Canker sores are abscesses formed by acute and chronic infection in the perirectal space. Most of them have a rapid onset, severe pain, and high fever, and most of them form anal leaks after rupture. It is equivalent to a perianorectal abscess in Western medicine.
Due to the different locations of occurrence, it may have different names
1.Anal subcutaneous abscess
2.Sciorectal interstitial abscess
3.Pelvic rectal hiatus abscess
4.Posterior rectal hiatus abscess
5.Submucosal abscess of the rectum
The disease is also known by different names in Chinese and Western medicine, such as dirty poison, hanging carbuncle, sitting horse carbuncle, cross-horse carbuncle, etc.
1.More often due to over-eating fatty, sweet, spicy, alcoholic wine and other things, damp heat is generated internally, injected into the large intestine, and contained in the anus.
2.Anal ulceration and poisoning, resulting in obstruction of the meridians and stagnation of blood and Qi.
3.It is caused by the deficiency of lung, spleen and kidney, and damp-heat is injected downward by deficiency. Western medicine believes that the disease is caused by the spread of inflammation to the perianal rectal space after the infection of the anal glands.
I. Clinical manifestations
The disease is more frequent in men than in women, especially in young adults. The main manifestations are pain, swelling and lumps around the anus. It is accompanied by various degrees of fever, lethargy and other systemic symptoms. Due to the different locations and depths of abscesses, the symptoms also vary, and the interstitial abscesses above the anal raphe are located deep and hidden.
The systemic symptoms are heavy while the local symptoms are light; the interstitial abscesses below the anal raphe are shallow.
The local redness, swelling, heat and pain are obvious while the systemic symptoms are light. The disease becomes pus in about 5-7 days, if it becomes pus for several months, and the pus is gray and thin after festering, not smelly or slightly smelly, without fever or low fever, it should be considered as tuberculous abscess.
(1) Subcutaneous abscess of the anus
It occurs in the subcutaneous tissue around the anus, with obvious local redness, swelling, heat and pain, and fluctuating pus, and mild systemic symptoms.
(2) Scirorectal interstitial abscess
It occurs between the anus and the sciatic tuberosity, and the infected area is wider and deeper than the subcutaneous abscess of the anus. Initially, it only feels discomfort or slight pain in the anal area, and gradually symptoms such as fever, chill, headache and loss of appetite appear, followed by intensification of local symptoms, burning or throbbing pain in the anus, and pain during defecation and coughing. The pain increases when walking, and even restlessness.
Anal finger diagnosis of the affected side is full, with obvious pressure pain and fluctuating sensation.
(3) Pelvic rectal interstitial abscess
It is located above the anal raphe and below the peritoneum, with deep and hidden location, and the local symptoms are not obvious, sometimes only a feeling of rectal cramping is felt, but the systemic symptoms are obvious. It can be palpated at the rectal wall on the affected side by anal palpation, with pressure pain and fluctuating sensation.
(4) Posterior rectal space abscess
The symptoms are the same as those of pelvic rectal hiatus abscess, but there is obvious feeling of cramping in the rectum, dull pain in the sacrococcygeal region, which may radiate to the lower extremities, and obvious deep pressure pain between the coccyx and the anus. There is tenderness, bulging and fluctuating sensation at the posterior rectal wall by anal fingering.
II. Laboratory and other auxiliary examinations
(1) Routine blood tests: WBC and N may be increased in different degrees.
(2) Ultrasound examination: It is helpful to understand the size and location of anal canker and the relationship between anal sphincter and anal levator muscle.
Differential diagnosis
1. Perianal folliculitis and boils
The lesion is only in the skin or subcutaneous, and because there is no pathological connection with the anal sinus, it will not form an anal leak after rupture.
2.Sacral anterior teratoma secondary infection
Sometimes it is similar to posterior rectal abscess. There is a mass in the posterior rectum on anal finger diagnosis, smooth, without obvious pressure pain and cystic feeling. x-ray examination shows tissue thickening and swelling between sacrum and rectum, or pre-sacral swelling pushing the rectum forward, and there are scattered calcified shadows, bone and teeth within the swelling.
3.Sacroiliac joint tuberculous abscess
Long course, history of tuberculosis, lesions without pathological connection with anus and rectum. bony changes are seen on X-ray.
IV. Treatment
The treatment of anal canker is mainly surgical, and attention is paid to the prevention of anal leakage formation.
1. Identification and treatment
(1) Internal treatment
(1) Heat and toxicity
Symptoms: Sudden swelling and pain around the anus, continuously increasing. It is accompanied by vicious cold, fever, constipation, and red urine; redness and swelling around the anus, with obvious pain to touch, hard texture, and hot skin; red tongue, thin yellow fur, and number of pulse.
Treatment: Clearing heat and detoxifying the toxin
Remedies: Xianfang Livestrong Drink and Huang Lian Detoxification Tang with addition and subtraction.
If there are signs of dampness and heat, such as yellowish coating on the tongue and slippery pulse, Dioscorea Z Percolating Dampness Tang can be used in combination.
