Inflammatory fistulas: causes, symptoms, diagnosis, treatment

The causes of the development of inflammatory fistulas: an incorrect tactic of managing patients with purulent diseases of the pelvic organs. In patients with a prolonged and recurrent course of the purulent process, when the surgical treatment is not timely, the perforation of the abscess (more often repeated) to the hollow organs and (or) the anterior abdominal wall occurs in patients with complications after previous operations. Formation of pridatkovovagatal fistulas contribute to multiple punctures or kolpotomii in patients with complicated forms of purulent inflammation.

[1], [2], [3]

Pridatkovo-intestinal fistulas

Symptoms

For the state of preperforation of the abscess in the distal parts of the intestine the following symptoms are characteristic:

• persistent pain, radiating into the rectum, lower back, navel, lower limbs;
• painful peristalsis;
• liquid stool, sometimes with an admixture of mucus, which is sometimes interpreted as a manifestation of dysbiosis on a background of massive antibacterial therapy;
• tenesmus;
• sharp soreness and "tension" of purulent formation in bimanual and rectovaginal studies.

In the case of perforation of the abscess in the intestine, the patients develop tenesmus and abundant discharge of mucus from the rectum, then - abundant, fetid, liquid, purulent discharge from the rectum, which is accompanied by an improvement in the general condition of the patient. Often this is regarded as a recovery and the patient is discharged from the hospital. However, it must be remembered that even in the presence of a fistula, there is no complete evacuation of the purulent formation of the uterine appendages. Inflammatory formation is preserved, fistulous, always convoluted, quickly obturated, which leads to another recurrence of inflammation.

A characteristic feature of the functioning fistula is the remitting flow with periodic exacerbation of the inflammatory reaction and the release of pus with feces.

Diagnostics

It is obligatory to carry out rectal-vaginal examination, it is necessary to determine the possible prolapse of the infiltrate or abscess in the direction of the rectum, and also assess the condition of the mucosa above it (mobile, limited mobile, immovable) - these signs reflect the fact and extent of involvement in the inflammatory process of the wall of the straight line guts. It should be noted that palpation is impossible to establish the place of possible perforation, since similar perforations occur mainly in the lower third of the sigmoid colon and the rectosigmoidal angle. In the presence of a functioning appendage-intestinal fistula and palpation of the subacute formation, rectal examination reveals an admixture or a significant amount of a purulent discharge.

The most informative methods of diagnosis of adnexa-intestinal fistulas are ultrasound and computed tomography.

The following echographic signs may indicate the threat of formation of adnexa-intestinal fistula:

1. destruction of the capsule of inflammatory education at the site of the intestine (when contrasting the intestine);
2. reduced echogenicity of fiber in the affected area;
3. tubo-ovarian formation is closely welded to the adjacent intestinal tract - the abscess capsule and the contrasted intestinal wall are not displaced relative to each other during filling and emptying.

Echopriznaki, suggesting the existence of adnexa-intestinal fistula:

1. in the structure of inflammatory education there are areas where the intestinal wall adjoins the abscess capsule without a clear boundary, and it is impossible to "divide" them on the echogram even when contrasting;
2. reduced echogenicity of fiber in the affected area;
3. There are gas bubbles in the structure of the GMWP (an indirect evidence of communication with the intestine or the presence of an anaerobic pathogen, which is always accompanied by severe destruction of tissues).

In a number of cases, the fistulous course is directly visualized: the echo-negative structure of the "convoluted" form with dense ehopozitivnye walls originating directly from the abscess.

Computed tomography allows us to clarify the localization of fistulas of inflammatory etiology, the stage of their formation, determine the degree of involvement in the process of the pelvic organs, as well as the depth of the destructive and inflammatory changes occurring in them.

