Chapter 13. NON-TUMOROUS DISEASES OF THE RECTUM AND PARARECTAL FATTY TISSUE

Definition and statistical data

Hemorrhoids is a varicose dilation of cavernous corpuscles located under the mucous membrane of the rectal ampulla (internal hemorrhoids) and (or) under the skin of the anus (external hemorrhoids).

About 10% of adult population aged 30-50 years suffer from hemorrhoids, males suffering 3-4 times more frequently than females. In the structure of coloproctological diseases in Russia hemorrhoids takes one of the first places and accounts for 20-35%.

Clinical picture and diagnostics

At initial stages hemorrhoids may reduce and appear again under the influence of unfavourable factors. Internal hemorrhoids is not innervated by cutaneous nerves and does not cause pain. Symptomatics is manifested in the periods of exacerbations and in case of complications.

Complaints

Discomfort in the anal region (sense of heaviness, sense of a foreign body presence, burning and itching). Pain in acute hemorrhoids. In hemorrhage - discharge of scarlet-coloured blood by drops or trickles during defecation (blood on the feces, on the toilet paper; rarely - discharge of dark blood with clots).

Anamnesis

Association of exacerbation with dietary disorders (spicy food, alcohol), disturbances of intestinal functions (constipation, diarrhea), physical exertion. Existence of chronic diseases (adenoma of the prostate, chronic bronchitis, colitis, etc.)

Physical examination

At inspection - enlarged external hemorrhoidal nodes covered by skin and prolapsed internal nodes covered by the mucous membrane. Visually it is possible to detect thrombosis of the nodes (with or without inflammation), presence of erosions as the source of bleeding. Examination is carried out in the knee-elbow position or in the squatting position at exertion.

Digital rectal examination

In chronic non-complicated hemorrhoids the nodes are not detected. In thrombosis - painful and dense nodes.

Anoscopy, rectoromanoscopy

The results help to reveal enlarged internal hemorrhoidal nodes, their thrombosis, ulceration and to exclude cancer of the rectum.

Irrigoscopy, colonoscopy

This method enables excluding pathology of the above lying portions (cancer, colitis, polyposis).

Even in existence of hemorrhoids clinical symptomatics may be conditioned by other diseases of the large intestine (colitis, polyps, colorectal cancer, diverticula). That is why digital rectal examination, anoscopy, rectoromanoscopy are obligatory methods of investigation in hemor-rhoidal nodes' enlargement, and irrigoscopy and colonoscopy must be performed in patients with suspicion for pathology of higher intestinal portions.

Characteristics of methods of treatment

Conservative treatment

Purpose

Means

Elimination of provocating factors

Active lifestyle with limited excessive physical exertions, gastro-intestinal function normalization, keeping the diet (exclusion of spicy food, alcohol)

Normalization of the bloodflow in the system of hemorrhoidal plexus: increase of the venous tonus and capillary strength

Application of phlebotropic agents on the basis of bioflavonoids (detralex, phlebodia, etc.)

Normalization of the internal sphincter tonus

Spasmolytics

Controlling of symptoms of acute hemor-rhoids: controlling of pain syndrome in thrombosis, inflammation phenomena, thrombolysis

Antibiotics, non-steroid anti-inflammatory agents (NAIA). Locally in the form of oinments, suppositoria: corticosteroids (prednizolon), heparin, proctoglyvenol, hepathrombin G, posterizan, etc.

Arrest of hemorrhage

Ethamzilate, suppositoria with adrenaline, collagenous sponges

Definition and statistical data

Anal fissure is the defect of the mucous membrane of the anal canal.

The incidence of anal fissure occurrence constitutes 10-15% of all diseases of the rectum and takes the third place after hemorrhoids and paraproctitis. It most frequently occurs in females under 40 years old.

Clinical picture and diagnostics

Acute fissure

Chronic fissure

Complaints

A severe pain in the anus at defecation and during 15-20 minutes after it. Frequently - a drop of scarlet-coloured blood on the feces or marks of blood on the toilet paper.

A severe pain in the anus during defecation remaining for several hours after it. Continuous pain intensifying at defecation with irradiation to the perineum, rectum, sacrum is possible. Fear of stools.

Anamnesis

Constipations, solid feces. Recent anal sex, anoscopy, rectoromanoscopy.

Pain at defecation for more than 2 months. Prolonged existence of hemorrhoids, colitis, non-specific ulcerous colitis (NUC), Crohn's disease is possible.

Physical examination

At inspection - existence of a linear defect of the anal canal mucosa, sometimes with transition onto the skin

At inspection - existence of a deep oval defect of the anal canal mucosa, sometimes with transition onto the skin with callous edges. Presence of "a guarding tubercle" and hyperplastic papilla alongside the wound's edges is possible.

Digital rectal examination

Acute tenderness, contact hemorrhage; spasm of the sphincter is possible.

A pronounced spasm of the sphincter, acute tenderness, solid elevated edges of the ulcer.

