结直肠肛管疾病

Colon,AnorectumDiseaseGeneralSurgeryThe2ndhospitalofShenyangMedicalCollegeXuDaozhiPartsofcolondividedintocecum;ascendingcolon;transversecolon;descendingcolonandsigmoidcolon.average150cminlength(120-200cm).diameterfromcecum(7.5cm)tosigmoidcolon(2.5cm).AnatomyColonhavethreeimportantanatomiclandmarks:colicbands(teniaecoli);haustraofcolon;epiploicappendices(epiploicaeappendices)AnatomyAnatomytheileocecalvalve:theterminalileumemptyintothececumviathehepaticflexureandthesplenicflexurerectum:upalongwiththesigmoidcolon.downalongwiththeanalcanal.12to15cminlength.serveasafecalreservoir.analcolumns;analvalvesandanalsinuses.anorectallineAnatomyanalcanal:upisanorectalline,downisanus.1.5to2cminlength.theepitheliumdiffer.theserrateddentate(orpectinate)line:demarcaterectumandanalcanal(importantanatomiclandmarks)theimportanceshow:upperismucosa,autonomicnerve,nopain.belowisskin,internalpudendalnerve,withkeenpain.Anatomybloodsupplydiffer:upperissuperiorrectalartery,inferiorrectalartery.belowisarteryofanalcanal.venousreturndiffer:upperissuperiorrectalplexus→superiorrectalvein→portalvein.belowisinferiorrectalplexus→veinofanalcanal→inferiorvenacava.lymphaticreturndiffer:upperisaortaabdominalisnearbyortheinternaliliaclymphnode.belowisinguinallymphnodeorexternaliliacnode.whiteline:intermusculargroove.Anatomyrectumandanalcanalmusculature:theanalcanalmusculaturewithitssphinctericapparatusistheterminalmuscularchannelofthegastrointestinaltract.internalanalsphinctermuscleisthecontinuationofthesmoothcircularlayeroftherectum.externalanalsphinctermuscleisacontinuoussheetofstriatedmuscleconstitutingthepelvicfloor.itdivideintosubcutaneousexternalanalsphinctermuscle;superficialexternalanalsphinctermuscle;deepexternalanalsphinctermuscle.levatoranimuscles:thepuborectalismuscle;pubococcygeousmuscle;illiococcygeousmuscle.theirfibersdecussatemediallyformfunnel-shaped.Anatomyanorectalring:internalanalsphinctermuscle;lowerlimboflongitudinalmuscleofrectum;deepexternalanalsphinctermuscleandproximallevatoranimuscles(thepuborectalismuscle).fecalincontinence.anorectalperipheralclearance:comprisemuchadiposeconnectivetissue.easilyinfectanalfistula.uplevatoranimuscles:pelvirectalclearance;retrorectalclearance.belowlevatoranimuscles:ischiorectalclearance;perianalclearance.Anatomyarterialsupplyandvenousandlymphaticdrainageofcolon;rectumandanalcanal:colon:rightcolon→superiormesentericartery(ileocolicartery;rightcolicartery;middlecolicartery.)leftcolon→inferiormesentericartery(leftcolicarteryandsigmoidartery).veinhavethesamenamewitharterysuperiormesentericvein↘inferiormesentericvein↗AnatomyportalveinAnatomycolonlymphaticdrainage:superiorcoliclymphnodes;paracoliclymphnodes;middlecoliclymphnodes;centralcoliclymphnodes.colicnerve:parasympatheticnervediffer,right→vagus;left→pelvicnervesympatheticnerve:superiormesentericneuroplexusandinferiormesentericneuroplexus.Anatomyrectumandanalcanal:artery:upperofpectinatelineissuperiorrectalartery;inferiorrectalarteryandmediansacralartery.belowofpectinatelineisanalcanalartery.vein:upperofpectinatelineissuperiorrectalplexus→superiorrectalvein→inferiormesentericvein→portalvein.belowofpectinatelineisinferiorrectalplexus→inferiorrectalveinandanalvein→internaliliacveinandinternalpudendalvein→interiorvenacava.Anatomyrectumandanallymphaticdrainage:mostimportantpathissuperiorrectalartery→nearbyinferiormesentericartery.nearbyinferiorrectalartery→internaliliaclymphnodes.downanalarteryandinternalpudendalartery→internaliliaclymphnodes.belowofpectinateline:downwardpassthroughperineumandinnerthigh→inguinallymphnodes→externaliliaclymphnodes.ischiorectalclearance→nearbyobturatorartery→internaliliaclymphnodes.nerve：upperisautonomicnerve(sympatheticnerveandparasympatheticnerve)belowisinternalpudendalnerveAnatomyphysiologycolonicmajorfunction:absorbwater;gluscose;electrolyteandbileacid.storeandtransportsoil.rectalmajorfunction:defecation;absorbtionandsecretion.AnorectalexaminationPostureanalinspectionRectalpalpationAnoscope;sigmoidoscope;fibercoloscopeexaminationX-ray;CT;MRIandrectalultrasoundendoscopeexaminationAnorectalfunctionexaminatinRectalinspection:Digitalexaminationofrectum:simpleandimportantclinicalexaminationways.mayfind:hemorrhoids;analfistula;rectalpolyp;anorectalcancerAnorectalexaminationSigmoidvolvulussigmoidmesenteryasaxle→volvulussigmoidcolonismostcommonlyinvolved,occupy65%-80%.cecumandtransversecolonmayoccur.Oldpeople(＞60y):youngpeople=20:1Ulcerativecolitis(UC)UCisnonspecificinflammatorydiseaseinvolvingthemucosaofthecolonandrectum.sigmoidandrectumoftenfind.Macro-pathology:mucosalappearancevarieswithminimalfriability;edemainthemilderstage.bleeding;erosionandfrankulcerationclinicalmanifestation:laxnesswithblood,stomachache.indicationsforoperations:includetoxicmegacolon.intractability

