Rectal fistula according to ICD 10. Constant pain and itching in the anus: meet anal fissure

Quite common in proctology. The pathology is quite severe and requires quick treatment, usually surgical. It is important for specialists to know the ICD 10 code for paraproctitis, this allows them to accurately determine the form of the disease and establish the most correct treatment tactics.

Acute and chronic forms are in different sections, which are discussed in more detail below.

Pathology is an inflammatory process in the perirectal tissue(it surrounds the rectum). The main causes of the disease are failure to comply with personal hygiene rules and injuries in the anal area, leading to infection of this area. The presence of diseases of the rectum (,) is important; they can provoke chronicity of paraproctitis, which leads to the formation.

The cause of the pathology can be any source of chronic infection in the body, especially in cases of weakening of a person’s defenses (observed in the presence of severe concomitant diseases).

Paraproctitis is manifested by severe pain in the perineal area, which intensifies when trying to perform an act of defecation. This leads to the emergence of .

When palpating the area of ​​inflammation, patients notice sharp pain; the boundaries of the accumulation of purulent contents can be determined.

The general condition of patients also worsens - body temperature rises, there will be complaints of weakness, apathy, and dizziness. Such patients experience dyspeptic symptoms - nausea, vomiting, lack of appetite.

As the disease progresses, it may result in the formation of a fistula. A channel with purulent contents is formed, which connects the intestinal cavity with environment. In such situations, treatment requires more serious and extensive surgery.

Classification of paraproctitis according to ICD 10

The following sections are distinguished in the international classification of diseases.

ICD 10 code for acute paraproctitis is K 61.0. Name - anal abscess. Depending on the location of the pathological formation in a given zone, it is divided into rectal (K 61.1), anorectal (K 61.2), ischiorectal (K 61.3) and intrasphincteric (K 61.4).

The first subtype is characterized by the fact that the abscess is located in the rectum, the second - around the anus. If an abscess forms in the ischiorectal fossa, this is an ischiorectal form of the disease.

If a pathological formation is found directly on the anus, an intrasphincteric abscess is exposed.

The clinical picture of acute paraproctitis is described above. General intoxication phenomena are more pronounced than in the chronic form of the disease.

Some clinicians use the name . With any acute inflammation of this area, a pathological secretion is formed. Therefore, the ICD 10 code for purulent paraproctitis is K 61.0. Patients should know that these forms of the disease are identical to each other.

In cases where the disease is not treated, the inflammatory process prolongs and becomes chronic.. Such situations are characterized by the formation of a fistula between the rectum and the external environment.

Patients will complain of purulent discharge that constantly stains their underwear, causing discomfort. The pain syndrome is not pronounced, it is disturbing during periods of exacerbation. The general condition of the patients is better than with acute form disease, no significant intoxication observed. But gradually patients become irritable, it is difficult for such patients to concentrate, and their performance decreases.

ICD 10 code for chronic paraproctitis is K 60.3. It is called an anal fistula and belongs to the heading K 60.0 - fissure and fistula of the anus and rectum.

Other codes related to chronic paraproctitis in the international classification are as follows: K 60.4 (rectal fistula) and K 60.5 (anorectal fistula). The first implies the formation of a pathological canal only within the anus, the second - between the intestinal cavity and the anus.

Conclusion

Paraproctitis is one of the unpleasant diseases in proctology; acute and chronic forms have equally unfavorable effects on the body. Symptoms of the inflammatory process of the pelvic floor tissue cause serious discomfort for patients, especially in the case of the formation of a fistula.

It is important for patients to see a doctor in time. Specialists need to correctly determine the type of pathology for the correct treatment path. For this purpose, it is imperative to have an idea of ​​the situation of this disease in the international classification of diseases.

Anorectal abscess. Cryptoglandular abscess.

ICD-10 CODE

K61. Abscess of the anus and rectum.

CLINICAL PICTURE

When transitioning to the chronic stage, paraproctitis in children occurs in fistulous and non-fistula variants.

The fistula variant accounts for 95% of cases. It is rarely found in the “classical” form, which is characterized by an internal opening in the intestine, a fistulous tract with more or less pronounced cicatricial changes in the tissue, as well as an external opening in the skin of the perineum (Fig. 28-11). This type of fistula is found only in older children, and in infants the external opening as such is usually absent. After the maturation phase, which lasts up to 3-4 weeks, after the opening of the perirectal abscess, the maturity phase begins. In this case, a fistula is formed on the basis of an already existing communication with the rectum, and an abscess is an intermediate stage in its formation. There is every reason to believe that a certain proportion of fistulas of this kind have a congenital basis. At the very beginning of the postnatal period, some of them for a short time have the form of incomplete internal ones (opening only into the intestinal lumen) without clinical manifestations, but then, due to the resulting inflammation, they turn into complete ones, sometimes located symmetrically.

