2020年10月28日星期三

hemorrhoids or cancer,Common sense of anorectal medicine

    1: Anatomy of the anorectum: rectum: the upper part is connected to the sigmoid colon, the lower part is connected to the anal canal, the total length is 12-15 cm, the rectal bladder lacuna, the female is rectal-uterine lacuna;

    Rectal column: there are about 10 where the lower end of the rectum connects with the anal canal;

    Anal flap: a half-moon-shaped wrinkle pocket between adjacent rectal columns;

    Anal sinus (anal recess): the funnel-shaped gap between the anal valve and the rectal wall, opening upward;

    Tooth line: the anal flap and the base of the rectal column, forming an irregular jagged edge at the junction of the rectum and anal canal; comparison of the anatomy between the upper and lower teeth

    Tissue blood supply innervation lymphatic drainage

    Dental line Mucosa Arteries: superior and inferior rectal arteries Autonomic nerves adjacent to the abdominal aorta

    Veins: superior rectal venous plexus-portal vein no pain or internal iliac artery

    Under the tooth line Skin Arteries: Anal artery Internal pudendal nerve Inguinal lymph

    Veins: inferior rectal vein-vena cava, acute pain, periiliac lymphatic

    Anal canal: 3 cm long, the upper edge is the tooth line, and the lower edge is the anal edge;

    Anal stent muscles: involuntary muscles, innervated by autonomic nerves;

    Extra-anal stents: divided into subcutaneous, superficial, deep, voluntary muscles; cutting off the subcutaneous stents of the external stents will not cause fecal incontinence, and cut off the deep, puborectalis, and internal stents of the anorectum. Ring, causing fecal incontinence;

    Two: Anorectal examination method:

    1. Position: According to the patient's physical condition and specific requirements.

    Knee-thoracic position: This position makes the anal canal droop, the anal area is clearly exposed, and the internal organs are moved up, and the pelvic cavity is empty. The inspection is convenient and easy to succeed. It is the most commonly used position;

    Left prone position: This position is suitable for people who are weak or who are doing simple treatment at the same time;

    Lithotomy position: Clearly exposed and can be used for double diagnosis at the same time. This position is also a common position for rectal and anal surgery; squatting position: It is suitable for checking internal hemorrhoids, prolapsed anus or rectal polyps, etc. This position has the greatest pressure on the rectum and anal canal, and internal hemorrhoids can be seen And the most serious cases of prolapse;

    Bent arm chair position: poor exposure, but convenient and time-saving, suitable for population health survey;

    2. Inspection: presence or absence of blood, pus, feces, mucus, fistula, lumps, eczema, ulcers, scars, anal tightening or relaxation, external hemorrhoids, prolapsed internal hemorrhoids or rectal mucosa, pinworms, anus Sentinel hemorrhoids, sentinel hemorrhoids, force the patient to the anus to observe for internal hemorrhoids, polyps or anorectal prolapse;

    3. Digital rectal examination: simple but extremely important;

    4. Anoscopy: enter the anus first, then exit slowly, observe, record according to the clock, and do not miss a comprehensive observation;

    Check the contraindications: anal stenosis, women's menstrual period, anal fissure or local inflammation and pain;

    5. Sigmoidoscopy: It is an important examination method for the diagnosis of upper rectal and lower sigmoid colon lesions. For: Unexplained blood in the stool, mucus stool, chronic diarrhea, tenesmus, thin stools, etc., should be considered for sigmoidoscopy;

    Methods: The day before the examination, give a no-dregs diet and laxatives, and an enema before the operation. The first digital anus examination, the lens is about 15 cm, the intestinal cavity becomes smaller and there are spiral mucosal folds, which is the sigmoid colon. Biopsy can be taken at the same time, but do not take the center of the ulcer or the ulcerated part of the tumor to avoid perforation.

