Anal leakage is a fistula formed when the rectum or anal canal communicates with the surrounding skin, also known as an anal fistula. It usually consists of a primary internal opening, a fistula, and a secondary external opening, but there are also cases with only an internal or external opening. The internal orifice is primary and most of them are in the anal sinus at the dentate line of the anal canal; the external orifice is secondary and is in the skin around the anus, often more than one. Most anal leaks are the sequelae of anal canker sores. It is clinically classified as either septic or tuberculous. It is characterized by recurrent localized pus flow, pain, and itching as the main symptoms, and the fistula can be palpated or probed to pass into the rectum.
Etiology and pathogenesis
After the ulceration of canker sores, the remaining toxins are not exhausted, and the blood flow is not smooth, so the sores do not fit together. Therefore, the Song? The “Taiping Sheng Hui Fang” says “The hemorrhoid fistula is caused by the poisonous gas of all hemorrhoids, which accumulate at the anus …… after penetrating the cavity, and the sore does not fit. The pus and blood, the head of the intestine swelling and pain, after a long time is not bad, so the name hemorrhoids fistula also.” The leaky tube does not close the mouth for a long time, the evil gas stays connected and consumes qi and blood.
According to Western medicine, anal fistula and perianal abscess belong to two pathological stages of purulent infection of the perianal space, respectively, the acute stage is perianal abscess and the chronic stage is anal fistula.
Diagnosis
1.Clinical manifestations
(1) Main symptoms of anal leakage
The disease can occur in all ages and different genders, but it is more common in adults. It usually has a history of recurrent anal canker, and has a history of self-rupture or incision and drainage.
①Pus flow: Intermittent or persistent localized pus flow that does not close for a long time. Generally, the pus is more frequent when it first forms, with a fecal odor, yellow and thick; after a long time, the pus is sparse, or sometimes absent, with intermittent pus flow; if it is too tired, the pus increases, and sometimes feces may flow; if the pus is already small but suddenly increases again, and there is pain in the anus, it often indicates an acute infection or the formation of a new branch.
Pain: When the fistula is open, there is usually no pain, but only a local feeling of swelling. If the external opening closes on its own and pus accumulates, local pain may occur or there may be chills and fever; if the pus flows out after ulceration, the symptoms may rapidly decrease or disappear. However, pain can also be caused by the large inner opening and the inflow of feces into the duct, especially when defecating.
(3) Itching: itching is caused by constant stimulation of the skin around the anus by pus, and sometimes it can be accompanied by perianal eczema.
(2) Physical examination
The external orifice is visible on visual examination of the anus, and those with a small raised external orifice are mostly septic; those with a large, depressed external orifice, purple surrounding skin, and subcutaneous penetration should be considered complex or tuberculous anal leakage. Low anal leaks can be palpated subcutaneously in the perianal area with hard cords, while high or tuberculous ones are usually not easily palpable. Examination with a probe can often find the internal opening.
(3) Classification
①Simple anal leakage: if there is only one external opening in the paranal skin, which is straight into the internal opening of the anal fossa on the dentate line, it is called complete leakage, also called internal and external leakage; if only the external opening is connected to the leakage tube without the internal opening, it is called single external leakage, also called external blind leakage; if only the internal opening is connected to the leakage tube without the external opening, it is called single internal leakage, also called internal blind leakage.
②Complex anal leakage: it is called horseshoe-shaped anal leakage if there are more than 3 openings inside or outside the anus; or if the ducts penetrate more than 2 gaps; or if there are many ducts and the branches are born horizontally; or if the ducts are born around the anus and shaped like a horseshoe.
In 1975, the first national anal colloquium formulated a unified classification standard for anal leaks, which is marked by a line drawn deep in the external sphincter, and those with leaking tubes passing above this line are considered high, while those below this line are considered low, and are classified as follows
Low simple anal leak: there is only one leak tube and it passes below the deep external sphincter with the internal opening near the anal sinus.
Low complex anal leak: the leaky duct passes below the deep layer of the external sphincter, has more than 2 external ports, or more than 2 ducts, and the internal port is in the area of the anal sinus.
High simple anal leak: only 1 canal with more than 1 canal passing through the deep external sphincter and the internal orifice is located in the anal sinus area.
High complex anal leak: those with more than 2 external ports and ducts, with branching sinus tracts, whose main duct passes above the deep layer of the external sphincter, and with 1 or 2 or more internal ports.
