Paraproctitis is an inflammation of the tissue surrounding the rectum that is usually caused by bacteria. It can be acute or chronic. Symptoms depend on the location of the abscess and range from pain and swelling near the anus to fever and abdominal pain. Diagnosis involves a digital rectal exam and sometimes ultrasound or fistulography. Treatment of acute paraproctitis involves surgically opening and draining the abscess, removing infected tissues. Chronic paraproctitis may require additional surgery to remove fistulas. Complications can occur if the infection spreads to nearby organs. Preventing recurrence involves a healthy lifestyle and regular bowel movements.

1. Paraproctitis

2. paraproctitis
•
(Pararectal abscess) - acute or chronic bacterial
inflammation of the peritoneal tissue

3. etiology
• Paraproctitis is one of the most frequent proctologic diseases
(20-40% of all diseases of the rectum). Paraproctitis in
frequency is the 4th place after hemorrhoids, anal fissures
and colitis. Men suffer from paraproctitis more often than
women.This ratio ranges from 1.5: 1 to 4.7: 1. Paraproctitis is
a disease of adults: there are rare descriptions of fistulas of
the rectum in children.

4. Etiology (flora)
• E. coli;
• Anaerobes;
• Staphylococcus aureus;
• White staphylococcus aureus;
• streptococcus;
• Enterococcus;
• Clostridial anaerobes: Cl.perfringens, Cl.Hystoliticum, Cl.oedematiens,
Cl.septicum

5. Pathogenesis. Ways of introduction of
infection into pararectal tissue

6. Columns of Morgagni
(columnae Morgani)

7. • Infection can penetrate through the anal glands, damaged rectum
mucosa, hematogenous and lymphogenous pathway, from
neighboring organs affected by the inflammatory process. A
number of researchers consider paraproctitis a fairly frequent
complication of ulcerative colitis and Crohn's disease. Purulent
processes in the cells around the rectum are observed in diseases
of the prostate gland, urethra, paraurethral, Cooper glands,​​
female sexual organs (perimetritis, bartholinitis), sometimes with
osteomyelitis of pelvic bones, spinal tuberculosis.

8. Typical ways of spreading the inflammatory
process
• The entrance gates are anal crypts, which open the ducts of the anal
glands, or (much less often) the damaged mucosa of the anal canal.
• In paraproctitis, fistulous holes are described on the scrotum, thigh,
anterior abdominal wall. In addition, it is possible that abscess can
break through into the lumen of the intestine at the level of the
ampullar part of it and even into the abdominal cavity.

9. Classification of paraproctitis.
The etiological principle distinguishes:
Nonspecific paraproctitis,
Specific paraproctitis,
Post traumatic paraproctitis.
By the activity of the inflammatory process:
Acute paraproctitis,
Recurrent paraproctitis,
Chronic paraproctitis (fistulas of the rectum).

10. Localization of abscesses
- Subcutaneous paraproctitis;
- Submucosal paraproctitis;
- Ischial-rectal paraproctitis;
- Behind-rectal paraproctitis;
- Pelvic-rectal paraproctitis (pelvio-rectal).

11. 52%
4%
42%
2%
частота различных форм
подкожный подслизистый -седалищно прямокишечный -тазово прямокишечный

12. • 1-subcutaneous;
• 2 submucosal;
• 3-ischial-rectal;
• 4-pelvis and rectum;
• 5- behind-rectal.

13. Retrorectal paraproctitis

14. clinics
• PECULIARITIES OF CLINIC AND PARAPROCTITIS ARE DETERMINED BY
LOCALIZATION OF THE FOCUS IN THE CELLULAR SPACES OF THE PELVIS
• At the beginning of the disease there is a short period with malaise, weakness and headache.
There is an increase in temperature above 37.5 ° C with chill

15. Subcutaneous paraproctitis

16. • Submucosal abscess is located under the mucosa of the rectum.
Symptoms in this form of location are similar to subcutaneous
paraproctitis, however, the pain syndrome and skin changes are
less pronounced

17. • With ischiorectal abscess, a purulent focus is located above the muscle
that raises the anus. Because of the deeper location of the abscess, the
local symptoms are more vague: blunt pulsating pains in the small
pelvis and rectum, intensifying with defecation. Changes from the skin
in the form of redness, swelling, swelling, asymmetry of the buttocks
occur later on the 5th-6th day from the onset of pain.The general state
of health is severe: the temperature can rise to 38 ° C, intoxication is
expressed

18. • The most severe is pelvio-rectal abscess.This is a rare form of acute
paraproctitis, when the purulent focus is located above the muscles
that form the pelvic floor, a thin layer of the peritoneum separates it
from the abdominal cavity. At the beginning of the disease, severe
fever, chills, joint pain predominate. Local symptoms: pain in the pelvis
and in the lower abdomen. After 10-12 days of pain intensifies, there is
a delay of stool and urine

19. Chronic paraproctitis
• Manifested festering fistula.The mouth of the fistulous passage can be located near
the anal opening of the rectum or at a distance from it on the buttocks.The pain is
usually not expressed. From the mouth of the fistula pus often diffuses feces. During
the development of chronic paraproctitis, the opening of the fistula can be closed,
pus stagnation occurs, abscesses develop, new tissue defects appear, pus
breakthrough and outflow into the rectum and outward, necrosis and other tissue
changes that significantly complicate the fistula.Thus, there are complex fistulous
systems with branching fistula, cavity depots and a lot of holes.