    Complications: bleeding, perforation;

    6. X-ray barium enema examination: filling defect or mucosal destruction;

    7. Defecation examination: suitable for long-term constipation, a method to determine the morphological function and dynamics of the anal sphincter and anorectal;

    8. CT examination: understand the location and size of the tumor, provide the relationship between the tumor and the surrounding pelvic organs and the scope of tumor invasion, and perform the staging of rectal cancer;

    9. MRI: Perform rectal examination before or after surgery;

    10. Intrarectal ultrasound scan: preoperative staging and postoperative review of rectal cancer;

    Three: hemorrhoids

    Definition: Soft venous masses formed by varicose plexus at the lower rectum and anal margin, which are more common in 20-40 years old;

    (1) Cause:

    1. Anatomical factors: the rectal anal canal is located in the lower part of the trunk, the portal vein system has no venous valve, and the pressure of the venous plexus in the hemorrhoid increases;

    2. Increased intra-abdominal pressure: pregnancy, dysuria, constipation, etc.;

    3. Chronic infection of lower rectum and anal canal:

    4. Birth defects or trauma:

    (2) Clinical manifestations:

    Internal hemorrhoids, external hemorrhoids, mixed hemorrhoids;

    1. Bleeding: not mixed with stool, or dripping blood during defecation;

    2. Prolapse: mostly in a circle;

    3. Pain: Pain is obvious during infection, erosion, thrombosis or incarceration;

    4. Itching: combined with eczema;

    Internal hemorrhoids: varicose plexus of the superior rectum;

    Stage I: Bleeding during defecation, no pain, no prolapse, it usually occurs on the left, right front and right back of the anal canal;

    Stage II: Prolapse during defecation force, can repay by itself, blood in the stool is obvious;

    Stage III: Defecation, coughing, straining, walking, squatting can be released, can not repay by oneself, must be backed with hands, easy to incarcerate and necrosis;

    Stage IV: Internal hemorrhoids continue to prolapse and cannot be repaid. The hemorrhoids are covered with skin, which usually occurs in the elderly;

    External hemorrhoids: located below the dental line, formed by the varicose vein plexus under the hemorrhoids, covered with skin on the surface and cannot be pushed into the rectum; thrombotic external hemorrhoids are prone to form, with external hemorrhoid skin tags;

    Mixed hemorrhoids:

    Diagnosis and differential diagnosis: diagnosis is not difficult;

    Differential diagnosis:

    Rectal cancer:

    Rectal adenoma: painless blood in the stool, pedicle, smooth surface;

    Prolapse of the rectal anal canal: can reach the annular wrinkle wall of the rectal mucosa;

    Anal fissure: often bleeding during defecation, severe pain during and after defecation;

    Anal papillary hypertrophy: Accompanied by chronic anal sinusitis, pain during defecation, and hardened hypertrophic nipples can be touched on digital examination;

    Treatment: Hemorrhoids in stage I: moisturize the intestines to lax, avoid sitting for a long time, defecate regularly, sit in hot water;

    Stage II hemorrhoids: local injection of sclerosing agent, causing periphlebitis: 5-10% phenol, vegetable oil, 5% sodium morrhuate;

    Stage III: Resection, lateral incision of the internal sphincter;

    Anal fissure: It is actually an anal canal ulcer. It is divided into acute and chronic. The stent muscles at the midline of the anal canal are weaker than the two sides. After the anal fissure is formed, it will cause secondary infection due to fecal friction The stent muscles contract spasm and contract, causing ischemia and forming chronic ulcers. The skin at the lower end of the ulcers forms skin tags due to long-term inflammatory stimulation, edema and proliferation, called sentinel hemorrhoids (sentinel hemorrhoids).

    One: Clinical manifestations: Pain: severe pain during defecation, unbearable, pain after defecation lasts for several hours, a vicious circle;

    Bleeding: small amount;

    constipation:

    Inspection: Prohibit digital rectal examination, or anoscopy, and lightly expose the anal canal;

    Two: Treatment: Conservative treatment: suitable for acute anal fissures, focusing on preventing and treating constipation, softening feces to relieve pain, hot bath;

    Anal expansion: Acute and chronic anal fissures, especially acute anal fissures are effective;

    Method: After anesthesia, expand the anus with the fingers to paralyze the internal and external sphincter for several days to one week to relieve pain and improve local blood circulation. The anal expansion should be relaxed. Start with 2 fingers, expand to 4-6 fingers, stretch 5-10 minute;

    Surgical resection: internal sphincterotomy, surgical complication is fecal incontinence

    Anal fistula:

    One: Definition: A chronic infectious fistula between the anal canal or rectum and the skin.

