1、重庆医科大学临床学院教案讲稿制表时间：12/13/2018 1重庆医科大学临床学院教案及讲稿（教 案）课程名称 普外科学 年级 07 留学生 授课专业 胃肠外科教 师 唐华 职称 副教授 授课方式 大课 示教 学时 3题目章节 Diseases of the Anorectum教材名称 作者出 版 社 版次教学目的要求掌握直肠癌、肛瘘、肛裂、肛周脓肿以及痔等常见肛直肠疾病的诊断与治疗措施。教学难点1、直肠癌手术方式的选择2、常见肛直肠疾病的鉴别诊断教学重点1、 直肠癌临床表现、诊断方法和手术方式的选择。2、 常见肛直肠疾病的诊断与鉴别诊断。外语要求 全英文教学教学方法手段大课、多媒体、PBL参
2、考资料 TEXTBOOK OF SURGERY;Fifteenth Edition;DAVID C.SABISTON,JR.,M.D.教研室意见 教学组长： 教研室主任：年 月 日 重庆医科大学临床学院教案讲稿制表时间：12/13/2018 2辅助手段时间分配（讲 稿）Surgical Anatomy and PhysiologyThe anatomic key to the anorectum is the pectinate line.Above it pain sensation is absent,blood drains to the portal and caval system,
3、and lymph drains along the superior rectal vessels or lateral to the obturator or iliac nodes.Below the pectinate line,pain is notably present,blood drains to the inferior vena cava,and lymph to the inguinal nodes.Anal glands empty into anal crypts at the pectinate line.When obstructed or infected,t
4、hese glands become the source of abscess and fistulas. Diseases of the AnorectumHemorrhoidsAnal fissureAnorectal abscessAnorectal fistulasRectal prolapseAnorectal cancerCommon positions for digital examinationSide-lying positionKnee-chest positionLithotomy positionSquatting positionAnterior flexion
5、positionHemorrhoidsEssentials of diagnosis:(emphasis)Rectal bleeding,protrusion,discomfort.Mucoid discharge from rectum.Possible secondary anemia.Characteristic findings on external anal inspection and anoscopic examination.General considerationsHemorrhoids (meaning flowing blood) represent a normal
6、 anatomic state and occur in all adults.Only when hemorrhoids become enlarged and symptomatic is treatment indicated.Hemorrhoids are classified as internal or external.Internal hemorrhoids are a plexus of superior hemorrhoidal veins above the mucocutane-ous junction which are covered by mucosa.Exter
7、nal hemorrhoids (inferior hemorrhoidal plexus) occur below the 重庆医科大学临床学院教案讲稿制表时间：12/13/2018 3mucocutaneous junction in the tissues beneath the anal epithelium of the anal canal and the skin of the perianal region.Hemorrhoids become symptomatic for many reasons.The most common cause is straining in
8、the squatting position at the time of bowel movement.Other important causative factors of symptomatic hemorrhoids include chronic constipation,pregnancy,obesity,the low-fiber diet ,etc.Clinical FindingsA.Symptoms and signs:1.Bleeding2.Protrude (prolapse)3.Discomfort and pain:occur only when there is
9、 extensive thrombosis with edema and inflammation.B.Examination:External hemorrhoids may be seen on inspection,particularly if they are thrombosed.If internal hemorrhoids are prolapsed,the redundant covering of mucin-secreting epithelium will be observed in one or several quadrants. Prolapse can be
10、produced when the physician asks the patient to strain while the buttocks are gently spread.On digital examination of rectum, internal hemorrhoids usually cannot be felt,and they should not be tender.Anoscopic examination is necessary to see internal hemorrhoids that do not protrude. Proctosigmoidos
11、copy must be done to exclude inflammatory or malignant disease at a higher level.Differential DiagnosisRectal bleeding,the most common manifes-tation of internal hemorrhoids ,also occurs with carcinoma of the colon and rectum, diverticular disease, adenomatous polyps,ulcerative colitis,and other les
12、s common diseases of the colon and rectum.Sigmoidoscopic examination must be performed.Barium enema X-ray studies and colonoscopy should be ordered selectively,depending on symptoms and findings.ComplicationsRarely,prolapsed internal hemorrhoids become irreducible because of congestion,edema,and thr
13、ombosis.Hemorrhoids may serve as a portasystemic shunt in portal hypertension,and bleeding in this situation can be profuse.Treatment重庆医科大学临床学院教案讲稿制表时间：12/13/2018 8The treatment of symptomatic internal hemorrhoids must be individualized. Hemorrhoids are normal,and therefore the goal of treatment is
14、not to obliterate hemorrhoidal plexuses but rather to render the patient asymptomatic.For this reason, hemorrhoidectomy is done less often today,and other modalities of treatment are more frequently used.Treatment is based on the presenting findings according to the following classification:First-de
15、gree:internal hemorrhoids cause painless,bright red rectal bleeding at the time of defecation.At this early stage,there is no prolapse, and anoscopic examination reveals enlarged hemorrhoids projecting into the lumen.Second-degree:hemorrhoids protrude through the anal canal on gentle straining but s