Rice. 28-11. Chronic paraproctitis with multiple simple fistulas in an infant.

Symptoms are characterized by periodic and strictly local exacerbations of the inflammatory process. At the site of the previously existing external opening, a small amount of purulent fluid accumulates, covered with a thin epidermal film. This film is easily destroyed, a drop or two of pus comes out, and then for several days a scanty serous-purulent discharge comes out through the fistulous opening. Pain and hyperemia around the fistula opening are moderate. After a short period of time, the fistula closes again. The intervals between such “exacerbations” can last from several weeks to several months and even years. The general condition of the child is satisfactory. Noteworthy is the fact that, despite repeated exacerbations, the emergence of new fistula tracts-branchings or new external fistula openings does not occur; sometimes, after a series of relapses, the fistula does not make itself felt for a long time. Apparently, the internal opening of the fistula is practically obliterated or has microscopic dimensions, so reinfection through it is minimal.

According to statistics, among all proctological pathologies, paraproctitis ranks 4th in terms of prevalence. Often the disease is diagnosed in men.

Paraproctitis (ICD-10 code - K61) refers to an acute or chronic inflammatory process occurring in the adipose tissue surrounding the rectum. Often the pathology is accompanied by hemorrhoids and occurs when pathogens penetrate through the affected skin of the anal area. If signs of the disease appear, you should definitely consult a doctor for diagnosis and subsequent treatment.

Classification

According to the classification, paraproctitis is divided into several types according to the form of its occurrence, the cause of its occurrence, and the location of the lesion. Depending on the course of the disease, it can be acute or chronic. Regardless of the classification of acute paraproctitis, it represents the character that formed in the patient for the first time. In turn, doctors identify several different forms of this disease. According to the classification of paraproctitis by localization, doctors distinguish the following types:

• rectal;
• submucosa;
• subcutaneous;
• ischiorectal;
• necrotic;
• pelviorectal.

All these forms have their own specific manifestations, which must be taken into account when making a diagnosis. Subcutaneous paraproctitis, a photo of which demonstrates the peculiarity of the pathology, is characterized by the presence of purulent inflammation of the subcutaneous tissue of the perianal area, which, with timely treatment, has a favorable prognosis.

With ischiorectal paraproctitis, a purulent-inflammatory process occurs in the rectal fossa. The submucosal form is characterized by the fact that inflammation occurs in the submucosal layer of the rectal canal. In the pelviorectal type of disease, the area of ​​purulent lesion is localized inside the pelvis.

The acute necrotic form is considered one of the most severe, as it provokes significant necrotic tissue damage and is characterized by lightning-fast progression. According to the classification of paraproctitis by etiology, the following types are distinguished:

• specific;
• nonspecific;
• anaerobic;
• traumatic.

The chronic type of pathology is characterized by the fact that inflammation affects almost the entire perirectal space and surrounding tissues. The disease is characterized by a long course with periods of exacerbation and remission, resulting in the formation of fistulas. The chronic form always develops against the background of an acute lesion with improper or inadequate treatment.

As a result, fistulas are formed, which do not heal for a very long time and combine the cavity of the perirectal abscess with other organs or open outward. According to the classification of chronic paraproctitis, complete and incomplete types are distinguished, as well as internal or external fistulas. In addition, they may differ in location. In addition, there are different types of paraproctitis, which are divided according to how they are located in relation to the sphincter. That is why fistulas such as:

• extrasphincteric;
• intrasphincteric;
• transsphincteric.

According to doctors, the most common reason the occurrence of a chronic form of the disease - improper treatment and late consultation with a doctor. That is why, if you have symptoms of the disease, you should immediately consult a doctor for treatment.

Causes

The main cause of the disease is pathogens that penetrate from the rectum. Any household injuries, wounds, as well as surgery on the mucous membrane can cause infection. In addition, bacteria can penetrate through sinusitis and caries. With the flow of lymph and blood, pathogens from the area of ​​inflammation are carried to other tissues and organs.

Another way bacteria can enter is by blocking the anal gland duct. Regardless of the type of paraproctitis, factors such as poor nutrition, the presence of inflammatory processes, and a sedentary lifestyle contribute to the formation of the disease. Additional provoking factors include:

• diabetes;
• weakened immune system;
• anal intercourse;
• vascular atherosclerosis;
• fissures in the anal area.

