Rectal and anal strictures
Introduction
Introduction Rectal and anal stenosis refers to the narrowing, deformation or varying degrees of intestinal obstruction of the anus, anal canal and rectum, called anal and rectal stenosis. Due to the stenosis, the anal stenosis and rectal stenosis (more than 2.5-5 cm above the dentate line or the rectum of the rectum), the stenosis is often within 10cm, which is related to the nature of the primary lesion, the upper end of the stenosis is dilated, and the stenosis continues. Smashed. Ulcers, formation of epilepsy or replaced by other tissues. This disease can generally provide important information for the diagnosis, but the upper lesion is more concealed, and multiple tests should be performed to make a correct diagnosis.
Cause
Cause
Etiology classification
First, anal stenosis
Anal stenosis is a stenosis caused by a fibrous band that occurs between the mucous membranes at the junction of the anus and the anal canal. Stenosis can be divided into: partial stenosis and total stenosis, and often combined with deformity.
(1) Classification according to the shape of the anus
1, the radial radial stenosis, that is, radial stenosis.
2, anal semi-circular stenosis, accounting for half of the anus stenosis.
3, the ring is narrow, accounting for the entire circumference of the anus, see the fiber band, only the probe can be inserted.
4, anal membranous atresia, only see the depression at the anus, the film across, that is, the thin layer of skin.
5, anal stenosis, lesion shape and rectal stenosis classification.
(2) Classification by cause
1, congenital anal stenosis: anal atresia, stenosis, anal canal stenosis, ectopic, congenital anal incontinence.
2, inflammation: abscess around the anus, cellulitis, anal tuberculosis, actinomycosis, granulomatous enteritis invading the anus, chronic ulcerative colitis, gonorrhea, schistosomiasis, chronic bacillary dysentery, amoebic dysentery, sexually transmitted lymph Granuloma and so on.
3, injury: part of the anus injury, burns, burns, corrosive drugs, iatrogenic trauma, penetrating injuries.
4, anus and anal canal, good tumors caused by stenosis
(1) benign tumors: benign tumors of the anus and anal canal, the arrangement of tumor cells and interstitial is the same as that of normal tissues, often with envelope, slow growth, less recurrence after resection, less malignant transformation. More common children. Children or adolescents, such as hemangioma, lymphangioma, fibroids, leiomyomas, lipoma, papillary fibroids, sebaceous cysts, dermoid cysts, inflammatory fibroids, endometriosis, teratoma, wrong Tumor, various polyposis, neurofibromatosis, schwannomas, neurocysts, ganglionoma, granulosa cell tumors, etc.
(2) malignant tumors: anal and anal canal cancer account for 1%-6% of anorectal cancer. It occurs in the dentate line and slightly above it called anal canal cancer; below the tooth line is called anal cancer. Anal canal cancer is more common than cancer around the anus, about 7:1. The former is more common in women, and the latter is more common in men. Older people over the age of 60 are more common, young and middle-aged are rare, children. Children are less likely to see. In the past, anal fistula and epilepsy tissue were considered to be malignant. In recent years, chronic enteritis and Crohn's disease have been found to have more chances of malignant transformation. Recently, homosexuals have also reported cancerous changes. The most common malignant tumors of the anus and anal canal are: squamous cell carcinoma, basal cell carcinoma, a hole of anal carcinoma, malignant melanoma, adenocarcinoma, and tympanic epithelial carcinoma. Rare people such as: carcinoid, Bowen disease (Bowen disease), perianal pie disease, malignant lymphoma. Plasmacytoma, lymphoid hyperplasia, fibrosarcoma, malignant fibrous histiocytoma, leiomyosarcoma, liposarcoma, metastatic tumor, chordoma, neoplasm, reticulocyte sarcoma, endothelial tumor, diffuse invasive carcinoma, obstructive carcinoma, perforation Cancer, multiple primary cancers, etc.
5, : due to stimulation caused by secondary spasm, such as anal fissure caused by internal sphincter spasm; long-term use of laxatives caused by internal sphincter spasm.
Second, rectal stenosis
Rectal stenosis is the growth of connective tissue in the intestinal wall, which makes the diameter of the rectal cavity narrow and narrow, and it is difficult for users to have progressive constipation. It is more common in middle-aged people aged 20-40, and the incidence of male and female is 1:4. It occurs more than 2.5-5 cm above the tooth line and the rectum ampulla.
