Canker sores are abscesses that develop as a result of acute or chronic infection in the perianorectal space. The disease is characterized by rapid onset, severe pain, high fever, and fistula formation after rupture. The disease is prevalent in young adults, especially in men. It belongs to the category of “dirty poison”, “hanging carbuncle”, “sitting horse carbuncle” and “cross horse carbuncle” in Chinese medicine.
Causes and Mechanisms
It is usually caused by excessive consumption of fatty, sweet, spicy and alcoholic beverages that damage the spleen and stomach, resulting in internal dampness and heat, which can be injected into the large intestine and block the anus; or the anus can be damaged and poisoned, resulting in obstruction of the meridians and stagnation of qi and blood. It can also be caused by deficiency of the lung and spleen, and damp-heat taking advantage of the deficiency and injecting downward.
Clinical manifestations
1. Symptoms. The clinical features of this disease are, first, local symptoms such as pain and sinking sensation at the anorectum, local redness, swelling, heat and pain in the anus, or ulceration and flow of pus, or flow of pus from the anus; first, systemic symptoms corresponding to the local symptoms of the anus, such as general malaise, chills, low fever, chills and fever, poor appetite, constipation, short red urine, etc., but not generally simple, low-level abscesses with heavy local symptoms. Abscesses under the dentate line are seen to have severe perianal pain and discomfort; abscesses on the dentate line have less pronounced local pain, mostly a feeling of swelling in the rectum, perineum and sacrococcygeal area, while systemic toxic symptoms such as chills and high fever are more severe.
The disease has a rapid onset and severe pain, the actual evidence of local redness, heat, swelling and pain, the rapid development of the disease; pus after ulceration yellow thick with fecal odor, accompanied by general discomfort, chills and fever, constipation, short urine red, yellow tongue coating, slippery pulse, deficiency evidence of local redness, heat, swelling and pain is not obvious, the formation of pus is slower, pus after ulceration but white and thin, not smelly or slightly with fecal odor, ulceration sunken; general weakness, generally no fever or with The tongue is thin and greasy, and the pulse is thin or moist. In the case of lung deficiency, coughing and coughing with blood, bone vapor and night sweating are seen; in the case of spleen deficiency, body fatigue and dullness, loose stools are also seen.
2. Physical signs. Inflammatory lesions with limited redness, swelling and pain around the anal verge can mostly be confirmed as perianal abscesses, but the inflammation on the skin surface of higher intermuscular abscesses is less obvious and often requires anal finger examination and, in a few cases, puncture and aspiration of pus. In the case of subdentate abscess, the perianal area is red and swollen, and inflammatory masses can be palpated with obvious tenderness or fluctuating sensation; in the case of supra-dentate abscess, the perianal signs are not obvious, and rectal finger examination can reveal a painful mass in the rectal wall, and at this time, the lesion can be easily detected by double-combination examination outside the anus. In subdental line abscesses, pus can be extracted by very shallow puncture; in supraglottic abscesses, the index finger should be placed in the rectum for guidance, and it is safer to puncture 2~125px through the paranal area, and the diagnosis can be confirmed after extracting pus. In submucosal abscesses of the rectum, the wall of the abscess cavity is often broken by palpation during finger examination and pus flows out.
Auxiliary examination
1. Routine blood tests can clearly show the degree of infection.
2.Ultrasonic examination can help to understand the size, location, and relationship with anal sphincter and anal levator muscle of anal canker.
Differential diagnosis
1. Perianal skin infection. Perianal folliculitis and boils are easily recognized because they are limited in scope and have a pus plug at the tip. Larger subcutaneous abscesses with localized pain, although obvious, are not related to the anorectum and do not form an anal fistula after rupture.
2, paranal sebaceous cyst infection. Paranal redness, swelling and heat pain are also seen, but the history is generally traced to a local swelling before infection, which is round, with a smooth surface and a small black spot formed by a blocked thick pore in the center of the mass. There is no primary internal opening in the anus in this disease, so there is no pressure point in the anus, and no anal fistula is formed after ulceration.
3, pre-sacral cyst and cystic teratoma infection . Detailed medical history usually reveals some signs of pre-sacral cysts. On finger palpation there is a mass behind the rectum, smooth, lobulated, without obvious pressure pain and cystic feeling. x-ray examination, pushing the rectum forward or to one side, reveals tissue thickening and tumor between the sacrum and rectum, with indeterminate scattered uneven calcification shadows and caudal displacement inside.
4.Purulent sweat gland abscess. Mostly in the anus and subcutaneous buttocks, the abscess is shallow and the lesion is extensive, the skin of the lesion area becomes hard, acute inflammation coexists with chronic fistula, the pus is viscous, becomes white powder porridge-like, and has a foul odor. The whole body has chronic consumption symptoms.
5. Acute necrotizing fasciitis of the anal perineum. The perineum and scrotum are infected with bacteria that cause necrosis of large areas of tissue around the perineum, and some form fistulas, with a wide range of lesions, rapid onset, often spreading to subcutaneous tissue and fascia, and invading the scrotum forward, but there is no internal opening in the anal canal.