In especially severe cases, inflammation affects several areas located near the intestines.

Main symptoms

The acute form of the disease is characterized by a sudden onset and intensity of manifestation. External symptoms of paraproctitis (photos on this topic are presented in the article) largely depend on the localization of the pathology, the area of ​​​​the lesion, the characteristics of the pathogen, as well as the body’s ability to resist. Some common clinical manifestations are observed in all types of this disease. These include:

• symptoms of poisoning;
• hyperemia and fever;
• problems with bowel movements;
• soreness in the anal area.

Each form of damage is characterized by certain symptoms. With subcutaneous paraproctitis, the symptoms, a photo of which allows you to determine the specific nature of the inflammation, are expressed in the form of severe redness of the skin, tissue compaction, swelling, pain on palpation, as well as the inability to sit normally. The affected area immediately changes, which forces the patient to immediately consult a doctor.

Symptoms of the ileorectal form are also nonspecific, and only after a week of the disease can one notice signs such as:

• swelling;
• skin redness;
• asymmetry of the buttocks.

Chronic paraproctitis (we cannot provide a photo for aesthetic reasons) is characterized by the formation of a fistula. It is a kind of formation with a channel going out. Purulent contents are released through the abscess located at the site. When the pathology is complicated, additional formations are formed.

Disease in children and pregnant women

Children are also periodically diagnosed with paraproctitis, however, it is not always possible to promptly recognize the course of the pathology. It is worth noting that this disease occurs mainly due to microtraumas, stagnation of feces, as well as blockage with viscous secretions. Since the classification of paraproctitis is quite extensive, it is necessary to carry out a diagnosis to exclude the presence of a perineal abscess.

Among the main signs are anxiety and causeless crying, increased temperature, the presence of compaction and redness near the anus. In case of fistula formation, purulent discharge may be present.

In some cases, the formation of paraproctitis in pregnant women is possible, which can have a very bad effect on the condition of the fetus, especially if there is a purulent formation in the first trimester of pregnancy. When the very first signs appear, you need to consult a doctor who will determine pregnancy management and treatment tactics.

It is imperative to understand exactly what classification, clinical picture, diagnosis and treatment of paraproctitis exists so that the development of dangerous complications can be prevented. Diagnosis of the disease implies:

• collection of complaints;
• examination of the rectal area and perineum;
• palpation of the abscess area;
• examination of the anus;
• laboratory test;
• probing the fistula;
• tomography;
• fistulography;
• ultrasound examination.

An experienced specialist for precise setting A correct diagnosis will be sufficient to collect anamnesis and existing complaints. However, in complex cases, additional diagnostic techniques are required. It is often necessary to differentiate paraproctitis from other diseases, since at the beginning of its course it does not have any characteristic signs.

Features of treatment

Regardless of the classification of paraproctitis, treatment mainly involves surgery. To do this, the doctor opens the purulent formation, drains it and removes it. Only this will allow for a complete cure.

The chronic form is mainly treated conservatively if there is an exacerbation of the inflammatory process. This is done to eliminate the abscess. The patient is also prescribed antibiotics and physical therapy. Full recovery occurs in approximately 5 weeks, subject to strict adherence to all doctor’s recommendations.

Drug treatment

A mandatory step in the treatment of paraproctitis is the use of antibiotics. They can be used systemically and locally. In acute cases of the disease, it may be prescribed antibacterial treatment after paraproctitis, as this will prevent the development of complications after surgery. In case of chronic disease, antibiotics can be prescribed during preoperative preparation and in the postoperative period.

Among the main drugs used for treatment are Gentamicin, Cefotaxime, and Metronidazole. It is worth noting that systemic antibacterial drugs are not used to treat all patients. Such products can also be used as powders, ointments and creams. Local use of antibacterial agents helps speed up the healing process and prevent the occurrence of infectious complications. Often drugs such as Levomekol or Levosin are prescribed. These drugs are applied directly to the wound, pre-treated with an antiseptic, 2 times a day. From above you need to cover the wound with a gauze bandage.

Surgical treatment

When treating paraproctitis, surgery is considered the main method. During surgery under epidural anesthesia or general anesthesia, the doctor opens the abscess, carries out subsequent drainage of this area, and then detects the fistulous tract and the affected crypt, as well as their elimination.

The operation is performed in a specialized medical facility, and this procedure requires a highly qualified surgeon, extensive experience and good knowledge of anatomy.