(1) Classification by shape and scope
1. Annular stenosis: The rectal cavity is reduced from the periphery to the inside and becomes a ring shape, and the narrow portion does not exceed 2.5 cm.
2, tubular stenosis: the narrow area is longer than 2cm, is tubular.
3, linear stenosis: a part of the intestine cavity is tightly stretched, and other parts have no abnormal changes.
4, stenosis: refers to a small part of the rectal cavity is narrow, in a semi-circular or petal shape, does not affect the entire circumference of the intestinal lumen.
5, the whole week stenosis: refers to the large area of the stenosis, involving the entire rectum.
(2) Classification by cause
1, congenital dysplasia can cause rectal stenosis.
2, inflammatory stenosis: such as ulcerative proctitis, catarrhal proctitis, granulomatous direct inflammation often cause rectal stenosis. Dysentery, lymphogranulomatosis, schistosomiasis, tuberculosis and gonorrhea can also cause rectal stenosis.
3, damage
(1) Trauma: such as gunshot wounds, blast wounds, burns, trauma, and secondary infections, the elderly are prone to form rectal stenosis and corrosive drugs.
(2) iatrogenic trauma: postoperative sphincter rectal resection; rectal, sigmoid colonic tuberculosis resection and anastomosis; rectal benign tumor ligation, resection, cauterization, radiotherapy damage to the rectum.
4. Rectal stenosis caused by benign and malignant tumors in the rectum and outside the rectum.
mechanism
First, congenital anorectal malformation
During embryonic development, the gut is differentiated into the foregut, midgut, and hindgut. The end of the intestine is inflated three weeks after the embryo. This expanded part is called the cloaca, which is connected to the ventral allanto, in embryonic development. On the fifth weekend, the saddle-like mesoderm tissue between the cloaca and the hindgut is long, forming a urinary rectal septum. This divides the cloaca into two parts, the anterior urinary sinus, the second half as the rectum, and the urogenital septum. The development merges with the cloaca membrane to form the perineal body. Most of the anorectal malformations are caused by abnormal development of the urinary rectal septum. The urogenital sinus can not be completely separated from the rectal anus, and various types of congenital anorectal malformations appear.
Second, inflammation caused by anorectal stenosis
(a) anal and anal canal stenosis
Mostly radial, semi-annular, ring-shaped epilepsy, and some cause anal deformity. The scar is hard, and some are elastic, so that the anus and anal can not be fully expanded. The scar can affect the skin, subcutaneous tissue and sphincter. There are a lot of fibrous tissue, polynuclear leukocytes and lymphocytes infiltration. This pathological change is more in the lower edge of the internal sphincter. obvious.
(two) rectal infection
In the early stage of inflammation, mucosal congestion, edema, and lymphatic reflux disorder, followed by mucosal erosion, ulceration, and necrosis. If it becomes chronic, it infiltrates into various layers of the rectal wall or extraintestinal tissue, and may have fibrous tissue hyperplasia, intestinal wall thickening, and then fiber. Tissue contraction, intestinal wall hardening, loss of elasticity, intestinal lumen stenosis; extra-rectal infection is the first acute lymphatic inflammation of the extraintestinal lymphatic vessels, that is, congestion, edema and subsequent invasion of the muscular layer, submucosal membrane congestion, edema, lymphatic drainage disorder And then the mucous membrane is erosive. After a long time, it becomes a chronic infiltrating myometrial lymphoid tissue. There are fibrous tissue hyperplasia in all layers of the rectum, and the intestinal wall is thickened, contracted, and becomes narrow. Above the stenosis, the feces compress the intestinal wall and the mucosa is ulcerated; the membrane below the stenosis is gray, thickened, hardened, and has no contractile force, often with nipple protrusion.
Third, the tumor causes stenosis
The mechanism is the narrowing of the ring stenosis caused by the infiltration of the malignant tumor around the rectum and the contraction of the scar caused by the secondary ulcer. The former is the main reason. As for benign tumors such as most polyposis, mechanical lumen diameter reduction can be caused. Uterine fibroids, benign tumors of bladder and benign tumors of surrounding tissues are all caused by extraintestinal compression.