The following CT-signs can speak about the threat of perforation of pelvic abscesses in the distal parts of the intestine or the formation of adnexa-intestinal fistula:

• in the structure of tubo-ovarian formation there are areas where the intestinal wall adjoins the capsule without a clear boundary;
• to divide by CT a boundary of the intestinal wall and formation is impossible, there is a sharp infiltration of fiber in the affected area; there is an increase in the image in the intestinal wall, corresponding to the density of detritus, which indirectly indicates the destruction of the wall to the mucous membrane.

The informativeness of the CT method in the diagnosis of adnexo-intestinal fistula is 93.75%.

An increase in the efficiency of diagnosis of genital fistulas is facilitated by fistulography in CT. The introduction of contrast preparation in the process of endoscopy (colonoscopy, cystoscopy) makes it possible to clarify the nature of the genital fistula or fistula (its course, extent) in all patients.

Colonoscopy is indicated for patients with clinical signs of preperforation and perforation in the distal parts of the intestine, as well as obtaining similar data during echography with additional contrasting of the rectum or CT.

In case of perforation of the abscess into the intestinal wall, as well as with incomplete fistulas, the intestinal mucosa in the place where the abscess adheres is edematous, smoothed, its vessels dilated, and when attempting to move it is inactive or immobile. With fistula functioning on the altered mucosa, a fistula is defined as a funnel-like retraction with pus discharged from it.

Preliminary staining of the intestinal mucosa with methylene blue (with enema) makes it easier to identify an altered mucosa site.

Differential diagnosis

Most often, purulent tubo-ovarian formations, complicated by fistula, have to be differentiated from Crohn's disease and malignant neoplasms of the intestine.

Crohn's disease, or granulomatous enterocolitis, is a chronic nonspecific segmental inflammatory bowel disease with a predominant localization of the process in the terminal ileum. The pathological process begins in the submucosal layer of the intestine, proceeding successively to the muscular and serous layers. Inflammatory edema of the intestinal wall develops, granulomas are formed. The lumen of the intestine narrows, and often fistula is formed, primarily with the ovaries, the fallopian tube, the bladder. All this can cause secondary infection and damage to the appendages of the uterus.

The course of the disease is undulating. According to endoscopy, three phases are distinguished: infiltrative, phase of cracks, phase of scarring, or remission. One phase turns into another sluggish, the course of the disease itself is "smoldering". In some cases, the process subsides or even ceases at one site of the intestine and arises in the distal distal areas. The sizes of the affected intestinal segments range from 6 to 18 cm. The moderate pain in the abdomen and the left hypogastric region prevail in the clinic, a frequent but decorated soft stool that does not contain mucus and pus even in the midst of the disease. There is always a prolonged febrile course with a rise in body temperature to 38-38.5 ° C, general weakness, pale skin, weight loss, sometimes imperative urges for defecation and violation of all types of metabolism, especially protein. Palpation of the abdomen is painful, sometimes a tumor-shaped formation is defined through the anterior abdominal wall, which is an inflammatory infiltrate or conglomeration of thickened intestinal loops.

Radiologic examination shows narrowing of the affected area of the intestine (symptom of the "cord"), thickening of the folds of the mucosa, smoothing of its relief. The affected area of the intestine takes the form of a rigid tube. The relief of the mucosa like a cobblestone pavement is typical for patients with severe and prolonged course of Crohn's disease. The gut lumen in these cases is deformed due to polypoid formations, destructive process, deep and wide cracks.

Surgical treatment for Crohn's disease is an extreme measure, gives a high percentage of complications and deaths. In this regard, for the exclusion of Crohn's disease, an endoscopic examination with obligatory biopsy is necessary. For differential diagnosis, the absence of purulent contents in the material obtained with puncture formation is important.

Significant difficulties arise in the differential diagnosis of inflammatory diseases of the uterine appendages and sigmoid colon cancer. The incidence of cancer of the sigmoid colon, which occurs under the guise of an inflammatory formation of the appendages, according to our data, is 0.7%. Malignant process in the sigmoid colon proceeds mainly with endophytic, infiltrating growth, more often it is a scirrhous cancer. By the time of differential diagnosis with tumor-like formation of the uterine appendages, the cancer of the sigmoid colon, as a rule, already reaches the II, and sometimes the III stage, i.e. The existing tumor is quite large.

