Prolapse Of The Rectum And Chronic Proctologic Diseases Flashcards
Rectal prolapse syndrome (prolapse of the rectum)
Protrusion, through the anal canal, of the rectal tissue layers or protrusion of abnormal formations/elements located in distal rectum.
In the presence of the rectal prolapse syndrome, physical examination, digital rectal and perianal area examinations allow to formulate clinical diagnosis and define treatment approach.
The most commonly it is reported for the rectal prolapse and chronic hemorrhoids.
Definition: Rectal prolapse
Protrusion of either the rectal mucosa or the entire wall of the rectum through the anal canal.
Types of protrusion of the rectum through the anal canal:
А) Mucosal prolapse or full-thickness rectal prolapse
B) Prolapse of hemorrhoids through the anal canal.
Clinical signs of the rectal prolapse:
A) Complaints:
- protrusion of different in size formations through the anal canal;
- rectal bleeding and mucus discharge through the anal canal.
B) Anamnesis:
- hard manual labor;
- parturition in women;
- constipations.
C) Objective signs:
а) physical examination: (performed when patient is straining in the squatting position)
- visual assessment of the protruded bowel dimensions;
- presence of changes in the rectal mucosal membrane (erosions, uclers, mucus, blood);
b) palpation:
- digital rectal examination;
- palpation of the prolapsing part of the rectum.
Diagnosis of the rectum prolapse:
Clinical signs:
a) complaints
b) case history;
c) objective signs.
A) Physical examination and palpation of the prolapsing rectum:
- during the examination a patient is squatting or positioned on the left side with the knees close to the chest (the patient is asked to strain and the prolapsed rectum dimensions are visually assessed);
- palpation of the protruded rectum is performed;
- the bowel is manually reducted and digital examination of the anal sphincter (its passive and active tone) is performed.
B) Instrumental methods of examination:
- sigmoidoscopy;
- proctography;
- radiography of sacrum and coccyx.
- Rectal speculum examination.
The rectal prolapse treatment principles:
A) Surgery is indicated for treatment of the rectum prolapse or prolapse of the rectal mucosapathologic
elements.
B) Extent of surgery is depended on the nature of the pathology.
Causes of the rectal prolapse:
А) Elevated intraabdominal pressure:
- hard manual labor;
- difficult delivery;
- constipation.
B) Damage of ligamentous apparatus of the rectum caused by traumas.
С) Disturbance and weaking of connection between mucous membrane and muscular layer of the rectum, as a result of inflammatory processes.
D) Anatomic and constitutional peculiarities of pelvis, rectum and ligamentous apparatus of the rectum:
- flattening of sacrococcygeal curvature;
- lenghthened sigmoid colon (pelvic colon) and mesosigmoid;
- mesorectum;
- pelvic floor muscle weakness.
Types of the rectum prolapse
А) Prolapse of the anal canal mucosal membrane (three degrees of severity):
- first degree the mucosa is protruding during the defecation and self-reducted;
- second degree the mucosal membrane is protruding during defecation and significant straining efforts, requires manually assisted reduction;
- third degree the mucosal membrane is protruding during lightintensity physical activities and requires manual reduction.
B) Prolapse of the rectum (three degrees of severity):
- first degree - rectal segment, up to 5cm long, is protruding during defecation; self reducted; little erosions in the mucosal membrane; diminished sphincter tone;
- second degree - 6-10 cm long rectal segment is protruding during physical activity; requires manual reduction; the mucosal membrane is edematous and eroded, local ulcers occur; sphincter relaxed;
- third degree - rectal segment longer than 10cm is protruding in a vertical/upright position of a patient; the bowel is not self reducted and protruding again after manual reduction in upright position, the mucosal membrane is ulcered and bleeding; anus is incompletely closed.