Fourth, traumatic stenosis
Most occur after hernia resection or rectal prolapse repair, especially when the rectum or membrane is removed too much, or at different points in the rectal cavity, the effect membrane is removed, and at the same level at the edge of the tangent It is most likely to form a narrow. As for the stenosis caused by radiation therapy, sputum injection treatment, foreign body stimulation, edible corrosive drugs, trauma, etc., the mechanism is caused by infection or ulceration caused by scar contracture.
Examine
an examination
Related inspection
Ultrasound examination of gastrointestinal diseases in rectal examination of anus
First, medical history
Past history is very important in diagnosis. For example, female patients, whose husband has a history of sputum and sputum, may be the most stenosis caused by syphilitic lymphogranuloma. Generally inflammatory stenosis, often containing purulent stools of blood and mucus. Tuberculosis, schistosomiasis, intestinal amebiasis, condyloma acuminata, Crohn's disease, etc. can all cause blind obstruction symptoms and right lower abdomen mass or ascites, anorectal stenosis. Postoperative, traumatic, burns, corrosive drug-induced injuries, injection treatment history, etc. can all have difficulty in defecation, more stools, pain, bleeding, and purulent secretions. After a long time, ulcer scar contracture causes anorectal stenosis. Benign tumors have chronic stenosis; while malignant tumors are hard and have a smooth surface, often invading some or all of the intestinal wall, growing fast, and narrowing, accompanied by stench and pus.
Second, physical examination
Visual examination of the anus often has feces and secretions, and often hardened scars and shallow cracks, the diagnosis of the diagnosis is sometimes decisive for the diagnosis, the movement should be gentle and avoid rough, so as not to cause anal sphincter spasm. The anal canal wall should be understood whether the female rectal vaginal fistula is affected, and the patient is treated for defecation. The anus is turned out, the lower lesion is damaged, and the skin around the anus is damaged. This has diagnostic value for finding the location, extent, shape, texture and cause of the stenosis in time. Because the anal anal canal is small, it can't pass the finger, and some can touch the hard fiber band or the ring narrow.
Female patients have symptoms such as disease and granuloma around the anus or genitalia, often suggesting syphilitic lymphogranuloma; some connective tissue external hemorrhoids, genital warts, various fistulas often in syphilitic lymphogranuloma, tuberculosis, cancer, ulcerative colitis Visible; such as valvular or membranous stenosis is often congenital; postoperative stenosis is often annular and linear; rectal cancer has no extensive stenosis caused by inflammation; valvular or membranous stenosis is typical tubular. In the late stage of rectal stenosis, there are many manifestations such as weight loss, anemia, malnutrition, and cachexia. Hepatosplenomegaly often indicates that the patient has schistosomiasis. Tuberculosis and cancer are common in the abdomen and lumps.
Third, laboratory inspection
(A) blood routine examination, bleeding and clotting time, erythrocyte sedimentation rate, plasma protein and lack of color man test. Anorectal and colonic diseases, a wide range of abscesses and erythrocyte sedimentation rate; enteritis, proctitis, diverticulitis, tuberculosis, and erythrocyte sedimentation rate can also be accelerated. Carcinoembryonic antigen (CEA) measurement is a surgical outcome and recurrence monitoring index for rectal anal stenosis.
(2) Dung routine and culture
Specimens of dilute stools, rectum, colon and anus around the anus should be vigilant at 37 ° C and checked within 1 h; normal formed feces can be examined within 24 h. A small amount of blood often comes from the rectum, sigmoid colon and descending colon. Blood can also occur when cecal hemorrhage and upper gastrointestinal bleeding are discharged, but hemorrhage often occurs in the upper part of the gastrointestinal tract. A small amount of bleeding in the stomach, small intestine and colon shows occult blood in the feces.
(three) fecal occult blood test
It is a simple way to find colorectal tumors and other causes of bleeding.
(4) Fru (Fie) test
It is a method of examining the inguinal lymphogranuloma. A positive indicates an infection, which does not indicate that the disease is active, but the false positive rate is high.
(5) Exfoliated cell examination
Benign or malignant tumors can be identified. And can identify colorectal cancer and diverticulitis.
Fourth, equipment inspection
(1) Exercise conduction check
1. The normal latency of the sinus and perineal nerve endings is 1.9ms. The incubation period of both anal incontinence and urinary incontinence increases.
