China Association of Chinese medicine anorectal Branch, Chinese Medical Association of colorectal surgery surgery branch of study group, Chi
China Association of Chinese medicine anorectal Branch, Chinese Medical Association of colorectal surgery surgery branch of study group, Chinese Association of integrative medicine in the diagnosis of Coloproctological Specialized Committee, standard reference "archosyrinx (2002, draft)" on the basis of the combination of evidence-based medical research results and expert opinions, formulate the "guide" of clinical diagnosis and treatment of anal fistula China, for reference for clinicians.
Anal fistula is chronic and pathological tunnel between the anal canal and perianal skin, often in the form of perianorectal abscess burst or incision and drainage, mainly related to anal gland infection. Chinese medicine called "anal fistual".
First, clinical manifestation
1 symptoms: recurrent perianal swelling, pus, acute inflammation period of fever.
2 local examination: the external appearance, location and secretion can be seen. Around the anus shallow anal fistula can touch a scleroma and act. Rectal palpation can be used to reach the mouth, depression, and nodules.
3 auxiliary examination:
(1) probe: preliminary exploration of the fistula.
(2) anorectal examination: with the use of hydrogen peroxide or methylene blue (concentration), can be used to determine the location of the mouth.
(3) fistulogrphy: using meglumine diatrizoate contrast medium, especially valuable for the diagnosis of complex anal fistula.
(4): transrectal ultrasonography to observe the trend, the internal fistula mouth, as well as the relationship between the judge and the sphincter fistula.
(5) CT or magnetic resonance imaging for the diagnosis of complex anal fistula, can better show the relationship between the fistula and anal sphincter.
4 Classification of anal fistula:
(1) domestic classification:
A. low anal fistula
The simple low anal fistula: inside the mouth in the anus recess, only a fistula through the external sphincter skin bottom or shallow, and the skin is.
Low complex anal fistula: there are two more than in the mouth or mouth, fistula in external sphincter anal fistula and lower superficial skin.
B. high anal fistula
High anal fistula: inside the mouth in the anus recess, only a fistula, walking in the above deep external sphincter.
High complex anal fistula: two above the mouth, through the fistula and the outlet is connected with the branch or within the cavity, the head of the external sphincter by more deep.
(2) Parks classification:
The classification depends on the relationship between anal fistula, fistula and anal sphincter is divided into: intersphincteric transsphincteric type, type, type, shape above the sphincter sphincter. When crossing the external sphincter of 30-50% fistula (high intersphincteric, above the sphincter, sphincter foreign), female front fistula, multiple recurrent fistula, fistula, or with anal incontinence, after treatment may cause anal incontinence of anal fistula were considered complex anal fistula.
Two, differential diagnosis
With anal fistula of tuberculous anal fistula, inflammatory bowel disease, anal fistula and perianal suppurative hidrosadenitis subcutaneous cyst infection, perineum urethral fistula, sacrococcygeal teratoma cyst or abscess, infection of pilonidal sinus infection, rectal endometriosis, Bartholin's gland cyst infection identification. In addition, no common tuberculosis or Actinomyces infection also showed specific anal fistula, detailed history and clinical examination is helpful to the correct diagnosis.
1 intrinsic damp
About anal pus pus, qualitative thick, anal pain, local swelling and heat, thirst without desire to drink, stool, urine short, body trapped heavy, red tongue, yellow greasy moss, pulse a few strings.
2 is the virtual evil Love
Perianal discontinuous thin pus pus, mouth skin dull, fistula when the break is faint pain, anus, accompanied by lassitude, pale tongue, thin, soft pulse.
3 heat accumulation
Suddenly pain around the anus, continue to increase, with chills, fever, constipation, urine short red. Perianal redness, tenderness, hard, hot surface. Red tongue, thin yellow tongue, pulse number.
