Paraproctitis - Causes, symptoms and treatment. MF.

Paraproctitis is a purulent inflammation of fatty tissue located around the rectum and anal sphincter. Purulent paraproctitis is acute and chronic. Acute paraproctitis consists in the formation of abscesses( limited cavities with pus) fatty tissue. Chronic paraproctitis is manifested by pararectal( near rectum) and perianal( around the anus) fistula, which often occurs after acute paraproctitis. Paraproctitis is the most frequent disease of the rectum after hemorrhoids.

The figure shows the location of abscesses in acute paraproctitis:
a - subcutaneous abscess;
b - ischiorectal or ileo-rectum abscess;
with - pelviorectal or pelvic-rectum abscess;
d - submucosal abscess;The
arrow shows Morgani crypts.

Causes of paraproctitis

Paraproctitis is caused by bacteria. Most often it is an E. coli, less often staphylococci, enterococci and anaerobic bacteria.
Infection enters fatty tissue from the lumen of the rectum due to mucosal wounds, cracks in the anus. The most frequent entrance gates are crypts Morgani - peculiar folds of the mucosa of the anal canal, one of them almost always communicates with the cavity of the abscess. Less often the infection penetrates through the skin due to injury, furuncle or prostate gland in its inflammation. In addition, the infection can be brought from another focus of infection by a bloodstream( hematogenous way of infection).

Predisposing factors of paraproctitis development:
• frequent constipation;
• hemorrhoids, anal fissures;
• Weakened immunity due to alcoholism, exhaustion, after a flu, sore throat;
• diabetes mellitus;
• Atherosclerosis.

Symptoms of paraproctitis

The clinical picture of paraproctitis varies significantly, depending on the location of the purulent focus. At the beginning of the disease there is a short period with malaise, weakness and headache. There is an increase in temperature above 37.5 ° C with chills.

With subcutaneous paraproctitis , when the abscess is located near the anus under the skin, the symptoms are most vivid: a painful swelling in the anus, with reddening of the skin above it. The pain gradually increases, acquiring an intense pulsating character, preventing sleep, sitting, defecation becomes extremely painful, a softening appears above the tumor. This form of paraproctitis is most common.

The submucosal abscess is located under the mucosa of the rectum. Symptoms in this form of location are similar to subcutaneous paraproctitis, but pain syndrome and skin changes are less pronounced.

When ishiorektnal abscess purulent focus is located above the muscle that raises the anus. Because of the deeper location of the abscess, the local symptoms are more vague: blunt pulsating pains in the small pelvis and rectum, intensifying with defecation. Changes from the skin in the form of redness, swelling, swelling occur later on days 5-6 from the onset of pain. The general state of health is severe: the temperature can rise to 38 ° C, intoxication is expressed.

The pelvioreceptal abscess is most severe. This is a rare form of acute paraproctitis, when the purulent focus is located above the muscles that form the pelvic floor, a thin layer of the peritoneum separates it from the abdominal cavity. At the beginning of the disease, severe fever, chills, joint pain predominate. Local symptoms: pain in the pelvis and in the lower abdomen. After 10-12 days of pain intensifies, there is a delay of stool and urine.

In a separate group, is given to the necrotic paraproctitis .This form of paraproctitis is characterized by a rapid spread of infection, accompanied by extensive necrosis of soft tissues and requires their excision, after which there are large skin defects that require skin plasty.

Chronic paraproctitis is manifested by purulent fistula. The mouth of the fistulous passage can be located near the anal opening of the rectum or at a distance from it on the buttocks. The pain is usually not expressed. From the mouth of the fistula pus often diffuses feces. During the development of chronic paraproctitis, the opening of the fistula can be closed, pus stagnation occurs, abscesses develop, new tissue defects appear, pus breakthrough and outflow into the rectum and outward, necrosis and other tissue changes that significantly complicate fistulas. Thus, there are complex fistulous systems with fusel branching, cavity depots and a multitude of holes.

The figure shows how numerous and diverse can be the system of fistulous passages in chronic paraproctitis.

Diagnosis of paraproctitis

If these symptoms occur, you should consult a surgeon. In the formulation of the correct diagnosis, the clinical picture and examination by the surgeon are of primary importance. To more accurately determine the location of the abscess, a digital rectal examination may be required, but in most cases it is severely painful and is performed under general anesthesia in the operating room just before the operation.

When confirming the diagnosis of acute paraproctitis, hospitalization in the on-duty surgical hospital is necessary. At admission, it is usually necessary to pass a general blood test, blood glucose, a general urine test.