Physiotherapy

Physiotherapeutic techniques are widely used in the acute form of the disease in the postoperative period, as well as in the chronic course of the disease. Physiotherapeutic techniques can be used in preparation for surgery to reduce the inflammatory process and destroy pathogens. The most effective physical therapy techniques are:

• ultraviolet irradiation in the affected area;
• electrophoresis;
• magnetic therapy;
• electrophoresis;
• irradiation with infrared rays.

When carrying out physiotherapeutic treatment of paraproctitis, patient reviews are very good, since such techniques help to very quickly eliminate existing disorders.

You can treat paraproctitis at home using folk remedies. However, it is worth remembering that an operation is required first, since this is a surgical pathology. Folk remedies can be used as a complement to primary treatment. In addition, you must first consult with your doctor.

You can stop inflammation using such means as:

• juice or infusion of red rowan berries;
• infusion of yarrow, sage and chamomile;
• herbal teas;
• calendula tincture;
• baths with sea salt.

Red rowan juice or infusion should be taken daily 3 times a day before eating. Red rowan has pronounced anti-inflammatory properties, and is also distinguished by its antibacterial, antimicrobial and anti-inflammatory effects.

Calendula tincture can be applied to the external outlet of the fistula for disinfection. Baths with mumiyo also have a good effect. To prepare them, you need to dissolve the mummy tablets in hot water, and when the solution reaches room temperature, pour it into a wide basin and sit in it. In addition, rectal suppositories made from raw potatoes can be used for treatment. From the vegetable you need to cut a cylinder as thick as your little finger, lubricate it with Vaseline and insert it into the anus overnight. This remedy helps reduce painful sensations and inflammation.

Diet

There is no special diet for patients suffering from paraproctitis. During the course of the disease, experts recommend adhering to fractional meals. You need to eat in small portions 4-5 times a day. Soups must be present in the diet. Dinner should be light and must consist of any fermented milk products or fresh vegetables.

From your usual diet you need to exclude fatty fish, poultry and meat, as well as spicy and fried foods, and also limit the consumption of alcohol, white bread, and baked goods. Meals should be prepared using gentle heat treatment. It is also important to maintain adequate water balance in the body, that is, consume at least 1.5 liters of water per day.

Recovery period

After surgery to remove paraproctitis, patients must follow the regimen. For 3 days you need to consume a lot of fluid, after which you are prescribed a strict diet. It is imperative to exclude fatty, fried, salty, and sour foods from your usual diet.

The postoperative period, which lasts for at least 3 weeks, is very important. During this entire time, it is imperative to carefully monitor the perineal area and postoperative wound. Must be appointed antibacterial agents for systemic use. Dressing of the wound using antiseptic solutions, ointments. A remedy to improve healing also helps in treatment.

Possible complications

Acute paraproctitis can be very dangerous due to its complications, among which are the following:

• melting of the urethra, vagina and other organs with pus;
• necrotic damage to the walls of the rectum;
• leakage of feces into the perirectal tissue;
• purulent inflammation peritoneum;
• formation of a retroperitoneal abscess.

All these complications can lead to the disease developing into sepsis, when pathogens enter the bloodstream and can even lead to the death of the patient. In addition to this, there are a number pathological conditions, which are formed against the background of the chronic form of paraproctitis, in particular, such as:

• formation of scar tissue;
• deformation of the rectal canal;
• leakage of feces from the anus;
• weakness of the anal sphincter;
• rectal stricture.

Chronic fistulas are covered from the inside with epithelium, the cells of which, with prolonged pathological processes may degenerate into a malignant form. The risk of cancer is another good reason to immediately seek help when the first signs of the disease appear. medical care.

Prevention and prognosis

Doctors distinguish between primary and secondary prevention of the disease. Primary implies strengthening immune system, saturating the body with vitamins, following nutritional rules. In addition, it is very important to lead an active lifestyle, normalize weight and promptly treat diseases that can trigger the development of paraproctitis.

Secondary prevention involves a set of measures that will help prevent relapse of the disease after surgery. For this it is shown:

• preventing constipation and quickly eliminating it;
• weight control;
• diet;
• maintaining personal hygiene;
• treatment of foci of chronic infection.

A timely visit to the doctor and strict compliance with all his instructions is the only prevention of the occurrence of a chronic form of the disease.

If you consult a doctor in a timely manner, the prognosis after treatment of paraproctitis is quite favorable. However, patients who consult a doctor too late or self-medicate are at risk of not only becoming chronic, but also causing the death of the patient. The chronic form of the disease, in the absence of timely treatment, can lead to the formation of fistulas and also progress to the malignant stage.

Anorectal abscess. Cryptoglandular abscess.

