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#1 Perianalni Apsces kod bebe

Posted: 15/11/2008 16:05
by nihada_77
Dali je iko izliječio perianalni apsces,bez operacije?Ako jeste molim vas da mi javite.Imam bebu od 6 mjeseci,koji je u prvom mjesecu zivota dobio perianalni apsces,liječimo se već 6 mjeseci!

#2 Re: Perianalni Apsces kod bebe

Posted: 15/11/2008 17:30
by neprilagodjena
A sta je to nihada??

#3 Re: Perianalni Apsces kod bebe

Posted: 15/11/2008 21:47
by nihada_77
Neznam nija kako da objasnim,izgleda kao čir, nalazi se na guzi,blizu čmara.Izlazi gnoj,dok ne zaraste,čim zaraste upali se.Tako da već od njegovog prvog mjeseca smo kod hirurga,koji ga rezu na zivo i čiste mu taj gnoj.Sad predlaze operaciju,na netu nisam nasla nikoga,sa slicnim slucajem,tj kod bebe vecinom su odrasli.

#4 Re: Perianalni Apsces kod bebe

Posted: 15/11/2008 23:57
by melb26sa
nihada_77 wrote:Neznam nija kako da objasnim,izgleda kao čir, nalazi se na guzi,blizu čmara.Izlazi gnoj,dok ne zaraste,čim zaraste upali se.Tako da već od njegovog prvog mjeseca smo kod hirurga,koji ga rezu na zivo i čiste mu taj gnoj.Sad predlaze operaciju,na netu nisam nasla nikoga,sa slicnim slucajem,tj kod bebe vecinom su odrasli.

Evo sta sam ja nasla guglanjem perianal abscess in babies:

Nisam neki strucnjak ali iz ovog sto sam procitala prvo vidi sa hirurgom da se radi fistulotomija a ne fistulektomija jer ova prva brze zaraste jer je manja rana (manje rezu). Zao mi je sto ti se beba pati sa ovim i nadam se da ce se sve uskoro rijesiti.

PS. Ako hoces, mogu ti ja konkatirati djecije bolnice ovdje u Chicagu (oni odgovaraju na mailove a mogu ih i nazvati) da vidim sta oni preporucuju.



http://www.emedicine.com/med/TOPIC2733.HTM

Perianal Abscess
Article Last Updated: Mar 3, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 12 Click here to go to the next section in this topic

* Authors and Editors
* Introduction
* Indications
* RELEVANT ANATOMY
* Contraindications
* Workup
* Treatment
* Complications
* Outcome And Prognosis
* Future And Controversies
* Multimedia
* References


Author: Andre Hebra, MD, Chief, Division of Pediatric Surgery, Medical University of South Carolina

Andre Hebra is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Association for Academic Surgery, Society of Laparoendoscopic Surgeons, South Carolina Medical Association, Southeastern Surgical Congress, and Southern Medical Association

Coauthor(s): Patrick B Thomas, MD, Fellow, Department of Pediatric Surgery, Texas Children's Hospital

Editors: Marc D Basson, MD, PhD, Chief of Surgery, John D Dingell VA Medical Center; Professor, Department of Surgery, Wayne State University School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Amy L Friedman, MD, Professor of Surgery, Director of Transplantation, State University of New York Upstate Medical University College of Medicine, Syracuse; Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy; John Geibel, MD, DSc, MA, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital

Author and Editor Disclosure

Synonyms and related keywords: anal abscess, perianal abscess, anorectal abscess, ischiorectal abscess, perianal fistula, digital rectal examination, DRE, rectal pain
INTRODUCTION
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* Authors and Editors
* Introduction
* Indications
* RELEVANT ANATOMY
* Contraindications
* Workup
* Treatment
* Complications
* Outcome And Prognosis
* Future And Controversies
* Multimedia
* References


Perianal abscess represents an infection of the soft tissues surrounding the anal canal, with formation of a discrete abscess cavity. The severity and depth of the abscess are quite variable, and the abscess cavity is often associated with formation of a fistulous tract. For that reason, both perianal abscess and perianal fistula are discussed in this article.

For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles Anal Abscess and Rectal Pain.
Problem

Anorectal abscesses originate from infection arising in the cryptoglandular epithelium lining the anal canal. The internal anal sphincter is believed to serve normally as a barrier to infection passing from the gut lumen to the deep perirectal tissues. This barrier can be breached through the crypts of Morgagni, which can penetrate through the internal sphincter into the intersphincteric space. Once infection gains access to the intersphincteric space, it has easy access to the adjacent perirectal spaces. Extension of the infection can involve the intersphincteric space, ischiorectal space, or even the supralevator space. In some instances, the abscess remains contained within the intersphincteric space. The variety of anatomic sequelae of the primary infection is translated into variable clinical presentations.
Frequency

The peak incidence of anorectal abscesses is in the third to fourth decades of life. Men are affected more frequently than women, with a male-to-female predominance of 2:1 to 3:1. Approximately 30% of patients with anorectal abscesses report a previous history of similar abscesses that either resolved spontaneously or required surgical intervention. A higher incidence of abscess formation appears to correspond with the spring and summer seasons. While demographics point to a clear disparity in the occurrence of anal abscesses with respect to age and sex, no obvious pattern exists among various countries or regions of the world. Although suggested, a direct relationship between bowel habits, frequent diarrhea, and poor personal hygiene and the formation of anorectal abscesses remains unproved.

