2020年11月19日星期四

hemorrhoids or anal cancer,Common clinical diseases and treatments in the community (anorectal section)-anal carbuncle

    Section 3 Anal carbuncle

    Overview

    Anal carbuncle is an abscess formed by acute and chronic infection in the space around the anorectum. The disease is characterized by sudden onset, severe pain, high fever, and anal fistula after rupture. The majority of young adults, especially men. It belongs to the categories of "dirty poison", "hanging carbuncle", "riding horse carbuncle" and "cross-horse carbuncle" in traditional Chinese medicine.

    Pathogenesis

    It is often caused by overeating fat, sweet, spicy, alcoholic wine, etc., which damages the spleen and stomach, damp and heat endogenous, betting on the large intestine, accumulating and blocking the anus; or the anus is damaged and poisoned, causing the meridians and collaterals to block, and the blood stagnation. There are also concealed lung and spleen deficiency, caused by betting on damp heat.

    Clinical manifestations

    1. Symptoms The clinical features of this disease are the local symptoms such as pain in the anus and rectum, feeling of sinking and sinking, local redness, swelling, heat and pain, or ulceration of pus, or pus flowing out of the anus; first, the local symptoms of the whole body and the anus are corresponding Systemic symptoms, such as general malaise, aversion to cold, low-grade fever, combination of cold and heat, poor appetite, constipation, short urine, etc., but not generally simple, low abscesses have severe local symptoms. Abscesses under the tooth line can be seen with severe pain in the perianal area and discomfort when falling. The abscesses on the tooth line have no obvious local pain, mostly in the rectum, perineum, and sacrococcyx. The symptoms of systemic poisoning such as chills and high fever are more severe.

    The disease has a rapid onset, severe pain, evidence of local redness, heat, swelling, and pain, and rapid development of the disease; the pus after ulceration is thick and yellow with fecal smell, accompanied by general malaise, cold and heat, constipation, short urine , Yellow and greasy tongue coating, slippery pulse strings, local redness, heat, swelling, and pain in the deficiency syndrome are not obvious, pus formation is slow, pus after ulceration is white and thin, not smelly or slightly smelly of feces, mouth mouth is sunken; general weakness , Generally, there is no fever or lack of heat, the tongue coating is thin and greasy, and the pulse string is thin or slow. In the case of lung deficiency, cough and hemoptysis, bone steaming and night sweats can be seen;

    2. Inflammation lesions with localized redness, swelling, heat and pain around the anal margin may be confirmed as perianal abscesses, but the skin surface inflammation of the intermuscular abscesses at a higher position is not obvious, and anal finger examination is often required. In a few cases, it is necessary Puncture to aspirate pus. Subdental abscess is red and swollen around the anus, palpable inflammatory mass with obvious tenderness, or fluctuating; the perianal signs of abscess on the tooth line are not obvious, and digital rectal examination can reveal a tender mass on the rectal wall. Double diagnosis outside the anus makes it easy to find the lesion. Subdental abscess puncture is very shallow and pus can be extracted; for dental abscess, the index finger should be put into the rectum as a guide. Paraanal 2~125px puncture is safer, and the diagnosis can be confirmed after the pus is extracted. In rectal submucosal abscess, the wall of the abscess cavity is often ruptured during digital examination and pus flows out.

    Auxiliary examination

    1. Routine blood examination can clearly show the degree of infection.

    2. Ultrasonic examination helps to understand the size and location of anal carbuncle and its relationship with the anal sphincter and levator.

    Differential diagnosis

    1. Skin infections around the anus. Skin infections such as folliculitis and boils around the anus are limited, with pus plugs on the top, easy to identify. Although the local pain of the larger subcutaneous abscess is obvious, it has nothing to do with the anorectum, and anal fistula does not form after the ulceration.

    2. Paraanal Sebaceous Gland Cyst Infection. Paraanal redness, swelling, heat and pain can also be seen. However, when the medical history is followed up, there is usually a local mass before infection, which is round and smooth with a small black spot formed by a blocked large pore in the center of the mass. There is no primary internal ostium in the anus, so there is no tender point in the anus, and anal fistula does not form after ulceration.

    3. Presacral cyst and cystic teratoma infection. A detailed medical history can usually reveal some signs of presacral cyst. After digital examination of the rectum, there is a mass, smooth, lobed, no obvious tenderness, and cystic sexiness. X-ray examination, pushing the rectum to the front or one side, visible tissue thickening and tumors between the sacrum and rectum, there are irregular scattered uneven calcification shadows and coccyx displacement.

    4. Suppurative sweat gland abscesses are mostly located under the skin of the anus and buttocks. The abscesses are shallow and have a wide range of lesions. The skin of the lesion area becomes hard, acute inflammation and chronic fistula coexist, and the pus is thick, powdery and porridge-like, with a foul smell. Symptoms of chronic wasting throughout the body.