In cancers of the sigmoid colon, pain may be associated with partial obstruction or bowel dysfunction. At the first stages, the dysfunction is not due to a mechanical obstruction, but to the accompanying spastic phenomena arising from the inflammation of the mesentery and caused by these pathological reflexes.

The febrile condition in sigmoid colon cancer with prolonged temperature rises to 38-39 ° C is most often caused by ulceration of the intestinal mucosa, decay and tissue necrosis in this department. In malignant lesions of the sigmoid colon, pathological discharge in the form of mucus, sometimes with an admixture of pus, occurs quite often. Characteristic is the accumulation of stool with subsequent abundant discharge and the emergence of a liquid stool.

When viewed in the left ileal region, a motionless, painful, tumor-like formation is defined without clear boundaries and contours, the dimensions of which may vary, but generally do not exceed 10 cm in diameter. The leading method of diagnosing sigmoid cancer is to date the X-ray examination of the intestine - irrigoscopy.

Direct radiographic signs of a malignant tumor of the sigmoid colon are the marginal or central defect of filling, narrowing of the lumen of the gut, changes in the relief of the mucous membrane, an additional shadow in the lumen of the intestine. Indirect signs include bowel spasm and lack of gaustration in a limited area, expansion of the intestine above and below the affected segment, incomplete evacuation of the contrast medium after defecation.

A great importance in the correct diagnosis of sigmoid colon cancer is acquired by rheumatoscopy and fibrocolonoscopy. Biopsy is the final stage of the examination of the patient. Of course, a positive response, indicating a malignant process, is final in the diagnosis. However, negative biopsy data, especially with infiltrative growth of the tumor, can not be a sufficient reason for excluding sigma cancer.

Treatment

The patients with adnexa-intestinal fistulas, of course, are shown an operation, which, we believe, should always be planned, as it requires, in addition to the traditional one, special preparation of the colon (there is always the possibility of intervention in the relevant parts of the colon). Preparation consists in the appointment of a slag-free diet and cleansing enemas (in the morning and in the evening) for 3 days.

Features of surgical intervention:

• The optimal is the performance of the intestinal stage before the gynecological. The intestinal stage is the most important because of the high risk of development of an anastomosis inconsistency or stitches in conditions of a purulent process, and consequently, peritonitis and intestinal obstruction, therefore it is necessary to perform it carefully. Separation of the intestine from the capsule of the abscess should be carried out in a predominantly acute way. Preliminarily it is necessary to isolate the abdominal cavity with napkins, since the contents from the abscess, as a rule, flow into the cavity of the small pelvis. An important condition is a radical excision of necrotic tissue around the fistula, but it is completely impossible to remove them due to the spread of the infiltration zone. In the case of incomplete adnexa-intestinal fistula (intact mucosa and part of the muscular gut layer), in the presence of conditions, the defect is closed with serous-muscular individual vikril sutures 000 on an atraumatic needle. If this can not be done (tissue cutting), it is permissible to bring the tube for the ADF to the destruction zone in the future.
• In the case when there is a complete fistula, and the infiltration zone with abscessing does not exceed 5 cm and is located on the same wall as the fistula, without extending circularly to other walls, it is necessary to resect this part of the intestine together with the fistula. At the end of the operation, a transanal intubation of the large intestine is carried out with the tube over the anastomosis zone.
• If the extent of the lesion is larger or it is annular, it is advisable to perform a gut resection with an anastomosis application. At the end of the operation, a transanal intubation of the large intestine is also performed, with the tube placed behind the anastomosis zone.
• Temporary colostomy is imposed in extreme cases - with extensive purulent-destructive bowel damage (the risk of insufficiency of sutures and peritonitis), as well as in the severe condition of the patient.
• The gut must be sewn according to all the rules of surgery by a non-absorbable or long-absorbing synthetic suture material (thin capron, vicryl, polysorb) in 2 floors. Do not use catgut. The filaments must be thin - No. 00 or 000, they should be applied using an atraumatic circular needle:
  • 1st row - mucocutaneous sutures with immersion of nodes in the lumen of the intestine;
  • The second row is serous-muscular sutures.