The occurrence of perianal abscesses in infants also is quite common. The exact mechanism is poorly understood but does not appear to be related to constipation. Fortunately, in infants this condition is quite benign and rarely requires any operative intervention other than simple drainage.
Etiology

Perirectal abscesses and fistulas represent anorectal disorders arising predominately from the obstruction of anal crypts. Infection of the now static glandular secretions results in suppuration and abscess formation within the anal gland. The abscess typically forms initially within the intersphincteric space and then spreads along adjacent potential spaces.
Pathophysiology

Perirectal abscesses and fistulas represent anorectal disorders that arise predominately from the obstruction of anal crypts. Normal anatomy demonstrates anywhere from 4-10 anal glands drained by respective crypts at the level of the dentate line. Anal glands normally function to lubricate the anal canal. Obstruction of anal crypts results in stasis of glandular secretions and, when subsequently infected, suppuration and abscess formation within the anal gland results. The abscess typically forms in the intersphincteric space and can spread along various potential spaces. Common organisms implicated in abscess formation include Escherichia coli, Enterococcus species, and Bacteroides species; however, no specific bacterium has been identified as a unique cause of abscesses. Less common causes of anorectal abscess that must be considered in the differential diagnosis include tuberculosis, cancer, Crohn disease, trauma, leukemia, and lymphoma.
Clinical

The classic locations of anorectal abscesses listed in order of decreasing frequency are as follows: perianal 60%, ischiorectal 20%, intersphincteric 5%, supralevator 4%, and submucosal 1% (see Media file 1). Clinical presentation correlates with the anatomical location of the abscess.

Patients with perianal abscesses typically complain of dull perianal discomfort and pruritus. Their perianal pain often is exacerbated by movement and increased perineal pressure from sitting or defecation. Physical examination demonstrates a small, erythematous, well-defined, fluctuant, subcutaneous mass near the anal orifice.

Patients with ischiorectal abscesses often present with systemic fevers, chills, and severe perirectal pain and fullness consistent with the more advanced nature of this process. External signs are minimal and may include erythema, induration, or fluctuance. On digital rectal examination (DRE), a fluctuant indurated mass may be encountered. Optimal physical assessment of an ischiorectal abscess may require anesthesia to alleviate patient discomfort that would otherwise limit the extent of the examination.

Patients with intersphincteric abscesses present with rectal pain and exhibit localized tenderness on DRE. Physical examination may fail to identify an intersphincteric abscess. Though rare, supralevator abscesses present a similar diagnostic challenge. As a result, clinical suspicion of an intersphincteric or supralevator abscess may require confirmation by CT scan, MRI, or anal ultrasonography. The latter is limited to confirming the presence of an intersphincteric abscess.

INDICATIONS
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* Authors and Editors
* Introduction
* Indications
* RELEVANT ANATOMY
* Contraindications
* Workup
* Treatment
* Complications
* Outcome And Prognosis
* Future And Controversies
* Multimedia
* References


As a rule, the presence of an abscess is an indication for incision and drainage. Watchful waiting while administering antibiotics is inadequate.

RELEVANT ANATOMY
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* Authors and Editors
* Introduction
* Indications
* RELEVANT ANATOMY
* Contraindications
* Workup
* Treatment
* Complications
* Outcome And Prognosis
* Future And Controversies
* Multimedia
* References


Classification of anorectal abscess

Abscesses are classified based on their anatomical location. The most commonly described locations are perianal, ischiorectal, intersphincteric, and supralevator. Media file 1 illustrates the different anatomical locations of anorectal abscesses.

Perianal abscesses represent the most common type of anorectal abscesses, accounting for approximately 60% of reported cases. These superficial collections of purulent material are located beneath the skin of the anal canal and do not transverse the external sphincter.

The next most common types of abscesses in descending order of frequency are ischiorectal, intersphincteric, and supralevator. An ischiorectal abscess forms when suppuration transverses the external sphincter into the ischiorectal space. Intersphincteric abscesses result from suppuration contained between the internal and external anal sphincters. A supralevator abscess results either from suppuration extending cranially through the longitudinal muscle of the rectum from an origin in the intersphincteric space to reach above the levators or as a result of primary disease in the pelvis (eg, appendicitis, diverticular disease, gynecological sepsis).

Horseshoe abscesses, while rare, result from circumferential infiltration of pus within the intersphincteric planes.

The Goodsall rule for perianal fistulas

The Goodsall rule states that the external opening of a fistulous tract located anterior to a transverse line drawn across the anal verge is associated with a straight radial tract of the fistula into the anal canal/rectum. Conversely, an external opening posterior to the transverse line follows a curved fistulous tract to the posterior midline of the rectal lumen. This rule is important for planning surgical treatment of the fistula (see Media files 2-3).

