2020年12月15日星期二

hemorrhoids and anal fissures,Anal Fistula In-Depth Dialogue: Understanding Anal Fistula

    Wang Yanmei: "This is a conversation between me and a patient. The content is about anal fistula. The tortuous path to medical treatment aroused the patient's strong desire to "create". A lot of the content was interviewed by him on the bed. His idea is to make his experience of this illness worthwhile. I admire his approach very much, and I was moved by his spirit, so I answered every question he raised seriously."

    Reason for dialogue

    Let me introduce myself first, my surname is Ma, male, 26 years old this year, my classmates and teachers call me Chinese Ma, maybe you guessed it, yes, I have been studying in the United States for eight years, and I am currently studying at a university in California Doctor of Journalism.  I also had some illnesses before and after coming to the United States, mainly some minor illnesses such as colds, fevers, abdominal pain and diarrhea. I had to bear it or be troubled at the school hospital, but the illness in 2014 made me stump.

    I was ill in June. One day I went to the library to study at night as usual. When I sat down, I felt pain in my buttocks. Going back to the dorm and touching it, the right side of the anus becomes hard. I went to the school infirmary the next day. They looked around, shook their heads and sent me to the hospital.

    The content is divided into six parts: understanding of anal fistula, treatment of anal fistula, difficulty in operation, recurrence of operation, prevention of anal fistula, and selection of doctor for anal fistula. If you don't want to make detours like me, and don't want to miss any more, you must read the whole article carefully.

    Dialogue 1: Understanding anal fistula

    Dr. Ma asked

    Maybe it was because I was ignorant. Before this illness, I only knew that I had hemorrhoids. I really didn't know that there was anal fistula. When I was hospitalized after returning home, I saw that there were so many patients like me in the ward. Professor Wang, is anal fistula common? Who is prone to get this disease?

    Professor Wang

    Reply

    There is a misunderstanding here. The reason why people don't understand that there are other diseases in the anus and rectum is because they are endorsed by hemorrhoids. As long as the anus is uncomfortable, our first reaction is, ah, we have hemorrhoids.

    In fact, there are three major diseases in the anorectal area, hemorrhoids, anal fistula, and fissure. The eldest has the highest incidence, the second is the most harmful, and the third is the most painful.

    When we go to the hospital to see a doctor, we must first choose a department. The current department names are basically called by human organs or systems. For example, we need to go to the anorectal department to see hemorrhoids, but this was not the case in the past, especially in the Chinese Medicine Hospital. , Named after disease. "Hemorrhoid fistula" represented anorectal disease in the past. You can see the status of anal fistula.

    In anorectal diseases, the incidence of anal fistula is about 8% abroad and 3.60% domestically. Although this data is not as good as hemorrhoids, it is not low.

    Contrary to hemorrhoids, anal fistulas are not like hemorrhoids. The older the age, the higher the incidence. It favors young men. Children between 1 and 10 years old and young men around 20 years old are absolutely high-risk groups. In addition, patients with other diseases are also very susceptible, such as intestinal inflammatory diseases, especially Crohn's disease, leukemia, diabetes, etc. Therefore, sometimes when anal fistula occurs, it is necessary to check whether these primary diseases exist.

    Dr. Ma asked

    I noticed that there are three names for this disease in China, anal fistula, anal leak, and perianal abscess. Can you explain them one by one? In addition, what is the meaning of this fistula or leakage? Is it really leaking manure?

    Professor Wang

    Reply

    Anal fistula and anal leakage are two names for the same disease, just like you must have an English name in the United States in addition to a Chinese name. Anal fistula is a common name in Western medicine and nowadays, and anal fistula is the name of Chinese medicine. Perianal abscess is the predecessor of anal fistula, which is a two-stage disease. The abscess has a larger focus and is a hole. When it is reduced to a tube, it is called an anal fistula.

    Fistula refers specifically to disease, and the meaning of leakage is broader, but one of the meanings expressed by the two is stubborn, persistent, unhealed, and outflow. Of course, most of this "thing" is pus, and a few patients may also have loose stools Intestinal mucus. So some people compare the anal fistula to a mouse that is good at stealing feces.

    Schematic diagram of the perianal abscess, with the ischiorectal fossa on the left and the pelvic and rectal fossa on the right.

    Perianal abscess (sciatic rectal fossa abscess)

    Anal fistula (bilateral, belonging to complex anal fistula)

    Dr. Ma asked

    I don’t understand one thing very much. Isn’t an anal fistula just a tissue infection? Isn’t the nature the same as a boil in the body? Why do injections and medicines or even surgery can’t be cured? What is it special?

    Professor Wang

    Reply

    This is a very good question. Not only you, but many patients go to the hospital and doctors recommend surgery, but they can’t understand it. Even some surgeons think it is very simple. Infection, incision and drainage is enough, and only after several failures do they realize the seriousness of the problem.