If conditions permit (focalization of the fistula on the rectum wall or in the rectosigmoidal region), for additional protection of the intestinal wall and prevention of peritonitis, the peritoneum of the intestine above the fistula or anastomosis zone is fixed to the posterior wall of the vagina.

• It is necessary to revise the genitals to determine the extent of intervention on them, with special attention to be given to assessing the extent of involvement in the inflammatory destructive process of the uterus and appendages on both sides. The volume of the gynecological stage is chosen strictly individually. In patients with fistula, we managed to perform organosaving operations only in 31.8% of cases. Most patients had multiple abscesses, expressed infiltrative changes in the parametric and pelvic tissue, the intestinal wall carrying the fistula, involvement of the uterus in the purulent process, leading to a high risk of developing severe purulent-septic complications or recurrence of the disease, which required the execution of the extirpation of the uterus tried to save part of the ovary).

Pridatkov-cystic fistulas

With the threat of perforation of the abscess in the bladder, the following clinical symptoms consistently appear in patients:

• increased frequency of urination;
• rezi with urination, which are followed by strong pains after each urination, gradually increasing; pains become permanent, acquire an intolerable cutting character;
• leukocyturia and proteinuria increase, urine becomes turbid.

The appearance of abundant purulent discharge from the urethra testifies to the dissection of the abscess into the bladder.

The danger of developing the described complication is very great. Its severity is determined by the nature of the microflora of the adnexal ulcer, the severity and duration of acute pelvioperitonitis and related intoxication, the initial functional changes in the kidneys and urinary system.

It should be emphasized that in connection with the direct threat of urosepsis, delay in the operation in these cases is unacceptable, in spite of its technical difficulties and unfavorable background.

The most informative methods of diagnosis of adnexa-cystic fistulas are also ultrasound and computed tomography.

It should be emphasized that echography (including transvaginal) should be performed with a well-filled bladder to detect an abscess of the vesicoureteral space. These conditions are necessary to clearly delimit the contours of the abscess, detect a defect in its anterior wall and evaluate the structural features of the posterior wall of the bladder.

Echographic signs of perforation of pelvic abscesses in the bladder:

1. There is an atypical "close" location of the abscess and bladder (abscess of cervical stump area, vaginal canopy or large abscess size - more than 15 cm).
2. The echogenicity of the pre-tubercular fiber is sharply reduced, there are cavities with a thick heterogeneous content.
3. The main feature is the destruction of the area of the capsule of the formation immediately adjacent to the posterior wall of the bladder, i. E. There is no clear boundary between the posterior wall of the bladder and purulent formation. The internal contour of the bladder is deformed, the structure of its wall is heterogeneous (thickened, contains multiple echo-negative inclusions), while the contents of the bladder can be determined by a non-uniform echopositive suspension in various amounts (accumulation of purulent exudate).

In a number of cases, the infiltrate of the pre-tubercular fiber contains fusiform structures that are formed, similar to those previously described.

When there is a threat of perforation of the MMWP into the bladder or the formation of the adnexa-urinary bladder, CT signs are of the following character:

• there is a sharp infiltration of paravezical fiber;
• there is deformation of the bladder contours with an inflammatory infiltrate;
• the formation closely adjoins the bladder and has clear contours, with the exception of the zone of adherence of the abscess and the wall of the bladder. The informativeness of the CT method in revealing the abscesses of the late-bile fiber, according to our data, was 100%.