CONTRAINDICATIONS
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* Authors and Editors
* Introduction
* Indications
* RELEVANT ANATOMY
* Contraindications
* Workup
* Treatment
* Complications
* Outcome And Prognosis
* Future And Controversies
* Multimedia
* References


Clinical suspicion of anorectal abscess warrants aggressive identification and surgical drainage. Delayed surgical intervention results in chronic tissue destruction, fibrosis, stricture formation, and may impair anal continence. Delayed incision and drainage of an anorectal abscess is contraindicated.

WORKUP
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* Authors and Editors
* Introduction
* Indications
* RELEVANT ANATOMY
* Contraindications
* Workup
* Treatment
* Complications
* Outcome And Prognosis
* Future And Controversies
* Multimedia
* References


Lab Studies

* No specific laboratory studies are indicated in the evaluation of a patient with a perianal or anorectal abscess.
* Certain groups of patients, such as patients with diabetes and patients who are immunocompromised, are at high risk for developing bacteremia, and possibly sepsis, as a result of an anorectal abscess. In such cases, complete laboratory evaluation is important. Laboratory evaluation of the septic patient is not the focus of this article.

Imaging Studies

* Imaging studies rarely are necessary in evaluation of the patient with an anorectal abscess; however, clinical suspicion of an intersphincteric or supralevator abscess may require confirmation by CT scan, MRI, or anal ultrasonography. The latter is limited to confirming the presence of an intersphincteric abscess.

Diagnostic Procedures

* Digital examination under anesthesia can be helpful in certain cases because patient discomfort can limit physical assessment significantly. For example, optimal evaluation for an ischiorectal abscess is performed in this manner.


TREATMENT
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* Introduction
* Indications
* RELEVANT ANATOMY
* Contraindications
* Workup
* Treatment
* Complications
* Outcome And Prognosis
* Future And Controversies
* Multimedia
* References


Medical therapy

In most patients with anorectal abscess, adjuvant medical therapy with antibiotics generally is not necessary. The presence of a systemic inflammatory response, diabetes, or immunosuppression justifies concomitant use of antibiotics.
Surgical therapy

Treatment of anorectal abscesses involves early surgical drainage of the purulent collection. Primary antibiotic therapy alone is ineffective in resolving the underlying infection and simply postpones surgical intervention. Any delay in surgical drainage of anorectal abscesses prolongs infection, augments tissue damage, may impair sphincter continence function, and may promote stricture and/or fistula formation. The ability to drain an anorectal abscess depends on location, patient comfort, and accessibility of the abscess.

Drainage of perianal or superficial abscesses usually can be accomplished in the office or emergency department using local anesthetics. A small incision is made over the area of fluctuance in close proximity to the anal verge. Pus is collected and sent for culture. Hemostasis is achieved with manual pressure, and the wound is packed with iodophor gauze. The gauze is removed after 24 hours, and the patient is instructed to take sitz baths 3 times a day and after bowel movements. Postoperative analgesics and stool softeners are prescribed to relieve pain and prevent constipation. The patient typically will follow up with his/her physician in 2-3 weeks for wound evaluation and inspection for possible fistula in ano.

A potential complication of anorectal abscess drainage is the formation of fistulous tracts. Management of fistulas will be addressed later in this review. The type of organism cultured from an anorectal abscess is an important predictor of fistula formation following surgical incision and drainage. Underlying anal fistulas are present in 40% of abscess cultures positive for intestinal bacteria; however, cultures growing Staphylococcus species are associated with perianal skin infections and typically have no subsequent risk of developing anal fistulas.

Treatment of ischiorectal, intersphincteric, and supralevator abscesses is performed best under general or regional anesthesia. In the case of ischiorectal abscess, a cruciate incision is made at the site of maximal swelling. Pus is drained and cultured. The ischiorectal fossa is probed with a finger or hemostat to disrupt loculations and facilitate drainage. Placement of a drain only is indicated for management of complex or bilateral abscesses.

To drain an ischiosphincteric abscess, a transverse incision is made within the anal canal below the dentate line posteriorly. The intersphincteric space is identified, and the plane between the internal and external sphincters is exposed. The abscess is opened to allow drainage, and a small mushroom catheter is sutured in situ to assist drainage and prevent premature wound closure.

Location and etiology will determine the drainage technique of supralevator abscesses. Failure to manage supralevator abscesses with consideration of the primary etiology may result in iatrogenic fistula formation. Evaluation with MRI or CT scan can exclude intra-abdominal or pelvic pathology as possible sources. If the supralevator abscess evolved from the extension of an ischiorectal abscess, external drainage through the ischiorectal fossa is indicated. If the abscess resulted from an upward extension of an intersphincteric abscess, appropriate drainage is created through the rectal mucosa. In cases of posterior supralevator abscess collections, a transverse incision is made in the posterior anal canal below the dentate line. The dissection extends from the intersphincteric plane through the puborectalis sling into the posterior anal space. A mushroom catheter then is sutured in place to ensure adequate drainage.