②Fire and poison incandescence evidence
Symptoms: severe perianal swelling and pain lasting for several days, pain like chicken pecking, difficulty in sleeping; accompanied by vicious chills and fever, dry mouth and constipation, difficulty in urination; perianal redness and swelling, with fluctuating sensation or pus when pressed; red tongue, yellow fur, slippery pulse.
Treatment: Clearing heat and detoxifying pus.
Treatment: Clearing heat and removing pus.
(3) Yin deficiency and toxin-loving evidence
Symptoms: perianal swelling and pain, dark red skin, long duration of pus formation, thin pus after ulceration, difficulty in convergence of sores; accompanied by afternoon hot flashes, disturbed heart and dry mouth, night sweating; red tongue, little fur, thin pulse.
Treatment: Nourish Yin and clear heat, dispel dampness and detoxify.
Remedies: Artemisia arborescens soup and Sanmiao Wan plus or minus. In case of lung deficiency, add Sha Shen and Mai Dong; in case of spleen deficiency, add Atractylodes Macrocephala, Yam and Lentil; in case of kidney deficiency, add Turtle Board, Xuan Shen, Sheng Di to Shu Di.
(2) External treatment
①In the beginning
(2) External treatment for the first symptoms: For the first symptoms, apply golden yellow ointment or Huanglian ointment externally, and for those with deep location, use golden yellow paste as an enema.
In case of deficiency, use Chonghe paste or Yanghe and Xinning paste for external application.
②Pus formation
Early incision and drainage are recommended, and surgical methods should be selected according to the depth of the abscess and the urgency of the disease.
③After ulceration
Use Jiu Yi Dan gauze to drain the abscess, and change the gauze to Sang Ji San when the pus is exhausted. If the abscess becomes leaky after a long time, it should be treated as anal leak.
2.Other treatments
(1) Surgery
① Abscess one-time incision method
Indication: superficial abscess
Operation method: Under lumbar anesthesia or local anesthesia, take a truncated position, disinfect locally, make an incision with the abscess, the incision is radial, and the length should be equal to the abscess, so that the drainage is smooth, and at the same time, look for the infected anal fossa or internal mouth at the tooth line, cut the tissue between the incision and the internal mouth, and scrape and remove to avoid the formation of anal leakage.
②One-time incision and hanging method
Indications: High-grade abscesses, such as abscesses of the sciatic-rectal space caused by infection of the anal saphenous fossa, abscesses of the pelvic-rectal space, abscesses of the posterior rectal space and horseshoe abscesses.
Then, a ball probe is used to probe into the abscess incision and gently probe the inner mouth along the bottom of the abscess cavity, and the other index finger is inserted into the anus to guide the search for the inner mouth, and after probing the inner mouth, the ball probe is pulled out, and a rubber band is ligated to the head of the ball and pulled into the incision through the abscess cavity, and the two ends of the rubber band are gathered and made to have certain tension and then ligated, and the wound is filled with red ointment gauze, and gauze is applied externally and fixed with wide adhesive tape.
③Splitting surgery
Indications: It is suitable for patients with deep abscesses who are weak or unwilling to be hospitalized.
Operation method: The incision should be made at the site of obvious pressure pain or fluctuation, as close to the anus as possible, with an arc-shaped or firing incision, which must be of sufficient length, and drained with red ointment gauze to keep the drainage unobstructed. When an anal leak is formed, it will be treated as an anal leak. For those with limited inflammation of the lesion or good general condition, if an internal opening is found, the incision and hanging method can be used to avoid secondary surgery.
(2) Postoperative treatment
Apply Chinese herbal medicine or antibiotics for clearing heat and detoxification, toli detoxification and laxatives as appropriate.
After each postoperative period, use bitter ginseng soup or 1:5000 potassium permanganate solution to sit in the bath after each bowel movement.
Hanging threads generally fall off on their own in about 10 days, and those who do not fall off after 10 days can tighten the threads or cut them off as appropriate, when the wound surface has been repaired shallow and flat, and can heal after another change of medicine.
After surgery in various ways, attention should be paid to the presence of high fever and chills, if any, they should be dealt with promptly.
(3) Precautions during surgery
① Positioning should be accurate: generally, puncture should be performed before abscess incision and drainage, and incision and drainage should be performed after pus is extracted
②Incision: a radial incision is feasible for superficial abscesses, and an arc-shaped incision should be made for deep abscesses to avoid sphincter damage.
③Drainage should be thorough: after incising the abscess, the abscess cavity should be probed with fingers to separate the fibrous septum in the abscess cavity to facilitate drainage.
④Prevent the formation of anal leakage: if the anal saphenous fossa of primary infection can be found during surgery, it should be cut or excised as much as possible to prevent the formation of anal leakage.
⑤If no internal opening can be found during surgery, one-time radical surgery should be performed reluctantly, and incision and drainage can be done.
V. Prevention and care
1.Keep the stool open and pay attention to anal cleanliness.
2.Actively prevent and treat anal lesions, such as anal cryptitis, anal adenitis, proctitis, internal and external hemorrhoids, etc.
3. Early treatment should be provided to prevent the expansion of inflammation after the disease.