2, spinal cord exercise latency normal spinal cord latency, external sphincter L is 5.5ms, L is 4.4 ms, puborectalis muscle activity latency is 4.8ms and L is 3.7ms.
(two) ultrasound examination
Intrarectal ultrasound imaging is more accurate, with high sensitivity, specificity and predictive value. The depth and stage of rectal cancer infiltration can be determined, and high tumor and bladder invasion and prostate invasion and local recurrence after surgery can be found, but lymph node invasion and pelvic spread cannot be clearly determined, and inflammation and cancer are difficult to distinguish. Can be guided to take a biopsy.
(three) rectal examination
Visible mucosal color, congestion, edema, presence or absence of erosion, ulcers, polyps, tumors, stenosis and foreign bodies. The medial malleolus, anal papilla, anal sinus and anal fistula can be examined near the dentate line.
(four) sigmoidoscopy
It is a simple and easy method. More than 70% of rectal and colon cancer can be seen directly with this mirror; in conventional sigmoidoscopy, adenoma and other lesions are found to be as high as 39%, and 15% of adenomas have malignant changes. The sigmoid colonoscope can be used to treat diseases in the rectal colon and improve the diagnostic accuracy.
(5) Fiber colonoscopy
The rectum, colon, cecum, ileocecal valve and ileum can be directly examined. Can also do biopsy, cancer screening. Polypectomy and cauterization are useful for early diagnosis of colon disease.
(6) Check by line
Chest X-ray examination confirmed the presence or absence of tuberculosis and tumor metastasis, and the presence of colon stenosis and obstruction in the abdomen. Barium enema examination can be seen in the large intestine, especially the rectal anus stenosis and mucosal arrangement shape, with or without damage, polyps and tumors.
(7) CT scan inspection
It is a sensitive method for examining anal canal and rectal cancer. Cancer invasion of the anterior tibial, pelvic wall, pelvic organs and lymph nodes can be found. Determine the size of the cancer, the intestinal wall, the fat around the rectum, the uterus and muscles. Preoperative and postoperative scans can help in the development of surgical and radiotherapy treatment options.
(8) MRI examination
It can be used for preoperative examination of rectal cancer and post-operative recurrence examination to determine the extent of residual cancer after radiotherapy. In addition, the rectal and anal stenosis and its degree of disease can be diagnosed.
Diagnosis
Differential diagnosis
Rectal stenosis: After rectal injury or inflammation, connective tissue hyperplasia in the intestinal wall, narrowing and narrowing the rectal cavity is called rectal stenosis. At the time of the examination, the anal sphincter is found to be loose, the stenosis can be detected upwards, the rectal wall becomes hard, inelastic, and sometimes the stenosis is large or stenotic; the finger can be extended above the stenosis to distinguish it from a ring or a tube, inflammatory or Cancerous, but not too strong, so as not to cause pain, bleeding or tearing the intestinal wall. By speculoscopy, it can be seen that the mucosa under the stenosis becomes thicker, the stenosis is scorpion-like or ring-shaped, and the stenosis has feces or purulent discharge. At the same time, it is necessary to do an X-ray examination of tincture or lipiodol enema, determine the location and thickness of the rectal stenosis, and also check the bacteria, amoeba and schistosomiasis to determine the cause. It is best to do a biopsy, remove the cancer, and confirm the diagnosis.
The narrow anus or anal canal is a clinical manifestation of congenital anorectal stenosis. The narrow part is more common in the anal canal or anus, and the range is short and ring-shaped, also known as anal membranous stenosis.
Anal canal stenosis refers to a series of clinical symptoms such as difficulty in defecation, thin stools, or pain in the anus after abdomen due to various reasons.
Anorectal pain is the most common symptom of anorectal disease. Due to the relationship between anatomy and physiology, the pain of anorectal disease occurs mostly in the lower abdomen, perineum, anal margin and lower rectum. The general symptoms are mild, with little weight loss, anemia, hypoproteinemia and so on.
Anorectal malformation is a common gastrointestinal malformation. It has a wide variety of pathological complexes. Not only the development of the anorectal itself, but also the muscles around the anus - the puborectal muscle, the external anal sphincter and the internal sphincter have different degrees of changes. One of the important changes in malformation, in addition to the high incidence of malformations associated with other organ malformations, some cases of multiple malformations or severely endanger the life of the sick child.