Anterior supralevator abscesses are superficial and more common in women. Surgical drainage may be approached using an anteriorly directed transanal incision or by a transvaginal approach entering the posterior cul-de-sac. A mushroom catheter is placed to ensure adequate drainage of the abscess collection. Patients with systemic signs of toxicity are admitted to the hospital and treated with intravenous antibiotics. If the patient does not improve clinically over the next 24-48 hours, reevaluation of the supralevator abscess by CT scan or reoperation may be indicated. In the face of recurrent, severe supralevator abscesses, some patients may require a diverting colostomy for optimal management.
Preoperative details

Because of the acute nature of anorectal abscesses, preoperative bowel preparation is not possible and typically is unnecessary.
Intraoperative details

Decisive management of anal fistulas relies on therapeutic interventions. Healing rarely is spontaneous, and failure to achieve adequate treatment often results in recurrent abscess, persistent drainage, and even malignancy. The main paradigms to follow in the management of anorectal fistulas include the following: determine the anatomy of the fistula, provide adequate drainage, eradicate the fistula tract, prevent recurrence, and preserve sphincter function. Preservation of sphincter function relies on maintaining integrity of the anorectal ring.

Once the external opening of the anorectal fistula has been identified and the surrounding tissue palpated, probing of the fistula tract is warranted. Aggressive probing of the fistula is discouraged to prevent formation of false channels. Using a blunt probe (eg, a small lachrymal probe), the internal origin of a primary fistula can be identified in the majority of cases. When searching for the opening within the anal canal of a fistulous tract the Goodsall rule is an excellent guideline. This rule states that an external opening anterior to a transverse line drawn across the anal verge is associated with a straight radial tract into the canal. An external opening posterior to the transverse line follows a curved fistulous tract to the posterior midline rectal lumen. Horseshoe fistulas occasionally are associated with both anterior and posterior openings within the anal canal.

Treatment options for the management of fistulas are aimed at providing definitive therapy while minimizing the morbidity of the procedure. For example, 2 widely accepted treatment interventions include fistulectomy and fistulotomy. Studies have demonstrated that removal of the entire fistula tract along with the surrounding scar tissue (ie, fistulectomy) unnecessarily results in a larger wound, prolonged healing time, and higher risks of incontinence. As a result, the more conservative approach of unroofing the tract without excision of all surrounding tissue (fistulotomy) usually is preferred and decreases the risks of incontinence and fistula recurrence, as well as shortens wound healing time. A fistulectomy is performed as a primary procedure for superficial fistulas that require minimal dissection of the fistula from the surrounding sphincter musculature. In contrast, simple fistulotomy for repair of high-level fistulas is contraindicated as the primary treatment.

Use of loose Setons is warranted in high-level fistulas (ie, trans-sphincteric and suprasphincteric) to reduce the risk of incontinence or in cases in which poor wound healing is anticipated. A Seton is a nonabsorbable nylon or silk suture that is guided through the fistula tract and tied exteriorly to maintain suture placement within the tract and to cause compression of the tract. The ischemic compression by the Seton and the local inflammatory reaction of adjacent tissues initiates fibrosis. Once fibrosis of the surrounding tissue develops, it helps maintain the integrity of the sphincter musculature during subsequent fistulotomy. Setons often are used in patients with fistulas secondary to inflammatory bowel disease (IBD). In addition, the Seton allows epithelialization of the fistulous tract, thereby preventing secondary closure and facilitating drainage of abscesses.

Another commonly used type of Seton is the cutting Seton, which can be used to gradually transect the anal sphincter musculature underlying the fistula by externally tightening the suture to induce pressure necrosis. Typically, retightening the Seton over a period of several days is necessary (this can be performed in the outpatient setting). The cutting Seton may eliminate the need for subsequent fistulotomy. While the cutting Seton is used as an effective therapeutic option for high-level fistulas, it is contraindicated in patients with IBD.
Postoperative details

Postoperatively, administer analgesics for pain, stool bulking agents, and stool softeners to prevent constipation. Follow-up evaluation of an incised anorectal abscesses is important to assess not only adequate healing but also the potential development of anorectal fistulas. The patient typically will follow up with his/her physician in 2-3 weeks for wound evaluation and inspection for possible fistula in ano.

Antibiotics are used in adjunct to surgical therapy for patients with comorbidities such as diabetes, valvular heart disease, or immunodeficiencies.
Follow-up

The patient typically will follow up with his/her physician in 2-3 weeks for wound evaluation and inspection for possible fistula in ano.

COMPLICATIONS
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* Authors and Editors
* Introduction
* Indications
* RELEVANT ANATOMY
* Contraindications
* Workup
* Treatment
* Complications
* Outcome And Prognosis
* Future And Controversies
* Multimedia
* References


Anorectal fistulas

Anorectal fistulas occur in 30-60% of patients with anorectal abscesses. The intersphincteric glands lie between the internal and external anal sphincters and are associated most commonly with abscess formation. Anorectal fistulas arise through obstruction of anal crypts and/or glands and are identified by purulent drainage from the anal canal or from the surrounding perianal skin. Other etiologies of anorectal fistulas are multifactorial and include diverticular disease, IBD, malignancy, and complicated infections such as tuberculosis and/or actinomycosis.