(4) The development pattern of anal leakage
Draw a horizontal line through the sciatic nodes on both sides of the anus. When the outer mouth of the leaky canal is within 100px from the anal verge before the horizontal line, and the inner mouth is at the tooth line opposite to the position of the outer mouth, its canal is mostly straight; if the outer mouth is beyond 100px from the anal verge, or the outer mouth is after the horizontal line, and the inner mouth is mostly at the posterior median tooth line, its leaky canal is mostly curved or horseshoe-shaped. (See Figure 12-14)
2.Laboratory and other auxiliary examinations
X ray iodine oil imaging can show the route of the leaky tube, its depth, whether there are branches and the location of the endo-port, and the relationship with the organs around the rectum.
Differential diagnosis
1.Purulent sweat glands in the anus is a chronic inflammatory disease of the skin and subcutaneous tissues, often forming leaky ducts and external openings under the perianal skin, flowing pus, and spreading to the surrounding area. On examination, multiple perianal subcutaneous leaky ducts and external openings can be seen, with dark brown and hard skin color and no internal opening in the anal canal.
2.Rupture of pre-sacral teratoma Pre-sacral teratoma is a congenital disease with abnormal embryonic development. Most of them develop in young and strong age, and there is no obvious symptom at the beginning, but if the tumor increases and presses the rectum, defecation difficulty may occur. If secondary infection occurs, it may ulcerate from behind the anus and there is an external opening in front of the caudal bone behind the anus, but anal palpation can often palpate a cystic swelling feeling in front of the sacrum without an internal opening. Hair, teeth and bone are visible in the cavity by surgery.
【Treatment】
Generally, surgical treatment is the main treatment. Internal treatment is mostly used before and after surgery to enhance physical fitness, reduce symptoms and control the development of inflammation.
1.Cognitive treatment
①Damp heat infusion evidence
Symptoms: frequent flow of pus around the anus, thick pus, anal swelling and pain, local burning; perianal ulcers, with cords leading to the anus when pressed; red tongue, yellow coating, string or slippery pulse.
Treatment: Clearing heat and relieving dampness.
Remedies: Ermiao Wan and Dioscorea Z Percolating Dampness Tang with addition and subtraction.
②Evidence of positive deficiency and evil attachment
Symptoms: perianal pus flow, thin texture, vague pain in the anus, dull color of the outer opening, the leak is healed at times; perianal ulcers, hard texture when pressed, or pus flows from the ulcers, and there are many cords leading to the anus; with fatigue; light tongue, thin coating, smooth pulse.
Treatment: Disinfection with toleration.
Remedy: Add and subtract Tori Disinfection San.
(3) Deficiency of Yin and fluid
Symptoms: perianal ulceration, depression of the external orifice, subterranean leaky tube, often without local hard cords to be retrieved, thin pus; may be accompanied by hot flushes and night sweats, disturbed heart and dry mouth; red tongue, little moss, thin pulse.
Treatment: Nourishing Yin and clearing heat.
Remedy: Artemisia annua and turtle nail soup with addition and subtraction. In case of lung deficiency, add Sha Shen and Mai Dong; in case of spleen deficiency, add Bai Zhu and Shan Yao.
2.Other treatments
The main treatment is surgery. All the leaky tubes will be cut open, and if necessary, the scar tissue around the leaky tubes can be appropriately trimmed so that the drainage can be smooth and the wounds can gradually heal. The key to success or failure of surgery is to correctly find the internal opening and cut or excise it, otherwise the wound will not heal, and even if it heals temporarily, it will recur again in the future. At present, the commonly used surgical therapies are thread hanging therapy, incision therapy, combination of incision and thread hanging, etc.
(1) Surgical treatment
①Wire hanging therapy
This method has been used in the Ming Dynasty. In the “Ancient and Modern Medical System”, it is said that “the medicine line is put down, the intestinal muscle grows with it, the remote place is mended, the water flows by the line, before the sore is penetrated, the goose tube is eliminated.” This treatment is simple, economical, does not affect the function of the anus, has small scarring, and has the advantage of smooth drainage. The mechanism is to use the mechanical action of the ligature wire to slowly strangle the canal with the pressure or contraction force generated by its tight binding, giving the broken end a chance to grow and produce inflammatory adhesions with the surrounding tissues, thus preventing the occurrence of anal incontinence caused by the sudden fracture and retraction of the rectal ring of the anal canal. At present, rubber bands are mostly used instead of silk threads, which can shorten the healing process and reduce postoperative pain.
Indications: It is suitable for low anal leakage within 100px from the anus with internal and external openings; it can also be used as an adjunct to incisional therapy or excisional therapy for complex anal leakage.
Contraindications: those with skin disease around the anus; those with pus still in the leak tube; those with severe tuberculosis, syphilis, etc. or extreme weakness; those with cancer.