Clinic-statistical classification of the rectal prolapse:
ICD10 Diagnosis Code К62.2 Anal prolapse
Layout of clinical diagnosis: {SXdegree} prolapse of the rectal mucosal prolapse
Degree of severity:
S1 1st degree
(Selfreducted protrusion of the rectal mucosa during defecation)
S2 2nd degree
(Protrusion of the rectal mucosal membrane during defecation and vigorous physical activities, not self-reducted, requires manually assisted reduction)
S3 3rd degree
(The mucosal membrane is protruding during light-intensity physical activities and requires manual reduction)
К62.3 Rectal prolapse
Layout of clinical diagnosis: {SXdegree} rectal prolapse {, due to EX} {complicated
with CX}
Degree of severity:
S1 1st degree
(Protrusion of the rectum during defecation, up to 5cm long; selfreducted; little erosions in the mucosal membrane; diminished sphincter tone)
S2 2nd degree
(Protrusion of the rectum during physical activities, 6-10cm long; manually reducted; the mucosal membrane is edematous and eroded, with local ulcers; anal sphincter relaxed)
S3 3rd degree
(Protrusion of the rectum in vertical/upright position of the patient, longer than 10cm; the bowel is not self-reducted and protruding again after manual reduction when recovering upright position; the mucosal membrane is ulcered and bleeding; anus is
incompletely closed)
Causes of the disease:
E1 elevated intraabdominal pressure
E2 pelvic floor muscle insufficiency
E3 insufficiency of ligamentous apparatus of the rectum
Complications:
C1 stangulation of the rectum
C2 strangulation and necrosis of the rectum
C3 rupture of the rectum
Management of the rectal prolapse:
A) Treatment of rectal mucosal prolapse:
- normalization of diet (elimination of constipations and diarrhoeas);
- sphincterolevatoroplasty, in case of anal sphincter insufficiency (fecal incontinence);
- circular excision of rectal mucosa with suturing, in case of rectal mucosal prolapse and necessity
of its manual reduction.
B) Treatment of rectal prolapse - surgical:
- fixation of the rectum to the sacral periosteum by means of alloplastics, in case of any severity of rectal prolapse with preserved function of the anal sphincter;
- fixation of the rectum by means of alloplastics is supplemented with sphincterolevatoroplasty, in case of rectal prolapse and insufficiency of the anal sphincter
Definition: Chronic hemorrhoids
Enlarged or dilated cavernous bodies of the rectum that protrude through the anal canal and require manual reduction.
Risk factors:
Chronic hemorrhoids
A) Congenital insufficiency of connective tissue in submucosal layer of the rectum, forming internal hemorrhoids.
B) Hard manual labor.
C) Works that require a lot of standing.
D) Pregnancy.
E) Chronic constipation.
Classification of hemorrhoids
Chronic
A) External hemorrhoids.
B) Internal hemorrhoids.
C) Mixed or combined hemorrhoids (presence of both external and internal hemorrhoids).
Clinical signs of chronic hemorrhoids
(depend on degree of severity):
• First degree of severity:
a) complaints:
- perianal itching;
- discomfort, sometimes feeling of foreign body in the rectum;
- possible bleeding during or straight after defecation;
b) visual examination, palpation:
- hemorrhoids are identified in the rectal cavity;
- soft-elastic consistency of the formations;
- painless on palpation.
• Second degree of severity:
а) complaints:
- hemorrhoids are protruding during defecation and capable of being spontaneously reduced;
- bleedings become almost continuous;
- exacerbation of the disease is possible after alcohol and hot and spicy food intake;
b) visual examination, palpation:
- hemorrhoids are protruding during straining efforts and manually reduced;
- soft-elastic consistency and painless on palpation.
• Third degree of severity:
a) complaints:
- hemorrhoids are protruding during straining efforts,
defecation, physical activity and manually reduced;
- mucus discharge from the rectum;
b) visual examination, palpation:
- hemorrhoids are protruding during straining efforts, defecation, physical activity and manually reduced;
- maceration and perianal inflammations;
- diminished rectal sphincter tone.
• Fourth degree of severity:
а) complaints:
- hemorrhoids are protruding with the slightest physical activity and irreducible (protruding again straight after manual reduction);
- incontinence of flatus and faeces;
b) visual examination, palpation:
- hemorrhoids are protruding with the slightest physical activity and irreducible (protruding again straight after manual reduction);
- protrusion of the piles is accompanied by protrusion of the mucosal membrane of the anal canal;
- anal sphincter tone decrease
Preliminary diagnosis based on the clinical findings
chronic hemorrhoids
Provisional diagnosis is based on the patient complaints, anamnesis and objective signs of disease confirmed by physical methods of examination.
Diagnosis
chronic hemorrhoids
Instrumental methods of examination:
- rectal speculum examination;
- sigmoidoscopy.