The Parks classification system defining the 4 major types of anorectal fistulas in order of decreasing frequency is as follows: intermuscular (70%), trans-sphincteric (23%), extrasphincteric (5%), and suprasphincteric (2%). The intersphincteric fistula is found between internal and external sphincters. The trans-sphincteric fistula extends through the external sphincter into the ischiorectal fossa. An extrasphincteric fistula passes from rectum to skin through the levator ani. Lastly, the suprasphincteric fistula spans from the intersphincteric plane through the puborectalis muscle, exiting the skin after traversing the levator ani.

The Goodsall rule states that an external opening of a fistulous tract anterior to a transverse line drawn across the anal verge is associated with a straight radial tract of the fistula into the anal canal/rectum. Conversely, an external opening posterior to the transverse line demonstrates a curved fistulous tract to the posterior midline rectal lumen. This rule is important for the planning of surgical treatment of the fistula, and it is illustrated in Media files 2-3.

OUTCOME AND PROGNOSIS
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* Authors and Editors
* Introduction
* Indications
* RELEVANT ANATOMY
* Contraindications
* Workup
* Treatment
* Complications
* Outcome And Prognosis
* Future And Controversies
* Multimedia
* References


Approximately two thirds of patients with rectal abscesses treated by incision and drainage or by spontaneous drainage will develop a chronic anal fistula.

The recurrence rate of anorectal fistulas after fistulotomy, fistulectomy, or use of a Seton is about 1.5%.

The overall incidence of major fecal incontinence after surgical management of complex suprasphincteric fistulas is estimated at approximately 7%.

FUTURE AND CONTROVERSIES
Section 10 of 12 Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic

* Authors and Editors
* Introduction
* Indications
* RELEVANT ANATOMY
* Contraindications
* Workup
* Treatment
* Complications
* Outcome And Prognosis
* Future And Controversies
* Multimedia
* References


Some surgeons advise performing a complementary colostomy to facilitate management of complex anal fistulas. This may be of some benefit in selected cases, but the perirectal infection may continue despite a diverting colostomy. Adequate drainage of the abscess is the most important factor in controlling progressive perirectal infection.

MULTIMEDIA
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* Authors and Editors
* Introduction
* Indications
* RELEVANT ANATOMY
* Contraindications
* Workup
* Treatment
* Complications
* Outcome And Prognosis
* Future And Controversies
* Multimedia
* References


Media file 1: Illustration of the major types of anorectal abscesses (submucosal not pictured).
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Media type: Image

Media file 2: Diagram illustrating the Goodsall rule for anorectal fistulas. Fistulas that exit in the posterior half of the rectum generally follow a curved course toward the posterior midline, while those that exit in the anterior half of the rectum usually follow a radial course to the dentate line.
Click to see larger picture Click to see detailView Full Size Image
Media type: Image

Media file 3: Illustration of the Goodsall rule for anorectal fistulas. Note the curved nature of the posterior fistulas and the radial (straight) orientation of the anterior fistulas.
Click to see larger picture Click to see detailView Full Size Image
Media type: Image


REFERENCES
Section 12 of 12 Click here to go to the previous section in this topic Click here to go to the top of this page

* Authors and Editors
* Introduction
* Indications
* RELEVANT ANATOMY
* Contraindications
* Workup
* Treatment
* Complications
* Outcome And Prognosis
* Future And Controversies
* Multimedia
* References


* Chandwani D, Shih R, Cochrane D. Bedside emergency ultrasonography in the evaluation of a perirectal abscess. Am J Emerg Med. Jul 2004;22(4):315. [Medline].
* Corman ML. Colon and Rectal Surgery. 4th ed. Philadelphia, Pa:. Lippincott-Raven;1998:224-271.
* Dozois RR, Nichols JR. Surgery of the Colon and Rectum. New York, NY:. Churchill Livingstone;1997:255-284.
* Fish D, Kugathasan S. Inflammatory bowel disease. Adolesc Med Clin. Feb 2004;15(1):67-90, ix. [Medline].
* Galandiuk S, Kimberling J, Al-Mishlab TG. Perianal Crohn disease: predictors of need for permanent diversion. Ann Surg. May 2005;241(5):796-801; discussion 801-2. [Medline].
* Lunniss PJ, Phillips RKS. Anal Fistula: Surgical evaluation and management. London, England:. Chapman & Hall;1996:1-183.
* Nelson R. Anorectal abscess fistula: what do we know?. Surg Clin North Am. Dec 2002;82(6):1139-51, v-vi. [Medline].
* Parks AG, Gordon PH, Hardcastle JD. A classification of fistula-in-ano. Br J Surg. Jan 1976;63(1):1-12. [Medline].
* Phillip GH. In: Gordon PH, Nivatvongs S, eds. Principles and Practice of Surgery for the Colon, Rectum and Anus. St. Louis, Mo:. Quality Medical Publ, Inc;1999:241-286.


