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The circular muscle of the rectum is called. Anatomy of intestinal vessels - arteries, veins. Blood supply to the rectum

2. Blood supply to the ureter

6. Blood supply to the ovary

7. Blood supply to the uterus

8. Vaginal blood supply

Bibliography

1. Blood supply to the rectum

The rectum, rectum, is the terminal part of the large intestine; feces accumulate in it and are then removed from the body. The rectum is located in the pelvic cavity, its length in an adult is on average 15 cm, and its diameter ranges from 2.5 to 7.5 cm. Behind the rectum are the sacrum and coccyx, in front of it in men are the prostate gland, urinary bladder, seminal vesicles and ampoules of the vas deferens, in women - the uterus and vagina.

The rectum is not actually straight, but forms two bends in the sagittal plane. The first is the sacral bend, flexura sacralis, corresponds to the concavity of the sacrum; the second - the perineal bend, flexura perinealis, is located in the perineum (in front of the coccyx) and is convexly directed forward. The curvatures of the rectum in the frontal plane are not constant.

The part of the rectum located in the pelvic cavity forms an extension at the level of the sacrum, which is called the ampulla of the rectum, ampulla recti. The narrower part of the intestine passing through the perineum is called the anal canal, canalis analis. The anal canal below has an opening that opens outward - the anus, anus.

In the walls of the rectum, the superior rectal artery (from the inferior mesenteric artery) and the paired middle and inferior rectal arteries (from the internal iliac artery) branch. Venous blood flows through the superior rectal vein into the portal vein system (through the inferior mesenteric vein) and through the middle and inferior rectal veins into the inferior vena cava system (through the internal iliac veins).

Rice. 1. Rectum, rectum. (The front wall has been removed.) 1 - ampulla recti; 2 - columnae anales; 3 - sinus anales; 4 - linea anwectalis; 5 - m. sphincter anl extemus; 6 - m. sphincter ani internus; 7 - plica transversa recti.

2. Blood supply to the ureter

The blood vessels of the ureter come from several sources. The ureteral branches (rr. ureterici) from the renal, ovarian (testicular) arteries (a. renalis, a. testicularis, s. ovarica) approach the upper part of the ureter. The middle part of the ureter is supplied with blood by the ureteric branches (rr. ureterici) from the abdominal aorta, from the common and internal iliac arteries. Branches (rr. ureterici) from the middle rectal and inferior vesical arteries go to the lower part of the ureter. The veins of the ureter drain into the lumbar and internal iliac veins.

3. Blood supply to the bladder

The bladder is located in the pelvic cavity and lies behind the pubic symphysis. With its anterior surface it faces the pubic symphysis, from which it is delimited by a layer of loose tissue located in the retropubic space. When the bladder fills with urine, its apex protrudes above the pubic symphysis and comes into contact with the anterior abdominal wall. The posterior surface of the bladder in men is adjacent to the rectum, seminal vesicles and ampoules of the vas deferens, and the bottom is adjacent to the prostate gland. In women, the posterior surface of the bladder is in contact with the anterior wall of the cervix and vagina, and the bottom is in contact with the urogenital diaphragm. The lateral surfaces of the bladder in men and women are bordered by the levator ani muscle. The loops of the small intestine are adjacent to the upper surface of the bladder in men, and the uterus in women. The filled bladder is located mesoperitoneally in relation to the peritoneum; empty, collapsed - retroperitoneal.

The peritoneum covers the bladder from above, from the sides and from behind, and then in men it passes to the rectum (rectovesical recess), in women - to the uterus (vesicouterine recess). The peritoneum covering the bladder is loosely connected to its wall. The bladder is fixed to the walls of the pelvis and connected to adjacent organs using fibrous cords. The median umbilical ligament connects the top of the bladder to the navel. The lower part of the bladder is attached to the walls of the pelvis and neighboring organs by ligaments formed by connective tissue bundles and fibers of the so-called pelvic fascia. Men have a puboprostatic ligament, lig. puboprostaticum, and in women - the pubovesical ligament, lig. pubovesic ale.

Vessels and nerves of the bladder. The superior vesical arteries, branches of the right and left umbilical arteries, approach the apex and body of the bladder. The lateral walls and bottom of the bladder are supplied with blood by branches of the inferior vesical arteries (branches of the internal iliac arteries).

Venous blood from the walls of the bladder flows into the venous plexus of the bladder, as well as through the vesical veins directly into the internal iliac veins. The lymphatic vessels of the bladder drain into the internal iliac lymph nodes.

4. Blood supply to the seminal vesicle

The seminal vesicle, vesicula (glandula) seminalis, is a paired organ located in the pelvic cavity lateral to the ampulla of the vas deferens, above the prostate gland, behind and to the side of the bottom of the bladder. The seminal vesicle is a secretory organ. The peritoneum covers only its upper parts. The surface of the seminal vesicle is lumpy. The seminal vesicle has an anterior surface facing the bladder and a posterior surface adjacent to the rectum. The length of the seminal vesicle is about 5 cm, width - 2 cm and thickness - 1 cm. When cut, it looks like vesicles communicating with each other.

On the outside, the seminal vesicle has an adventitial membrane, tunica adventitia.

The excretory duct of the seminal vesicle connects with the terminal section of the vas deferens and forms the ejaculatory duct, ductus ejaculatorius, which pierces the prostate gland and opens into the prostatic part of the male urethra, on the side of the seminal colliculus. The length of the ejaculatory duct is about 2 cm, the width of the lumen is from 1 mm in the initial part to 0.3 mm at the point of confluence with the urethra.

Vessels and nerves of the seminal vesicle and vas deferens. The seminal vesicle is supplied with blood from the descending branch of the artery of the vas deferens (branch of the umbilical artery). The ascending branch of the vas deferens artery brings blood to the walls of the vas deferens. The ampulla of the vas deferens receives blood through the branches of the middle rectal artery and the inferior cystic artery (from the internal iliac artery).

Venous blood from the seminal vesicles flows through the veins into the venous plexus of the bladder, and then into the internal iliac vein. Lymph from the seminal vesicles and vas deferens flows into the internal iliac lymph nodes. The seminal vesicles and vas deferens receive sympathetic and parasympathetic innervation from the plexus of the vas deferens (from the inferior hypogastric plexus).

5. Blood supply to the prostate gland

The prostate gland, pro stata, is an unpaired muscular-glandular organ that secretes a secret that is part of the sperm.

The prostate gland is located in the anterior lower part of the small pelvis under the bladder, on the urogenital diaphragm. The initial section of the urethra and the right and left ejaculatory ducts pass through the prostate gland.

The urethra enters the base of the prostate gland, leaving most of the gland behind it, and exits the gland at the apex.

The transverse size of the prostate gland reaches 4 cm, the longitudinal (upper-lower) is 3 cm, the anteroposterior (thickness) is about 2 cm. The mass of the gland is 20-25 g. The substance of the prostate gland has a dense consistency and a grayish-red color.

Blood supply to the prostate gland. The prostate gland is supplied with blood by numerous small arterial branches arising from the inferior vesical and middle rectal arteries (from the system of internal iliac arteries). Venous blood from the prostate gland flows into the venous plexus of the prostate, from it into the inferior vesical veins, which flow into the right and left internal iliac veins. The lymphatic vessels of the prostate gland drain into the internal iliac lymph nodes.

6. Blood supply to the ovary

The ovary, ovarium (Greek oophoron), is a paired organ, the female reproductive gland, located in the pelvic cavity. In the ovaries, female reproductive cells (eggs) develop and mature, and female sex hormones that enter the blood and lymph are formed. The ovary has an ovoid shape, somewhat flattened in the anteroposterior direction. The color of the ovary is pinkish.

The surfaces of the ovary pass into a convex free (posterior) edge, margo liber, in front - into the mesenteric edge, margo mesov aricus, attached to the mesentery of the ovary. At this edge of the organ there is a groove-shaped depression, called the gate of the ovary, hilum ovarii, through which the artery, nerves enter the ovary, veins and lymphatic vessels exit.

