I. Diagnosis
(A) Disease diagnosis
1. Diagnostic criteria of traditional Chinese medicine: refer to the industry standard of traditional Chinese medicine of the People’s Republic of China “Diagnostic and efficacy criteria of traditional Chinese medicine” (ZY/T001, 7-94).
(1) Anal leakage is the cavity left behind after the anal canker becomes pus and collapses or is incised
It is also called hemorrhoid leakage. History of anal canker sores. The lesion has an external orifice, a canal, and an internal orifice that can be signified.
(2)Disease classification
Low anal fistula.
Simple low anal fistula: with only one canal and located below the rectal ring of the anal canal.
Complex low anal fistula: two or more ducts, located below the rectal ring of the anal canal, with more than two external or internal ports.
High anal fistula.
Simple high anal fistula: with only one canal that crosses the anorectal ring or is located on it.
Complex high anal fistula: there are two or more canals, located above the anorectal ring, and there are more than two external or internal ports.
2.Western medical diagnostic criteria: refer to the “Diagnostic criteria for anal fistula” developed by the Chinese Society of Traditional Chinese Medicine, Colorectal Surgery Group of the Chinese Society of Surgery, and the Committee of Colorectal Diseases of the Chinese Society of Integrative Medicine in 2006.
(1) Symptoms.
Repeated episodes of perianal swelling and pain, pus flow, and fever in the acute inflammatory stage.
(2) Local examination.
Visual examination reveals the external orifice morphology, location and secretions. Superficial anal fistulae can be palpated around the anus with cords and their rows. Internal orifices, depressions and nodules can be palpated by rectal palpation.
(3) Ancillary examinations
Probe examination: preliminary exploration of the fistula.
Anoscopy: used in conjunction with methylene blue, the location of the internal opening can be initially determined.
Fistulography: contrast agents such as pancystic glucosamine can be used, which is especially useful for the diagnosis of complex anal fistulas.
Endorectal ultrasound: to observe the course of the fistula, the internal orifice, and to determine the relationship between the fistula and the sphincter.
CT or MRI: used for the diagnosis of complex anal fistula, which can better show the relationship between the fistula and the sphincter.
(ii) Diagnosis of symptoms
1. Damp-heat infusion syndrome: perianal ulceration, frequent pus overflow, thick pus, white or yellow color, local redness, swelling, heat, pain, and pressure with cords leading into the anus; may be accompanied by dullness, unpleasant stool, short red urine, heavy body, red tongue, yellow greasy coating, and slippery pulse.
2, deficiency of evil: perianal fistula often flowing pus, thin pus, anal vague pain, the outer mouth of the skin is dark, sometimes ulcerated, sometimes healed, pressed hard, more cords to the anus; can be accompanied by fatigue, no facial color, short of breath, lazy speech, light tongue, thin moss, moist pulse.
3. Yin deficiency: fistula with depression of the external opening, dark skin around, pus is clear and thin, and there are cords leading to the anus when pressed; it may be accompanied by hot flashes and night sweats, sleeplessness, thirst, loss of appetite, red tongue with little or no moss, and thin and feeble pulse.
II. Treatment plan
(A) General treatment
1, pay attention to rest, strengthen nutrition, diet should be light, avoid eating spicy and stimulating food.
2, keep the stool regular and fluent, prevent diarrhea or constipation, in order to reduce the stimulation of feces on the internal orifice of the anal fistula.
3.Keep the anus clean.
(2) Select oral herbal tonics to identify the symptoms
1. Damp-heat infusion syndrome
Treatment: clear heat and dampness.
Recommended formula: Dioscorea Z percolating dampness soup with addition and subtraction, Huang Bai, Cang Zhu, Yin Hua, Dandelion, Zi Hua Di Ding, Dioscorea Z, Poria, fried gardenia, Che Qian Zi, Bai Zhu, Yin Chen.
2.Deficiency of the right and the wrong
Treatment: Support the positive and dispel the evil.
Recommended formula: Tory Disinfectant Drink plus or minus, raw astragalus, angelica, panax notoginseng, soapberry, Chuanxiong, fried white atractylodes, poria, white peony, rehmannia, licorice.