Perianal Abscess excerpt

Article Last Updated: Mar 3, 2006

#5 Re: Perianalni Apsces kod bebe

Posted: 16/11/2008 00:34
by nihada_77
Hvala ti melb26sa.Ovo sto citam sve sam vec radila,popio je antibiotika 10,od inekcija geramicina,sirupa amoxibosa,penbritina.,,Radjena je i drenaza,imao je dren 5 dana.Malo se smiri pa se opet upali,hirurg je mislio da nije šta povezano sa čmarom,pa mu je i čmar širio naživo.Jer kaze anestezija ne djeluje kad je upala u pitanju.Beba mi prolazi užasne bolove,a i ja zajedno sa njim.Svake sedmice idemo na čišćenje,i to sve tako naživo ga reže.On misli da nema kanala sa debelim crijevom,jer mu je gurao prst u analni otvor.Tako da bi voljela znati,ako iko ima da se izliječio od apscesa,bez operacije,jer idemo opet na kontrolu u utorak,a predlaže mu operaciju.Velika hvala melb

#6 Re: Perianalni Apsces kod bebe

Posted: 16/11/2008 01:56
by Latina
nihada_77 wrote:Hvala ti melb26sa.Ovo sto citam sve sam vec radila,popio je antibiotika 10,od inekcija geramicina,sirupa amoxibosa,penbritina.,,Radjena je i drenaza,imao je dren 5 dana.Malo se smiri pa se opet upali,hirurg je mislio da nije šta povezano sa čmarom,pa mu je i čmar širio naživo.Jer kaze anestezija ne djeluje kad je upala u pitanju.Beba mi prolazi užasne bolove,a i ja zajedno sa njim.Svake sedmice idemo na čišćenje,i to sve tako naživo ga reže.On misli da nema kanala sa debelim crijevom,jer mu je gurao prst u analni otvor.Tako da bi voljela znati,ako iko ima da se izliječio od apscesa,bez operacije,jer idemo opet na kontrolu u utorak,a predlaže mu operaciju.Velika hvala melb
Kakav je ovo horor...Boze moj ! :shock:

Prvo sto moras uraditi je - PROMIJENITI DOKTORA ! To da anestezija ne djeluje kad je u pitanju upala je NEBULOZA. Beba se izlaze mucenju i bolovima radi ovog neeticnog "dr" i ne nosi bebu vise kod njega. Perianalni absces se moze aspirirati i iglom, ali se svaki zahvat radi pod lokalnom anestezijom. Beba se moze i blago sedirati da nije izlozena bolovima, ali dijete ne smijes izlagati patnji i traumatizirati ga vise.

The usual treatment of perianal abscess is incision and drainage. In infants, this procedure can be performed with local, topical anesthetic. General anesthesia may be required for older children.

Without intervention, as many as 85% of children with perianal abscess present with a recurrent abscess or progression to fistula.

Patients with perianal abscesses that recur after adequate incision and drainage require an examination under anesthesia to identify the fistula.


link :

http://www.emedicine.com/ped/topic2940.htm

ako treba prevesti, reci

sretno

#7 Re: Perianalni Apsces kod bebe

Posted: 16/11/2008 04:32
by Nosferatu
Polako, polako samo.

Ne oplesti po doktoru odmah.

To da je dijetetu manje od 6 mjeseci i da ne mogu koristiti anesteziju koje koriste na odraslima stoji. Nije mi jasno medjutim sto ne koriste inhalation agenta tj. gas da uspavaju dijete? Mozda procedura zahtjeva vise vremena i ona kratko traje a mozda procedura nije tolika da se mora dijete kompletno anestizirati ali - za sve postoji nacin.

Nije mi jasno sta je to po tebi "na zivo"? Neces mi valjda reci da mu ne dadnu lokalnu anesteziju nego prvo sto urade je izvuku noz pa rezi? A ti to gledas? I ako nije tako, polako. Niko nije od bola umro, ali od anestezije i ljekova za bolove - jeste, mnogima je depresiran centar za disanje i ljudi se uguse, stoga - nije nista onakvim kakvim to tebi izgleda. Ako je dijete budno - ali ima lokalnu anesteziju - sve zavisi o obimu operacije koliko je to prihvatljivo a koliko nije. Anestezija nije sala narucito ne ako se radi o malim procedurama - elipticni rez, uvuci dren, nabaci par savova da se nista ne pomakne i slicno. To da je za tebe takvo nesto veliko - jeste - jer je tvoje dijete, ali ne zahtjeva svaki slucaj generalnu anesteziju. Tj. kad imas dijete ispod 6 mjeseci nista nije sala i sve moze da se iskomplicira.

Perianalna absces je zeznuta stvar. Prvo sto tebi treba je dijagnoza a to znaci da li dijete ima fistulu analnu (najgori slucaj) da li ima perirectalno/analani abses (ili vise njih - moguce da su samo jednu - drenirali a ostale ostale - tamo gdje su i bile) i odakle dolazi tj. sta kreira dzep gnoja koji se stvara. Tvoj materinski instinkt da ne treba operacija tj. da je operacija zlo a dobro je davati sirupice i slicno, te vara. Operacija je jedini nacin, ako mene pitas, ali - kontrolirana operacija tj. manje vise - "procedura" a ne operacije jer - treba se znati sta je gdje, sta je problem, na koji nacin ce problem da se pokusa rijesiti. Za to treba dijagnostika u vidu CT skenranja i takodje da dijete proguta - kontrast i ima niz onda - rentgenoloskih imidza koje ce dobar radiolog da pogleda i utvrdi sta je gdje - anatomski. Meni se cini da se do tog odgovora jos uvijek nije doslo. Dren je trebao da rijesi ovo ali nije. Sto znaci da se mora ici dalje. Pored izbora da li da ima dijete operaciju ili ne, bitan je i izbor da li je to sad pod mora ili nije.