Near each ovary there are rudimentary formations - an appendage of the ovary, a periovarian (appendage of the epididymis) and vesicular appendages, remnants of the tubules of the primary kidney and its duct.

The epididymis (epovary), epoophoron, is located between the leaves of the mesentery of the fallopian tube (mesosalpinx) behind and lateral to the ovary and consists of a longitudinal duct of the epididymis, ductus epoophorontis longitudinalis, and several convoluted tubules flowing into it - transverse ducts, ductuli transversi, the blind ends of which are facing to the hilus of the ovary.

The periovary, paroo~phoron, is a small formation that also lies in the mesentery of the fallopian tube, near the tubal end of the ovary. The periovary consists of several disconnected blind tubules.

The ovary is supplied with blood by the branches of the ovarian artery (a. ovarica - from the abdominal aorta) and ovarian branches (rr. ovaricae - from the uterine artery). Venous blood flows through the veins of the same name. The lymphatic vessels of the ovary drain into the lumbar lymph nodes.

7. Blood supply to the uterus

The uterus, uterus (Greek metra), is an unpaired hollow muscular organ in which the embryo develops and the fetus is born. The uterus is located in the middle part of the pelvic cavity, lies behind the bladder and in front of the rectum. The uterus is pear-shaped and flattened in the anteroposterior direction. It distinguishes between the bottom, body and neck.

The fundus of the uterus, fundus uteri, is the upper convex part of the uterus, protruding above the line where the fallopian tubes enter the uterus and passes into its body. The body of the uterus, corpus uteri, is cone-shaped, represented by the middle (larger) part of the organ. Downwards, the body of the uterus passes into a rounded part - the cervix uteri. The junction of the uterine body and the cervix is ​​narrowed and is called the isthmus of the uterus, isthmus uteri. The lower part of the cervix protrudes into the vaginal cavity, therefore it is called the vaginal part of the cervix, portiovaginalis cervicis, and the upper part of the cervix, lying above the vagina, is called the supravaginal part of the cervix, portio supravaginalis cervicis. On the vaginal part you can see the opening of the uterus, ostium uteri (uterine os), leading from the vagina into the canal of the cervix and continuing into its cavity.

The blood supply to the uterus occurs through the paired uterine artery, a branch of the internal iliac artery. Each uterine artery passes along the lateral edge of the uterus between the leaves of the broad ligament of the uterus, giving off branches to its anterior and posterior surfaces. Near the fundus of the uterus, the uterine artery divides into branches leading to the fallopian tube and ovary. Venous blood flows into the right and left uterine venous plexuses, from which the uterine veins originate, as well as veins flowing into the ovarian, internal iliac veins and venous plexuses of the rectum.

8. Vaginal blood supply

The vagina, vagina (colpos), is an unpaired hollow organ in the shape of a tube located in the pelvic cavity and extending from the uterus to the genital slit. At the bottom, the vagina passes through the urogenital diaphragm. The length of the vagina is 8-10 cm, the thickness of its wall is about 3 mm. The vagina is slightly curved posteriorly, its longitudinal axis with the axis of the uterus forms an obtuse angle (slightly more than 90°), open anteriorly. The vagina with its upper end starts from the cervix, goes down, where its lower end opens into the vestibule with the opening of the vagina.

The vaginal arteries originate from the uterine arteries, as well as from the inferior vesical, middle rectal and internal genital arteries. Venous blood from the walls of the vagina flows through the veins into the vaginal venous plexus, and from it into the internal iliac veins.

Bibliography

1.Prives M.G., Lysenkov N.K., Bushkovich V.I. Human anatomy. - M.: Medicine, 1985.

2.Sapin M.R., Bilich G.L. Human anatomy: A textbook for students of biological specialties of higher educational institutions. - M.: Higher School, 2000.

3. Sinelnikov R.D. Atlas of human anatomy: Textbook: in 3 volumes. M.: Medicine, 1978-1981.

The rectum is the final part of the human digestive tract.

The anatomy and physiology of the rectum differs from that of the large intestine. The rectum has an average length of 13-15 cm, the diameter of the intestine ranges from 2.5 to 7.5 cm. The rectum is conventionally divided into two parts: the ampulla of the intestine and the anal canal (anus). The first part of the intestine is located in the pelvic cavity. Behind the ampulla is the sacrum and coccyx. The perineal part of the intestine has the form of a slit located longitudinally, which passes through the thickness of the perineum. In men, in front of the rectum there is a prostate gland, seminal vesicles, bladder and ampulla of the vas deferens. In women, the vagina and uterus. In the clinic, it is convenient to use the conditional division of the rectum into the following parts:

  1. supramullary or rectosigmoid;
  2. superior ampullary;
  3. mid-ampullary;
  4. inferior ampullary part;
  5. crotch part.

Clinical anatomy of the organ

The rectum has bends: frontal (not always present, changeable), sagittal (constant). One of the sagittal bends (proximal) corresponds to the concave shape of the sacrum, which is called the sacral bend of the intestine. The second sagittal curve is called perineal and is projected at the level of the coccyx, in the thickness of the perineum (see photo). The rectum on the proximal side is completely covered by the peritoneum, i.e. located intraperitoneally. The middle part of the intestine is located mesoperitoneally, i.e. covered with peritoneum on three sides. The terminal or distal part of the intestine is not covered by the peritoneum (located extraperitoneally).

Anatomy of the rectal sphincters

On the border between the sigmoid colon and the rectum there is the sigmorectal sphincter, or according to the author O'Berne-Pirogov-Muthier. The basis of the sphincter is made up of smooth muscle fibers, located circularly, and the auxiliary element is a fold of the mucous membrane, occupying the entire circumference of the intestine, located circularly. Along the intestine there are three more muscle sphincter.

  1. The third sphincter or proximal (according to the author Nelaton), has approximately the same structure as the first sphincter: it is based on circular smooth muscle fibers, and an additional element is a circular fold of the mucosa, which occupies the entire circumference of the intestine.
  2. Internal sphincter of the rectum, or involuntary. It is located in the area of ​​the perineal flexure of the intestine, ending at the border where the superficial layer of the external anal sphincter connects with its subcutaneous layer. The base of the sphincter consists of thickened smooth muscle bundles that run in three directions (circularly, longitudinally and transversely). The length of the sphincter is from 1.5 to 3.5 cm. The longitudinal fibers of the muscle layer are woven into the distal sphincter and into the external sphincter of the anus, connecting with the skin of the latter. The thickness of this sphincter is greater in men; it gradually increases with age or with certain diseases (accompanied by constipation).
  3. Voluntary external sphincter. The basis of the sphincter is the striated muscle, which is a continuation of the puborectalis muscle. The sphincter itself is located in the pelvic floor. Its length ranges from 2.5 to 5 cm. The muscular part of the sphincter is represented by three layers of fibers: the subcutaneous part of the circular muscle fibers, a cluster of superficial muscle fibers (united and attached to the bones of the coccyx at the back), a layer of deep muscle fibers associated with the fibers of the puborectalis muscle . The external voluntary sphincter has auxiliary structures: cavernous tissue, arteriolo-venular formations, connective tissue layer.

All rectal sphincters provide the physiological process of defecation.