    Two: Classification: ①High anal fistula: The location of the fistula is above the deep part of the external sphincter;

    ②Low anal fistula: ------------ down;

    ③Simple anal fistula: an external mouth;

    ④Complex anal fistula: multiple external openings;

    Three: Clinical manifestations: There is a history of incision and drainage of perianal abscess, secretion flows out, and a hard cord between the external mouth and the anus can be felt on the digital rectal examination;

    Four: treatment

    Rarely heals on its own

    Anal fistula incision and resection: Correctly handle the internal opening. Only when the internal opening is cut or resected can the anal fistula be cured. All branch tubes should be opened one by one without missing. Surgery generally only cuts all the internal sphincter muscles and most of the external sphincter muscles, and generally does not cause fecal incontinence;

    Thread-hanging therapy: suitable for high anal fistula, which can avoid anal incontinence;

    Colorectal cancer:

    1. The incidence rate ranks fourth and fifth in the incidence of malignant tumors in China, accounting for 8.25%. In the past ten years, the incidence rate has increased; the age of onset is mostly 30-70 years old, accounting for 80%, and patients under 30 years old account for 10 -15%, male: female = 1.5 to 2.0:1; in all colorectal cancers, rectal and rectal-b junction cancers account for 60 to 70%, followed by sigmoid colon, cecum, ascending colon, descending colon, and transverse colon. Rectal cancer is more common in the middle and lower rectum, accounting for about 70-80%. Multiple cancers are more common, accounting for about 5-8%, and can appear in different parts at the same time or successively; 2: Causes

    1. Dietary factors: high-fat, low-fiber diet, increase the intestinal bile acid and cholesterol metabolites, increase anaerobic bacteria in stool, increase carcinogenic factors; lack of fiber in food, reduce stool volume, and intestinal movement Slowing down, so that the concentration of carcinogens in the intestine increases, the contact time of carcinogens with the colorectal mucosa is prolonged, and the chance of colorectal cancer is increased;

    2. Strong genetic tendency:

    A: Familial multiple adenomatosis is an autosomal dominant genetic disease, involving all the large intestine and even the entire digestive tract. If it is not treated, 100% of it will become malignant;

    In patients with colorectal cancer, 50% have two or more cancer foci.

    Gardner's syndrome: familial multiple adenomatosis with multiple skin epidermoid cysts and soft tissue tumors, skull and mandibular multiple osteomas, is called "Gardner's syndrome";

    Turcot's syndrome: patients with central nervous system malignant tumors;

    B: Cancer family syndrome (cancer family syndrome): It is an autosomal dominant inherited disease, with a penetrance rate of 90% (that is, 90% of children can be affected); cancers have an earlier age of onset, often multiple colorectal cancers; Such patients are also more likely to suffer from endometrial cancer, ovarian cancer and other organ cancers;

    C: Family members of colorectal cancer patients die from colorectal cancer 4 times higher than the average person;

    D: Inflammatory colorectal disease: The chance of colorectal cancer in patients with ulcerative colitis is 5-10 times higher than that of normal people. The longer the disease period, the larger the lesion area, the higher the risk of canceration, and the incidence of Crohn's disease and schistosomiasis enteritis. The chance of colorectal cancer is also greater than that of normal people;

    E: Colorectal adenoma: The risk of cancer in such patients increases. The larger the polyps, the greater the number, the worse the epithelial differentiation, and the higher the chance of cancer.

    In terms of pathological classification, the malignant transformation rate of villous adenoma is as high as 40%, and the chances of mixed and tubular adenomas are 20% and 5% respectively;

    F: Other related factors: people who have had colorectal cancer in the past, have received radiotherapy in the pelvis, have been exposed to synthetic fibers, dyes, and rubber for a long time, and lack of certain trace elements (such as molybdenum, selenium, etc.);

    Three: diagnosis

    Take a comprehensive medical history; different tumor sites have different symptoms:

    A: Right colon: usually umbrella or ulcer type, protruding intestinal cavity, often accompanied by abdominal masses, anemia, intermittent melanosis, weakness, weight loss, etc.;

