributing and making. As the contributing factors violations of an anatomic structure of pelvic bones, forms and lengths sigmovidny and a rectum, pathological changes in muscles of a pelvic bottom act. A special role is played by a structure of sacral and coccygeal department of a backbone which represents a bend from the turned kpereda concavity. Normal the rectum settles down in the field of this curvature. At weak expressiveness or lack of curvature that often occurs at children, the rectum slides off on a bone framework down that is followed by its loss.
As other contributing moment the dolikhosigma - the extended sigmovidny gut and its bryzheyka can serve. It is noticed that at patients a rectal prolapse length of a sigmovidny gut is on average 15 cm more, and bryzheyka – on 6 cm, than at healthy people. Also loss of a rectum can be promoted by weakening of muscles of a pelvic bottom and an anal sphincter.
The making factors
Those moments which directly provoke a prolapse belong to the making factors of loss of a rectum. First of all, this physical tension: and loss can be caused as by single excessive effort (for example, a weight raising), and permanent hard work which is followed by increase in intra belly pressure. Sometimes pathology is a consequence of a trauma - falling on buttocks from height, strong blow to a sacrum, a rigid landing with a parachute, injuries of a spinal cord.
At children as frequent immediate causes serve the diseases of respiratory system proceeding with hoarse painful cough – pneumonia, whooping cough, bronchitis, etc. Also quite often lead polyps and tumors of a rectum to a rectal prolapse; the gastrointestinal diseases which are followed by chronic diarrhea, locks, a meteorizm; pathology of urinogenital system – an urolithic disease, prostate adenoma, , etc. In all these cases the constant natuzhivaniye, tension of a belly wall and increase in intra belly pressure is noted.
At women the prolapse of a rectum can develop after numerous or difficult delivery (at a narrow basin at the woman in labor, a large fruit, a mnogoplodiya) and to be combined with loss of a uterus, vagina, an urine incontience. Besides, proctologists warn that interest in anal sex and anal masturbation can be the reason of loss of a rectum. Most often the etiology of a disease has multifactorial character with prevalence of the leading reason which clarification is extremely important for treatment of pathology.
Classification: types and stages
Classification of types and extents of loss of a rectum is of the greatest interest to experts in the sphere of a clinical proktologiya. In typological classification distinguish hernial and invaginatsionny options of a rectal prolapse. The hernial mechanism of loss is caused by shift of a duglasov of a pocket and a forward wall of a rectum down. Weakness of muscles of a pelvic bottom in combination with continuous increase in intra belly pressure is gradually led to a rectum prolapse to the anal canal and to an exit outside.
Over time the site of loss of a rectum becomes circular (with involvement of all walls) and increases. The sigmovidny guts and loops of a small intestine which are displaced down can get to a gryzhepodobny pocket of duglas – it is so formed the sigmotsel and the enterotsel. At an intestinal invagination or an internal rectal prolapse there is an intrarektalny introduction of a part of a direct or sigmovidny gut, as a rule, without their exit outside.
On the mechanism leading to loss of a rectum allocate 3 degrees of a rectal prolapse: I – loss is connected only with defecation; II – loss is connected with defecation and physical activity; III – loss happens when walking and in vertical position of a body.
In a children's proktologiya the classification of loss of a rectum offered by A. I. Lenyushkin is used. By anatomic criteria the author distinguishes loss only of a mucous membrane of a rectum and all its layers. At the 1st degree of a prolapse the site of a rectum no more than 2-2,5 cm long drops out; at the 2nd – 1/3-1/2 lengths of all rectum; at the 3rd – all straight line, sometimes also the site of a sigmovidny gut. By clinical criteria A. I. Lenyushkin allocates stages of loss of a rectum:
- compensated – a prolapse occurs during defecation and is set independently;
- subcompensated – a prolapse happens at defecation and moderated physical tension; reposition of the dropped-out gut is possible only by means of a manual grant; the nedostatochyonost of an anal sphincter of the I degree is noted;
- dekompensirovanny – loss of a rectum can be connected with cough, laughter, sneezing; also the calla, a nedostayotochnost of a sphincter of the II-III degree is followed by an incontience of gases.
Symptoms of loss of a gut
The clinic of loss of a rectum can develop suddenly or gradually. The first option is characterized by the unexpected beginning most often connected with sharp increase in intra belly pressure (physical activity, a natuzhivaniye, cough, sneezing etc.). The loss of a rectum which is followed by sharp belly-ache owing to a tension of a bryzheyka develops in time or after a similar episode. The painful attack can be so expressed that leads to a condition of a collapse or shock.
Gradual development of a rectal prolapse is more often noted. In the beginning loss of a rectum happens only at a natuzhivaniye during the act of defecation and is easily liquidated independently. Gradually after each chair there is a need to set a rectum a hand. Progressing of a disease leads to loss of a rectum during cough, sneezing, stay in vertical position.
Loss of a rectum is followed by feeling of a foreign matter in back pass, discomfort, impossibility of deduction of gases and kalovy masses, frequent false desires on defecation (tenezmam). Belly-ache amplifies at defecation, walking, loading, and after reposition of a gut decreases or absolutely passes.