Wall structure

The walls of the rectum consist of three layers: serous, muscular and mucous (see photo). The upper part of the intestine is covered with a serous membrane in front and on the sides. In the uppermost part of the intestine, the serosa covers the posterior part of the intestine and passes into the mesorectum. The mucous membrane of the human rectum forms multiple longitudinal folds that are easily straightened. From 8 to 10 longitudinal mucous folds of the anal canal are permanent. They have the shape of columns, and between them there are depressions called the anal sinuses and ending with semilunar valves. The valves, in turn, form a slightly protruding zigzag line (it is called anorectal, dentate or comb), which is the conventional boundary between the squamous epithelium of the rectal anal canal and the glandular epithelium of the ampullary part of the intestine. Between the anus and the anal sinuses there is a ring-shaped zone called hemorrhoidal. The submucosa provides easy movement and stretching of the mucous membrane, due to its loose connective tissue structure. The muscle layer is formed by two types of muscle fibers: the outer layer has a longitudinal direction, the inner layer has a circular direction. The circular fibers thicken to 6 mm in the upper half of the perineal part of the intestine, thereby forming the internal sphincter. Muscle fibers in the longitudinal direction are partially woven into the external sphincter. They also connect to the levator ani muscle. The external sphincter, up to 2 cm high and up to 8 mm thick, contains voluntary muscles, covers the perineal section, and also ends with the intestine. The mucous layer of the rectal wall is covered with epithelium: the anal columns are lined with flat non-keratinizing epithelium, the sinuses are lined with stratified epithelium. The epithelium contains intestinal crypts, extending only to the intestinal columns. There are no villi in the rectum. A small number of lymphatic follicles are found in the submucosa. Below the intestinal sinuses there is a boundary between the skin and the mucous membrane of the anus, which is called the anal-cutaneous line. The skin of the anus has a flat, non-keratinizing stratified pigmented epithelium, it has pronounced papillae, and the anal glands are located in its thickness.

Blood supply

Arterial blood approaches the rectum through the unpaired superior rectal and rectal arteries (middle and lower). The superior rectal artery is the last and largest branch of the inferior mesenteric artery. The superior rectal artery provides the main blood supply to the rectum to its anal region. The middle rectal arteries depart from the branches of the internal iliac artery. Sometimes they are absent or not equally developed. Branches of the inferior rectal arteries arise from the internal pudendal arteries. They provide nutrition to the external sphincter and the skin of the anal area. In the layers of the rectal wall there are venous plexuses, called subfascial, subcutaneous and submucosal. The submucosal, or internal, plexus is connected to the others and is located in the form of a ring in the submucosa. It consists of dilated venous trunks and cavities. Venous blood flows through the superior rectal vein into the portal vein system, and through the middle and lower rectal veins into the inferior vena cava system. Between these vessels there is a large network of anastomoses. The superior rectal vein lacks valves, so the veins in the distal rectum often dilate and develop symptoms of venous stasis.

Lymphatic system

Lymphatic vessels and nodes play a large role in the spread of infections and tumor metastases. In the thickness of the mucous membrane of the rectum lies a network of lymphatic capillaries, consisting of one layer. In the submucosal layer there are plexuses of lymphatic vessels of three orders. In the circular and longitudinal layers of the rectum there are networks of lymphatic capillaries. The serous membrane is also rich in lymphatic formations: it has a superficial finely looped and deep broadly looped network of lymphatic capillaries and vessels. The lymphatic vessels of the organ are divided into three types: extramural upper, middle and lower. From the walls of the rectum, lymph is collected by the upper lymphatic vessels, they run parallel to the branches of the superior rectal artery and empty into the lymph nodes of Gerota. Lymph from the side walls of the organ is collected in the middle lymphatic vessels of the rectum. They are directed under the fascia of the levator ani muscle. From them, lymph flows into the lymph nodes located on the walls of the pelvis. From the lower rectal lymphatic vessels, lymph goes to the inguinal lymph nodes. The vessels begin from the skin of the anus. Lymphatic vessels from the ampulla of the intestine and from the mucous membrane of the anal canal are connected to them.

Innervation

Different parts of the intestine have separate branches of innervation. The rectosigmoid and ampullary parts of the rectum are innervated mainly by the parasympathetic and sympathetic nervous systems. The perineal section of the intestine is due to the branches of the spinal nerves. This may explain the low pain sensitivity of the ampullary part of the rectum and the low pain threshold of the anal canal. Sympathetic fibers provide innervation to the internal sphincter, a branch of the pudendal nerves - the external sphincter. Branches arise from the 3rd and 4th sacral nerves, providing innervation to the levator ani muscle.

Functions

The main function of this section of the intestine is to evacuate feces. This function is largely controlled by the consciousness and will of a person. New research has established that there is a neuroreflex connection between the rectum and the internal organs and systems of the body, carried out through the cerebral cortex and the lower levels of the nervous system. Food begins to be evacuated from the stomach just a few minutes after eating. On average, the stomach is emptied of its contents after 2 hours. By this time, the first portions of chyme reach the bauhinium valve. Up to 4 liters of liquid pass through it per day. The human colon absorbs about 3.7 liters of the liquid part of chyme per day. Up to 250-300 grams are evacuated from the body in the form of feces. The human rectal mucosa ensures the absorption of the following substances: sodium chloride, water, glucose, dextrose, alcohol, and many medications. About 40% of the total mass of feces consists of undigested food debris, microorganisms, and waste products of the digestive tract. The ampullary part of the intestine acts as a reservoir. Feces and gases accumulate in it, stretch it, and irritate the interoceptive apparatus of the intestine. The impulse from the higher parts of the central nervous system reaches the striated muscles of the pelvic floor, the smooth muscles of the intestine and the striated fibers of the abdominal muscles. The rectum contracts, the anus rises, the muscles of the anterior abdominal wall, the pelvic floor diaphragm contract, and the sphincters relax. These are physiological mechanisms that ensure the act of defecation.

Measuring rectal temperature

The rectum is a closed cavity, so the temperature in it is relatively constant and stable. Therefore, the results of thermometry in the rectum are the most reliable. The temperature of the rectum is almost equal to the temperature of human organs. This method of thermometry is used in a certain category of patients:

  1. patients with severe exhaustion and weakness;
  2. children under 4-5 years of age;
  3. patients with thermoneuroses.

Contraindications include diseases of the rectum (hemorrhoids, proctitis), stool retention when the ampullary part of the intestine is filled with feces, and diarrhea. Before you start measuring temperature, you need to lubricate the end of the thermometer with petroleum jelly. An adult patient can lie on his side; it is more convenient to place children on their stomach. The thermometer is inserted no more than 2-3 cm. An adult patient can do this himself. During the measurement, the patient continues to lie down, the thermometer is held with the fingers of the hand, which lies on the buttocks. Avoid abrupt insertion of the thermometer, its rigid fixation, or movement of the patient during measurement. The measurement time will be 1-2 minutes if you use a mercury thermometer.

Normal temperature in the rectum is 37.3 - 37.7 degrees.

After measuring, place the thermometer in a disinfectant solution and store it in a separate place. The following symptoms may indicate diseases of the rectum.

  • Constipation. To determine the cause of constipation, you should consult a specialist and undergo the necessary research. Constipation can be a sign of serious diseases: intestinal obstruction, tumor diseases, intestinal diverticulosis.
  • Symptoms indicating the presence of a chronic anal fissure: bloody discharge after defecation, pain before and after defecation. A proctologist will detect this disease during a routine visual examination.
  • Sharp, intense pain in the rectal area, poor general health and increased temperature with signs of intoxication are indications for calling emergency services. The listed symptoms may indicate an inflammatory process of subcutaneous fatty tissue - paraproctitis.
  • The reason for contacting a specialist is nonspecific symptoms characteristic of many diseases of the rectum (cancer, polyps, hemorrhoids): sudden weight loss, there is an admixture of blood and mucus in the stool, the patient is bothered by severe pain before and after defecation.

The rectum is the final section of the large intestine. The beginning of the rectum corresponds to the level of the upper edge of the 3rd sacrumnew vertebra. The rectum is located in the pelvic cavity and runs vertically along the concavity of the sacrum from the promontory to the anus. Its length is 16-18 cm. She has the shape of a double bend in the sagittal plane and three bends in the frontal plane: the upper and lower are convex to the right, and the middle one to the left. At proximal O th borders of the rectum, the transverse semilunar folds of the mucous membrane of the sigmoid colon in the rectum give way to a smoother epithelial lining.A thin pink mucous membrane covers the sacral and perineal flexures of the intestine and reaches the upper part of the anal canal.