3.Yin deficiency
Treatment: Nourish yin and toxin.
Recommended formula: Artemisia annua and turtle shell soup with addition and subtraction, Artemisia annua, turtle shell, Zhi Mu, Sheng Di, Dan Pi.
(C) External treatment methods
1.Chinese herbal fumigation method: Applicable before and after surgery to relieve symptoms.
Indications: Symptoms include redness, swelling, pain, downward movement, wetness and itching.
Treatment: Clearing heat and detoxifying, relieving swelling and pain, winning dampness and relieving itching.
Recommended prescription: wild chrysanthemum, dandelion, mugwort, bitter ginseng, cypress, pepper, rhubarb, ice chips.
Put the medicine in a gauze bag, put the bag in a basin, brew it with 1500ml of boiling water, smoke it first and then wash it (sit in the bath), use it after the stool or before going to bed.
2.Chinese herbal medicine external application method: for acute local swelling and pain, use plucking ointment, golden ointment and other treatment.
(D) external use of proprietary Chinese medicine
According to the condition, use Chinese medicines with the effect of clearing heat and dispelling dampness, regulating qi and relieving pain, such as Ma Yinglong hemorrhoid suppository, Ma Yinglong musk hemorrhoid cream, Puji hemorrhoid suppository, Jin Xuan fumigant, rehabilitation new liquid, etc.
(E) Surgical treatment
1.Treatment principle.
Remove the primary lesion, drainage smoothly, tighten the line in stages, avoid excessive damage to the sphincter and protect the function of the anus.
2.Surgical methods.
Anal fistula cutting and hanging: reasonable choice of cutting and hanging lines and drainage hanging lines. One-stage cutting and hanging: applicable to high anal fistula involving most of the external anal sphincter above the shallow part. Second-stage cutting and hanging wire: suitable for some high anal fistulas combined with difficult residual cavity, or those requiring secondary surgery and postoperative drainage.
The patient is placed in a lithotomy or lateral position, and under local or saddle anesthesia, a sterilized rubber band or thick silk is tied to the end of the probe, and then the tip of the probe is gently probed inward from the external opening of the fistula, and the fistula is passed through the internal opening. Lift the rubber band, cut the skin layer between the inside and outside of the fistula, tighten it like a skin band, and clamp it with a hemostat close to the subcutaneous tissue; tighten the rubber band with a thick wire under the hemostat and make a double ligature, then loosen the hemostat. Incision dressing with petroleum jelly gauze, after each postoperative bowel movement, fumigation sitz bath, and change the dressing, if the ligature tissue is more, after a week again tied tight hanging line, until the hanging line off.
3.Postoperative treatment
(1)After surgery, control defecation for 48 hours according to the trauma, and fumigate and take a sitz bath after each defecation.
(2)Change medicine on the trauma surface for one or two times a day, and use Jiuhua cream as appropriate.
(3) According to the condition, tighten the thread at the appropriate time.
(4) According to the condition and clinical reality, the comprehensive anal and intestinal treatment instrument and intelligent perianal fumigation instrument can be used.
(6) Care
(1) After surgery, it is advisable to eat more fresh vegetables and fruits, such as cauliflower, celery, cabbage, bok choy, banana, pear, kiwi, etc., to strengthen nutrition. Avoid chili, raw onion, raw garlic, leek, pepper and other spicy and stimulating products and lamb, lychee, cinnamon and other hot products.
2, to develop a good habit of regular defecation, to prevent dry stool, damage to the anal canal, causing infection.
3. Develop the habit of washing the local area after defecation or washing the anus every morning and evening to keep the anus clean.
III. Evaluation of therapeutic effect
(I) Evaluation criteria
Cured: the fistula disappears, the symptoms of swelling, pain and pus disappear, the surgical wound basically heals, and the defecation function is normal.
Improvement: the symptoms of anal fistula with swelling, pain and pus are reduced, the surgical wound is healed and the defecation function is normal.
Ineffective: the symptoms of anal fistula swelling, pain and pus remained the same.
(II) Evaluation method
Before and after treatment, we compared the presence of fistula, improvement of painful and pus symptoms, healing of the surgical incision and anal sphincter function.