ICD-10 CODE

K61. Abscess of the anus and rectum.

CLINICAL PICTURE

When transitioning to the chronic stage, paraproctitis in children occurs in fistulous and non-fistula variants.

The fistula variant accounts for 95% of cases. It is rarely found in the “classical” form, which is characterized by an internal opening in the intestine, a fistulous tract with more or less pronounced cicatricial changes in the tissue, as well as an external opening in the skin of the perineum (Fig. 28-11). This type of fistula is found only in older children, and in infants the external opening as such is usually absent. After the maturation phase, which lasts up to 3-4 weeks, after the opening of the perirectal abscess, the maturity phase begins. In this case, a fistula is formed on the basis of an already existing communication with the rectum, and an abscess is an intermediate stage in its formation. There is every reason to believe that a certain proportion of fistulas of this kind have a congenital basis. At the very beginning of the postnatal period, some of them for a short time have the form of incomplete internal ones (opening only into the intestinal lumen) without clinical manifestations, but then, due to the resulting inflammation, they turn into complete ones, sometimes located symmetrically.

Rice. 28-11. Chronic paraproctitis with multiple simple fistulas in an infant.

Symptoms are characterized by periodic and strictly local exacerbations of the inflammatory process. At the site of the previously existing external opening, a small amount of purulent fluid accumulates, covered with a thin epidermal film. This film is easily destroyed, a drop or two of pus comes out, and then for several days a scanty serous-purulent discharge comes out through the fistulous opening. Pain and hyperemia around the fistula opening are moderate. After a short period of time, the fistula closes again. The intervals between such “exacerbations” can last from several weeks to several months and even years. The general condition of the child is satisfactory. Noteworthy is the fact that, despite repeated exacerbations, the emergence of new fistula tracts-branchings or new external fistula openings does not occur; sometimes, after a series of relapses, the fistula does not make itself felt for a long time. Apparently, the internal opening of the fistula is practically obliterated or has microscopic dimensions, so reinfection through it is minimal.

Anorectal fistula

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2015

Anorectal fistula (K60.5), Rectal fistula (K60.4), Anal fistula (K60.3)

Proctology, Surgery

General information

Brief description

Recommended
Expert advice
RSE at REM "Republican Center for Healthcare Development"
Ministry of Health and Social Development of the Republic of Kazakhstan
dated December 10, 2015
Protocol No. 19

Protocol name: Fistulas of the rectum.

ICD-10 code:
K60.3 - Anal fistula
K60.4 - Rectal fistula
K60.5 - Anorectal fistula (fistula between the rectum and anus)

Abbreviations used in the protocol:
AG - Arterial hypertension
ALT - Alanine aminotransferase
AST - Aspartate aminotransferase
CD - Crohn's disease
ZAPK - obturator apparatus of the rectum
ELISA - Enzyme immunoassay
MRI - magnetic resonance imaging
UAC - General blood test
OAM - General urine test
SPK - rectal fistulas
Ultrasound - Ultrasound examination
ECG - Electrocardiography

Date of protocol development/revision: 2015

Protocol users: general surgeons, coloproctologists, general practitioners.

Classification

Clinical classification
Rectal fistulas are divided into:
by morphology:
· epithelial;
non-epithelial.
in relation to the lumen of the rectum:
· complete (there is an internal and external fistula opening);
· incomplete internal (there is no external hole, there is only an internal one).
according to the location of the internal opening in the anal canal or rectum:
· rear;
front;
· lateral.
in relation to the external anal sphincter:
· intrasphincteric;
· transsphincteric;
· extrasphincteric.

Extrasphincteric fistulas are divided into 4 degrees according to their complexity:
1) first degree of complexity of extrasphincteric fistula: the internal opening is narrow, without scars around it, there are no abscesses or infiltrates in the tissue, the course is quite straight;
2) second degree of complexity: there are scars in the area of ​​the internal opening, but there are no inflammatory changes in the tissue;
3) third degree of complexity: the internal opening is narrow without any scarring around it, but there is a purulent-inflammatory process in the tissue;
4) fourth degree of complexity: the internal opening is wide, surrounded by scars, in the perirectal tissue there are inflammatory infiltrates or purulent cavities.

High-level rectal fistulas are distinguished separately, in which the internal fistula opening is located above the dentate line, in the lower ampullary section of the rectum.

Clinical picture

Symptoms, course

Diagnostic criteria making a diagnosis:

Complaints and anamnesis:

Complaints:
· the presence of an external fistula opening on the skin of the perianal region, perineum or gluteal region;
· discharge from the external fistula opening, serous, purulent or sanguineous;
· discharge of pus from the rectum;
· periodically occurring painful infiltrate in the perianal area, perineum;
· discomfort in the anus;
· pain in the anus.