Differential diagnosis of chronic hemorrhoids:
Differentiation from rectal diseases:
- rectal tumor;
- rectal polypus;
- rectal mucosal membrane prolapse
Clinic-statistical classification of chronic hemorrhoids:
ICD10 code I84 Hemorrhoids
Layout of clinical diagnosis: Chronic {LX} hemorrhoids {in stage of ХX}, {complicated with OX}
Localization:
L1 internal
L2 external
L2 mixed
Course of disease:
Х1 remission {SX degree of severity}
Degree of severity:
S1 1st degree (no prolapse, hemorrhoids stay inside the anal canal)
S2 2nd degree (hemorrhoids protrude on straining efforts, defecation; spontaneously reducible)
S3 3rd degree (hemorrhoids protrude on straining efforts, defecation and light physical activity; require manually assisted reduction)
S4 4th degree (hemorrhoids protrusion at rest, spontaneously irreducible, piles protrude straight after manual reduction)
Х2 exacerbation {QX}
Clinical signs:
Q1 trombosed hemorrhoids without inflammation
Q2 trombosed hemorrhoids with inflammation
Q3 necrotic hemorrhoids, inflammation of skin and subcutaneous tissue
Complications:
O1 chronic bleeding, {hemorrhage TX}
O2 acute bleeding, {hemorrhage TX}
Management of chronic hemorrhoids:
А) Conservative treatment (1-2 degree of severity):
a) normalization of digestive system functioning (regulation of intestinal contents consistency and its large intestinal transit);
b) toilet of perianal area after each defecation act;
c) local treatment:
- phlebotropic drugs (detralex, deflon, diomin, hesperidin);
- anesthetics (suppositories and ointments – ultraproct, posterisan, proctoglyvenol, nefluan).
B) Surgical treatment:
• for 1-2 degree hemorrhoids: minimally invasive surgical methods:
- rubber band ligation of hemorrhoids;
- infrared coagulation of hemorrhoids;
- cryotherapy of hemorrhoids;
- sclerotherapy of hemorrhoids;
- bipolar electrocoagulation of hemorrhoids;
• for 3-4 degree hemorrhoids: hemorrhoidectomy
Work capacity examination and rehabilitation of patients:
chronic hemorrhoids
A) Work capacity restoration in 15-20 days after surgery.
B) Patients suffering from chronic hemorrhoids and operated in that regard require normalization of the factors that contribute to disease progression or relapse.
Chronical pain syndrome in the area of the anal canal
Conditioned by a range of chronic slowly developing proctologic diseases or as consequence of past acute pathologic processes.
Analysis of clinical signs of the disease and examination of the perianal area and rectum allows to formulate clinical diagnose and choose treatment approach.
The most commonly this condition is observed in case of 1st-2nd degree chronic hemorrhoids, chronic rectal fissure, rectal fistulas, epithelial coccygeal ducts.
Definition: pain syndrome in the area of the anal canal
The conditions are referred to chronical proctologic pathology and characterized by the pain syndrome and discomfort in the rectal area, anal canal and perianal areas.
Clinical signs of chronic diseases of the anal canal and perianal area:
А) Complaints:
- pain in the anal canal and perianal areas;
- pain increase after defecation;
- rectal bleeding and mucus discharge from the rectum.
B) Anamnesis:
- assessment of clinical course of the disease;
- acute conditions of the anal canal and perianal area in past history.
C) Objective signs:
a) visual examination:
- visual change of the skin around the anal canal;
- visual detection of fistulous openings, hemorrhoids, skin maceration, tumorlike masses;
b) palpation:
- digital examination of the rectum;
- palpation of soft tissues of the perianal area
Diagnosis
chronic diseases of the anal canal and perianal area
– rectal speculum examination;
– sigmoidoscopy;
– colonoscopy;
– in case of rectal fistula, epithelial coccygeal ducts – probe investigation of the fistulas, contrast radiography of fistulas (fistulography).
Treatment program for chronic proctologic diseases of the anal canal and perianal area:
Choice of treatment method is conditioned by nature of the identified pathology.
Definition: Anal fissures
Defects of mucosal membrane of the anal canal of linear or trigonous shape with indurated edges
Causes of chronic anal fissure development:
A) Mechanical causes:
- traumatization of the mucosal membrane caused by fecal masses.
B) Infectious causes:
- nonspecific inflammation of the anal glands located in the rectal crypts, with development of fibrous tissue, decrease in elasticity of tissues and formation of fissures;
- specific inflammation with formation of fissures (syphilis, tuberculosis).
Clinical signs of chronic anal fissure:
A) Complaints:
а) pain:
- increases during or after defecation;
- irradiates into perineum, genitals, urinary bladder;
- accompanied by dysuric disorders in men and dysmenorrhea in women;
b) anal sphincter spasm;
c) blood in faeces is possible:
- during or after defecation;
- bright red blood color;
- small amount of blood emerging as blood stripes in faeces in accordance with location of the fissure.