    Anal fistula is not a fake infection, it is also a "boil", but it is a special boil, its particularity lies in its unique disease site-around the anus and rectum, the result:

    1. Poor drainage-abundant perianal muscles and high pressure in the anal canal.

    2. The source of infection is in the intestine instead of the skin, which will cause continuous infection.

    3. Continuous pollution of feces.

    4. Anal glands are infected first and then spread.

    5. After one site is infected, the spread will be serious, which will cause multiple sites to develop disease.

    It is the effect of these factors that make this infection not only "deep-rooted" but also "entrenched". It is difficult to remove it easily if you want.

    Dr. Ma asked

    Do you mean that an abscess must form an anal fistula? After I got sick, I studied some American articles about perianal abscess and anal fistula on the Internet, including the introduction on the ASCRS (American Society of Colorectal Surgeons) webpage, which stated that only 50% of abscesses will develop into anal fistula. How would you rate it?

    Professor Wang

    Reply

    I have also seen the information you consulted. The American colleagues are indeed too optimistic and too conservative on this issue.

    Let's talk about conservativeness. They proposed "survival with fistula". This may be because they can't find an ideal method, or they have scruples about the side effects of surgery, and they have taken a helpless move. Imagine getting sick at a young age, and then dealing with pus and blood for a lifetime, I am afraid it is hard to imagine. Because of this, many Chinese patients in the United States eventually choose to return to their home country for treatment. I receive no fewer than 20 such patients every year.

    Furthermore, we are optimistic. According to our decades of observation, the probability of abscess not forming anal fistula is less than 5%. If surgery is not actively taken, more than 95% of patients will develop anal fistula. This is true even in children with anal fistula.

    Dr. Ma asked

    "Survival with fistula"? This is a very interesting formulation. Isn't anal fistula harmless to the human body?

    Professor Wang

    Reply

    Of course not, so I said that our American counterparts are too conservative and too optimistic. Let me introduce three cases first.

    Case 1: This is a patient treated in 2011 when I assisted Xinjiang. A male, 54 years old, had anal fistula for half a year and had difficulty in defecation. He went to the hospital to diagnose complex anal fistula with cicatricial rectal stenosis. So he underwent a diversion operation. The anus is discharged from the belly. The anal fistula and stenosis did not improve for three months, so I found me. what's going on? Anal fistula causes rectal stenosis. Of course, after my treatment, the intestines have been changed back.

    Case 2: This case was about 15 years ago. He had 4 operations in three years, but they all relapsed. Later, in the fifth year of diagnosis, I found that the local tissues were excellent, and pathological tests were performed. It was cancerous.

    Case 3: This was experienced by a student of mine in Inner Mongolia. This patient is still his friend, and the perianal abscess found him. Because he was familiar with a lot of things, he asked him to be rescued. My students didn’t deal with it as a big problem. The syringe pumped pus and the infusion was anti-inflammatory. After 5 days, the local abscess enlarged, the fever did not go away, and it came again. This time my student performed an operation on him, but his condition suddenly worsened 3 days after the operation, and he was rushed to a higher-level hospital for 7 days, and finally died. The cause of death was infection.

    Although these three are extreme examples, anal fistula is by no means a disease that can be peacefully coexisted with. I once wrote an article calling him the number one killer of the anus, which is not an exaggeration. Abscesses and anal fistulas cannot be operated without surgery. Surgery will also cause a certain degree of damage to the anal tissue. The only way to do this is to operate early and perform smart operations to minimize the damage.

    Dr. Ma asked

    It turns out that anal fistula is so terrible. I often see the name "complex anal fistula" when I check information. How do I understand it? Is complexity intractable?

    Professor Wang

    Reply

    This cannot be understood completely in terms of the meaning of the word. The medical definition of "complex anal fistula" refers to two or more fistulas. If there is only one fistula, it is called "simple anal fistula". Of course, under the same conditions, complex anal fistula is definitely better than simple Anal fistula is intractable.

    A complex anal fistula may be caused by the direct formation of an abscess, or it may be caused by a delayed anal fistula. So early treatment is of great significance.

    Dr. Ma asked

    What about high anal fistula? How to define high and low positions?

    Professor Wang

    Reply

    The full name of anal fistula is called anorectal fistula. We can understand it this way. Fistulas located around the anus or anal canal are low fistulas, and fistulas located around the rectum are high fistulas. Of course, the medical division is much more complicated than this.

    In fact, it was first proposed by the British to divide anal fistula into high and low positions. Taking the tooth line as the boundary, upward is the high anal fistula, and downward is the low anal fistula. This method is simple, clear and practical. Because the dental line is the dividing line between the anus and the rectum, we can see it, and the anal sinus located at the dental line is the infected internal ostium of the anal fistula.

    In the domestic high and low position, the deep layer of the external sphincter is selected. This can be done anatomically, but it is clinically difficult because the deep layer of the external sphincter is the most invisible muscle in the perianal area and has poor operability.