Operation method: Lumbar anesthesia or local infiltrative anesthesia, taking the lateral position with the patient’s side underneath or in the truncated position. After routine sterilization, first tie a rubber band at the end of the ball-tipped probe (silver or copper), then gently probe the probe inward from the outer mouth of the leaky canal, insert the index finger deep into the anal canal to assist the probe, find the inner mouth near the dental line of the anal canal, and probe the probe out from the inner mouth, bend the probe and pull it out from the anal opening so that the rubber band enters the leaky canal through the outer mouth. After pulling out from the inner mouth, lift the rubber band, cut the skin and subcutaneous tissue between the inner and outer mouths of the leaky canal, pull the rubber band tightly and hold it close to the subcutaneous incision with hemostatic forceps, tighten the rubber band and double ligature it with thick silk thread below the hemostatic forceps, and then cut the excess rubber band at 37,5px outside the ligature line. Release the hemostatic forceps, fill the wound with red ointment gauze to stop bleeding with pressure, outside the gauze pad, wide adhesive tape fixed (see Figure 12-15)
If the thread is hung with a medicinal thread, tighten the thread and tie a live knot with one or two buckles for future tightening of the thread; or the end of the thread can be threaded into another section of the thread and held out by the anus so that the thread becomes double stranded around the leaky tube, then tighten it and tie a live knot and tighten the thread once every 1~2 days until the thread falls off.
②Cutting therapy
Indications: low simple anal leakage and low complex anal leakage; for high anal leakage, incision must be combined with thread hanging therapy to avoid anal incontinence.
Contraindications: the same as hanging wire therapy.
Operation method: Lumbar anaesthesia or local infiltration anaesthesia, take the truncated or lateral position. After routine disinfection, a piece of saline gauze is inserted into the anus, and then a blunt-tipped needle syringe is used to inject 1% methylene blue (melanin) or gentian violet solution into the outside of the leaky canal. The slotted probe is gently inserted through the outer mouth of the leaky canal, and then the skin and subcutaneous tissue and the outer wall of the leaky canal are cut along the probe path to leave the leaky canal partially open, and then the slotted probe is inserted into the remnant of the leaky canal. The surface tissue of the probe was cut in the same way until the entire leaky canal was safely cut. The skin and subcutaneous tissues on both sides of the wound were trimmed to form a small wound with a wide base, so that the drainage was unobstructed. Carefully stop the bleeding, fill the trauma with red ointment gauze strips, pad the outer gauze, and fix with wide adhesive tape compression.
(2) Precautions during surgery
(1) The probe should not be used violently when probing from the external mouth to avoid causing false passage.
②If the leaky tube passes below the rectal ring of the anal canal, the leaky tube can be cut all at once. If the leaky tube passes above the rectal ring of the anal canal, it must be added with hanging wire therapy, that is, first cut the leaky tube below the shallow part of the lower part of the external sphincter skin and below it, and then use a rubber band to have the remaining tube mouth to pass into and have the inner mouth to lead out and tie it to the rectal ring of the anal canal. If the anorectal ring has been fibrotic, it can also be cut all at once without hanging thread.
If the leakage tube passes between the deep and shallow layers of the external sphincter, the two external sphincters cannot be cut at the same time when the muscles there have not formed fibrosis, and when cutting the external sphincter, it should be cut at a right angle to the muscle fibers, not at an oblique angle.
(4) High anal leakage through the caudal ligament can be cut longitudinally, and the caudal ligament cannot be cut transversely to avoid forward displacement of the anus.
(3) Postoperative treatment
①Keep the stool open after surgery, and give laxatives if necessary.
②Postoperative pain can be treated with painkillers or ear acupuncture.
③After the stool every day, use bitter ginseng soup or 1:5000 potassium permanganate solution to sit in the bath and change the medicine.
④Generally after hanging, the rubber band can fall off in about 7 days. If it does not fall off after 10 days, it can be cut, and if the ligature rubber band is loose, it needs to tighten the line once again.
⑤ The wound must start to grow from the base to prevent premature adhesion sealing of the surface and formation of pseudo-healing.
⑥After the canal is cut or hung open, change the medication to the closure with raw muscle sanitary gauze or raw muscle yu red cream.
(7) After incision or hanging, a small amount of pus may flow out from the anal fistula, and the swelling around it gradually dissipates; if there is still more thick water, check whether there are branches or residual tubes.
Prevention and care]
1.Keep the anus clean frequently and develop good hygiene habits.
2.It is advisable to treat anal canker early when it is found, which can prevent posterior anal leakage.
3. Patients with anal leakage should be treated early to avoid the accumulation of pus and poor drainage caused by blockage of the external opening, which may lead to new branched canals.