When carrying out cystoscopy, there is a characteristic picture: deformation of the wall of the bladder and bullous edema with areas of hemorrhage. Usually, at the location of the bullous edema, perforation of the purulent formation takes place. As a rule, a breakthrough of the abscess occurs in the region of the tip of the bladder to the right or to the left of the midline.

Features of surgical intervention in patients with adnexa-pleural fistulas:

1. In the operation on the vesicoviral genital fistulas of inflammatory etiology, only the peritoneal access should be used.
2. After restoration of normal anatomical interrelations of the pelvic organs, two consecutive stages of the operation are performed - gynecological and urological.
3. When a combination of vesicoureteral fistula with intestinal genital, the first stage of the operation begins with the secretion and stitching of the intestinal fistula, then perform adequate intervention on the genitals and, most recently, on the bladder and ureter.
4. The gynecological stage of the operation consists in removing the foci of abscess formation and providing the most adequate conditions for draining the cavity of the small pelvis, including the urological zones of the operation.
5. An obligatory condition for performing the urological stage of the operation, we consider revision of the ureters on both sides, especially in those cases when significant changes in the kidney function, ureter dilatation and kidneys were revealed before the operation.
6. The urological stage consists in the actual reconstruction of the bladder with the elimination of the fistula and restoration of the normal passage of urine through the ureters. The last intervention is performed if there are indications to it established during the operation (ureteric stricture, urinary leakage in parametrized fiber, scar deformity of the ureter's mouth).
7. In the presence of incomplete vesicular-genital fistulas, the altered tissues of paravezical fiber and bladder are economically excised, separate vikril or catgut stitches (No. 00) are placed on the atraumatic needle on the bladder muscle.
8. When plastic incomplete vesicular-genital fistulas should seek to be careful and try to do without opening the bladder. If the excision of the mucosa of the bladder has occurred in the excision of tissues, there is no particular danger in this situation. Sewing the bladder in such cases is the same as with a full bladder fistula:
   • after additional mobilization of the mucous membrane of the bladder, it is pulled into the wound (the entire defect should be visualized well);
   • the mucosa of the bladder are sewn with separate catgut sutures (No. 00 or 000) on the atraumatic needle in the transverse direction; In contrast to the intestinal seam, the nodes should be located outside the bladder mucosa; distance between seams - 0,5-0,7 cm;
   • the second row of sutures is applied to the muscles of the bladder with catgut or vikril No. 00, preferably in the intervals between the first row of seams;
   • on cellulose and peritoneum with catgut or vikril No. 1 separate seams (third row) are applied. In those cases when the gynecological stage includes the extirpation of the uterus, the seam line is additionally peritonized by the vaginal wall, sewing it to the wall of the bladder above the superimposed sutures.
9. At the end of both stages, a separate peritonization of the bladder and zones of operation in the pelvic region is performed, with mandatory isolation of the sewn fistula from the infected abdominal cavity.
10. In order to reliably prevent urinary peritonitis, the vaginal dome is in all cases left open in the abdominal cavity.
11. Obligatory stages of the operation are sanation and drainage of the abdominal cavity and pelvic cavity. Sanitation is carried out with a 1% aqueous solution of dioxidine. For drainage in all cases, it is advisable to use the ADF. The tubes are led to the zone of greatest destruction and into the lateral channels by a transvaginal route - through an open dome of the vagina or a colpotomic wound. 12. The bladder is drained with a Foley catheter.

Pridatkovo-vaginal fistulas

They arise as a result of instrumental manipulations conducted for the purpose of treatment of the MHWM (multiple punctures of pelvic abscesses, colpotomy). In the overwhelming majority of cases, they are located in the upper third of the posterior wall of the vagina (in places of manipulation). They are defects of the mucosa with the kaleznymi edges. When carrying out vaginal examination and palpation of the appendages, the amount of discharge from the fistula opening increases. The nature of the fistula (its length and its connection with the adnexa formation) is better echographically determined by its contrasting, for example, the insertion of a metallic probe into it.

