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Necrotizing paraproctitis
Last reviewed: 23.04.2024
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The isolation of this pathology into a separate group is due to both the vastness and severity of infection by the infectious process of fatty tissue, muscles and fascia in the rectum and perineum, and the peculiarities of treatment. Disease necrotizing paraproctitis is characterized by rapid generalization of infection, the development of multi-organ dysfunction and requires the implementation of necrectomy and intensive care. Severe soft tissue damage can cause both individual microorganisms, and associations of aerobes, anaerobes and facultative anaerobes.
Anaerobic clostridial paraproctitis
Anaerobic clostridial necrotic paraproctitis is the heaviest form. Pathogens: CI. Petfringens, Cl. Novyi, Cl. Septicum and Cl. Histotyticum.
The incubation period of the disease is very short, sometimes it is only 3-6 hours, rarely 1-2 days. The onset of action of the gas infection is manifested by the fact that the patient has an unexplained anxiety against the background of relative well-being, a rapid increase in the pulse rate, a decrease in blood pressure, and often a gray-cyanotic color of the face. Simultaneously with this there are strong pressing pains in the perineum, often simply intolerable. Strongest pain can be explained by tissue ischemia.
Clostridia produce toxins that cause hemolysis, destruction of cells and intermediate substances, and disrupt blood circulation. Depending on the type of pathogen, tissue swelling or gas formation may predominate, in some cases the disintegration of muscles and other tissues quickly turns into an amorphous mass, which leads to decay. Due to gas and edema, the interstitial pressure increases, leading to partial or complete compression of the venous and then the arterial vessels.
When examining the perineum, there is no hyperemia characteristic of inflammatory processes, because of the swelling of the tissues, the skin becomes white and shiny, later, due to hemolytic processes, it acquires a brownish and then a black-gray color. When palpation is felt crepitation - "crackling" of gas bubbles in the tissues. Hyperemia and local fever are absent, lymph nodes usually do not increase. With puncture, a cloudy yellow-brown liquid with an unpleasant sweet-putrefactive odor is found in place of pus, when a tissue is cut, a liquid containing bubbles of gas flows out. The muscles are flabby and as the necrosis increases, they decay. Also fascial septa are affected.
Severe pain, severe general condition, absence of signs of banal inflammation (hyperemia, pus), swelling of the tissues, change in color and skin type should lead to the idea of the possibility of gas infection. When the crepitation appears, the diagnosis is unquestionable. On the X-ray patterns, a characteristic "pincushion" is determined due to the stratification of muscles under the influence of gas. Confirm the presence of clostridial infection bacterioscopically and bacteriologically. A smear from the wound (from the surface of the muscles) is stained with a methylene blue solution, "clumsy" sticks (like matches scattered from a matchbox), myolysis, gas bubbles and the absence of leukocytes testify to the presence of gas gangrene. For bacteriological confirmation of the diagnosis, a piece of muscle should be taken from the wound.
Anaerobic nonclostridial necrotic paraproctitis
Anaerobic nonclostridial necrotic paraproctitis causes non-spore-forming anaerobes - bacteroides and fusobacteria. Predisposing factors for the development of non-clostridial infection are necrotic or poorly blood-supplying tissues, local decrease in the ascitiveness of oxidative processes, weakening of immunity, tissue acidosis and selection of anaerobes due to the intake of antibiotics.
With non-clostridial infection, inflammation can occur in the cellulite (cellulite), muscles (myositis), fascia (fasciitis). Observe edema and necrosis of tissues, sometimes with the formation of gas bubbles. Hyperemia and pus do not happen. When the tissues are dissected, detritus and a turbid liquid with a strong odor (the so-called colibacillary) are detected, due to the presence of bacteroides. Development is accompanied by fever, chills, severe general condition due to toxemia.
The diagnosis is usually based on clinical signs. Bacteriological confirmation of the diagnosis is not always possible. Difficulties arise already at the time of taking the material for the study - it must be performed in the complete absence of oxygen. These same requirements should be followed when transporting and handling a smear. Growth of microorganisms requires considerable expenses and lasts 4-6 days.
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Putrefactive necrotic paraproctitis
Another heavy form, identified as putrefactive necrotic paroprokitis, causes the association of non-spore-forming anaerobes (bacteroides, fuso-bacteria, peptococci), E. Coli and protea. Putrefactive necrotic paraproctitis often occurs against the background of diabetes mellitus, a decrease in immunity due to malnutrition, hypothermia and severe vascular diseases.
The process captures pararectal tissue and can later spread to other areas (anterior abdominal wall, lumbar region). Very often in men necrosis of the cellulose passes to the area of the scrotum and even the penis. Such a process is known as gangrene Fournier. Fatty tissue and skin are necrotic, while a stinking liquid is released, sometimes with gas bubbles ("swamp" gas). The putrefactive process causes severe intoxication.
How is necrotizing paraproctitis treated?
Treatment of necrotic paraproctitis should begin immediately. It includes emergency surgery, intensive infusion and antibacterial therapy, correction of organ dysfunctions.
Surgical intervention provides for a wide opening of affected cell spaces with the obligatory excision of devitalized tissues until the bleeding edges of the wound appear, the lavage and drainage of the cavities. During subsequent dressings, it is often necessary to excise newly detected non-viable tissues, resulting in large and deep tissue defects. Operation with a disease such as necrotic paraproctitis does not provide for the search and excision of the affected crypt. Therapy requires the creation of wide access of oxygen to the foci of infection, which is provided by open wound management and treatment in the pressure chamber. Principles of antibacterial and intensive therapy, as well as methods of correction of organ dysfunctions in sepsis are reflected in separate chapters of this manual.
What prognosis does necrotic paraproctitis have?
Delay with surgical intervention, inadequate conduct of intensive and antibiotic therapy makes the forecast extremely unfavorable.