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Abstract: The patient presented with diarrhea after a spicy diet, followed by anal swelling and pain, and self-medication did not work well. Since the lesion had become septic at the time of consultation, medication was not effective, and surgery was finally chosen.
Basic information】Female, 38 years old
Type of disease】Acute anal sinusitis
Hospital】Hegang City People’s Hospital
Date of consultation】January 8, 2022
Treatment plan】Surgical treatment (anal sinusotomy and dilation) + medication (Ceftriaxone sodium for injection, Ma Yinglong musk hemorrhoid cream, compound keratanate suppository)
Treatment period】1 week of hospitalization, 3 weeks of postoperative outpatient medication change, 3 months of follow-up
Treatment effect】Anal swelling, pain and burning sensation disappeared
I. Initial consultation
The patient, Ms. Cui, came to the clinic early in the morning, complaining of anal swelling and pain, as well as a hot and spicy feeling. The examination revealed that the anal canal was normal in appearance, and the finger diagnosis revealed tightness and burning sensation in the anal canal, and the anoscopy revealed redness, erosion and suppuration in the anal fossa behind the anal canal.
Second, the treatment process
Although the patient was suffering from acute sinusitis, he had suppuration and the effect of medication was not good, so surgery was recommended. After admission, the relevant tests were further improved. The blood routine showed elevated leukocytes, suggesting infection, and no abnormalities were found in coagulation and biochemical and electrocardiographic tests. After intestinal cleansing, the patient was given an anal sinusotomy and dilation under sacral anesthesia, and the operation went smoothly and took about 15 minutes. After the operation, the patient was given anti-infective treatment with ceftriaxone sodium for injection for 3 days. On the second postoperative day, the patient had one bowel movement, and the anal pain was tolerable during the bowel movement. After cleaning the anus, the patient was given a sitz bath, anal dressing change (Ma Yinglong musk hemorrhoid cream and compound keratanate suppository), and oil gauze was placed to drain the internal anal wound. The patient’s anal discomfort was relieved on the day of surgery, and he was discharged after 1 week with slight anal swelling. After 3 weeks of outpatient drug change after discharge, the anal wound healed and the anus was free of any discomfort. No abnormality was seen at the follow-up for 3 months.
III. Treatment effect
The patient was suffering from acute anal sinusitis with a short course and obvious anal discomfort. The anal pain and burning sensation were significantly relieved on the day of surgery, and the condition was effectively controlled. One week after surgery, the patient had only slight anal swelling and discomfort, and anal pain and burning sensation no longer existed. After 3 weeks of outpatient treatment after discharge, the anal wound was completely healed without incisional infection, and the anal area was free of any discomfort and no abnormality was seen on follow-up.
IV. Notes
We are glad that the patient’s condition has improved after treatment. Patients should avoid strenuous exercise after surgery to prevent bleeding from incisional tears in the anal area, and should still insist on outpatient review and medication changes after discharge to avoid incisional infection and false healing. Pay attention to cleanliness and hygiene, wash fruits and vegetables, and eat less spicy and stimulating food, such as spicy hotpot and roadside barbecue, to avoid intestinal infections that may trigger the disease. The anal area should be cleaned in time after the bowel movement to keep it clean and hygienic to avoid perianal infections that may trigger the disease. Avoid sitting, squatting and standing for a long time, and do more functional anal exercises, such as anal lifting, to promote the absorption of perianal inflammation.
V. Personal insight
In this case, the patient paid more attention to his own health, and came to the hospital in time after his anal discomfort did not improve with drug treatment. At this time, although the anal sinus was infected with pus, it had not yet developed to the stage of perianal abscess, which reduced the difficulty of treatment and alleviated the pain during treatment, and eventually received better results, fully illustrating the importance of early diagnosis and early treatment. For acute anal sinusitis, keeping normal stools and paying attention to a healthy diet are important preventive measures, and try to quit smoking, alcohol and spicy food to prevent the disease from recurring.