Muscularis The rectum consists of 2 layers: the outer - longitudinal and the inner - circular. Longitudinal muscular the layer covers the rectum on all sides and is located more or less evenly along its entire length. Internal circular the layer is located around the circumference of the rectum in the form of different-sized rings and spirals, which, sequentially contracting, slowly move the contents of the rectum to the anus. The muscle bundles of the circular layer in some places become significantly thicker, playing the role of sphincters.
The circular layer of the muscular lining of the rectum plays the role of regulators of the tone of the intestinal wall, and the longitudinal layer ensures the spread of peristaltic and propulsive contractions. The structural features of the rectal wall ensure its elasticity; therefore, it can stretch, increase in volume and serve as a temporary reservoir for intestinal contents. The mucous membrane of the rectum allows its walls to stretch when filled with contents, followed by the formation of numerous transverse and longitudinal folds after it is emptied.
Transverse folds spiral into one another. During defecation (emptying), these folds give the movement of feces a translational-rotational character and act as a kind of brake that prevents the rapid movement of feces to the anus.

ANAL CHANNEL



The rectum passes through the anal triangle, which ends in the anus (anal canna). The anus is a slit-like opening that passes into the anus (anal canal).
Depending on the length, there are two names for the anal canal: long (about 4-4.5 cm) “surgical” and short anatomical anal canal. The anatomical anal canal (shorter), about 2 cm, extends from the anal valves to the edge of the anus. A long “surgical” (about 4-4.5 cm) anal canal, the upper limit of which is the “pectineal line or the level of the levator ani muscles. This corresponds to the distal end of the dilated, or ampullary, portion of the rectum. In a calm state, the anal canal has the appearance of a sagittal fissure, the side walls of which touch when closed. As feces pass through, the anal canal acquires rounded contours, varying from 3 to 6 cm. The lumen of the anal part is an anteroposterior slit, the side walls of which are in close contact. At the top of the anal canal there is another row of longitudinal folds on the mucous membrane, known as the “anal columns” (columns of Morgagni). Between which are the anal (anal, Morganian crypts) sinuses, bounded below by the semilunar anal valves (Ball's valves). Morgagni's crypts are the openings of the anal glands. Mucus that accumulates in the anal sinuses facilitates the passage of feces through the narrow anal canal. The anal sinuses, or anal crypts as clinicians call them, are the most common portal of entry for pathogenic microorganisms. An inflammatory process in the anal gland may cause the development of acute paraproctitis. The lining of the anal canal from the anorectal line to the anus is represented by flat non-keratinizing epithelium without skin appendages. The lining of the anal canal is called the anoderm.

Musculature.



In the perineal flexure of the rectum, the thickness of the circular muscle increases, forming the internal sphincter, which extends distally about 30 mm and represents the innermost layer of the muscular wall of the anal canal over the proximal 30 mm of its total length. The thickness of the muscles of the internal sphincter is from 3 to 5 mm in circumference. Outside the fibers of the internal sphincter are the fibers of the longitudinal muscle. At the anorectal border, the longitudinal muscle fuses with the downward fibers of the pubococcygeus muscle, forming a united longitudinal muscle layer, which splits to allow passage of both sides of the external sphincter.
The muscle fibers intertwined at the level of the anal valves are called the Parkes ligament, which supports the mucosa. Disruption of Parkes' ligaments causes a permanent downward shift of the anal mucosa, in which it loses its normal topographic connection with the sphincters.

Striated muscles. Distal to the smooth muscles are the fibers of the external sphincter.
They are distinguished: a deep portion of the external sphincter in the form of a ring covers the centrally located internal sphincter; the lower fibers are attached to the coccyx, in front to the bulb of the cavernous bodies in men and the vaginal constrictors in women.
Surface portion: starts from the posterior surface of the coccyx and the coccygeal-anal ligament, around the anus it is divided into two parts, covering it on both sides and attached to the tendon center of the perineum.
The subcutaneous part of the sphincter is usually considered as a multi-fascicle ring of muscles, without pronounced ventral and dorsal ligaments. The superficial part is an elliptical muscle attached posteriorly to the coccyx, partly forming the most superficial layer of the postanal plate.

BLOOD SUPPLY TO THE RECTUM

The blood supply to the rectum and anal sphincters is provided by five arteries: the unpaired superior rectal artery and two pairs of middle and inferior rectal arteries.
Superior rectal artery (A.rectalis sup) is a direct continuation of the inferior mesenteric artery. At level S III, the superior rectal artery is divided dichotomously into right and left branches passing alongboth sides of the distal rectum. Each vessel divides into a number of small arteries, passing below the level of the anorectal ring to approximately the level of the valves of Morgagni. On average, five branches of the superior rectal artery reach this level. Meintjes (2000) using color duplex scanning found that there are six permanent branches of the superior rectal artery at 1, 3, 5, 7, 9, and 11 o'clock (in the supine position).
Middle rectal artery (A. rectalis med) inconsistent, found in 70% of cases either on one or both sides, found in the submucosal layer of the anal canal.
Inferior rectal arteries (A. rectalis inf.) are branches of the internal pudendal artery, sending their branches through the external anal sphincter to the distal part of the canal. The branches then extend proximally into the submucosal layer.
According to most researchers, there are anastomoses between the arteries supplying the rectum and anus.
Venous drainage from the rectum and anal canal carried out through veins running parallel to the main arterial blood supply. Thomson (1975) showed evidence of a loose connection between the main veins draining the anal canal. The outflow of venous blood from the rectum is carried out through the rectal veins. The superior rectal vein drains into the inferior mesenteric vein, which belongs to the portal vein system. The middle and inferior rectal veins flow into the inferior vena cava system: Thus, the branches of two venous systems (portal and inferior vena cava) connect in the walls of the rectum.

Anatomy of hemorrhoids.


Hemorrhoidal plexus- is a congenital venous plexus, formed during embryogenesis and races
placed at the top of the anus. Hemorrhoidal plexuses can be seen during anoscopy as submucosal cushions. First description of cavernthe heat of the vascular tissue gave F.C. Stelzner (1962). He discovered the presence of cavernous vascular tissue located in the transitional section of the rectum just anterior to the anorectal line, which is the source of the formation of internal hemorrhoids.
A peculiarity of the structure of cavernous veins is the presence in their walls of small arteries that do not break up into capillaries, but directly open into the lumen of these veins.

Thomson (1975) showed that vascular tissue, which he called “vascular cushions,” is concentrated at the 3–4, 7, and 11 o’clock positions in the canal level or above the anal valves. These cushions are found in the submucosa and include dilated blood vessels (mainly veins), smooth muscle, and connective tissue.
By about 10 years of age, the cavernous veins in this area become larger and more often form into groups. The cavernous tissue of the rectum in children is poorly developed. Cavernous structures acquire the most typical structure in individuals aged 18-40 years.

W. Thomson (1975) showed that the smooth muscle of the submucosal layer arises partly from the internal sphincter itself and partly from the fibers of a long portion of this muscle connecting the fascial partitions of the internal sphincter. The Treitz muscle forms a network of connective tissue around the venous hemorrhoidal plexuses and secures the anal canal in. time of defecation. It also strengthens the perianal skin due to the penetration of fibers through the distal portion of the internal sphincter. Elastic cavernous bodies, surrounded by connective tissue structures and the Treitz muscle, enable hemorrhoids to change in size and participate in the retaining function of the anal sphincters.

The rectum is the “straight” organ in lower mammals – hence its Latin name. However, in humans, it curves adjacent to the sacral cavity, starting at the promontory of the sacrum and ending below the coccyx. The relationship of the rectum with the anal canal is of paramount importance, since the work of the sphincter apparatus, which controls the evacuation of feces, is ensured by nerves located in the danger zone, which can be damaged during surgical interventions in the depths of the pelvis. The rectum is located deep in the pelvis, is in close contact with many vital organs and therefore operations on it are extremely difficult. Particularly great difficulties arise when it is necessary to restore intestinal continuity, since the operation takes place in a limited space.

The rectum extends from the sigmoid colon to the anus and has a length of 12–16 cm. There are two main sections of the rectum: pelvic and perineal. The first lies above the pelvic diaphragm, the second - below. In the pelvic region there is an ampulla and a small area above it - the supramullary part. The perineal section of the rectum is also called the anal canal.