Antibiotici pomazu minmalno samo jer dzep gnoja nije vaskuliziran tj. tu nema krvotoka, a antibiotici su u krvi ili su u crijevima tj. ne mogu doci do epicentra infekcije. Ne samo to vec bakterije imaju tendenciju da formiraju absces tj. odvajaju se od ostatka tijela tkivom koji unisti rat izmedju bakterije i imunog sistema - dakle "no man's land" - to je dio koji je nekrotican i zbog kojeg - ne moze se rijesiti problem bez operacije. Vecinski to su anaerobni organizmi. Znaci njima je hava otrov. Ali i anerobni organizmi napredni imaju mogucnost da prezive na vazduhu. Medjutim - ne svi. Zbog toga drenaza plus antibiotici su najcesce pristup koji se koristi i dovoljan je - ukoliko se zna sta se radi i ukoliko dijete nije formiralo fistulu. Fistula je manje vise - tunel - koji vodi kroz tkivo - npr. od anusa ka nekom dijelu guze ali ne i vani. Ta fistula se kao trakt koji se puni izmetom i inficira jer ne moze izaci van se mora zatvoriti. Ako se ne zatvori, dzaba i drenaza, jer ce da se sve ponovi iznova i opet. Kako se zatvara fistula? Operacijom. Mora se prvo locirati i onda - na poseban nacin zatvoriti da nebi 20-30 godina kasnije - sve se opet ponovilo. Sta je u ovome problem najveci. Analni sfingter. Tj. misic anusa. Ako se iztraumatizira pretjerano moze dovesti do toga da dijete mora cijeli zivot nositi pelene. Kroz taj sfinger se ne smije - napraviti rez - a problem je takodje sto sve ovo sto se desava - desava se vrlo blizu tog analnog sfingtera - tako da je ovo nekad tesko izbjeci a nekad se ne moze izbjeci i mora se zatvoriti fistula a onda sta bude bude sa kontrolom. Samo tog dijela sto se tice, ne znam da li je bolje sto je dijete mladje, ili nije. Njie bolje jer su oziljici veci, ali je bolje jer nije naucilo kontrolirati taj sfingter, te kasnije moze lakse da se nauci, a ne iznova da se opet "trenira".

Operirati na sljepo - dijete ispod 6 mjeseci - nije velika pamet ako mene pitas. Ali nije velika pamet ni gledati te infekcije, koje ne mozes rijesiti na drugi nacin. Ovaj problem koji ima - nije - rijedak. Problem koji imas takodje - ne ubija, ne treba operacija na srcu otvorena, ne treba resekcija crijeva u duzini od 2-3 metra, ali treba neko ko zna sta radi i trebas i ti - da takvome pomognes jer oni rijesavaju tvoj problem a ne ti njihov, iako su za to placeni i trebali bi da budu malo, humaniji u pristupu jer se radi o dijetetu od 6 mjeseci.

Mene samo interesuje da li je dijete izgubilo dosta na tezini i da li zaostaje za vrsnjacima po svim stvarima - od obima glave, visine, tezine i po znacima razvoja mentalnog. Ako su odgovori na ovo pitanje da - onda bih ozbiljno razmiljao o operaciji. Ko ti ovdje najvise moze pomoci, je iskusan pedijatar koji je imao ovakve slucaje i koji su bili komplikovani, a trebao bi svaki pedijatar da je barem imao ih par. Drugo sto treba je pedijatrijski hirurg. Ne znam da li je hirurg kojem si dijete nosila bio treniran pedijatrijski ili ne (ne mogu vjerovati da nije a po opisu mi nekako zvuci to malo previse "umri muski"). I na kraju treba babo da se prikljuci takodje, da on svoja muda nategne jer dijete je u pitanju pa da sa tebe skine malo breme, tj. da on malo mozga i donosi odluke, jer i on je pomogao da se dijete napravi, sad ne moze tebi sve uvaliti a on da bude posmatrac.