    B: Left colon: Cancer often grows infiltratingly, which is easy to cause ring-shaped stenosis, often causing abdominal pain, difficulty in stool, pus and blood in the stool, and intestinal obstruction;

    C: Rectal cancer: often manifested as changes in bowel habits, pus and blood in the stool, tenesmus, anal pain, such as tumor invasion of the sacral plexus nerve, often severe pain in the sacral coccyx. In the late stage, the bladder may be involved, penetrate the vaginal wall, and form a rectal-vaginal fistula; in the late stage, inguinal lymph nodes may metastasize;

    Common diagnostic methods:

    A: Rectal examination: 70% of rectal cancer can be found through digital rectal examination;

    B: Fecal occult blood test: About 50% of stool occult blood positive is caused by colorectal cancer, occult blood test should be repeated 3 times;

    C: Barium enema and sigmoidoscopy: suspicious patients over 40 years of age should be routinely examined, and fiber colonoscopy should be performed if necessary. If rectal cancer has been diagnosed by digital rectal examination and rectal endoscopy, full colonoscopy is still required. To exclude whether there are cancer foci at the same time in the proximal colon;

    D: To determine the extent of disease and metastasis, a comprehensive examination of colorectal cancer patients should include: chest X-ray, liver function, liver ultrasound, abdominal CT, CEA measurement, intrarectal ultrasound scan, IVP (for patients with low cancer or urinary system symptoms) );

    Four: Pathology and transfer methods

    The general classification of colorectal cancer: protruding type, ulcer type, infiltrating type, proofing type.

    Histological classification: papillary adenocarcinoma, tubular adenocarcinoma, mucinous adenocarcinoma.

    Degree of differentiation: low-grade malignancy (highly differentiated), moderately malignant (moderately differentiated), and high-grade malignant (poorly differentiated);

    Duke's staging: established in 1935, according to the depth of tumor invasion and the presence or absence of lymph node metastasis,

    Stage A: Cancer is confined to the intestinal wall;

    Stage B: Cancer penetrates the intestinal wall;

    Stage C: The lymph nodes have metastasized;

    Stage C1: The cancer has metastasized to adjacent lymph nodes;

    Stage C2: Metastasis of mesenteric lymph nodes or root lymph nodes of mesenteric vessels;

    Stage D: distant transfer;

    China proposed the clinicopathological staging of colorectal cancer in 1978:

    Stage I: (equivalent to Dukes stage A), the cancer is confined to the intestinal wall, and is divided into three sub-stages

    Stage Ⅰ0: The lesion is limited to the mucosal layer;

    Stage Ⅰ: The lesion invades the submucosa;

    Stage I2: The disease involves the muscular layer of the intestinal wall but does not penetrate the intestinal wall;

    Stage II: The lesion has penetrated the intestinal wall without lymph node metastasis;

    Stage III: The cancer has penetrated the intestinal wall and has lymph node metastasis;

    Stage III1: Lymph node metastasis is limited to the vicinity of the cancer;

    Stage Ⅲ2: Mesangial lymph nodes, lymph node metastasis at the root of mesangial vessels;

    Stage IV: Patients who cannot be resected or cannot be completely resected due to extensive infiltration of the lesion, distant metastasis or planting and dissemination; Five: Prognosis of colorectal cancer, the 5-year survival rate is 30-40%, the best prognosis among common malignant tumors, colon cancer Better than rectal cancer; radical resection, the 5-year survival rate can reach 55-70%, some stage IV cases can still be treated with palliative resection, the survival time can be prolonged, and the quality of life can be improved; the primary tumor is still early, there is For single or several liver or lung metastases, radical resection of the primary tumor can be performed, followed by local or extensive resection of the metastasis; factors affecting the prognosis of colorectal cancer: disease course, tumor location, disease stage, treatment level, immune status;

    Six: Direct infiltration of colorectal cancer metastasis: implantation and dissemination: lymphatic metastasis: hematogenous metastasis: It is an important dissemination route of colorectal cancer, often invading veins, with a chance of up to 20-30%, especially for rectal cancer;

    Seven: Treatment Surgical treatment is the main method: according to different parts of the tumor, different surgical methods are selected; preoperative bowel preparation: oral antibiotics that are not absorbed by the intestine, clean enema;