Anamnesis:
Single or multiple opening of acute paraproctitis, pain of unknown origin in the anus and rectum, spontaneous opening of an abscess in the anus.

Physical examination
Examination of the patient on a gynecological chair in a lateral or knee-elbow position. Assess the presence of an external fistula opening on the skin of the perianal area, perineum or gluteal region.
A digital examination of the rectum reveals a fistula opening and the presence of pararectal infiltrates.

Diagnostics

List of basic and additional diagnostic measures

Basic (mandatory) diagnostic examinations performed on an outpatient basis(in case of emergency hospitalization, diagnostic examinations are carried out that were not carried out at the outpatient level):
general blood test;
general urine analysis;

Contrast radiography (fistulography) of the fistula tract.

Additional diagnostic examinations performed on an outpatient basis:
· ECG to exclude cardiac pathology;
general radiography of organs chest in order to exclude pathology of the pulmonary system;
· sigmoidoscopy.

The minimum list of examinations that must be carried out when referred for planned hospitalization: in accordance with the internal regulations of the hospital, taking into account the current order of the authorized body in the field of healthcare.

Basic (mandatory) diagnostic examinations carried out at the hospital level:
· blood clotting time;
· biochemical analysis blood (total protein, urea, creatinine, glucose, bilirubin, ALT, AST);
· blood type, Rh factor;
· blood test for HIV;
· blood test for syphilis;
· determination of markers of hepatitis B (HBsAg) and C (anti-HCV);
· sigmoidoscopy;
· test with dye;
· examination of the fistula tract with a button probe;
· physical examination: digital examination; determination of skin reflex from perianal skin; determination of the tone and volitional efforts of the PAP.

Additional diagnostic examinations carried out at the hospital level:
· ECG to exclude cardiac pathology;
· radiography of the chest organs to exclude lung pathology;
Colonoscopy (UD-B);
· fistulography (UD-V);
· ultrasonography with a rectal sensor (UD-V);
· computed tomography of the pelvis and perineum;
· magnetic resonance imaging of the pelvis;

Instrumental studies:
· during anoscopy or sigmoidoscopy, the internal fistula opening is visualized;
· with fistulography, a fistulous tract is revealed, with the presence of leakage cavities in the pararectal cellular spaces, with a highly located internal fistula opening, with horseshoe-shaped, recurrent extrasphincteric fistulas, with differential diagnosis between a rectal fistula and a pararectal cyst;
· with ultrasonography with a rectal sensor, incl. three-dimensional, the location of the fistula tract is determined in relation to the anal sphincter, with clarification of the location of the internal fistula opening;
· with computed tomography or magnetic resonance imaging of the pelvis and perineum, it is possible to assess the location of fistulous tracts and cavities in patients with perianal complications in Crohn's disease.

Indications for consultation with specialists:
· therapist (cardiologist) - for correction of persistent arterial hypertension(AH), chronic heart failure, cardiac arrhythmia.
· endocrinologist - for diagnosis and correction of treatment of diseases of the endocrine system ( diabetes mellitus)
anesthesiologist - if catheterization is necessary central vein to prepare for surgery.

Laboratory diagnostics

Laboratory research:
In peripheral blood: leukocytosis due to bacterial infection.

Differential diagnosis

Differential diagnosis

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Treatment

Treatment goals:
· excision of the fistula tract with elimination of the internal opening of the fistula;
· prevention of fistula recurrence.

Treatment tactics:
The only radical method of treating rectal fistulas is surgery.

Surgical intervention

Surgical intervention provided in an inpatient setting

The most common types of operations for rectal fistulas:.
· excision of the fistula into the lumen of the rectum;
· excision of the fistula into the lumen of the rectum with opening and drainage of the leaks;
· excision of the fistula into the lumen of the rectum with suturing of the sphincter;
· excision of the fistula with an elastic ligature;
· excision of the fistula with movement of the muco-submucosal, muco-muscular or full-thickness rectal flap into the anal canal.

Selection of operation method, is mainly determined taking into account the following characteristics:
· localization of the fistulous tract in relation to the external anal sphincter;
· the degree of development of the cicatricial process in the intestinal wall, the area of ​​the internal opening and along the fistula;
· the presence of purulent cavities and infiltrates in the perirectal tissue.

Contraindications: severe diseases of various organs and systems in the stage of decompensation. If it is possible to achieve an improvement in the condition after treatment, then surgery becomes possible.
The timing of radical surgery is determined mainly by clinical course diseases.