16、pontaneously reduce.Third-degree:hemorrhoids protrude with straining and must be reduced manually after defecation.Fourth-degree:hemorrhoids is fixed protrusion.A.Medical treatment:Most patients with early hemorrhoids (first- and second-degree) can be managed by simple local measures and dietary adv
17、ice.B.Injection treatment:a form of sclerotherapyC.Rubber band ligationD.CryosurgeryE.HemorrhoidectomyF.Other operative procedures:PPH(procedure for prolapse and hemorrhoids)Anal FissureEssential of DiagnosisnSymptoms:Rectal pain related to defecationBleedingConstipationSigns:Ulceration of anal cana
18、lHypertrophic anal papillaSentinel pileSpasm of sphincterAnal tendernessStenosisGeneral considerationsnFissures represent denuded epithelium of the anal canal overlying the internal sphincter.They are painful because of their location below the mucocutaneous 重庆医科大学临床学院教案讲稿制表时间：3/17/2011 8juncture.An
19、al ulcers are usually single and occur in the posterior midline or,less commonly ,in the anterior midline.The fissure triad(emphasis) has been formed:1.the ulcer itself,2.the hypertrophic papilla,3.the sentinel pile.Two of the most important factors in the genesis of fissures are irritant diarrheal
20、stools and tightenning of the anal canal secondary to nervous tension.Other factors may be habitual use of cathartics,chronic diarrhea, avulsion of an anal valve,childbirth trauma, laceration by a foreign body,or iatrogenic trauma such as the passage of a large speculum or prostatic massage. Often a
21、 cause cannot be definitely identified.Clinical findingsA.Symptoms :Rectal pain related to defecation.Bleeding.Constipation.B Signs:Ulceration of anal canal, hypertrophic papilla,Sentinel pile, Spasm of sphincters,anal tenderness, Stenosis.C.Special Examinations:A small-caliber anoscope can be intro
22、duced with pressure on the side of the anal canal opposite the lesion.The hypertrophic papilla,ulcer,and associated lesions can then be seen.Sigmoidoscopic examination should be deferred (but not omitted) until it can be done painlessly.Differential DiagnosisOther anal ulcerations that must be diffe
23、rentiated from fissure include the primary lesion of syphilis,anal carcinoma,tuberculous ulceration,and ulceration associated with blood dyscrasias and granulomatous enteritis higher in the intestinal tract.TreatmentA.Medical Treatment:1.Treat constipation:diet with high fiber and more water(hydroph
24、ilic softening the stools is the mainstay of medical treatment).2.Ichthammol or hydrocortisone applied in the anal canal with a “pile pipe”.3.Warm sitz baths after a painful bowel movement.B.Surgical Treatment:重庆医科大学临床学院教案讲稿制表时间：3/17/2011 8Lateral internal sphincterotomy, Forceful anal dilation unde
25、r general anesthesia.Anorectal AbscessEssential of Diagnosis:Persistent throbbing rectal pain.External evidence of abscess,such as palpable induration and tenderness,may or may not be present.Systemic evidence of infection.General considerationsAnorectal abscess results from the invasion of the para
26、rectal spaces by pathogenic microorganisms.The incidence is much higher in men.The most common cause is infection extending from an anal crypt into one of the pararectal spaces.The others include infection of hair follicles,a complication of deep anal fissure,hemorrhoids,or trauma.Clinical Findings1
27、.Persistent throbbing rectal pain.2.Inspection discloses the characteristic evidence of external swelling,with redness, induration and tenderness. These signs may not be presented in deeper abscess,but digital rectal examination may reveal the tender swelling.3.Systemic evidence of infection:feverCo
28、mplicationsUnless the abscess is evacuated promptly by surgery or ruptures spontaneously,it will extend into other adjacent anotomic spaces.Treatment1.Surgical treatment:The treatment of pararectal abscess is prompt incision and adequate drainage.2.Antibiotics3.Warm sitz baths and analgesics are pal
29、liative.Anorectal FistulasEssential of Diagnosis:Chronic purulent discharge from a para-anal opening.Tract that may be palpated or probed leading to rectum.General ConsiderationsBy definition,a fistula must have at least 2 opening connected by a hollow tract-as opposed to a sinus,which is a tract wi
30、th but one opening.Most anorectal fistulas originate in the anal crypts at the anorectal juncture. The crypt becomes injured or infected,the infection extends,and an abscess occurs. When the abscess is opened or when it ruptures, a fistula is formed.Clinical FindingsA.Symptoms and signs:(emphasis)1.