The supramullary part of the intestine is covered by peritoneum on all sides. Next, the intestine begins to lose peritoneal cover, first from the back, being covered with peritoneum only in front and from the sides, and even lower, at the level of the 4th sacral vertebra (and partly of the 5th), the peritoneum covers only the anterior surface of the intestine and passes to the posterior surface in men Bladder. The lower part of the rectal ampulla lies under the peritoneum.

The mucous membrane of the rectum has longitudinal folds, which are often called Morganian columns. Between them are the anal (Morgani) sinuses, bounded below by the semilunar anal valves. Transverse folds of the mucosa, which do not disappear when the rectum is filled, are located in its different parts. One of them corresponds to position n. sphincter tertius and is located on the border between the ampullary and supramullary parts of the intestine. The intestinal mucosa forms folds: closer to the anus - longitudinal, and higher - transverse. In the ampullary part there is one fold on the right wall, two on the left. At the border of the ampullary and anal parts of the rectum, corresponding to the position of the internal sphincter, there is a well-defined fold, especially on the posterior wall of the intestine - valvula Houstoni. When the intestine fills, these folds can straighten and increase its volume.

At a distance of 3–4 cm from the anus, the circular muscle fibers, thickening, form the internal sphincter, and at a distance of approximately 10 cm from the anus there is another thickening of the circular muscle fibers, known as the Hepner muscle (m.sphincter tertius). The external sphincter of the rectum is located in the circumference of the anus and consists of striated muscle fibers (Fig. 193).

The blood supply to the rectum is carried out by 5 arteries: one unpaired – a. rectales superior (terminal branch of the inferior mesenteric artery) and two paired ones – a. rectales media (branch of a. iliaca interna) and a. rectalis inferior (branch of a. pudenda interna) (Fig. 194).

The veins of the rectum (Fig. 195) belong to the systems of the inferior vena cava and portal veins and form a plexus, which is located in different layers of the intestinal wall. There are external and internal hemorrhoidal plexuses. The external plexus is located under the skin of the anus, in the circumference and on the surface of the external sphincter of the rectum. The submucosal plexus, the most developed, is located in the submucosa; it can be divided into three sections: upper, middle, lower. In the final section of the rectum, the veins of the submucosal plexus have a special cavernous structure. The subfascial plexus lies between the longitudinal muscle layer and the rectal fascia. In the area of ​​the rectum between the longitudinal folds and the anus - zona hemmoroidalis (venous ring) - the submucosal plexus consists of tangles of veins penetrating between the circular bundles. The outflow of venous blood from the rectum is carried out through the rectal veins, of which the upper one is the beginning of the inferior mesenteric vein and belongs to the portal vein system, and the middle and lower ones belong to the inferior vena cava system: the middle ones flow into the internal iliac veins, and the lower ones into the internal pudendal veins (Fig. . 195).

Rice. 193. Anatomy of the rectum. 1 – middle transverse fold (valvula Houstoni); 2 – upper transverse fold (valvula Houstoni); 3 – muscle that lifts the anus (m. levator ani); 4 – lower transverse fold (valvula Houstoni); 5 – anal (anal) columns (Morgani); 6 – jagged line; 7 – internal hemorrhoidal plexus; 8 – anal gland; 9 – internal anal sphincter; 10 – external hemorrhoidal plexus; 11 – anal crypts; 12 – external anal sphincter

Rice. 194. Blood supply to the rectum. 1 – inferior mesenteric artery; 2 – sigmoid arteries; 3 – mesentery of the sigmoid colon; 4 – superior rectal artery; 5 – superior rectal artery (branching); 6 – internal pudendal artery; 7 – inferior rectal artery; 8 – internal iliac artery; 9 – obturator artery; 10 – median sacral artery; 11 – superior cystic artery; 12 – inferior cystic artery; 13 – middle rectal artery; 14 – superior rectal artery

Rice. 195. Veins of the rectum. 1 – inferior vena cava; 2 – common iliac veins; 3 – median sacral vein; 4 – inferior mesenteric vein; 5 – sigmoid veins; 6 – superior rectal vein; 7 – external iliac vein; 8 – internal iliac vein; 9 – obturator vein; 10 – cystic (upper) and uterine veins; 11 – middle rectal vein; 12 – internal pudendal vein; 13 – portocaval anastomoses; 14 – inferior cystic veins; 15 – internal pudendal vein; 16 – inferior rectal vein; 17 – venous plexus of the rectum; 18 – external hemorrhoidal plexus; 19 – internal hemorrhoidal plexus

The innervation of the rectum is carried out by sympathetic, parasympathetic and sensory fibers. Lymphatic vessels accompany arterial vessels. Lymphatic drainage is carried out from the upper and middle sections of the rectum to the lower mesenteric nodes, and from the lower section to the lower mesenteric and/or iliac and periaortic nodes. Below the dentate line, lymphatic drainage occurs into the iliac nodes.

For successful surgical interventions in the pelvis, knowledge of the detailed anatomy of the mesorectum and its contents in adults plays a critical role.



Mesorectum (a set of tissues located between the wall of the rectum and its visceral fascia) is not described as an identifiable structure in most works on human anatomy, although it is mentioned by many embryologists.

The mesorectum is derived from the dorsal mesentery, a general visceral mesentery surrounding the rectum, and is covered by a layer of visceral fascia, providing a relatively bloodless layer, the so-called “holy plane” mentioned by Heald. The goal of surgery is to gain access while remaining within this fascial layer. Posteriorly, this layer passes between the visceral fascia surrounding the mesorectum and the parietal presacral fascia (Fig. 196). The last layer is usually referred to as Waldeyer's fascia. Inferiorly, at the S4 level, these fascial layers (mesorectal and Waldeyer) unite into the rectosacral ligament, which must be divided when mobilizing the rectum.

A more accurate understanding of the rectum, mesorectum, innervation and vascularization of them and surrounding structures has appeared recently. New developments in imaging techniques such as endorectal ultrasound (ERUS) and magnetic resonance imaging (MRI) will undoubtedly shed light on the “normal” anatomy of these structures.

Rice. 196. Mesorectum. 1 – mesorectum; 2 – lymph nodes; 3 – visceral fascia; 4 – lumen of the rectum. T – tumor growing into the mesorectum

What is Hemorrhoids

Hemorrhoids are a pathological enlargement of the cavernous vascular plexuses with the formation of hemorrhoids, their prolapse from the anal canal with periodic bleeding and frequent inflammation. According to various authors, this disease affects up to 10–15% of the adult population. The share of hemorrhoids in the structure of coloproctological diseases is 35–40%. From 10 to 60% of patients with this disease seek medical help. Many patients self-medicate for a long time and seek help only when various complications develop that they cannot cope with on their own.

Translated from Greek, the word “hemorrhoids” means bleeding, and it is the main symptom of this disease. Hemorrhoids are one of the most ancient human diseases. Even 2 thousand years BC, in Egypt, hemorrhoids were known and isolated as a separate disease. Doctors of that time even tried to operate on patients with hemorrhoids, removing hemorrhoids that prolapsed from the anus. The symptoms of this disease are mentioned in the works of Hippocrates, who wrote that hemorrhoids are associated with frequent constipation, with the fact that people who drink a lot of strong drinks and spicy foods are more susceptible to this disease.

Only in the 18th century were cavernous formations discovered in the distal part of the rectum. The mechanisms of the pathogenesis of hemorrhoids were studied much later, a hundred years later, a great contribution to this was made by famous Russian surgeons N.V. Sklifosovsky, A.V. Starkov, P.A. Butkovsky and A.N. Ryzhikh.

In the 30s of the 20th century, Milligan and Morgan proposed an operation - hemorrhoidectomy - to treat hemorrhoids. Various modifications of it are still used today.

Etiology and pathogenesis

Hemorrhoids are nothing more than an increase in the size of the cavernous submucosal plexus of the rectum. These plexuses are arteriovenous anastomoses and are located in typical places - at 3, 7 and 11 o'clock (with the patient in the supine position), respectively, the three terminal branches of the division of the superior rectal artery (Fig. 197).