extraintestinalsymptom,dysplasia-carcinoma,massivebleeding,perforatedulcertreatment:removalofthecolonandrectum.IntestinalpolypsandpolyposisAcolorectalpolypisanymassprojectingintothelumenofthebowel,itarisefromtheintestinalmucosa.grossappearanceclassifiedpedunculatedorsessile.histologicappearanceclassified①adenomapolyp(tubularadenomaandvillousadenoma,ortubulovillousadenoma),②inflammatorypolyp,③hamartomas.④organicpolyppolyps>100→polyposis.thereisa50%chancethatavillousadenomagreaterthan2cmwillcontainacancer.treatmentusuallyremovepolypbycolonoscopy.removedbyasnareforpedunculatedpolyp,forsessilepolypofenrequiresegmentalcolectomy.Coloncancercommonmalignanttumorofgastrointestinaltract,41-65yearsincidencehigh.commonlypolypsandpolyposis→cancer,adenoma→cancer.etiology:muchanimaltallow,animalprotein.lackofmovement.heredity,precancerosishistologytype:adenocarcinoma,mucoidcarcinoma,undifferentiatedcarcinoma.protrudedtype:commonlyoccuratrightcolonorcecum.infiltratingtype:commonlyoccuratleftcolon.ulcerativetype:commontype*GrosspathologytypeClinicalpathologicalstageTNMstages:T:primarytumor.N:lymphnode.M:metastasis0:TisN0M0.Ⅰ:T1N0M0orT2N0M0.Ⅱ:T3N0M0orT4N0M0.Ⅲ:anyTN1M0orN2M0.Ⅳ:anyTNM1.Prognosis:fivesurvivalrate:Ⅰ93%;Ⅱ80%;Ⅲ60%;Ⅳ8%.Metastasis:lymphaticmetastasis,hematogenousMetastasis,directinvasion,peritonealimplantationClinicalmanifestationalterationsinbowelhabitsandcharacteristicsoffeces.earlyfindings.abdominalpain.abdominaldiscomfort.abdominalmass.intestinalobstruction.generalsymptoms:anemia,thin,fatigue,lowfever.rightcoloncancer:generalsymptomsanemia,abdominalmass,thinaremajormanifestation.leftcoloncancer:intestinalobstruction,constipationanddiarrhea,hematocheziaaremajormanifestation.Diagnosis*highriskgroupis>40haveanyfollowingone:first-degreerelatieshavehistoryofcolorectalcancer.havehistoryofcancer,intestinaladenomaorintestinalpolyps.thestooltestpositiveforoccultblood.havetwofifthfollowingmanifestations:mucousbloodystool,chronicdiarrhea,chronicconstipation,chronicappendicitis,historyofpsychologicaltrauma.fibercoloscope,CT,ultrasound,CEA.radicalcolectomy:resectionrangeincludethesegmentofcoloncontainingcancer,itsmesenteryandregionallymphnode.radicalrightcolectomy:applytocecum,ascendingcolon,hepaticflexureofcolon.radicaltransversecolectomy:applytotransversecolon.radicalleftcolectomy:splenicflexuresofcolon.anddescendingcolon.radicalsigmoidectomy:sigmoidcolon.operationofobstructingcoloncancer:colostomy.chemotherapyofcoloncancer.TreatmentAnalfissureGenerally:ananalfissureisalinerulcerofthelowerhalfoftheanalcanal.locatedintheposteriorcommissureinthemidlineoranteriormidline.commonlyyoungpeople.fissureawayfromthislocationshouldraisethepossibilityofassociatedCrohndisease,tuberculosis,ulcerativecolitis.Etiology:maybeassociatedwiththefollowingfactors：AnatomyExternalinjury：defecationisthedirectreasonwiththemechanicalinjury*Fissuretriad：thefissureitself,hypertrophicanalpapillathesentinelpile.ClinicalManifestationTypicalmanifestation：pain,constipationandbloodPaincycle：defecationpain→→intervalpain↑↓painrelieve←←sphinctercontractionpainfissure↔constipationviciouscycleBlood：coverthefeces，blooddrop,rarelylargeamountofblood.Diagnosistypicalclinicalmanifestationsfissuretriad：thefissureitselfhypertrophicanalpapillathesentinelpile.differentdiagnosis:crohndisease,ulcerativecolitis,perianaltumor.TreatmentNon-operativetreatment※Principle：removesphincterismus,relievepain,helptodefecate,stopviciouscycle,improvelocalcure.Specificmeasure：