Ako sam ti sta valjao, valjao, ako nisam... najsigurniji je put da nadjes finog pedijatra, koji zna da mater dijeteta od 6 mjeseci koje treba operaciju je i sama pacijent. Pa da s tobom fino, polako, da te nije strah i da ne dramis, ako dramis. A onda treba to rijesiti fino, i nadati se bez komplikacija dugotrajnih, to je ono sto se pokusava izbjeci. Sta moze dovesti do komplikacija. I operacija ali i dugotrajne infekcije. Svaka instrumentalizacija je traumatska i postavlja se pitanje takodje kad operacija ne rijesi problem - koliko je odmogla tj. da li se je problem pogorsao kao rezultat operacije. Ali - na kraju dana - ako se je sve pokusalo a dijete i dalje ima infekcije, ja mislim da nema drugog nacina. Medjutim onima kojima dadnes dijete u ruke trebala bi da vjerujes dovoljno a i oni da u tebe uljevaju neko pouzdanje. Lazno ili stvarno, o tome je tesko govoriti, jer kao sto vidis - nije nista 100% a nece niko odluke za tebe da pravi - tj. ti moras, tvoje je dijete. Ono sto bih ja pitao hirurga je - koliko je ovakvih operacija imao, i koji mu je uspjeh, koje su komplikacije, da li mora dijete bas sad da se operira ili moze se naci nacin na koji da se saceka do 1-2 godine, dijete je vece, lakse podnjeti moze operaciju i lakse se oporaviti, ali ti i sama znas vecinu odgovora na ova pitanja - ti provodis najvise vremena s dijetetom. Pitanje je da li moze da ceka. Ako je odgovor da ne moze, postoji samo jedno pitanje. Ko ce uraditi operaciju. I to je kljucno. Po meni mnogo bitnije od tog da li ce ili nece se operisati. A ti fino, vidi gdje i koje imas pedijatrijske hirurge na raspolaganju pa izaberi onog u kojeg imas najvise pouzdanja. Znam da nije laka odluka, ja je nikad nisam morao donjeti ali - ljudi koji rade taj posao - moraju da rade posao a ne da budu emotivni po pitanju istog, jer mozes samo jedno od to dvoje. Zbog toga pored operacije, treba ti i podrska familije i prijatelja, da ti oni pomognu takodje, ali u razmjerama proporcionalno s onim sto je problem. Pricanje o tome kako ti dijete rezu na zivo, osim ako to nije istina ne stimuliraju ove odnose, a ti ako onima koji rezu na zivo, ides na kontrole poslje toga, i cekas da ovo sve prodje samo od sebe tj. bude samo gore, a odgovora nemas, nemas alternative, ni ljudi ni opcija, ne znam samo ti mogu ovo reci, budi dio solucije a ne dio problema. Ako budes ti dio problema, svi ce drugi takodje biti dio problema, vjeruj mi. To tako ide, svugdje, a narucito kod nas.

#8 Re: Perianalni Apsces kod bebe

Posted: 16/11/2008 12:59
by nihada_77
Mnogo ti hvala Nosferatu!Nisam znala za taj misic.Moram to da pitam.Ne daj Boze.Što se tice moje bebe,on masAllah odlicno napreduje,nema bolova.cak i kad mu pritiscem,njega ne boli,nije imao ni temperaturu radi apscesa,spava,na kilazi dobiva i vise od normalnog.Al to kad idemo na ciscenje,i kad kazem na zivo,znaci bas na zivo,nikakva anestezija!Inace sam isla na kosevo,djecija hirurgija,posto gore vlada haos,nadjemo privatnog dj.hirurga inace prof.kod njega idemo vec 3 mjeseca.Koji nam je sad predlozio operaciju,on kaze da nema dubine,tj nema fistule,al kad se zagnoji to je povrsinski.Jer prvi put je bilo bas duboko,i tvrdo na dodir ispod mosnji.Znam da ima i tezih slucajeva,bolesti,i kazem nedaj Boze goreg.Al meni je moja beba jedna,a njima hiljadu i jedna(doktorima).Moja pedijatrica kaze,da je imala samo jednu djevojcicu,nekad davno i uspjesno je izlijecena nakon prvog puta drenaze..A prof.kaze da je imao operacija apscesa i da su svi uspjesno zavrseni,on ovako kaze:Ma joj sta sam ih ja uradio,evo sad cu vam ja dati telefone pa se cujte sa njima.Tad sam imala osjecaj,da on misli da mu nevjerujem,pa sam se bas osjecala bezveze.Inace,kad idemo kod ljekara ja sam vec uspanicena,i samo mislim kad dodjemo tamo sta ce da mu radi!Naravno da cu pristati na operaciju,ako je to za moje djete jedina opcija.Nadala sam se da cu naci nekog,koje vec to imao i zavrsio bez operacije!Ili je i operisan,a da je beba. Hvala jos jednom

#9 Re: Perianalni Apsces kod bebe

Posted: 16/11/2008 14:21
by Latina
:roll:

#10 Re: Perianalni Apsces kod bebe

Posted: 16/11/2008 14:48
by PalaSa Marsa
nihada_77 Zelim ti puno srece ..Vama i vasoj bebi..

#11 Re: Perianalni Apsces kod bebe

Posted: 16/11/2008 14:50
by neprilagodjena
I od mene sve najbolje i sretno nihada.

#12 Re: Perianalni Apsces kod bebe

Posted: 04/12/2009 14:08
by mimamima
Imam bebicu od mjesec i pol kojoj je dijagnostificiran perianalni apsces, vec dva puta je rađena incizija i drenaža, ali nakon što rez zacijeli upala se vrati, molim vas ako mi mozete reći da li ste uspijeli izljećiti apsces i na koji način. Unaprijed hvala

#13 Slobodni softver

Posted: 16/01/2012 06:00
by kotyara
Get free stuff ovdje:
http://goo.gl/IaCCo

#14 Re: Perianalni Apsces kod bebe

Posted: 16/01/2012 09:01
by headbanger
..