6, Crohn’s disease. Crohn’s disease occurs in about 20% of perianal abscesses, and the anus often has atypical anal fissures and fistulas. Local redness and swelling, more self-infarction, but no obvious pain and systemic symptoms.
7, tuberculous abscess. It can be seen as bone steam and night sweating, tiredness and fatigue, coughing and hemoptysis, dullness and dry stool; or no systemic symptoms, only wide ulcers, subterranean, thin pus, or pulmonary tuberculosis foci can be found on X-ray for differentiation. Clinically, tuberculous abscesses take longer to become pus.
8.Anal rectal cancer. In the early stage, there may be changes in bowel habits and pus and blood mucus, and the stool strips become thin and flat. Proctoscopic examination, the mass is dark red and uneven in height. Finger examination, hard texture, nodularity, flat base couch diffuse, or top depression, pathological section can confirm the diagnosis.
9.Thrombosed external hemorrhoid. The thrombosed external hemorrhoid also has a mass next to the anus, and the pain is also heavier, but it is purple in color, smaller in scope, harder to touch, not purulent, no fluctuating feeling, and no systemic symptoms.
10. Endometriosis. This disease occurs in menstruating women, in the perineum, anus or rectum can be found in the boundaries of the bulging mass, hard, menstrual period increased, but no systemic symptoms. The diagnosis can be confirmed by pathological examination.
Treatment
1.Internal treatment
(1) Heat and toxin accumulation type
Symptoms: sudden swelling and pain in the perianal area, with persistent aggravation, accompanied by chills, fever, constipation, red urine, redness and swelling in the perianal area, obvious tenderness, hard texture, and surface {heat. Red tongue, thin yellow coating, pulse count.
Treatment: Clearing heat and detoxifying the toxin
Formula: Xianfang Livestrong Drink or Huang Lian Detoxification Tang plus reduction
Andrographis paniculata 9 g Glycyrrhiza glabra 6 Fangfeng 9 g Myrrh 6 g Red peony 9 g Angelica dahurica 6 g Angelica sinensis 9 g Boswellia 6 g Bayberry 9 g Smallpox powder 9 g Soapberry 9 g Honeysuckle 15 g Chen Pi 6 g Huang Lian 9 g Scutellaria baicalensis 6 g Huang Bai 6 g Gardenia 9 g
Commonly used traditional Chinese medicine: Niuhuang waking up and eliminating pills
(2) Hot poison incandescence evidence
Symptoms: Severe anal swelling and pain lasting for several days, pain like chicken pecking, difficulty in sleeping; accompanied by chills and fever, dry mouth and constipation, difficulty in urination, redness and swelling around the anus, with fluctuating sensation or pus on puncture. The tongue is red, the coating is yellow, and the pulse is stringent and slippery.
Treatment: Clearing heat and detoxifying pus
Astragalus 9 g Saponaria 9 g Angelica 6 g Chuanxiong 9 g Burdock 9 g Hypericum 9 g Goldenseal 15 g Angelica 9 g
Formula: Pus-Transmitting San plus reduction
Commonly used traditional Chinese medicine: Rhizoma Rhizoma
(3) Evidence of Yin deficiency and toxin attachment
Symptoms: anal swelling and pain, dark red skin, long duration of pus formation, thin pus after ulceration, sores difficult to converge; accompanied by afternoon hot flashes, disturbed heart and dry mouth, night sweating. The tongue is red, with little coating and a fine pulse.
Treatment: Nourishing Yin, clearing heat and detoxifying toxins.
Radix: Artemisia annua and turtle nail soup with Sanmiao Wan plus reduction
Artemisia annua 9 g turtle nail 9 g fine raw earth 15 g Zhi Mu 9 g Dan Pi 9 g Huang Bai 9 g Cang Zhu 9 g Chuan Niu Qi 9 g
Commonly used traditional Chinese medicine: Zuo Gui Wan
(4) The evidence of deficiency of evil
Symptoms: Weakness or deficiency of qi and blood, the sore is flat, the skin is purple and stagnant but not fresh, it is not hot when pressed, it is painful when touched, the pus is slow to form; it does not close after ulceration, the pus is thin, the food is not fragrant, the abdomen is distended and the stool is loose. Pale tongue, thin white or thick white coating, sunken and thin pulse.
Treatment: Benefit Qi, tonify blood, and tonify the sores.
Radix: Tori Disinfection San Plus Reduction
Radix Codonopsis pilosulae 15 g Radix Astragali 15 g Radix Angelicae Sinensis 9 g Chuanxiong 9 g Radix Paeoniae 9 g Poria 9 g Chen Pi 6 g Yinhua 15 g Radix Glycyrrhiza Uralensis 6 g
Commonly used Chinese patent medicine: Ten Perfect Great Tonic Pill
(5) Dampness and phlegm coagulation evidence
Symptoms: Diffuse soft lumps without head, no redness or heat, soreness and swelling in the anus; dark red and slightly hot pus over time, thin pus like flotsam and jetsam after ulceration, dripping, grayish surface of the sore and not converging; accompanied by hot flushes and night sweats, emaciation, blood in the sputum. The tongue is red with little coating or thick white, and the pulse is fine or slippery.