At loss of a rectum from back pass there is a release of slime or blood connected with traumatizing vessels in edematous and friable mucous the dropped-out site. At the long course of a disease dizurichesky violations – a faltering or frequent urination can join. At an internal rectal prolapse on a forward wall of a gut the solitary ulcer of a polygonal form, with a diameter of 2-3 cm is formed. The ulcer has smooth edges and the superficial bottom covered with fibrin; existence of a granulyatsionny shaft is not peculiar. In the absence of an ulcer focal hyperaemia and hypostasis mucous can be noted.
At rough or untimely reposition of the dropped-out piece of a rectum there can be its infringement. In this case hypostasis quickly accrues and blood supply of fabrics is broken that can lead to a necrosis of the site of loss of a rectum. The most dangerous is the simultaneous shift of loops of a small intestine in a bryushinny pocket – at the same time sharp intestinal impassability and peritonitis quite often develops.
Diagnostics and inspection
Loss of a rectum is distinguished on the basis of results of survey of the proctologist, functional tests and tool researches (a rektoromanoskopiya, a kolonoskopiya, an irrigoskopiya, a defektografiya, a manometriya, etc.). At survey the dropped-out site of a rectum has the form of a cone, the cylinder or a sphere of a bright red or cyanotic shade with existence in the center of a slit-like or star-shaped opening. Moderate hypostasis mucous and easy bleeding is noted at contact. Reposition of the dropped-out gut leads to restoration of a blood-groove and normal type of mucous. If loss of a rectum at the time of survey is not defined, to the patient suggest to natuzhitsya, as at defecation.
Carrying out a manual rectal research allows to estimate a sphincter tone, to distinguish loss of a rectum from hemorrhoids, anal polyps which are low located and dropping out through an anus. By means of endoscopic inspection (rektoromanoskopiya) the intestinal invagination and existence of a solitary ulcer on a forward wall of a rectum easily comes to light. Carrying out a kolonoskopiya is necessary for clarification of the reasons of loss of a rectum – a divertikulyarny disease, tumors etc. At detection of a solitary ulcer the endoscopic biopsy with a cyto-morphological research of a bioptat for an exception of endofitny cancer of rectum is carried out.
By means of an irrigoskopiya existence anatomic (dolikhosigma, invagination) and functional changes in a thick gut is defined (a kolostaza, violations of a passage of barium). Degree of a rectal prolapse is specified during a defektografiya (proktografiya) – a rentgenokotrastny research at which x-ray pictures are carried out at the time of simulation of the act of defecation. When carrying out an anorektalny manometriya function of the muscles surrounding a rectum and their participation in defecation process is estimated. Consultation of the gynecologist with survey on a chair is shown to women with loss of a rectum.
Treatment of loss of a rectum
Manual reposition of body brings only temporary improvement of a state and does not solve a problem of a rectal prolapse. Pararectal introduction of skleroziruyushchy medicines, electrostimulation of muscles of a pelvic bottom and a sphincter also do not guarantee full treatment of the patient. Conservative tactics can be applied at an internal prolapse (invagination) at persons of young age with the anamnesis of loss of a rectum not longer than 3 years.
Radical treatment of loss of a rectum is carried out only surgically. Many techniques of radical elimination of a prolapse of a rectum which can be carried out by promezhnostny access, by a chrevosecheniye or a laparoscopy are offered. The choice of the technology of operation is dictated by age, a physical condition of the patient, the reasons and extent of loss of a rectum.
Now in proktologichesky practice operations of a resection of the dropped-out piece of a rectum, plasticity of a pelvic bottom and the anal channel, a resection of a thick gut, fixing of disteel department of a rectum and the combined techniques are used. The resection of the dropped-out department of a rectum can be carried out by its circular cutting off (across Mikulich), scrappy cutting off (on Nelatona), cutting off with imposing of a sborivayushchy seam on a muscular wall (Delorm's operation), etc. in the ways.
Carrying out plasticity of the anal channel at loss of a rectum is directed to narrowing of back pass by means of a special wire, silk and mylar threads, synthetic and autoplastichesky materials. All these methods are used quite seldom in view of the high frequency of a recurrence of loss of a rectum and post-operational complications. The best results are achieved by sewing together of edges of muscles-levatorov and their fixing to a rectum.
At an inert rectum, a solitary ulcer or a dolikhosigma different types of an intra belly and bryushnoanalny resection of disteel departments of a large intestine which are often combined with the fixing operations are carried out. At a necrosis of the site of a gut the bryushnopromezhnostny resection with imposing of a sigmostoma is carried out. Among methods of fixing there are rektopeksiya the greatest distribution received a rectum podshivaniye by means of seams or a grid to longitudinal ligaments of a backbone or a sacrum. The combined surgical techniques of treatment of loss of a rectum mean a combination of a resection, plasticity and fixing of disteel departments of intestines.
Forecast and prevention
The right choice of a surgical grant allows to eliminate loss of a rectum and to restore evakuatorny ability of a thick gut at 75% of patients. The lasting bezretsidivny effect can be reached only at an exception of etiologichesky factors of loss of a rectum (locks, ponos, physical tension and so forth).
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