Paraproctitis

PARAPROCTITIS (paraproctitis, synonym peri-proctitis), inflammation of the tissue surrounding the rectum; occurs as a result of infection penetrating either directly through the wall of the rectum when it is damaged or via lymphatic pathways. There are many opportunities for damage to the mucous membrane; most often its integrity is compromised during the passage of stool, especially in the area of the sphincter, where the fecal column, grasped by the soft parts, is forced through with some violence; hard lumps of feces can cause tears in the mucous membrane due to friction and stretching; if the intestinal contents contain hard, pointed food residues, the mucous membrane can suffer deep and serious damage. In the folds of the mucous membrane, especially in sinus Morgagni, if they are deep, pieces of feces or foreign bodies can become lodged, which with prolonged residence can lead to ulceration. The likelihood of infection penetrating this way is confirmed by the fact that most fistulas of the anus open with their internal opening in sinus Morgagni. In addition to these factors contributing to the penetration of infection into the tissue surrounding the rectum, one must also consider the possibility of P. developing on the basis of processes in the mucous membrane: catarrhal condition, ulcers, looseness of the mucous membrane in hemorrhoids, when the latter due to stagnation phenomena is highly susceptible to infection and with the slightest trauma becomes easily permeable to microorganisms. The latter can also penetrate from the skin of the anus in eczema, intertrigo, etc.; in suppuration of adjacent organs, most often in purulent processes in the prostate gland, urethra, Cowper's glands, Bartholin's glands, in the rectouterine pouch (Douglas space), etc. Often the cause of P. can be metastatic abscesses. Without violation of the integrity of the rectal mucous membrane, infection can penetrate via lymphatic pathways. Inflammation of the pararectal tissue can be diffuse or limited. I. Diffuse paraproctitis: a) The septic form occurs most often after severe injuries or after major surgical interventions on the rectum. 1-2 days after injury with high temperature and general septic condition, the wound and surrounding tissues begin to be infiltrated with serous-purulent fluid and soon separate putrefactive secretions. With such phenomena, despite wide opening of the cavity and general treatment in combination with serological measures, success is not achieved—patients die within 2-10 days. Particularly dangerous is the penetration of infection into cavum pelvi-rectale, as from here it can easily penetrate into the retroperitoneal pelvic tissue and spread to the kidneys or to the anterior abdominal wall. Part of the peritoneum and intestine may necrose and lead to septic peritonitis. Similarly, a progressing phlegmon can spread to the scrotum, penis, and perineum. Besides this fulminating phlegmon, which is caused by staphylococci and streptococci, and sometimes other bacteria, there is also inflammation of the tissue characterized by gas formation. This type of P. is caused by the bacillus coli. The clinical picture in this case is less severe, but patients rarely recover, b) Diffuse suppuration (phlegmon) of the pararectal tissue occurs most often in diseases of the rectum, for example, in disintegrating cancers, infected thrombi, in 'strangulated' hemorrhoids, etc. But often the etiological moment cannot be precisely established. One must remember about diabetes. This type of P. can also develop on the basis of infection introduction in urinary phlegmons and prevertebral abscesses. The process usually begins with severe pain, high temperature, and poor general condition. The deeper the localization, the more pronounced the general phenomena. In the area of the anus, diffuse edema is noted, initially localized on one side, and after 1-2 days spreading to the other half. The skin is smooth, shiny. Palpation of the area of inflammation at the height of the process is very painful. When inserting a finger into the rectum, which is very painful and requires great caution, a hot, edematous, pulsating mucous membrane is noted. A clear softening cannot be detected. In superficial processes, the pus, very quickly perforating the skin, flows outward. Usually a large amount of pus is observed in processes that do not proceed too severely. The presence of gas-forming bacteria is not necessary. The infection is most often mixed. Treatment consists in wide opening and drainage of the cavities (no fissure should be left unopened). Incisions are made from the skin side, around the rectum from front to back, on one or both sides. The sphincters are incised. II. In limited inflammation of the pararectal tissue, superficial and submucosal abscesses are distinguished. a) Superficial ones can arise on the basis of furuncles, fissures, suppurating hemorrhoidal nodes, diverticula, and various types of injuries. They are located under the skin at the edge of the anus, which is why they are called subcutaneous. They are located below the sphincter. Subcutaneous abscesses can spread to the ischium and sometimes open into cavum ischio-rectale or rise upward into the submucous space of the anal portion. b) Submucosal abscesses are located directly above the entrance to the anal opening, rarely higher, and can spread downward into the subcutaneous tissue and upward into the overlying submucous tissue of the rectum. This type of P. opens either through the skin or most often through the mucous membrane of the anus, especially in sinus Morgagni, being the most common cause of fistula formation. More rarely, opening occurs through the loose connective tissue between the external and internal sphincter in fossa ischio-rectalis. Clinically they proceed as acute abscesses, more rarely as cold abscesses. Treatment is only surgical and should be undertaken early to avoid perforation and undermining of tissues. In subcutaneous and submucosal abscesses, the covering skin and mucous membrane should be incised throughout their entire length by an incision running radially to the anus, without damaging the sphincter.

F. Yanishevsky.