34) Ano-rectal abscesses & Fistula in Ano скачать в хорошем качестве

34) Ano-rectal abscesses & Fistula in Ano

Anorectal Abscesses - Abscesses around lower rectum and anal canal are known as ‘Anorectal abscesses’ -as this often culminates in fistula –in – ano. Classification – 1)Perianal (60%), 2)Ischio-rectal (30%), 3)Submucous & 4)Pelvi –rectal (10%) 1)Perianal absecesses – Causes- a) arise from acute inflammation of anal gland, b) infection of a thrombosed ext. pile. Clinical features –Throbbing pain around anus, fever, headache . Rx – I & D , -antiboitics cover, -inadequate & defective incision will lead to anal fistula. The cruciate incision is placed on the most prominent part. Cavity is packed & healing will start by granulation tissue. 2)Ischio –rectal abscess- Cause- i)extention of anal gland inflammation laterally through the external sphicter. ii)infection may be through blood or lymph. iii)penetrating injury causing direct infection from outside. iv)extention from pelvi –rectal abscess through haitus of schwalbe. Clinical features- -pain becomes exuberant during defaecation. A tender brawny indurated swelling is seen. Rx – I & D –with a cruciate incision with packing of gauze of antibiotics . 3)Submucous abscess – Situated just deep to the mucous membrane of the anal canal above the dentate line. Rx- I& D & packing. 4)Pelvi –rectal abscess Fistula in Ano -an inflammatory track which has an ext. opening (secondary opening) in the peri-anal skin and internal opening (primary opening ) in the anal canal or rectum. -this track is lined by unhealthy granulation tissue & fibrous tissue. CAUSE- a) the fistula usully originates from a perianal abscesess in the inter sphincteric space of the anal canal from infection of the anal gland. Due to the tone of the internal sphincter the duct can not apply discharge the contents of the gland. Several other disorders must be considered which may cause fistula in ano - b)Ulcerative colitis, c) Crohn’s disease, d) tuberculosis & e)colonial carcinoma of the rectum. Classifications –Broadly, anal fistula can be divided in to 2 groups- i)Low level fistula, ii)High level fistula . I)Low level fistula –these fistula open into the anal canal below the anorectal ring. Can be subdivided into i) Subcutaneous type, ii)Submucous type, iii)Intersphincteric type, iv)Trans-sphincteric type, v) Supra-sphincteric type. II) High level fistula –these fitula open into the anal canal at or above the anorectal ring. Clinical features- -past history of perianal abscess can be received. -TB is a very common cause of multiple fistula in this country, -Granulation tissue may be seen pouting out from the mouth of the fistula . -Induration of the skin and subcutaneous tissue around the fistula . -An external opening for each side of the ischo-rectal fossa may be seen with inter communicating track lying posterior to the anus.This is called ‘horse-shoe fistula’. Goodsall’s Rule – This rule relates the location of the internal opening to the external opening. -If the external opening is anterior to an imaginary line drawn –across the midpoint of the anus, the fistula runs straight directly into the anal canal. -If the external opening is situated posterior to that line, the track usually will curve and the internal opening will be on the midline posterior of the anal canal. An exception to this rule is when the external opening is anterior to this imaginary line, but is situated more than 1.5 inches (3.75 cm) away from the anus. In this case the track will curve posteriorly and end in the posterior midline. Rectal exam.- This is must be extremely important. -The internal opening must be felt by digital examination if it is above anorectal ring, it is a high fistula. Proctoscopoy–s Lipodol injection - CXR- to exclude tubreculosis is important as fistula in ano is often associated with tuberculosis in this country . Rx – Low level fistula -Cord like induration representing the track . Fistula track must be laid open with probe and & knife & unhealthy granulation tissue on the wall of the fitula is scrapped off with a Volkmann spoon or the whole track with the fibrous tissue is excised. The cavity is packed with roller guaze wrung with weak antiseptic lotion . High level fitula – i) Supra levator fistula is motly secondary to Crohn’s disease or ulcerative colitis or Carcinoma or foreign body. This recquires treatment of the primary condition & the fistula is ignored. Any attempt to lay open the fistula will cause inincontinence ii) Trans-sphincteric fistula with a perforating secondary track –A seton of heavy black silk or a rubber band is passed round the deeper part of the track . iii) High iner-sphincteric fistuls – also treated in similar fashion as above. Horse shoe fistula – is usully not treated by redical unroofing procedure. (fistolotomy) Instead a posterior midline internal sphincterotomy combined with lying open the deep part of the fistula track is performed The lateral tracks are exercised.