1.sitzbathswith：5000KMnO4

2.stoolsofteners,bulkingagents,takemorewaterandfoodwithabundantfibrin.

3.localanesthesiarelaxtheinternalsphincterandimprovebloodflowtotheanorectumOperativetreatment(Adaptation:conservativemeasuresfailed)

1.fissureresection

2.internalanalsphincterotomyPerianorectalabscessGeneralConsideration:PerianorectalabscessismostcommonlyacuteinflammationofPerianorectalsofttissueEtiology:mostlybecauseoftheinfectionoftheanalglandssomeforperianalskininjure,infection,analfissure,internalhemorrhoids.ClinicalManifestationPerianalAbscess

mostcommon;

severeandcontinuousthrobbingpainthatworsenwithambulationandstraining;

fewpatientswithfever,urinaryretentionandsepsis;

swellinganddischargearenotedlessfrequently.

Ischiorectalabscesscontinuousswellingpainandbecomethrobbingpainthatworsenwithambulationandstraining.Sometimewithurinaryretention,andrectaltenesmussystemicinfectionissignificant。erythematousmass,obviousredandfluctuant。Ifdon’tdrainintime,spreadintotheperirectalskinandcausethehighlevelfistulaClinicalManifestationPelvirectalabscessInfectedbytherectitis,rectalulcer,orrectalinjure.Inearlystage,thesystemicinfectionisobvious,butthelocalsymptomsisnot,andoftenmisdiagnosedawarenessofdefecationincrease,urinaryretention.Palpatethemassintherectalwall,tendernessandfluctuant.UltrasonographybyanusorpelvicCTisusefulfordiagnosisTreatmentNon-operativetreatment（1）antibiotic（2）sitbaths（3）localphysicaltherapy（4）stoolsofteners,bulkingagentsOperativetreatment:Accuratediagnosis,drainedsurgically。Attentions：（1）rightlocation（2）“cut”choice（3）drainradically（4）preventionoffistula（5）cultivationofpusAnalfistulaGeneralconsiderationthefistulaiscomposedbytheinternalentrance，externalentranceandthefistulacanal。Theinternalentrancelocateatthelowrectumoranus,onenumber，theexternalentrancelocateattheperianalskin,oneormore.EtiologyMostfistulasderivefromsepsisoriginatingintheglandsoftheanalcanalatthedentateline.Peri-anorectalabscess.Someoccurasaresultofobstetricinjury,crohn’sdisease,diverticulitis,radiationandsoon.ClassificationaccordingtothelevelLowlevelfistula：fistulalocateunderdeepoftheexternalsphincterHighlevelfistula：fistulalocateabovedeepoftheexternalsphincteraccordingtothenumberofentrance

SimplefistulaComplicatedfistula*accordingtotherelationshipbetweenfistulaandsphincterInter-sphincterfistulaTrans-sphincterfistulaSupra-sphincterfistulaExtro-sphincterfistulaClinicalmanifestationAcutechronicrecurringabscessorchronicdrainingsinusoverthesacrococcygealorperianalregion.Pain,tenderness,purulent,blood,mucinousexcretiondrainage,.generalsymptoms(fever,chill,weak).abovesypmtomsrepeatedoutbreakTreatmentblockageways:biologicalproteinglue.operation:1fistuladissection:lowlevelfistula.2sectondivision3fistulectomyEtiology:unclear1analcushiontheory2varicositytheory3perianalinfection(spicyfood/drinkalcohol)*Internalhemorrhoid：3、7、11(lithotomyposition)1painlessintervalbleedingafterdefecation2internalhemorrhoidprotrusionHemorrhoidClinicalmanifestationClassification：1internalhemorrhoidIpainlessbleeding,withoutprotrusionIIprotrusionwithdefecationspontaneousreduction,bleeding；IIIprotrusion,spontaneousofwithbowelmovement,requiringmanualreduction,occasionallybleeding；IVpermanentlyprolapsed,irreducible,occasionallybleeding2externalhemorrhoids:Discomfortanus、wetnastiness，perianal-pruritus,sometimeseverepainifthrombosis3complicatedhemorrhoidInternalhemorrhoiddeveloptoIIIdegree,thenbecomethemixedhemorrhoidDiagnoseandDifferentialdiagnosisDiagnosis:anorectalinspection,anoscopeDifferentialdiagnosis：rectalcancer;

rectalpolyps;rectalprolapse→→Treatment*threeprinciples:(1)notreatmentwithoutsymptoms.(2)lightenorremovesymptomsforwithsymptoms.(3)conservativetreatmentisfirst.Generaltreatment:changehabitualfoodanddefecation,sitbathandsoftenersInjectiontherapyRubberbandligationTreatmentdoppler-guidedhemorrhoidalarteryligationSurgicaltreatment:(1)simplehemorrhoidectomy(2)externalthrombushemorrhoidectomy(3)Procedureforprolapseandhemorrhoid（PPH）RectalCancercommonenteronmalignanttumor*aboutrectalcancerhavethreeepidemiologycharacteristicinchina:(1)rectalcancer>coloncancer.(2)lowrectalcanceroccupy60%-75%.(3)youngpeople(<30years