    I personally think that the most important dividing line is the pelvic floor. The muscles of the pelvic floor are also called the levator ani, which means that the levator ani is the most scientific. Why do you say that? Speaking of anal fistula, we have to look back at its predecessor, a perianal abscess. High anal fistula comes from high perianal abscess. There are four abscesses in the human body that we call high, the pelvic rectal fossa abscesses under the rectal mucosa, behind the rectum, and on both sides of the rectum. These abscesses are located inside and outside the rectum, and are located in the pelvis. So high anal fistula is actually a fistula around the rectum, of course on the levator ani muscle. The pelvic floor can be palpable with digital examination.

    The reason why anal fistula must be divided into high and low positions is mainly because it is related to an important organization, which is what we often call "anal straight ring". This ring is composed of the internal and external sphincter muscles and the levator ani muscle, which is the most important tissue for maintaining anal function. The high anal fistula passes through this ring. How to deal with this ring during surgery is a world problem. The low anal fistulas are basically under this ring, even if it is in accordance with the most primitive surgical methods, generally there will be no major problems.

    Dr. Ma asked

    I first went to the doctor because there was a broad bean-sized lump on my buttocks. The pain was not obvious, but it hurts when I sit down and press. When I went to see the doctor, the first anorectal specialist who performed the operation on me also thought that I was not a perianal abscess, but just a normal boil. What are the symptoms of perianal abscess in the early stage? How to diagnose as soon as possible if the symptoms are not obvious like me?

    Professor Wang

    Reply

    Let me make two points first:

    First, with the anus as the center point, the infection site is within 8cm from this center point, 80% of which are perianal abscesses, within 5cm, this possibility rises to 95%, and within 3cm, the possibility is almost 100% .

    Second, the manifestations of perianal abscess can be summarized in four words: redness, swelling, heat, and pain. Red means that the appearance looks red. Swelling is a local bulge, or induration or mass on the touch. Heat, local skin temperature is high, or body temperature rises, the temperature is directly proportional to the scope of infection. Pain. Almost all patients have this symptom, which is persistent and progressive. The pain is obvious in the low position, and the high position may be manifested as falling swelling and feeling of bowel movement.

    Nowadays, the diagnosis of abscess can use MRI, CT and B-ultrasound, especially B-ultrasound, which is very common and the effect is very good.

    It is worth noting that perianal abscess is different from infections in other parts of the body. It is sometimes very dangerous. If it is not treated in time, it may cause septic shock and even life-threatening, just like the previous case. Therefore, once you find the above symptoms around the anus, you must go to the hospital for examination and treatment in time.

    This figure reveals the correspondence between the position of the outer mouth from the anal edge and the position of the inner mouth.

    Dr. Ma asked

    I found that when talking about perianal abscess and anal fistula, there is a keyword that appears very frequently, which is "inner mouth". Can you explain to us what the lower inner mouth is?

    Professor Wang

    Reply

    A typical anal fistula is an unobstructed and intact tube, one inside the anus and the other outside the anus. The port in the anus is the inner port.

    95% of the position of the internal mouth is located at the dentate line of the junction between the anus and the rectum, 70% of which are located at the posterior median dentate line. About 5% are located in the rectal wall.

    The positioning of the internal opening is sometimes difficult. Many internal openings are usually closed. Only about 30% of the internal openings of anal fistulas have depressions and indurations that can be felt. There are many methods for positioning the internal mouth, but none of them is universal. Clinically, it depends on the specific condition and reasonable selection, and sometimes multiple methods are needed. This is one of the reasons why anal fistula is difficult to treat and easy to relapse.

    The reason why the internal opening appears frequently is because it is the source of infection and the core of treatment for anal fistulas and abscesses. It is like a tree root. If the internal opening cannot be found or the internal opening is not opened, it is like just cutting off the trunk. , The roots will still grow new branches. The reason why you go back to your country for the third operation is because you did not touch the root of the disease-the inner mouth-in the previous two operations.

    This shows how important the inner mouth is.

    Comparatively speaking, perianal abscess is more difficult to locate than the internal opening of anal fistula, which is why many doctors in many hospitals treat perianal abscess several times.

    Dr. Ma asked

    After your introduction, many questions in my mind have been solved. Finally, there is another question. We are talking about anal fistula. There is another type of fistula called "rectovaginal fistula". Is it the same as anal fistula?

    Professor Wang

    Reply

    Recto-vaginal fistula is similar to anal fistula. Similarity is that neither can be cured by itself or with drugs. Only surgery can be cured. The difference is that the pathogenesis is different. In comparison, the treatment of rectovaginal fistula is more difficult.

    The main cause of rectovaginal fistula is trauma, and some of it is caused by congenital or local infection. Gynecological surgery and anorectal surgery are the main causes of trauma. I once encountered a patient who was caused by hymen repair. This should not be the case.

    To be continued >>>>>

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