    5. Acute necrotizing fasciitis of the anus and perineum due to bacterial infection in the anus and perineum and scrotum, a large area of ​​tissue around the anus is necrotic, and some form fistulas, with a wide range of lesions, acute onset, and often spread to subcutaneous tissues and fascia , Invades the scrotum forward, but there is no internal opening in the anal canal.

    6. Crohn's disease Perianal abscess in Crohn's disease accounts for about 20%, and there are often atypical anal fissures and fistulas in the anus. Local redness and swelling, self-ulceration, but no obvious pain and systemic symptoms.

    7. Tuberculous abscesses can be seen with bone steaming, night sweats, fatigue, fatigue, coughing, hemoptysis, appetite, dry stool; or no systemic symptoms, only a wide ulcer, with a sneaking, thin pus, or tuberculosis of the lungs can be found when X-rays are taken Stoves are identified by funding. Clinically, tuberculous abscesses take a long time to form pus.

    8. Anorectal cancer. In the early stage, there may be changes in bowel habits, pus, blood and mucus in the stool, and the note becomes thin and flat. Proctoscopy revealed that the mass was dark red and uneven. Finger examination, the texture is hard, nodules, the base is flat and scattered, or the top is sunken, pathological sections can be diagnosed.

    9. Thrombotic external hemorrhoids Thrombotic external hemorrhoids also have a mass beside the anus, and the pain is heavier, but the color is dark purple, the area is small, the touch is hard, no purulent, no fluctuating feeling, and no systemic symptoms.

    10. Endometriosis This disease occurs in women who have given birth. It can palpate unclear bumps in the perineum, outside anus or in the rectum. The texture is hard and the menstrual period increases, but there are no systemic symptoms. The diagnosis can be confirmed by pathological examination.

    treatment

    1. Internal governance

    (1) Heat accumulation type

    Syndrome: Sudden perianal swelling and pain, continuous aggravation, accompanied by aversion to cold, fever, constipation, red urine, perianal swelling, obvious tenderness, hard texture, and hot surface. Red tongue, thin yellow coating, pulse count.

    Treatment method: clearing away heat and detoxification

    Recipe: Xianfang Huoming Yin or Huanglian Jiedu Decoction plus or minus

    Pangolin 9 g licorice 6 parsnip 9 g myrrh 6 g red peony 9 g angelica 6 g angelica 9 g frankincense 6 g fritillaria 9 g trichosanthin 9 g saponins 9 g honeysuckle 15 g tangerine peel 6 g berberine 9 g scutellaria 6 g phellodendron 6 g Gardenia 9 g

    Commonly used Chinese patent medicine: Niuhuang Xingxiao Pills

    (2) Excessive fever certificate

    Syndrome: severe anus swelling and pain, lasting for several days, pain like a chicken pecking, difficult to sleep soundly; accompanied by chills and fever, dry mouth, constipation, difficulty urinating, redness and swelling around the anus, fluctuating sensation or pus from puncture. Red tongue, yellow coating, slippery pulse.

    Treatment method: clearing away heat and toxic substances

    Astragalus 9 g Saponaria thorns 9 g Angelica root 6 g Chuanxiong 9 g Burdock Seed 9 g Pangolin 9 g Honeysuckle 15 g Angelica 9 g

    Recipe: Touyusan addition and subtraction

    Commonly used Chinese patent medicine: Xihuang Wan

    (3) Yin deficiency and poison love syndrome

    Symptoms: Anal swelling and pain, dark red skin color, long time for pus formation, thin pus after ulceration, difficult to agglomerate sores; accompanied by afternoon hot flashes, upset dry mouth, night sweats. Red tongue, little moss, fine pulse.

    Treatment method: nourish yin, clear away heat and detoxify

    Recipe: Qinghao Biejia Decoction and Sanmiao Pills

    Artemisia annua 9 g turtle shell 9 g Xishengdi 15 g Anemarrhena 9 g Danpi 9 g Cork 9 g Cangzhu 9 g Chuan Niu Lacquer 9 g

    Commonly used Chinese patent medicine: Zuogui pill

    (4) Syndrome of Righteousness and Evil

    Syndrome: weak body or deficiency of qi and blood, sore shape flat and collapsed, skin color is not fresh, not hot, tenderness is light, pus formation is slow; after ulceration does not close the mouth, the pus is thin, and the food is absorbed Not fragrant, bloating and loose stools. The tongue is pale, the fur is thin or thick, and the pulse is heavy and thin.

    Treatment method: replenishing qi and blood, containing poison and restraining sores

    Recipe: Tuoli Duli San

    Codonopsis 15 g raw astragalus 15 g angelica 9 g chuanxiong 9 g red peony 9 g tuckahoe 9 g dried tangerine peel 6 g silver flower 15 g raw licorice 6 g

    Commonly used Chinese patent medicine: Shiquan Dabu Pills

    (5) Damp phlegm coagulation syndrome

    Syndrome: loose agglomerates, soft headless, neither red nor hot, sore and uncomfortable anus; dark red and slightly hot into pus over time, after ulceration, the pus becomes thin like flocculent, dripping endlessly, sore face is gray and white and not constricted; accompanied by Hot flashes and night sweats, weight loss, blood in sputum. Red tongue with little or thick white coating, thin pulse or slippery.