B) Anamnesis:
a) continual occurrence of the fissure;
b) defecation disorders (constipations,
diarrheas) ;
c) alcohol abuse.
C) Objective signs:
а) visual examination:
- performed in knee-elbow position with slight straining efforts of the patient (anus goes down that allows visual examination of external part of the fissure);
- physician opens the anal orifice with the help of napkins for better examination of the anal canal.
Preliminary diagnosis
Anal Fissure
Preliminary diagnosis is based on the patient complaints, anamnesis and objective signs of disease confirmed by physical methods of examination
Diagnosis:
Anal Fissure
A) Laboratory examination:
a) CBC;
b) urinnalysis.
B) Instrumental examination:
a) rectal speculum examination of anal canal and rectum.
Differential diagnosis:
Anal Fissure
Includes diseases of the rectum:
- coccygodynia
- anal form of ulcerative colitis;
- Crohn’s disease;
- anal form of rectal cancer
clinic-statistical classification of anal fissure:
ICD10 Diagnosis Code К60.1 Anal fissure
Layout of clinical diagnosis: {XX} anal fissure, {FX,} {LX localization,} {QX,}
{complicated by OX}
Course of disease:
X1 Acute
X2 Chronic
Stage of the process:
F1 newly diagnosed
F2 recurrent
Localization: L1 anterior L2 posterior L3 leftsided L4 rightsided L5 multiple
Clinical signs:
Q1 with anal sphincter spasm
Q2 without anal sphincter spasm
Complications:
O1 periproctitis/perirectitis/paraproctitis
O2 anemia
Management of chronic anal fissure:
А) Conservative treatment:
a) normalization of digestion (elimination of constipations, diarrheas);
– elimination of spicy, salty and smoked foods;
– ingestion of foods that normalize defecation;
b) drug therapy:
– spasmolytics;
– anaesthetics;
– fatty microenemas, antiseptics (rectal administration);
– suppositories (containing belladonna, anesthesin);
c) physiotherapy:
– thermal procedures (baths, hotwater bags);
– d’arsonvalization, UHF therapy, diathermy, laser therapy.
B) Surgical treatment:
a) indications for surgical treatment:
– ineffectiveness of drug therapy;
– bleeding;
– fistulas;
b) surgical methods:
– excision of the fissure in longitudinal direction and suture of the defect in transverse direction
Work capacity examination and rehabilitation of patients:
Anal Fissure
A) Disability to work lasts 7–10 days until healing of fissure by conservative measures; ability to work is restored in the course of three weeks after surgery.
B) Dieting and normalization of defecation (prevention of constipations)
Definition: Rectal fistula
The presense fistula tract between rectum and perianal area in consequence of endured inflammatory process in perirectal fat.
Causes of rectal fistulas development:
A) Chronic proctologic pathology accompanied by traumatization of the rectal wall.
B) Acute paraproctitis.
Types and localization of rectal fistulas
1) rectal ampulla;
2) intrasphincteric (submucous) fistula;
3) transsphincteric fistula;
4) extrasphinteric fistula;
5) extrasphincteric complex fistula;
6) anal sphincter
Clinical signs of rectal fistulas:
A) Complaints:
a) occurrence of fistulous openings in perianal area:
- purulent discharge from the fistula;
- periodical closing of the fistula with subsequent exacerbation of inflammatory process;
b) perianal itching.
B) Visual examination:
a) fistulas in perianal area;
b) asymmetry of perianal area.
C) Palpation:
a) palpation allows to detect direction of fistulous tract and potential localization of its internal opening;
b) pus discharge from fistula is possible under pressing in projection of fistulous tract;
c) on digital rectal examination approximate localization of internal fistulous opening may be discovered.
Preliminary diagnosis:
rectal fistulas
Preliminary diagnosis is based on the patient complaints, anamnesis and objective signs of disease confirmed by physical methods of examination.
Diagnosis:
Rectal fistulas
Instrumental methods of examination:
- rectal speculum examination;
- sigmoidoscopy;
- color test with 1% methylene blue solution (the rectum is tamponed and staining agent is injected into external fistulous opening; location of the staining agent on the tampon determines localization of internal fistulous opening);
- probing of the rectal fistula with metal probe to determine fistulous tract direction in relation to sphincter
- contrast fistulography.
Differential diagnosis:
Rectal fistulas
- pilonidal sinuses;
- congenital cysts of paraproctium;
- Corhn’s disease;
- fistulas of specific etiology (tuberculosis, syphilis, actinomycosis).