Rice. 197. Localization of hemorrhoids. 1 – on the posterolateral wall (at 7 o’clock on the dial); 2 – on the anterolateral (at 11 o’clock); 3 – on the side wall (at 3 o’clock); 4 – superior rectal artery

Cavernous plexuses are not a pathology, but normal cavernous vascular formations that form during normal embryogenesis and are present in people of any age, including embryos and children. In children, the cavernous formations of the rectum are poorly developed, their sizes are small, and the cavernous cavities (sinuses) are unclear. With age, the size of the sinuses and individual cavernous plexuses increases and this is the anatomical substrate of the future main internal hemorrhoids. The hemorrhoidal plexuses are an important anatomical formation that plays a decisive role in the so-called “thin” anal holding of stool. Due to their elastic consistency, there is a delay in the venous outflow of blood when the m is tense. sphincter ani internus. All this makes it possible to retain solid components of feces, air and liquid in the rectal ampulla. Relaxation of the sphincter during defecation leads to the outflow of blood from the hemorrhoidal plexuses and emptying of the rectal ampulla. It should be noted that such a physiological mechanism occurs during the formation of normal feces. Too hard stool inhibits the urge to defecate, while the hemorrhoidal plexuses become overfilled with blood for much longer. Subsequently, their pathological expansion and further transformation into hemorrhoids occurs. On the other hand, loose stools stimulate too frequent emptying of the rectum, which usually occurs against the background of an incompletely relaxed sphincter and still overcrowded hemorrhoidal plexuses. Their constant traumatization occurs, which ultimately leads to secondary changes, i.e., to the formation of hemorrhoids. An important role in the development of hemorrhoids is the disturbed relationship between the inflow and outflow of blood from the cavernous bodies. Factors such as pregnancy and childbirth, obesity, excessive alcohol and coffee consumption, chronic diarrhea, sedentary, sedentary lifestyle, straining during bowel movements, smoking, heavy lifting, prolonged cough lead to increased intra-abdominal pressure and stagnation of blood in the pelvis. Hemorrhoids increase in size. The development of dystrophic processes in the common longitudinal muscle of the submucosal layer of the rectum and the ligament of Parks, which hold the cavernous bodies in the anal canal, leads to a gradual but irreversible displacement of hemorrhoids in the distal direction and their subsequent loss from the anal canal.

Classification

By etiology:

1) congenital (or hereditary);

2) acquired: primary or secondary (symptomatic). By localization (Fig. 198):

1) external hemorrhoids (subcutaneous);

2) internal hemorrhoids (submucosal);

3) combined.

According to the clinical course:

1) spicy;

2) chronic.

Highlight 4 stages of chronic hemorrhoids:

Stage I manifested by bleeding, hemorrhoids do not fall out.

Stage II– hemorrhoids fall out when straining and are reduced on their own.

Stage III– hemorrhoids fall out and can only be adjusted manually. Moreover, at first the nodes fall out only during defecation, and then with an increase in intra-abdominal pressure.

IV stage– hemorrhoids fall out even at rest, are not reduced or fall out again immediately after reduction.

In addition, there are three degree of severity acute hemorrhoids:

I degree– external hemorrhoids are small in size, have a tight-elastic consistency, are painful on palpation, the perianal skin is slightly hyperemic, patients experience a burning sensation and itching, which intensifies with defecation.

II degree– characterized by pronounced swelling of most of the perianal area and its hyperemia, pain on palpation and digital examination of the rectum, severe pain in the anus, especially when walking and sitting.

Rice. 198. Localization of hemorrhoids. 1 – internal; 2 – external

III degree– the entire circumference of the anus is involved in the inflammatory infiltrate, palpation is sharply painful, in the area of ​​the anus purple or bluish-purple internal hemorrhoids covered with fibrin deposits are visible. If left untreated, node necrosis may occur. Clinical picture and objective examination data

Complaints. The patient has complaints, as a rule, when complications of hemorrhoids occur - thrombosis of hemorrhoids or bleeding from these nodes. In this case, patients are concerned about the prolapse or protrusion of a dense, painful node from the anus (during thrombosis), the presence of scarlet blood in the stool (during bleeding) - from small drops and streaks to heavy bleeding. These complaints are usually associated with the act of defecation and are accompanied by a feeling of discomfort, bloating or even pain in the anus, anal itching - the latter often precedes episodes of bleeding. These symptoms are especially aggravated after eating a lot of spicy food, which is due to stagnation of blood in the pelvic area.

In external hemorrhoids, the hemorrhoidal plexuses are located distal to the dentate line, in the anal canal, lined with anoderm. It, together with the adjacent skin, is innervated by somatic sensory nerves, which have nociception (the physiological ability to perceive and transmit pain), which is the cause of severe pain in the anus during exacerbation of external hemorrhoids and interventions in this area. In internal hemorrhoids, the nodes are located proximal to the dentate line of the anal canal, under the mucous membrane, which is innervated by autonomic nerves and is relatively insensitive to pain. All this explains the painless course of internal hemorrhoids.

When collecting anamnesis, you can trace a certain sequence of complaints. One of the first symptoms is anal itching. Bleeding usually appears later. The resulting bleeding is often persistent, prolonged and intense, sometimes leading to severe anemia. Subsequently, patients begin to notice protrusion and prolapse of the nodes, often with a tendency to become inflamed or pinched.

It is also necessary to keep in mind the diseases that cause secondary hemorrhoids (portal hypertension, pelvic tumors, etc.).

An objective examination of the patient begins with examination of the anal area. In this case, you can see enlarged, collapsed or compacted and inflamed hemorrhoids at 3, 7 and 11 o’clock (Fig. 199). In some patients, the nodes are not clearly grouped in the indicated places, which indicates the scattered nature of the cavernous bodies of the rectum. The internal nodes may resemble a mulberry and bleed easily on contact. When the patient strains, the nodes may protrude outward. With a digital examination, hemorrhoids can be identified, which during an exacerbation become dense and sharply painful. Therefore, in case of obvious thrombosis of hemorrhoids, digital examination should be carried out with extreme caution or even refrain from it. With long-standing hemorrhoids, even a decrease in the tone of the rectal closure apparatus may develop.

It is mandatory to carry out sigmoidoscopy, allowing to assess the form and stage of the pathological process. In addition, it is necessary to examine the upper parts of the rectum and exclude other diseases, in particular a tumor process.

To do this, you should perform irrigoscopy and/or fibrocolonoscopy. Differential diagnosis

First of all, it is necessary to exclude tumors of the colon, as well as inflammatory diseases or diverticulosis of the colon, in which there is bleeding from the rectum. In this case, special attention should be paid to the presence of such alarming symptoms in the patient as alternating constipation and diarrhea, bloating, periodic cramping abdominal pain, the appearance of pathological impurities (mucus, blood) in the stool, weight loss, fever, anemia, etc. In addition, rectal bleeding can also be caused by adenomatous polyps, ulcers, and anal fissures.

Itching in the anus can also occur with helminthiasis, contact dermatitis, or insufficient hygiene of the anorectal area. Pain during defecation or palpation of hemorrhoids can be a sign not only of thrombosis of external hemorrhoids, but also anal fissure (can be a concomitant disease in 20% of people suffering from hemorrhoids) or perianal (intersphincteric) abscess.

In addition, as already indicated, portal hypertension can be the cause of varicose veins of the rectum.

Complications

1. Bleeding. Occurs when the mucous membrane over the hemorrhoidal node becomes thinner, while blood flows out from erosions or diffusely. It is fresh and liquid. Blood appears on toilet paper or drips after defecation from the anus. Patients note such bleeding periodically; it is more often observed with constipation. In case of rectal cancer or ulcerative colitis, blood in the stool is observed with any stool (not necessarily dense), with tenesmus and is mixed with stool, and with hemorrhoids, blood covers the stool. Repeated, even small, hemorrhoidal bleeding, as already noted, can lead to anemia.

2. Inflammation. When inflamed, internal hemorrhoids are red, enlarged, painful, bleeding from superficial erosions. Reflex spasms of the anus occur, and digital examination can be painful.