Anoscopy, rectoromanoscopy, irrigoscopy, colonoscopy are performed in suspicion for back-ground diseases of the large intestine. Considering an acute pain and spasm of the sphincter these investigations, and sometimes digital rectal investigation, are carried out with the use of local anesthesia. In specialized clinical departments there are performed sphincterometry, electromyography and electromanometry in order to verify the functional condition of the rectal sphincters.

In suspicion of a specific lesion of the anal canal (syphilitic gumma, tuberculosis, actinomycosis, AIDS) anamnestic data as well as the findings of morphological and microbiological studies are of great importance.

Characterization methods of treatment

Conservative treatment

Purpose

Means

Normalization of stools

Keeping the diet (exclusion of spicy food, alcohol). Food rich in vegetable fibers. Purgative agents, cleansing enemas.

Liquidation of pain syndrome, controlling of the elevated tonus of the internal anal sphincter, improvement of bloodsupply.

Baths with a slight solution of potassium permanganate. Suppositoria and ointments with anesthetics, spirit-novocaine and lidocaine - hydrocortisone blockades. "Medicamentous sphincterotomy": blockators of calcium canals (diltiazem in tablets and locally in the form of gel), nitroglycerin (in tablets and locally in the form of ointment), injections of botulotoxin (botox).

Intensification of restorative capacities of the damaged tissues.

Ointments and gels with actovegin, solcoserile.

In the majority of cases an acute anal fissure heals at stool normalization during 5-7 days. In the rest of patients the fissure transforms into chronic and requires carrying out of the complex conservative treatment during 6-8 weeks. In case conservative treatment fails to be effective, a surgical intervention is indicated.

Definition and statistical data

Acute paraproctitis is an acute purulent inflammation of pararectal fatty tissue in the form of abscesses and phlegmons which characteristic feature is the connection with the rectal lumen.

The disease is noted in 0.5% of the population. Acute paraproctitis accounts for 25% of the total number of diseases of the rectum and anal canal. Males suffer 2 times more frequently than females.

Clinical picture and diagnostics

Subcutaneous, submucous

Ischiorectal

Pelviorectal

Com-plaints

Intensive pain in the anal region and perineum, elevation of the body temperature.

At the initial stage - chills, fatigue, dull continuous pains alongside the passage of the rectum, intensifying at cough and defecation.

Chills, fatigue, headache, dull continuous pains deep in the pelvis, lower abdomen, intensifying at defecation. Constipations, tenesmus, dysuria are possible.

Physical examination

In subcutaneous paraproctitis - hyperemia of skin and swelling on the side of damage close to the anus, pain at superficial palpation. sometimes - fluctuation. In submucous paraproctitis the skin is not changed.

At the initial stage skin changes are not pronounced. In spreading of the abscess - characteristic inflammatory skin changes.

Visible skin changes in the anal region are not noted.

Digital rectal examina-tion

The upper boundary of paraproctitis (a tender infiltrate) is detected beneath the anorectal line. Above the line the rectum wall is elastic.

A tender infiltrate in the anal canal at the level of the anorectal line and above it. The upper border of the infiltrate is reached with a finger.

Rectum wall infiltration, a tender infiltrate in the surrounding tissues and its protrusion into the rectum lumen. Its upper border is not reached with a finger.

The diagnosis of pelviorectal paraproctitis (most difficultly diagnosed) may be verified by US with the use of a rectal sensor, by CT or NMRI. These studies verify the topic diagnostics of the damaged crypt, abscess and pus passage (intrasphincteric, transsphincteric or extrasphincteric).

Definition and statistical data

Chronic paraproctitis is a chronic inflammation of the anal crypt and pararectal fatty tissue resulting in the formation of a fistulous passage connected with the rectum lumen.

Chronic paraproctitis constitutes 20-30% in the structure of proctological diseases taking the 4^th place after hemorrhoids, anal fissure and colitis. More frequently it occurs in males.

Differential diagnostics

With a coccygeal cyst Coccygeal cysts, in contrast to coccygeal passages, do not have primary orifices.

With a pararectal fistula

The tube introduced into the external orifice of the fistula is detected in the rectum lumen at digital examination and anoscopy.

Introduction of the staining substance and fistulography verify communication with the rectum lumen, which is lacking in a coccygeal passage.

With presacral teratoma

Presacral teratomas are located between the posterior wall of the rectum and anterior surface of the sacrum; they are detected at digital examination of the rectum. They may have a communication with the skin which looks like the primary orifice of the coccygeal passage.

USI and fistulography allow verifying the diagnosis.

With osteomyelitis of the sacral bones

In osteomyelitis of the sacrum and coccyx formation of fistulas on the skin of sacral-coccygeal region is possible.

In proper anamnesis (trauma, tuberculosis) X-ray of the pelvic bones enables doctor to detect the foci of destruction.

Definition and statistical data

Prolapse of the rectum is the abaissement (entropion) of all layers of the rectum outside the limits of the anus.

Among proctological diseases prolapse of the rectum accounts for 0.3-2%. Up to 33% of patients are children aged 10-12 years. In adults prolapse of the rectum develops more frequently in males, predominantly of working capacity age (20-50 years).