Treatment: Tonifying the spleen and stomach, drying dampness, resolving phlegm and eliminating swelling.
Formula: Er Chen Tang and Bai He Gu Jin Tang plus reduction
Fuxianxia 6 g Poria 9 g Chen Pi 6 g Lily 9 g Xuan Shen 15 g Prince’s ginseng 15 g Dioscorea 9 g Phellodendron 9 g Atractylodes Macrocephalae 9 g Roasted licorice 6 g
Commonly used traditional Chinese medicine: Baihe Gujin Wan
2.External treatment method
(1) External application method
In the initial stage: for those with actual evidence, apply Jinhuang Paste and Huanglian Paste externally, and for those with deep and hidden position, use Jinhuang San to mix paste and enema; for those with deficiency evidence, use Chonghe Paste or Yang and Xingying Paste.
Pus-forming stage: external application of poison plucking cream or thousand hammer cream can be applied to make it collapse at an early stage, or use head biting cream to erode the pus head, while following with external application of hoop surrounding medicine to prevent the spread of pus and poison. In the later stage of ulceration, the pus-removing medicine is mainly used, and the pus is drained with the pus-removing medicine or Jiuyi Dan oil gauze, and the red powder gauze is also used for drainage.
At the later stage: when the pus is exhausted, the main purpose is to produce muscle to close the mouth, and the application is to produce muscle san or pearl san gauze.
If the abscess is tuberculous but not ulcerated, Yanghe paste is used externally, and after ulceration, Jiuyi Dan gauze is used, and when the mouth is converged, the raw muscle Yuhong paste is used. If the skin around the anus is drenched with water and moist and erosion, Qing Dai San is applied externally, and if the skin is itchy, Qing Dai Cream is applied externally.
(2) Fumigation method: After the abscess has collapsed, fumigation treatment with Chinese herbal medicine can clear heat and detoxify, reduce swelling and pain, astringent and stop bleeding, dispel dampness and itching, and dispel decay and regenerate muscle. Commonly used bitter ginseng soup, Wu Bei Zi soup, hemorrhoid disease lotion, etc., sit in the bath after the external application of ointment.
3.Surgery. Abscess has become appropriate early incision and drainage, and according to the depth of the abscess site and the urgency of the disease to choose the surgical method. The shallow abscess can be used for one-time incision method; the high abscess needs to perform one-time incision and hanging method; the deep abscess mostly adopts sub-operation.
When incision and drainage, attention should be paid to accurate positioning and thorough drainage; radial incision is feasible for superficial abscesses and arc-shaped incision for deep abscesses to avoid damage to the sphincter; primary anal saphenous fossa should be incised during surgery to prevent the formation of anal fistula; after ulceration, drainage should be done with Jiuyi Dan gauze, and the pus should be replaced with myogenic gauze; if the abscess becomes leaky over time, it should be treated as anal fistula.
4. Postoperative treatment. Apply Chinese herbal medicine or antibiotics to clear heat and detoxify and drain pus, as well as laxatives as appropriate. After the operation, use bitter ginseng soup or 1:5000 potassium permanganate solution to sit in the bath and change the medicine after each stool. The threads generally fall off by themselves in about 10 days, and can be tightened or cut as appropriate. At this time, the wound surface has been repaired shallowly and flattened, and can heal rapidly after the drug change, without the sequelae of anal incontinence. After surgery in various ways, attention should be paid to the presence of high fever and chills, if any, they should be treated promptly.
Referral principles
1.If the diagnosis is unknown and further examination at higher level hospital is needed
2.Those with high deep abscess, heavy symptoms of systemic infection and unable to drain thoroughly due to conditions should be promptly referred for incision and drainage.
Health and rehabilitation
1.Living and living regularly, insisting on exercise to enhance the ability to resist diseases.
2, to prevent eating spicy, fried, fatty, wine and other irritating food and hair, to prevent constipation and diarrhea.
3.Keep your clothes and pants breathable, pay attention to anal cleanliness and avoid local humidity.
Health education
1.Actively prevent and treat anal lesions such as anal cryptitis, anal adenitis, anal papillitis, proctitis, internal and external hemorrhoids, etc. to prevent infection and abscess formation.
2.If you have symptoms such as anal swelling, pain and discomfort, discharge, etc., you may be ill and should be examined promptly and treated early. Anal perineal injury should be given proper treatment in time.
3.Once a perianal abscess is formed, anti-infection treatment should be carried out immediately. Once a perianal abscess occurs, it should be incised early and drained thoroughly to prevent the inflammation from expanding.
4.Actively treat the primary diseases, such as inflammatory bowel disease, tuberculosis, etc.
Commonly used western medicine reference
Non-surgical conservative treatment can be used in the stage of non-pus formation. The pathogenic bacteria of perianal abscess are characterized by polymicrobial (mixed infection) and high infection rate of anaerobic bacteria, antibiotic treatment can be combined with 2-3 antibiotics effective against gram-negative bacilli.