3. Thrombosis of internal hemorrhoids occurs suddenly: one of the nodes becomes significantly enlarged, purple, very painful on palpation and defecation. The acute condition lasts 3–5 days, after which the node undergoes connective tissue changes. Then, during rectal examination, it is felt in the form of a dense nodule.

4. Prolapse of hemorrhoids. If internal hemorrhoids reach large sizes, then they extend beyond the anorectal line and appear in front of the anus either only when straining (descending hemorrhoids), or constantly (prolapsed hemorrhoids).

Treatment of hemorrhoids can be conservative or surgical.

Diet. If you have hemorrhoids, you need to eat regularly, at the same time, eat more plant fiber against the background of increased water consumption (1.5–2 liters per day). You should limit products made from white refined flour and whole milk, while fermented milk products can and should be consumed daily, especially those enriched with bifidobacteria and lactobacilli. Drinking mineral waters enhances intestinal motility. Highly and moderately mineralized waters are recommended, as well as waters containing magnesium ions and sulfates, such as “Essentuki”, “Moskovskaya”. It is necessary to exclude alcoholic drinks, as well as hot, spicy, fried, smoked foods, since the consumption of these products leads to an increase in blood flow in the perianal area and blood stagnation in the pelvic area.

The tasks that drug therapy should solve are the following: relief of pain, thrombosis of the hemorrhoid, elimination of the inflammatory process and prevention of re-exacerbation of hemorrhoids. When choosing local treatment for acute hemorrhoids, it is necessary to take into account the prevalence of any of the symptoms. In case of bleeding, the amount of blood loss, its intensity and the severity of posthemorrhagic anemia should be assessed. It should be noted that the prevention of exacerbation, first of all, consists in normalizing the activity of the digestive tract, treating constipation, which occurs in more than 75% of patients with hemorrhoids. Increased intake of fiber and fluid leads to softening of stool, prevention of constipation and a decrease in the duration and intensity of straining during bowel movements. The optimal dose of insoluble fiber is 25–30 g per day. You can get it by eating fiber-rich foods such as breakfast cereals, wholemeal bread, brown rice and wholemeal pasta, fruits, vegetables and salads (at least three servings of vegetables and fruits daily), and legumes (lentils, beans, peas, etc.). If diet therapy is ineffective, you should resort to laxatives (for example, Fibodel, Regulan, Normacol, Normacol-plus, methyl cellulose).

The indication for conservative treatment is the initial stage of chronic hemorrhoids. It consists of general and local use of painkillers and anti-inflammatory drugs, cleansing enemas, ointment dressings and physiotherapy.

To eliminate pain, the use of non-narcotic analgesics and local combined painkillers in the form of gels, ointments and suppositories is indicated. For local therapy, drugs such as aurobin, ultraproct, proctoglivenol, etc. are used. In addition, new painkillers nefluan and emla, which have a high concentration of lidocaine and neomycin, are effective.

Combination drugs containing analgesic, thrombolytic and anti-inflammatory components are indicated for thrombosis of hemorrhoids complicated by their inflammation. This group of drugs includes proctosedyl and hepatothrombin G, produced in the form of ointment, gel bases and suppositories. The pharmacokinetics of the latter drug is that heparin and allantoin, by binding plasma coagulation factors and having an inhibitory effect on hemostasis, cause a thrombolytic effect, and panthenol stimulates metabolic processes, granulation and epithelialization of tissues. Polidocanol, which is part of it, provides an analgesic effect. To relieve inflammation, in addition to local treatment, nonsteroidal anti-inflammatory drugs are used that have a combined effect, including analgesic (ketoprofen, diclofenac, indomethacin, etc.).

The basis of general treatment is the use of phlebotropic drugs that increase the tone of the veins, improve microcirculation in the cavernous bodies and normalize blood flow in them. This group includes drugs such as escin, tribenoside, troxerutin, as well as new generation drugs: Detralex, Cyclo-3 Forte, Ginkor-Forte, Endotelon, etc.

If conservative treatment is ineffective, especially in the later stages of the disease, combined treatment should be carried out, including conservative and minimally invasive methods or conservative and surgical methods.

There are the following main types of minimally invasive interventions for hemorrhoids: injection sclerotherapy, infrared coagulation, latex ring ligation, cryotherapy, diathermic coagulation, bipolar coagulation.

At stage I of hemorrhoids, sclerotherapy has proven itself to be quite effective. A sclerosing drug (ethoxysclerol, thrombovar, fibrovein) is injected circularly subcutaneously just above the dentate line. As a rule, 1 ml of sclerosing agent is sufficient, the procedure is repeated 2-3 times within two weeks. For sclerotherapy according to Blanchard (Fig. 200), a sclerosant solution is injected directly into the area of ​​the vascular pedicle of the hemorrhoid in typical places (3, 7, 11 hours).

Rice. 200. Introduction of sclerosant into the area of ​​the vascular pedicle of the hemorrhoid (according to Blanchard)

The therapeutic effect does not consist in disrupting the blood supply to hemorrhoids, as previously assumed, but in their fixation above the dentate line. The advantage of sclerotherapy is a fairly low level of postoperative complications. The main drawback limiting the use of this minimally invasive technique is the high rate of relapses - up to 70% three years after therapy. An effective method, especially indicated for bleeding hemorrhoids in stage I, is infrared coagulation of hemorrhoids. The therapeutic effect is based on stimulation of necrosis of the mucous membrane through thermocoagulation.

The technique of ligating enlarged hemorrhoids (optimally performed in stage II of the disease) using a rubber ring, leading to their necrosis and rejection, was proposed in 1958 by R. S. Blaisdell, and subsequently simply improved and simplified by J. Barron (1963) . Currently, this method of treating hemorrhoids is effectively used by many proctologists (Fig. 201).

Surgical treatment carried out in patients with stages III and IV of the disease.

Rice. 201. Ligation of internal hemorrhoids. A – capture of the hemorrhoid with a clamp; B – dropping the latex ring onto the neck of the knot; B – the leg of the node is ligated. 1 – internal hemorrhoidal node; 2 – ligator; 3 – latex ring; 4 – clamp

The most common method currently is the Milligan-Morgan hemorrhoidectomy, which gives good results. The essence of the operation is to excise hemorrhoids from the outside inward with ligation of the vascular pedicle of the node, cutting off the node. As a rule, three external and corresponding three internal nodes are excised at 3, 7, 11 o'clock, with the obligatory leaving of bridges of the mucous membrane between them in order to avoid narrowing of the anal canal. Three modifications of the operation are used:

Closed hemorrhoidectomy with restoration of the anal mucosa with sutures (Fig. 202);

Open - leaving an unsutured wound (if there is a risk of narrowing of the anal canal and complications such as anal fissure, paraproctitis) (Fig. 203);

Submucosal hemorrhoidectomy (from under the mucous layer, a high-frequency coagulator is used to acutely remove the node, leaving the stump of the node in the submucosal layer under the sutured mucosa. Transanal resection of the mucosa using the Longo method is an alternative to classical surgical intervention for excision of hemorrhoids (Fig. 204). In 1993 Italian Antonio Longo developed a fundamentally new approach to surgical intervention for hemorrhoids. The essence of the operation is to perform a circular resection and suturing the prolapse of the mucosa with hemorrhoids. During the Longo operation, only the part of the rectal mucosa that is located above the dentate line is removed.

Rice. 202. Closed hemorrhoidectomy. A – excision of the hemorrhoid;

B – wound of the anal canal after removal of the node;

B – suturing the anal canal wound with a continuous suture

Rice. 203. Open hemorrhoidectomy. The anal canal wound remains open

The mucosal defect is stitched using a circular stapler using the “end to end” type. As a result, hemorrhoids are not removed, but are pulled up and sharply reduced in volume due to a decrease in blood flow into the cavernous bodies. Due to the excision of the circular strip of the mucosa, conditions are created under which the blood supply to the nodes decreases, which leads to their gradual desolation and zobliteration.