The treatment of chronic paraproctitis is carried out by a proctologist surgeon, since in this case a more complex operation is required, but the primary examination is usually performed by a general surgeon.

Symptoms of paraproctitis are similar to the following diseases: suppurative teratoma( swelling) of pararectal tissue, abscess of the Douglas space, swelling of the rectum. Subcutaneous paraproctitis can be confused with abscessed boils and festering atheroma. In any case, these diseases require examination by a surgeon.

If it is difficult to diagnose, ultrasound examination of the perineal region may be required. Ultrasound examination allows to establish the localization and dimensions of the abscess, the nature of changes in surrounding tissues. The use of a rectal ultrasound sensor helps in topical diagnosis of purulent motion and affected crypt. Fistulography makes it possible to evaluate the direction of the fistulous course in chronic paraproctitis and consists in the introduction of a contrast medium into the fistulous course with subsequent radiographic examination. Radiography or computed tomography of the sacrum and coccyx can help in the diagnosis of a congenital tumor.

Paraproctitis treatment

Paraproctitis treatment is only surgical. In acute paraproctitis, an operation is performed to open the purulent cavity, it must be performed immediately after the diagnosis is established. The operation is performed under general anesthesia, most often under intravenous anesthesia, or using spinal anesthesia when the patient does not feel pain in the lower half of the trunk, but remains conscious. The purpose of the operation - opening of the abscess, evacuation of pus and setting of drainage. In the future, the wound is openly, it heals independently or superimposes secondary seams.

The performed operation allows to stop the purulent process, but does not relieve the disease itself, because the cause of the disease is the intake of pus from the crypt of the rectum in the fistulous course. Therefore, an attack of acute paraproctitis may recur or develop chronic paraproctitis with fistulous strokes on the skin. Therefore, after suffering acute paraproctitis, it is necessary to consult a proctologist surgeon about performing a radical operation.

With chronic paraproctitis, more complex operations are performed, which allows achieving a stable remission of the disease. The purpose of the operation is to excise the fistula along with the inferior tissue, interrupt the communication with the rectum and create favorable conditions for the healing of the wound. It is necessary to know that fistulous courses can be located outside of the sphincter of the rectum. When excising the fistula, a sphincter injury can lead to anal incontinence - incontinence of the stool and gases. Therefore, when the fistula is located outside of the anal pulp, the ligature method is also used, which consists in carrying the filament through the fistula and tying it. Gradually she cuts through the sphincter, after which it is tied up tighter. Due to slow eruption through the anal pulp, the sphincter of the rectum has time to recover, which allows to avoid this complication.

In the postoperative period, antibacterial therapy( cefotaxime, gentamicin, amikacin) is performed and daily dressings are performed with antiseptic ointments( Levomecol).

Prevention of recurrence of the disease

In order to achieve a stable effect, in addition to the radical surgery performed, it is necessary to adhere to a number of rules.

• Control of constipation. It is necessary to achieve a regular soft stool.
• The diet should contain plant foods rich in fiber( fresh fruit vegetables, especially beets, cabbage), as well as fermented milk products( kefir, curdled milk, cottage cheese).You should avoid the product of dough.
• With diabetes it is necessary to maintain a normal blood sugar level, otherwise purulent diseases can not be avoided.
• Maintaining normal body weight.
• Observance of personal hygiene rules - regular washing after stool.
• Treatment of chronic hemorrhoids and anal fissures.

Complications of paraproctitis

It is necessary to realize that delay in referring to a surgeon in case of symptoms of the disease can lead to unfortunate consequences, among which the following can be distinguished.

• Purulent fusion of the rectum wall with the spread of intestinal contents to the pararectal tissue. Wide access to pararectal tissue for the contents of the gut may lead to even more severe consequences, as indicated below.
• Formation of purulent fistula between the rectum and vagina.
• Purulent melting of the urethra, transfer of purulent process to the scrotum followed by gangrene.
• Breakthrough pus in the free abdominal cavity and retroperitoneal tissue with the development of peritonitis and retroperitoneal phlegmon, which lead to sepsis( infection of blood) and death.
• Necrosis of the skin in the area of ​​dissemination of the abscess.

Thus, the only way to prevent the development of complications is an early request for medical help to a doctor surgeon.
As William Shakespeare said: "Excessive slowness leads to a sad end."Therefore, take care of your health. It is better to overestimate the severity of your symptoms than it is too late to seek medical help.

Surgeon-physician Tevs DS