21. Factors of chronic course
• The internal fistula opening (covered with the epithelial lining of the mouth of an infected
one or more anal glands opening in the Morgan crypt) is a source of permanent or periodic
infection of the pararectal tissue.
• Presence of a formed fistulous course, single or branched, located superficially or deep in
the pelvic tissues.The healing is impeded by the epithelialization of the fistula wall, which
prevents their collapse and makes the lumen open for reinfection.The internal surface of
the fistulous course is lined with granulation tissue or glandular epithelium.
• Activation of dormant surgical infection. Infection can stay in the tissues of the body more or
less for a long time without causing a disease (latent phase), but then under the influence of
various factors manifests itself in the form of acute paraproctitis (active phase). In
paraproctitis, the focus of a dormant infection can have a morphological substrate.They are
either scars at the site of the open abscess, or the remainder of the fistulous course, or a
ligated, undisclosed stitch

22. Diagnostics
• The basis of diagnosis are typical complaints and pains in the area of the rectum and​​
anus.When making a diagnosis, you need a digital rectal examination, sometimes
performed under anesthesia in the operating room because of pain.
• From laboratory methods, it is necessary to study the blood and urine, blood for
glucose, and in case of doubt - ultrasound examination of the perianal region,
including using a rectal sensor. In the presence of fistulous strokes, fistulography is
shown, the introduction of a contrast medium into the fistula with the execution of a
series of X-ray photographs.

23. treatment
• In the very initial stage of the disease, with a small infiltrate in the
perianal area, conservative treatment methods are used: sedentary
warm baths with potassium permanganate solution, lumbar procaine
blockade, warmers, UHF therapy, etc. All thermal procedures are
combined with antibiotic therapy.

24. Operative treatment
• Surgical treatment of acute paraproctitis includes early emergency
surgical intervention by opening the abscess with removal of pus and
necrotic tissues, examination of the abscess cavity with a finger,
separation of the bridges and drainage of the cavity.

25. The choice of method of anesthesia
-Infiltration anesthesia
(Vishnevsky AS, Ryzhikh AN);
- cerebrospinal anesthesia
(Yudin SS);
-operational anesthesia
(Yakovlev NA, Makhaev NM);
-General anesthesia.

26. The patient's position on the operating table

27. POSITION ON DEPAGE

28. Radical operations in acute paraproctitis can be
grouped as follows
• 1. opening and draining of the abscess, excision of the affected crypt and dissection
of the purulent course into the lumen of the intestine;
• 2. opening and draining of the abscess, excision of the affected crypt and
sphincterotomy;
• 3. dissection and drainage of the abscess, excision of the affected crypt, ligation;
• 4. dissection and drainage of the abscess, delayed excision of the affected crypt and
movement of the gut flap to interrupt the infection pathway from the lumen of the
rectum

29. • Apply radial, semilunar, crosswise incisions, the most convenient of
them - semilunar and radial.They provide a gaping wound and an
outflow of purulent exudate, as well as less traumatic. Strict bed rest is
necessary.
• When putrefied necrotic paraproctitis during the operation, complete
excision of dead fiber is performed within healthy tissues, and two or
three additional cuts of the skin and subcutaneous tissue for draining
are performed.

30. The incisions used in
acute paraproctitis:
1 - perianal abscess; 2
- behind-mousse; 3 -
Ischiorectal.

31. • Surgical approaches used for ischiorectal (1) and pelviorectal (2) abscesses.

32. DISSECTION with subcutaneous
paraproctitis

33. With subcutaneous-submucosal paraproctitis, the incision is made in the radial direction
through an interested crypt.

34. With ischial-rectal paraproctitis, a radial incision can not be
opened, it is dangerous to damage the sphincter.

35. INCISION of the retrectectal paraproctitis

36. REASSESSMENT of abscess cavity

37. Complications of paraproctitis
Purulent fusion of the rectum wall with the spread of intestinal contents into the
pararectal tissue.Widespread access to pararectal tissue for the contents of the
intestine can lead to even more severe consequences as follows:
• Formation of purulent fistula between the rectum and the vagina • Purulent melting of
the urethra, the transition of the purulent process to the scrotum followed by gangrene •
Breakdown of pus into the free Abdominal cavity and retroperitoneal tissue with the
development of peritonitis and retroperitoneal phlegmon, which lead to sepsis and
death.? Necrosis of the skin in the area of dissemination of the abscess​​

38. Complications of acute
paraproctitis

39. Prevention of recurrence of the disease
• To achieve a lasting effect, in addition to the radical surgery performed, it is
necessary to adhere to a number of rules.
• • Fighting with constipation. It is necessary to achieve a regular soft stool. •
The diet should contain plant foods rich in fiber (fresh fruit vegetables,
especially beets, cabbage), and fermented milk products (kefir, curdled milk,
cottage cheese).You should avoid a dough product. • In diabetes, the normal
blood sugar level should be maintained, otherwise purulent diseases can not
be avoided • Maintaining normal body weight • Observance of personal
hygiene rules - regular washing after stools • Treatment of chronic
hemorrhoids And anal fissures.