    Treatment method: tonic the spleen and stomach, dry dampness and resolve phlegm

    Recipe: Erchen Decoction and Baihe Gujin Decoction

    Pinellia 6 g Poria 9 g Tangerine peel 6 g Lily 9 g Scrophulariaceae 15 g Pseudosperma chinensis 15 g Digu peel 9 g Cork 9 g Atractylodes 9 g Fritillaria 9 g Roasted licorice 6g

    Commonly used Chinese patent medicine: Baihe Gujin Wan

    2. External governance

    (1) External application method

    In the early stage: For positive patients, use Jinhuang ointment and Huanglian ointment for external application, for those with deep hidden position, use Jinhuangsan to adjust paste enema; for deficiency syndrome, use Chonghe ointment or Yanghe Jiening ointment.

    Pus stage: You can apply externally plastering or qianchui ointment to make it ulcerate early, or use biting ointment to erode the pus head. At the same time, external application of hoop medicine is continued to prevent the spread of sepsis. In the late stage of ulceration, pus-lifting and decay-removing medicines are mainly used for drainage, and drainage can be done with Tiaoyusan or Jiuyidan oil gauze, or red pink gauze.

    Later period: When the pus is exhausted, the main purpose is to grow the muscle and close the mouth, and apply the Shengji powder or pearl loose yarn.

    If the tuberculosis abscess is not ruptured, use Yanghe ointment for external application, use Jiuyi Dan gauze strip after the ulceration, and use Shengjiyuhong ointment when tightening the mouth. Indulge in the perianal skin with nourishing water, and apply Indigo Naturalis powder externally to those with damp and erosions, and externally apply Indigo Naturalis ointment to the itchy skin.

    (2) Fumigation and washing method: After the abscess is ulcerated, it can be treated by traditional Chinese medicine fumigation and washing, which can clear away heat and detoxify, relieve swelling and pain, astringent and stop bleeding, dispel dampness and relieve itching, and dispel rot and promote muscle. Commonly used Kushen Decoction, Wubeizi Decoction, hemorrhoid lotion, etc., and ointment is applied externally after taking a bath.

    3. Surgery The pus should be incised and drained early, and the surgical method should be selected according to the depth of the abscess and the severity of the disease. A one-time incision can be used for superficial abscesses; a one-time incision and thread-drawing method is required for high abscesses; and most deep abscesses use fractional surgery.

    During incision and drainage, attention should be paid to accurate positioning and thorough drainage; radial incisions are possible for superficial abscesses, and curved incisions for deep abscesses to avoid damage to the sphincter; primary anal cryptitis should be incised during the operation to prevent anal fistula formation; After draining with Jiuyi Dan gauze strips, the pus is exhausted and replaced with muscle-producing loose gauze strips; if leakage occurs over time, treat it as anal fistula.

    4. Postoperative treatment, as appropriate, use Chinese medicine or antibiotics and laxatives for heat-clearing and detoxification, tori pus drainage. Use Kushen Decoction or 1:5000 potassium permanganate solution to sit in the bath and change the dressing every time after the operation. Those who hang the thread usually fall off on their own in about 10 days, and the thread can be tightened or cut off as appropriate. At this time, the wound has been repaired and flat, and can be quickly healed after dressing change, without sequelae of anal incontinence. After various methods of surgery, pay attention to whether there is high fever, chills, etc., and deal with it in time.

    Principles of Referral

    1. The diagnosis is unclear and requires further examination at a higher level hospital.

    2. High-level deep abscess, severe systemic infection symptoms, and unable to completely drain due to conditions, should be referred for incision and drainage in time.

    Health and rehabilitation

    1. Regular daily life, insist on physical exercise, and enhance disease resistance.

    2. Prevent eating spicy foods, oil-boiled fried, fatty, alcoholic and other irritating foods and hairs, and prevent constipation and diarrhea.

    3. Keep the clothes and pants breathable, pay attention to clean the anus, and avoid local moisture.

    health education

    1. Actively prevent and treat anal lesions, such as anal cryptitis, anal gland inflammation, anal papillitis, proctitis, internal and external hemorrhoids, etc., to prevent infection from forming abscesses.

    2. If you have symptoms such as anal swelling, pain, discomfort, discharge, etc., you may be sick and should be checked in time and treated early. Anal and perineal injuries should be treated promptly.

    3. Once perianal abscess is formed, anti-infective treatment should be performed immediately. Once perianal abscess occurs, it should be incised early and drained thoroughly to prevent the expansion of inflammation.

    4. Actively treat primary diseases, such as inflammatory bowel disease and tuberculosis.

    Commonly used western medicine reference

    Non-surgical conservative treatment can be used in the non-purulent stage. The pathogenic bacteria of perianal abscess are characterized by multibacteria (mixed infection) and high infection rate of anaerobic bacteria. Antibiotic treatment can be combined with 2-3 antibiotics that are effective against gram-negative bacilli.

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