Principle of treatment
Surgery is the main method for the treatment of anal fistula, the basic principle is: removal of the lesions, unobstructed drainage, as far as possible to reduce anal sphincter injury, protect the anal function. Due to the complexity of anal fistula and some special pathological background, postoperative anal fistula has some recurrence rate. In view of the special importance of pathological and physiological environment and anal function of high complex anal fistula, with fistula survival ", can also be used as a principle to choose, should not blindly pursue radical operation and ignore the possible serious complications caused by. Traditional Chinese medicine treatment is limited to the patient's recovery period adjustment and is not suitable for surgery.
Two, non-surgical treatment
(a) TCM Treatment
1 types of syndrome
(1) the poisoning caused by intrinsic
Treatment: heat detoxification, dehumidification swelling.
Example: Bixie Shenshi Decoction and five kinds of disinfection decoction.
Commonly used drugs: 30g, the Bixie coix seed, Poria, Cortex Phellodendri, Cortex Moutan, 12g 15g, G 30 Alisol each talc (bag), rice 6G, 9g of honeysuckle flower, wild chrysanthemum, dandelion, Viola 4G.
(2) the love of evil
Treatment: replenishing qi and blood, Tori shengji.
Commonly used drugs: ginseng, Atractylodes, Poria, licorice, angelica, chuanxiong, radix rehmanniae, Radix Paeoniae Alba, Radix Astragali, cinnamon 10g.
(3) heat accumulation
Treatment: purging fire detoxification, blood stasis.
Five cases: disinfection drink with Xianfang Huoming decoction.
Commonly used drugs: honeysuckle, wild chrysanthemum, dandelion, 10g, angelica 10g, Herba Violae frankincense, myrrh 10g, 10g to 10g, Zaoci tail.
2 Chinese medicine external wash
Qingrejiedu, swelling and pain. Such as: Sophora flavescens decoction, detoxification soup, etc..
(two) sticking method
The simple non inflammatory fibrin adhesive blocking feasible anal fistula treatment, the utility model has the advantages of no sphincter damage, does not affect the anus function, and the operation is easy, but the high recurrence rate.
Three, surgical treatment
(I) operation mode
1 fistula incision (except operation): suitable for simple anal fistula. Fistula incision of anal fistula resection is better, wound healing, a relatively long period of time, can cause incontinence.
2 thread hanging: reasonable selection of cutting thread and drainage line. A cutting seton: suitable for high anal fistula involving most of the external anal sphincter more shallow. The two part: suitable for cutting seton high anal fistula with residual cavity drainage or difficult to handle, two times of surgery and postoperative. Long term drainage hung: suitable for high anal sphincter by Crohn's disease patients, to prevent the formation of recurrent abscess and anal function. The short-term drainage Seton: although short-term clinical reports of hanging line drainage in the treatment of anal fistula, completely retained sphincter, will not lead to incontinence, but because of its high recurrence rate, clinical application should be cautious.
3 mucosal flap surgery: for patients and female goes in front of high anal fistula in clear anal fistula without severe infection.
Clinical also can use the organic combination of incision, exclusion, hanging wire, suture method, reduce trauma.
(two) postoperative complications
Especially high complex anal fistula may occur after anal mucosa eversion, displacement, defect, anal incontinence and other complications. The wound should be reduced as much as possible, and the anal sphincter repair or skin flap surgery should be performed if necessary.
(three) treatment of special patients
1 anal Crohn's disease
At the same time in systemic treatment as far as possible to conservative treatment. No symptoms of Crohn's disease: without surgical treatment of anal fistula; anal fistula of low Crohn's disease: the fistula incision; anal fistula complicated Crohn's disease: long-term hanging line for palliative treatment of this. If the intestinal mucosa is normal, the normal mucosa can be used to close the mouth.
2 tuberculous anal fistula
Combined with antituberculosis drugs (isoniazid, rifampicin, ethambutol, streptomycin) combined with traditional Chinese medicine (including traditional Chinese medicine topical ointment and bath), the main component are: Purslane, phellodendron, Lithospermum, Sophora, angelica, angelica, dried alum, with superficial fistula, self-healing may be non operative, invalid choice incision