31、Chronic (intermittent or constant) purulent discharge from a para-anal opening.There is usually a history of a recurrent abscess that rupture spontaneously or was surgically drained.重庆医科大学临床学院教案讲稿制表时间：3/17/2011 82.A cordlike tract that may be palpated or probed leading to rectum.B.Special examinatio
32、ns:Digital rectal examination will frequently reveal a defect at the site of the scarred internal opening.Proctoscopy ( rectoscopy) Fistulography may be useful for the complex elusive fistula.Differential DiagnosisHidradenitis suppurativa:a disease of the apocrine sweat glands.Pilonidal sinusGranulo
33、matous disease:regional enteritis, CrhondiseaseInfected comedones, infected cysts,chronic folliculitis. and bartholinitis.Rectal dermoid cystsColoperineal fistulasSinuses from trauma and foreign bodies.ComplicationsWithout treatment,chronically infected fistulas may be the source of systemic infecti
34、on.Treatment In most fistulas the only effective treatment is fistulotomy or fistulectomy.Rectal CancerEssentials of diagnosis:Rectal bleeding.Alteration in bowel habits.Sensation of incomplete evacuation.Intrarectal palpable tumor.Sigmoidoscopic findings.Clinical FindingsA.Symptoms and Signs:1.Rect
35、al bleeding:It is the most common symptom,which is the passage of red blood with bowel movements (hematochezia).Blood may or may not be mixed with stool or mucus.2.Alteration in bowel habits:alternating constipation and increased frequency of defecation(not true watery diarrhea).Physical examination
36、 is important to determine the extent of the local disease,to reveal distant metastasis,and to detect diseases of other organ systems.Intrarectal palpable tumor:Distal rectal cancers can be felt as a flat,hard,oval or 重庆医科大学临床学院教案讲稿制表时间：3/17/2011 8encircling tumor with rolled edges and a central dep
37、ression.Its extent,the size of the lumen at the site of the tumor,and the degree of fixation should be noted.B.Laboratory Findings:CEA(carcinoembryonic antigen)-CEA levels are high in 70% of patients with cancer of the large intestine.But,CEA does not serve as a useful screening procedure,nor is it
38、an accurate diagnostic test for rectal cancer in a curable stage.CEA is helpful in detecting recurrence after curative surgical resection.C.Imageing Studies:CT/MRI are helpful in assessing extramural extension in patient with rectal cancer. CT,ultrasonography are useful in detecting of liver metasta
39、ses.Endorectal ultrasonography is ver y useful in detecting the depth of penetration of rectal cancer.D.Special Examinations:Proctosigmoidoscopy:Colonoscopy.Barium enema.TreatmentA.Surgical treatment:1.Abdominoperineal resection of the rectum(Miles procedure).2.Low anterior resection of the rectum(Dixon procedure).3.Local excision.4.Palliative procedure (Hartmann procedure):colostomyB.Adjuvant therapy1.Chemotherapy:adjuvant chemotherapy,new adjuvant chemotherapy.2.Radiotherapy3.Other therapy