Non-drug treatment:

Mode:
· on the first day after surgery - strict bed rest;
· on the 2-3rd day after surgery - mode II;
· further - with a smooth course of the postoperative period - free mode.

Diet:
· on the first day after surgery - hunger;
· further - with a smooth course of the postoperative period - table No. 15.

Drug treatment provided at the stationary level:
Drug treatment is carried out with one of the following drugs, according to the table.

List of main medicines:

Drugs (active ingredients) used in treatment

Hospitalization

Indications for hospitalization, indicating the type of hospitalization:

planned hospitalization: if you suspect a rectal fistula.

emergency hospitalization: exacerbation of chronic paraproctitis with the formation of an abscess.
It is not advisable to delay radical treatment for a long time, because the exacerbation may recur; the inflammatory process with subsequent scarring of the wall of the anal canal, sphincter and pararectal tissue can lead to deformation of the anal canal and perineum and the development of anal sphincter insufficiency.

Prevention

Preventive measures
A possible means of prevention is timely surgical treatment acute paraproctitis with adequate drainage of the purulent cavity and subsequent monitoring of wound healing.
. First of all, you should make sure that after opening acute paraproctitis, patients have a clear understanding of the possibility of incomplete healing of the wound with subsequent formation of a fistula or the possibility of recurrence of the purulent-inflammatory process in the pararectal tissues.
. It is necessary to ensure that patients, after opening acute paraproctitis, understand the importance of promptly notifying the doctor of the appearance of any clinical manifestations.
. A possible measure to prevent the development of the disease is timely treatment of concomitant diseases of the anorectal zone (hemorrhoids, anal fissure, cryptitis).

Further management
. In the postoperative period, patients who have undergone surgery for an anal or rectal fistula require regular dressings, which consist of cleaning the wounds with antiseptic solutions and applying water-soluble ointment bases to the wound surface.
. To date, there is no definite data on the need to use antibacterial drugs in the postoperative period. It may be advisable to carry out antibacterial therapy after plastic surgery regarding a rectal fistula (reduction of a flap of the rectal wall, excision of the fistula with suturing of the sphincter), as well as in the presence of a pronounced inflammatory process in the pararectal tissues and the rectal wall in order to speed up its relief.
. The need to soften stools through diet and laxatives may be advisable after plastic surgery for rectal fistula.
. Complex physiotherapeutic treatment - daily ten-minute sessions of UV irradiation, the use of UHF exposure in the range of 40-70 W and microwave therapy in the range of 20-60 W.
. Hyperbaric oxygenation.
In duration, this period in most cases ranges from 7 to 11 days after the patient’s admission to the hospital, and in case of extrasphincteric fistulas - up to 2-3 weeks or slightly longer.

