High anal fistula refers to the fistula and its branches above the levator ani muscle and the anorectal ring, which is called anal leakage in Chinese medicine. The disease can occur in all ages and different genders, and it is more common in young men. Anal fistula is a common anorectal disease, with an incidence rate of 1.67% to 2.6%. High anal fistula is the most difficult to treat, and it is one of the more difficult diseases in anorectal surgery, with a recurrence rate of about 10%.
Due to the special anatomical and physiological environment of the perianal area, once a high anal fistula occurs, it often leads to repeated perianal infection, swelling and pain, and scarring. When pus penetrates the wall and spreads along the sphincter gap, it can cause multiple complicated anal fistulas, rectovaginal fistulas, rectal urethral fistulas and rectal bladder fistulas and other serious complications, which will eventually affect the normal physiological functions of the surrounding organs, and even cause sepsis due to infection. Seriously threaten the life safety of patients.
1. Abscess ulcerated
Abscesses that exceed the deep layer of the external anal sphincter are caused by spontaneous ulceration or incision and drainage. Common ischiorectal fossa abscess, submucosal abscess, and high anal fistula later.
2. Rectal and Anal Injury
Trauma, swallowing bones, metals, anal thermometers, anoscopy, etc. cause anorectal injury, and bacteria invade the wound can cause high anal fistula.
3. Perineal surgery
Internal hemorrhoid injection into the muscle layer by mistake or infection after surgery, infection after postpartum perineal suture, infection after prostate and urethral surgery, etc., can spread to the anorectum and cause abscesses and fistulas.
Many cases of tuberculosis complicated by tuberculosis anal fistula have been reported in the past. As high as 26.9%, in recent years it has dropped significantly to 4% to 10%. Mainly caused by swallowing tuberculosis, a few can also be caused by blood infection.
5. Ulcerative colitis
6. Crohn's disease
As many as 14% to 76% of Crohn's disease with anal fistula.
7. Rectal and anal canal cancer
Rectal and anal canal cancer spreads to the deep part with anal fistula.
8. Blood infection
Diabetes, leukemia, aplastic anemia and other diseases reduce the body's resistance, and anal fistula is often caused by blood infection.
Lymphogranuloma, actinomycosis, coccosacral osteomyelitis, rectal and sigmoid diverticulitis can also cause anorectal abscess and fistula.
Intermittent or continuous discharge of pus from the anus,
2. Swelling and pain
-Normally no pain, only feel the anal mouth swelling or falling pain, when the pus drains smoothly, the swelling and pain will be relieved immediately. Sometimes pain can be caused by the large internal mouth and the feces flowing into the pipe, especially when the pain is aggravated during defecation.
The continuous outflow of pus or secretions stimulates the perianal skin and causes dampness and itching, sometimes accompanied by perianal eczema.
4. Systemic symptoms
Recurrent high anal fistulas, long-term bleeding, and physical weight loss, listlessness and other symptoms. Tuberculous anal fistula has thin pus and may be accompanied by symptoms such as flushing of cheeks and low fever. If the outer mouth is temporarily closed and pus accumulates, local swelling and pain may occur, and it may be accompanied by systemic symptoms such as fever and chills; after the outer mouth is ruptured, the symptoms can be quickly reduced or disappeared.
Visible rupture of the outer mouth, induration can be palpable if the outer mouth is closed. Sometimes when pressing the fistula, secretions may overflow from the outer mouth.
You can understand the depth of the fistula tube, the direction and the position of the internal opening by touching it. High anal fistulas are generally difficult to touch with rigid cords. Induration or depression can be felt near the tooth line.
The main observation is whether there is hyperemia, depression, and pus in the anal crypt. During the treatment, the probe can be used to determine the position of the internal mouth.
4. Dyeing inspection
Place a piece of dry gauze inside the anus and inject the methylene blue solution from the outer mouth. If the inner mouth is not closed, the gauze will be colored, which can help find the position of the inner mouth.
5. X-ray inspection
Inject 30%-40% lipiodol from the external opening of the anal fistula. The distribution of the fistula can be seen in the photograph, which can show the condition of the high anal fistula.
6. Imaging examination
Intra-anal B-ultrasound and magnetic resonance imaging examinations, the former is of high diagnostic value for clarifying the relationship between the range of high anal fistulas and the sphincter; the latter is helpful for complicated high anal fistulas, shoe-shaped anal fistulas and difficult clinically difficult cases Diagnostic value.
1. Digital anorectal examination: digital examination can often palpate light tenderness at the internal mouth, but high complex anal fistulas are often unable to touch the cords under the perianal skin due to the high position of the fistula.
2. Probe inspection: Probe inspection combined with digital anorectal examination can help find the position of the internal mouth, estimate the direction and length of the fistula, the height of the fistula, and the relationship with the sphincter.
3. Staining inspection method: Staining inspection is to inject methylene blue and gentian purple liquid from the outer mouth into the fistula to help find the inner mouth, but the staining method must be used before the probe inspection to avoid false passages caused by the probe inspection Misdiagnosed due to staining.
High anal fistulas cannot heal spontaneously. Surgical treatment is the most effective way to cure high anal fistulas. However, when symptoms such as pus, redness, and pain occur during the onset, medications can be used to temporarily relieve symptoms.
(1) External treatment Use huoxue swelling and pain relief lotion to sit in the bath, and apply golden ointment.
(2) Use of antibiotics Antibiotics can be used during the acute attack period, but generally do not exceed one week.
(3) Oral use of traditional Chinese medicine. Use 萆薢 Shenshi Decoction plus Huadu Dehumidification Decoction, and use Xianfang Huoxing Decoction with fever.
2. Surgical treatment
Once an anal fistula is formed, surgery is the fundamental way to cure a high anal fistula. However, excessive damage to the anal straight ring during the operation will cause irreversible anal damage and cause a series of psychological and economic burdens on the patient. Therefore, the operation should fully protect the anal straight ring, the core structure of the anus. At present, the commonly used surgical methods are mainly divided into two major directions: sphincter sparing and sphincterotomy.
(1) Sphincter preservation surgery methods include: Coring-out method, hanging thread, anal fistula resection, mucosal valvuloplasty, biological patch internal orifice repair, bioprotein glue sealing and microanal fistula resection.
(2) Sphincterotomy. At present, thread-hanging therapy is still an important method for the treatment of high anal fistulas. It can maintain anal function as much as possible while treating high or complex anal fistulas. Including: low-cut high-hanging method, cut-hanging partial suture, incision-hanging thread exclusion and two-way isobaric drainage.
1. After high anal fistula, there may be urinary retention, bleeding, leakage of air and stool, long healing time, etc., and timely symptomatic treatment is required.
2. Surgical treatment of high anal fistula can be cured. However, for high complex anal fistulas, the internal orifice is not clear during the operation and there are many branches, and there is a possibility of recurrence after operation. In some patients, anal sphincter muscles may be abnormally controlled during surgery.
3. Patients with diabetes, leukemia, Crohn's disease, ulcerative colitis and other diseases need to actively treat the primary disease at the same time.
4. Anal fistula that has not been cured for a long time still has the risk of cancer.
1. Preventing constipation and diarrhea, avoiding imbalance of intestinal flora, is of great significance to preventing the formation of high anal fistula.
2. Treat anal cryptitis and anal papillitis in time to avoid the development of perianal abscess and anal fistula.
3. Develop good living habits, defecate regularly, take a bath after defecation every day, and keep the anus clean, which has a positive effect on preventing infection.
Department of Anorectal, Tongchuan District Hospital of Traditional Chinese Medicine, Dazhou City