Rice. 204. Operation Longo. A – application of a circular purse-string suture to the mucous membrane of the rectum above the hemorrhoid; B – tightening the purse-string suture between the head and the base of the stapler; B – appearance of the anal canal after suturing the mucosa, hemorrhoidal vessels and tightening the hemorrhoids

The prognosis for hemorrhoids is usually favorable. The use of conservative therapy and minimally invasive methods, either alone or in combination with each other or with surgical methods, can achieve good results in 85–90% of patients.

Acute paraproctitis

Acute paraproctitis is an acute purulent inflammation of the peri-rectal tissue. In this case, the infection penetrates into the tissues of the peri-rectal region from the lumen of the rectum, in particular from the anal crypts and anal glands.

Paraproctitis ranks 4th in frequency after hemorrhoids, anal fissures and colitis (up to 40% of all diseases of the rectum). Men suffer from paraproctitis more often than women. This ratio ranges from 1.5:1 to 4.7:1.

Etiology and pathogenesis

As already noted, acute paraproctitis occurs as a result of infection in the perirectal tissue. The causative agents of the disease are Escherichia coli, staphylococcus, gram-negative and gram-positive bacilli. Most often, polymicrobial flora is detected. Inflammation caused by anaerobes is accompanied by particularly severe manifestations of the disease - gaseous cellulitis of the pelvic tissue, putrefactive paraproctitis, anaerobic sepsis. The causative agents of tuberculosis, syphilis, actinomycosis are very rarely the cause of specific paraproctitis.

The routes of infection are varied. Microbes penetrate into the perirectal tissue from the anal glands, which open into the anal crypts. As a result of the inflammatory process in the anal gland, its duct is blocked, an abscess is formed in the intersphincteric space, which breaks into the perianal or pararectal space. The transition of the process from the inflamed gland to the perirectal tissue is also possible through the lymphogenous route. In the development of paraproctitis, injuries to the rectal mucosa by foreign bodies contained in feces, hemorrhoids, anal fissures, ulcerative colitis, and Crohn's disease can play a certain role. Paraproctitis can be secondary. In this case, the inflammatory process moves to the perirectal tissue from the prostate gland, urethra, and female genital organs. Rectal injuries are a rare cause of post-traumatic paraproctitis. The spread of pus through the pararectal tissue spaces can go in different directions, which leads to the formation of various forms of paraproctitis.

Classification

According to etiology, paraproctitis is divided into banal, specific And post-traumatic.

According to the activity of the inflammatory process - on acute, infiltrative And chronic (rectal fistulas).

According to the localization of abscesses, infiltrates, leaks - subcutaneous, submucosal, intermuscular (when the abscess is located between the internal and external sphincter), ischiorectal (ischiorectal), pelvic-rectal (pelviorectal), retrorectal (one of the types of pelvic-rectal) (Fig. .205).

You can select 4 levels of difficulty acute paraproctitis.

Paraproctitis of the first degree of complexity includes subcutaneous, submucosal, ischiorectal forms that have an intrasphincteric connection with the lumen of the rectum, intermuscular (intersphincteric) paraproctitis.

To the II degree of complexity - ischial, retrorectal forms of paraproctitis with transsphincteric communication through the superficial portion of the anal sphincter (less than 1/2 portion, i.e. less than 1.5 cm).

Paraproctitis of the III degree of complexity includes forms as in the II degree, but with streaks, pelviorectal paraproctitis with the capture of 1/2 portion of the anal sphincter (more than 1.5 cm in thickness), recurrent forms.

Paraproctitis of the IV degree of complexity includes all forms (ischial, retro, pelviorectal) with an extrasphincteric course, with multiple leaks, anaerobic paraproctitis.

Rice. 205. Options for localizing ulcers: 1 – subcutaneous; 2 – intermuscular;

3 – ischiorectal; 4 – pelviorectal.

There are subcutaneous, ischeorectal and pelviorectal paraproctitis (more about this below). Clinical picture and objective examination data

The onset of the disease is usually acute. In this case, increasing pain appears in the rectum, perineum or pelvis, accompanied by an increase in body temperature and chills. The severity of the symptoms of acute paraproctitis depends on the localization of the inflammatory process, its prevalence, the nature of the pathogen, and the reactivity of the body.

When the abscess is localized in the subcutaneous tissue, there is a painful infiltrate in the anus and skin hyperemia, accompanied by an increase in body temperature. Increasing pain, intensifying when walking and sitting, when coughing, when defecating. On palpation, in addition to pain, there is softening and fluctuation in the center of the infiltrate.

The clinical picture of ischiorectal abscess begins with general symptoms: feeling unwell, chilling. Then dull pain appears in the pelvis and rectum, aggravated by defecation. Local changes - asymmetry of the buttocks, infiltration, skin hyperemia - appear in the late stage (on the 5th-6th day).

Pelviorectal paraproctitis, in which the abscess is located deep in the pelvis, is the most severe. In the first days of the disease, general symptoms of inflammation predominate: fever,

The unpaired superior hemorrhoidal artery is the terminal branch of the unpaired inferior mesenteric artery. Its branches run along the posterior surface of the rectum and branch along its walls. Its branches participate in the blood supply - on the right at 7, 11 o'clock, on the left - with one stem at 3 o'clock to the distal part of the sigma.

The paired middle hemorrhoidal artery is a branch of the hypogastric artery or internal pudendal artery. Its branches branch in the lower part of the rectal ampulla.

The inferior/paired/hemorrhoidal artery arises from the pudendal artery in the ischiorectal fossa and supplies blood to the anal canal of the intestine.

Vienna. The veins of the same name run parallel to the corresponding arteries. Together they form the venous plexus of the rectum. Two plexuses must be distinguished. External - forms a venous network in the surrounding tissue and in the muscle layer, and internal - it is located in the submucosal layer. Venous trunks are formed from the venous network of the rectum. The superior rectal vein runs with the superior hemorrhoidal artery, drains into the inferior mesenteric vein, and carries blood through the portal vein to the liver. The middle and lower rectal veins, like the veins of other pelvic viscera, drain blood through the hypogastric veins into the iliac veins and into the inferior vena cava. Thomson /1975/ showed that vascular tissue is concentrated at 4, 7, 11 o'clock. These vascular cushions are located in the submucosa and are supported by connective tissue and smooth muscle (Treitz), after rupture of which the vascular tissue prolapses, causing hemorrhoids.

Innervation. The skin of the anus and voluntary muscles of the rectum are innervated by the roots of the 3-4-5 sacral nerves.

Physiology of the rectum. The activity of the large intestine is closely related to the functioning of the entire body.

As you know, in a person, about 4000 g of food gruel (chyme) passes from the small intestines to the large intestines per day. Out of 4 liters of chyme, 150-200 formed feces remain in the large intestines. It consists of the remains of undigested food, waste products of the intestines and living and dead bacteria. The number of bacteria occupies a significant part of the feces - up to 50% or more.

The most important functions of the rectum and anal canal are:

1) reservoir - accumulation and retention of feces;

2) towing, i.e. act of defecation;

3) suction.

A.M.Aminev attaches great importance to the type of defecation. He distinguishes two main types of defecation: one-stage and two- or multi-stage type. In the first type, defecation occurs simultaneously and quickly. In the second, after several tensions of the abdominal press, all the contents accumulated in the rectum are thrown out. But there is no feeling of complete bowel movement. A person is left with a feeling of dissatisfaction and incompleteness. After a few minutes, a repeated, urgent urge to defecate appears. The second portion of intestinal contents is expelled. This is explained by the characteristics of the nervous system, as well as the shape of the intestine. With ampullary intestine, all feces accumulate in the ampoule and are thrown out at once. With a cylindrical rectum, two-stage defecation often occurs. The latter, according to Aminev, contributes to the occurrence of certain diseases of the rectum. Two- and multi-stage acts of defecation, which sometimes last up to 15-30 minutes or more, contribute, in his opinion, to the expansion of the venous network of the rectum, leading to stretching of the suspensory apparatus, contributing to the occurrence of hemorrhoids, rectal prolapse, etc.