Clinic-statistical classification of the rectal fistulas:
Clinicstatistical classification of the rectal fistulas:
ICD10 Diagnosis Code К60.4 Rectal fistula
Layout of clinical diagnosis: {BX {RX}} rectal fistula
Type:
B1 complete / amphibolic
B2 internal
B3 blind
Prevalence of the process:
R1– simple {Lх}
Localization:
L1 (intrasphincteric)
L2 (transsphincteric)
R2 complex extrasphincteric ({TX degree. })
Degree of severity:
(T1) 1 degree
(narrow internal opening without surrounding cicatricial process, abscesses and infiltrations in the perianal fatty spase)
(T2) 2 degree
(narrow or wide internal opening, but without inflammatory changes in fatty spases)
(T3) 3 degree
(narrow internal opening without cicatrical process around fistula but with occurrence of purulent inflammatory changes in the perirectal fat)
(T4) 4 degree
(wide internal opening with inflammatory infiltration or purulent cavities)
Treatment of the rectal fistulas
Surgical.
Choice of surgical method depends on relation of the fistula to sphincteric apparatus:
- for transsphincteric or extraspincteric fistulas ligature method is applied;
- for subdermalsubmucosal fistulas- fistulectomy (excision of the fistula) on probe according to Gabriel.
Work capacity examination and rehabilitation of patients:
rectal fistulas
А) Temporary incapacity to work comes to 3-4 weeks after surgery till the wound healing.
B) Dieting and defecation normalization (prevention of constipations).
Definition: Pilonidal sinuses
Located in intergluteal region above sacrum and coccyx and made up of tubular formations paved with stratified squamous epithelium and opened by one or several fistulous openings in skin.
Causes of occurrence of pilonidal sinuses
congenital development defects:
- abnormal hair ingrowth;
- remnant of spinal chorda;
- disorder of reduction of coccygeal vertebras.
Clinical signs depend on the disease course:
pilonidal sinuses
А) Without clinical signs (accidental finding of sinus openings during medical examination):
а) visual examination:
- one or two sinus openings in distal part of intergluteal fold near apex of coccyx above border of anal region
- diameter of openings from 1 to 3 mm;
- hair growth from openings is possible;
b) palpation: under pressing above fistula turbid or purulent fluid discharge from the opening is possible.
B) Acute course of disease:
a) common features of inflammation: body temperature 39-40 °C, fever;
b) local signs of inflammation:
- pain in intergluteal region, intensive, radiating into the rectum;
- swelling and infiltration in intergluteal region;
- hyperemia of skin above infiltration;
- possible fluctuation above infiltration;
- possible spreading of inflammatory process into perirectal fat.
C) Chronic course of disease:
- recurrent course;
- purulent discharge from fistula.
Preliminary diagnosis
pilonidal sinuses
Preliminary diagnosis is based on the patient complaints, anamnesis and objective signs of disease confirmed by physical methods of examination.
Diagnosis:
pilonidal sinuses
А) Rectal speculum examination.
B) Sigmoidoscopy.
C) Contrast fistulography
Differential diagnosis:
pilonidal sinuses
- congenital cysts of pararectal fat;
- chronic periproctitis;
- fistulas of specific etiology (tuberculosis, syphilis, actinomycosis).
Clinics-tatistical classification
pilonidal sinuses
ICD10 Diagnosis Code L05.0 Pilonidal sinuse
Formula of clinical diagnosis: Pilonidal sinuse {ХX} {complicated by OX}
Course of disease:
Х1 without clinical signs
Х2 acute
Х3 chronic
Complications:
O1 abscess of intergluteal region
O2 phlegmon of intergluteal region
O3 phlegmon of perirectal fatty spases.
Treatment of pilonidal sinus:
Surgical treatment:
а) pilonidal sinuses without clinical signs - elective surgery: excision of pilonidal sinuses;
b) pilonidal sinuses, acute course - urgent operation: drenage of the abscess ;
c) pilonidal sinuses, chronic course - elective surgery: excision of pilonidal sinuses after sanation of chronic purulent focci.
Work capacity examination and rehabilitation of patients:
pilonidal sinuses
Temporary disability lasts 10-15 days until wound healing.
Causes of the pain syndrome development in perianal area:
A) Chronic hemorrhoids.
B) Chronic rectal fissure.
C) Rectal fistulas.
D) Epithelial coccygeal ducts.
E) Perianal condylamas