    Surgical options: Ⅰ: Cecum and ascending colon cancer: Resection of the right colon, including 10-15 cm of the terminal ileum;

    Ⅱ: Liver flexure, splenic flexure and transverse colon: Resection of transverse colon, part of ascending colon, part of descending colon;

    Ⅲ: Cancer of descending colon and sigmoid colon: Resection from splenic flexure to sigmoid colon, proximal rectum and its mesangium and lymph nodes;

    Ⅳ: rectum: less than 7 cm, Miles

    7-10 cm, Dixon

    Higher than 10 cm, front excision;

    Ⅴ: Colon cancer with intestinal obstruction: The right colon is currently resected and anastomosed in one stage;

    Left colon-there is controversy;

    Upper middle part of rectum-Hartman operation;

    Adjuvant treatment:

    Ⅰ: Chemotherapy: Patients with advanced tumors, recurrence and metastasis after surgery should all be treated with chemotherapy, usually 5-fu, FT207, UFT, mitomycin, etc. Combination chemotherapy is better. There is no definite conclusion about postoperative chemotherapy for colorectal cancer, but for patients with lymph node metastasis, postoperative chemotherapy may be beneficial;

    Ⅱ: Radiotherapy: Preoperative radiotherapy can shrink rectal cancer and reduce the rate of local recurrence; postoperative radiotherapy can reduce or delay local recurrence. Radiotherapy can also relieve presacral pain, but it has no obvious pain relief effect on colon cancer;

    Eight: Postoperative recurrence and metastasis 40-70% of patients after radical resection have local recurrence and distant metastasis. The biological behavior of colorectal cancer is relatively good. With the progress of surgery, radiation, and drugs, some recurrence and metastasis Long-term survival can still be achieved for most patients, and the survival time of most patients is prolonged; 70% of colorectal cancer recurrence cases occurred within 2 years after surgery, and 6% recurrences over 5 years. 80-90% of patients with local recurrence died within 3 years; local recurrence is the recurrence in the original surgical field, including: recurrence of anastomotic, pelvic, perineal and abdominal wall incisions. The most visceral metastasis is liver, followed by lung and bone. , Ovary, brain; the role of CEA: treatment of patients with recurrence and metastasis: Studies have shown that 20% of patients who recurred after rectal cancer death until death are limited to local recurrence. If early diagnosis and active treatment can be achieved, better The effect of treatment; 40% of patients can survive for 5 years after resection of isolated liver metastases;

    Nine: The progress of rectal cancer is total mesangial resection; the 5 cm rule is abolished and the 3 cm rule is abolished; 3000 cases of rectal cancer resection specimens study: only 2.3% of patients with lymphatic metastasis at 1 to 2 cm distal to the lesion. The rectum can be elongated by 3 to 5 cm after bilateral lateral ligament cut; application of stapler; new surgical method: Parks: transabdominal resection of rectum, colon-anal anastomosis via anal canal; Oskar: free transabdominal cut, distal Resection through the anus, and the proximal end is pulled out for anastomosis; Shafik: free through the abdomen, circular incision at the edge of the anal crease, dissecting the lower edge of the internal and external sphincter muscles, separating upwards between the internal and external sphincter until the abdominal and pelvic separation junction Resection of the end colon and suture with the perianal skin; middle and low rectal cancer anus preservation surgery: 26% in the 1950s, 93% in the 1980s, common complications of anus preservation surgery: intestinal necrosis, leakage, stenosis, obstruction, bowel retraction , Infection; 150 domestic stapling anus preservation operations: the 1-4 year survival rates are 94%, 84%, 76%, and 63%, which are similar to the Miles operation of the same disease stage;

    Ten: Auxiliary examination for recurrence: 65% of recurrence is within 2 years, follow-up for at least two years; regular CEA; pelvic X plain film, sometimes visible soft tissue shadows; pelvic B-ultrasound; CT examination: can show 1 cm in diameter;

没有评论:

发表评论

hemorrhoids essential oils,The procedure of hemorrhoid fistula surgery and precautions before and after surgery

    Hemorrhoid fistula surgery procedure and precautions before and after surgery     1. Come to the outpatient clinic every Monday or Wedn...