Features of the operation

1. In the process of performing the extirpation of the uterus, sufficient mobilization of the upper third of the vagina, mainly of the lateral and posterior walls, is performed, for which the cardinal ligaments intersect in stages after the separation of the anterior wall of the rectum behind, the bladder and the pre-tubercular fascia in front.
2. It is advisable to open the front or side wall of the vagina and lastly to resect the upper third of the back wall of the vagina that carries the fistula, already under the control of vision (from the inside), to completely excise necrotic tissues on the one hand and not to remove excess vaginal tissues, thereby not shortening it .
3. Resection of the posterior wall of the vagina is advisable to wedge. With a small fistula, the posterior wall of the vagina is covered, as usual, with separate catgut sutures with seizure into the stitches of the sacro-uterine ligaments; with a significant defect in the posterior wall, separate seams are first applied to the wedge-shaped excised part of the vagina in order not to shorten it, and then the vaginal tube is, as usual, lined with separate catgut sutures.
4. The abdominal cavity is sanitized and drained by tubes for APD transvaginally.

Pridatca-abdominal fistulas

Causes

Fistulas are formed due to two main causes: non-radically removed suppurative appendage, inappropriate or misuse of suture material. As a result, fistulous passages starting from the newly formed capsule of the purulent appendage formation of the purulent cavity to the anterior abdominal wall begin to form. Fistulous passages are usually sinuous, involve various organs in the process, forming dense infiltrates around themselves.

Symptoms

When perforation of abscesses threatens through the anterior abdominal wall (always after previous operations) intense pains of "pulling" character arise in the postoperative scar area, infiltration and hyperemia of the latter. Through the formed fistulous course, a small amount of purulent contents is periodically separated. However, even during this period, fever persists in patients, sometimes with chills, the general condition suffers, the functions of the organs involved in the process are disrupted.

In patients with functioning fistulas at the time of palpation of pelvic floor formations with gynecological examination, the purulent discharge from the prospective fistula passages on the anterior abdominal wall increases.

Diagnostics

Destruction of the tissues of the anterior abdominal wall is well visualized in both echoscopic and radiological studies (CT).

The informative value of the CT method in diagnosing the emerging or formed abdominal-adnexal fistula is 100%.

On echo- and tomograms, the following stages of development of abdominal fistulas differ:

1. destruction of tissues to aponeurosis,
2. destruction of tissues to the skin,
3. visualization of the formed fistulous course.

Increasing the effectiveness of diagnosis is facilitated by fistulography. The introduction of a contrast agent into the external foramen of the fistula on the anterior abdominal wall allows one to determine its course and extent.

Features of the operational aid

The operation in such cases should begin with an oval dissection of the tissues around the fistulous passage from the skin to the aponeurosis. After this, the formed "tube" is closed with sterile gauze napkins and produces a median abdominal incision above the fistulous course with a bypass of the navel. Subsequent excretion of the fistula should be performed in an acute way, gradually in the direction from the anterior abdominal wall into the interior of the small pelvis. In some cases, for a better orientation, you can periodically audit the fistula by a button probe. The choice of the volume and technique of surgical intervention on the pelvic organs is outlined above. Obligatory conditions for such operations, we believe the need for a complete sanation of the abdominal cavity and the creation of optimal conditions for the outflow of the wound separable. As a suture material in these operations, only catgut threads should be used.

The anterior abdominal wall after excision of the purulent fistula is carefully sutured with the obligatory isolation and juxtaposition of the edges of the aponeurosis all over to prevent postoperative hernias. It is advisable to superimpose a two-row seam from capron or caproag (1st row individual seams - peritoneum-aponeurosis, 2nd row - individual seams subcutaneous tissue - skin). Subcutaneous tissue before suturing is sanitized with a 10% solution of dioxidine. In the postoperative period, wearing a bandage is recommended.