Information

Sources and literature

1. Minutes of meetings of the Expert Council of the RCHR of the Ministry of Health of the Republic of Kazakhstan, 2015
   1. List of used literature: 1) Aminev A.M. Guide to proctology. M., 1973; vol.3, p.63-345. 2) Dultsev Yu.V., Salamov K.N. Paraproctitis. M., 1981. 3) Fedorov V.D., Dultsev Yu.V. Proctology. M, 1984, pp. 136-154, 299-307. 4) Ommer A., ​​Herold A., Berg E., et al. Cryptoglandular Anal Fistulas. Dtsch Arztebl Int. 2011;108(42):707-713. 5) Bleier J., Moloo H. Current management of cryptoglandular fistula-in-ano. World J Gastroenterol. 2011;17(28):3286-3291. 6) Zanotti C, Martinez-Puente C, Pascual I., et al. An assessment of the incidence of fistula-in-ano in four countries of the European Union. Int J Colorectal Dis. 2007;22:1459-1462. 7) Sainio P. Fistula-in-ano in a defined population. Incidence and epidemiological aspects. Ann Chir Gynaecol. 1984;73:219-224. 8) Vorobiev G.I. Basics of coloproctology. M, 2006, pp. 135-152. 9) Shelygin Yu.A., Blagodarny L.A. Directory of coloproctologist. Littera, 2012. 10) Becker A., ​​Koltun L., Sayfan J. Simple clinical examination predicts complexity of perianal fistula. Colorectal Dis. 2006;8:601-604. 11) Schwartz D.A., Wiersema M.J., Dudiak K.M., et al. A comparison of endoscopic ultrasound, magnetic resonance imaging, and exam under anesthesia for evaluation of Crohn’s perianal fistulas. Gastroenterology. 2001;121:1064-1072. 12) Gonzalez-Ruiz C, Kaiser A.M., Vukasin P., et al. Intraoperative physical diagnosis in the management of anal fistula. Am Surg. 2006;72:11-15. 13) Weisman R.I., Orsay C.P., Pearl R.K., Abcarian H. The role of fistulography in fistula-in-ano: report of five cases. Dis Colon Rectum. 1991;34:181-184. 14) Bussen D., Sailer M., Wening S., Fuchs K.H., Thiede A. Wertigkeit der analen Endosonographie in der Diagnostik anorektaler Fisteln. ZentralblChir. 2004;129:404-407. 15) Lengyel A.J., Hurst N.G., Williams J.G. Pre-operative assessment of anal fistulas using endoanal ultrasound. Colorectal Dis. 2002;4:436-440. 16) Maor Y., Chowers Y., Koller M., et al. Endosonographic evaluation of perianal fistulas and abscesses: comparison of two instruments and assessment of the role of hydrogen peroxide injection. J Clin Ultrasound. 2005;33:226-232. 17) Ratto C, Grillo E, Parello A, Costamagna G, Doglietto G.B. Endoanal ultrasound-guided surgery for anal fistula. Endoscopy 2005;37:722-728. 18) Toyonaga T., Matsushima M., Tanaka Y., et al. Microbiological analysis and endoanal ultrasonography for diagnosis of anal fistula in acute anorectal sepsis. Int J Colorectal Dis. 2007;22:209-213. 19) Toyonaga T. , Tanaka Y., Song J.F., et al. Comparison of accuracy of physical examination and endoanal ultrasonography for preoperative assessment in patients with acute and chronic anal fistula. Tech Coloproctol. 2008;12:217-223. 20) Buchanan G.N., Halligan S., Bartram C.I., Williams A.B., Tarroni D., Cohen C.R. Clinical examination, endosonography, and MR imaging in preoperative assessment of fistula in anno: comparison with outcome-based reference standard. Radiology. 2004;233:674-681. 21) Guillaumin E., Jeffrey R.B. Jr., Shea W.J., Asling C.W., Goldberg H.I. Perirectal inflammatory disease: CT findings. Radiology. 1986;161:153-157. 22) Yousem D.M., Fishman E.K., Jones B. Crohn disease: perianal and perirectal findings at CT. Radiology. 1988;167:331-334. 23) Sahni V.A., Ahmad R., Burling D. Which method is best for imaging of perianal fistula? Abdominal Imaging. 2008;33:26-30. 24) Schaefer O., Lohrmann C, Langer M. Assessment of anal fistulas with high-resolution subtraction MR-fistulography: comparison with surgical findings. J MagnReson Imaging. 2004;19:91-98. 25) Nelson J., Billingham R. Pilonidal disease and hidradenitis suppurativa. In: Wolff B.G., Fleshman J.W., Beck D.E., Pemberton J.H., Wexner S.D., eds. The ASCRS Textbook of Colon and Rectal Surgery. New York: Springer; 2007:228 -235. 26) Gaertner W.B., Hagerman G.F., Finne CO., et al. Fistula-associated anal adenocarcinoma: good results with aggressive therapy. Dis Colon Rectum. 2008;51:1061-1067.

Information

List of protocol developers:
1) Abdullaev Marat Shadybaevich - doctor medical sciences, professor, State Public Enterprise at the Central City Clinical Hospital of the Almaty City Health Department, director, chief freelance coloproctologist of the Ministry of Health of the Republic of Kazakhstan.
2) Enkebaev Marat Kobeiuly - Candidate of Medical Sciences, State Public Enterprise at the Central City Clinical Hospital of the Almaty City Health Department, doctor of the department of coloproctology and acute chemical insufficiency.
3) Marat Alibekovich Kalenbaev - Candidate of Medical Sciences, State Public Enterprise at the Central City Clinical Hospital of the Almaty City Health Department, head of the department of coloproctology and acute chemical insufficiency.
4) Elmira Maratovna Satbaeva - Candidate of Medical Sciences, RSE at the PVC “Kazakh National Medical University named after S.D. Asfendiyarov” Head of the Department of Clinical Pharmacology.

Conflict of interest: absent.

Reviewers: Shakeev Kairat Tanabaevich - Doctor of Medical Sciences, Deputy Chief Physician of the Hospital of the Medical Administration of the President of the Republic of Kazakhstan, Astana.

Conditions for reviewing the protocol: review of the protocol 3 years after its publication and from the date of its entry into force and/or in the presence of new methods with a high level of evidence.

Attached files

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