Parents, upon discovering a fistula in their child, panic. There's nothing scary here though.

It is important to make a competent diagnosis and determine correct treatment. In this case, the fistula is an open hole near anus, formed as a result of the development of a pathological process. Although it can occur in other points of the body.

The cause may be the penetration of infection into the rectum (this is called proctitis), or into the tissues located next to it (paraproctitis). When infectious process develops in the tissues, pus accumulates, which, trying to break through the skin, forms a fistula.

Paraproctitis or rectovestibular fistula occurs in infants on the bottom because the tissue in it is loose. Between them grooves appear, which various reasons begin to become inflamed. Microbes penetrate through them into tissue cells located near the rectum.

In a baby, the skin at the anus is very vulnerable, especially when stool is delayed. Its integrity is violated if the mother does not take good care of hygiene, the child constantly wears a diaper, or he has diarrhea. In such a child, the rectum becomes contaminated, and a fistula appears at the anus near the tailbone.

Types of fistulas

Sometimes parents call fistulas in children on the tailbone a second hole in the butt. Children's fistulas occur infrequently and, as a rule, are congenital. In some cases, they are provoked by acute paraproctitis. There are complete and incomplete. Fistulas that open only towards the intestine or perineum are called complete. In the first period of a child's life, feces come out through them. If the hole is very narrow, then the child’s underwear becomes soiled with pus or mucous secretions.

In the case when the fistula is incomplete and is open towards the perineum, there may be no discharge.

Sometimes the fistula supposedly heals, but this is a misleading impression. Pus accumulates, breaks through the healed skin, and is released in large quantities. An incomplete fistula, which opens towards the intestine, may not bother you until it festers. Then the feces become purulent. There are cases when the fistula closes on its own. You can see a parapractical fistula in a child in the photo.

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Symptoms

How to identify a rectal fistula? His hallmark- a small hole on the buttocks, sometimes there can be several such holes, infrequently - they appear in multiple numbers.

The hole secretes mucus in an amount that depends on the reason for its appearance.

In cases where a pararectal fistula appears at the anus, pus is released, which is odorless. Fistula in children causes a lot of inconvenience, they are capricious, they need to be washed more often to prevent progression.

Characteristic features:

• Suddenness of manifestation.
• Anxious child behavior.
• Heat.
• Loss of strength, loss of appetite, exhaustion.
• When stool - pain, crying. The younger the children, the greater the risk.
• Breakthrough of pus on the skin.
• Purulent feces
• Pain in the anus.

See what a rectal fistula located at the anus looks like in the photo.

Diagnostics

Diagnostics are carried out in order to correctly determine the treatment method. A complete description is drawn up and its length is determined. A fistula acquired at birth is never long. And often it is incomplete.

Using radiography, it is determined whether it communicates with the rectum. Probing and injection of contrast agents into the fistulas help with this. A complete fistula is visible to the naked eye - it is a hole in the buttock near the tailbone. Incompletely covered by skin, it is located inside. Before the examination, bowel cleansing is performed. Usually the intestine is cleaned or.

Fistulas usually have one hole; if there are several, then it is a horseshoe shape.

The rectum is also examined using fingers. Tests with dye are also carried out. There are also additional research. The anus is examined using a speculum so that it can be detected inner part fistula, this detection makes it easier to probe its course.

The probe is carefully inserted into the hole until its tip appears there. This does not always work out, because its course is quite narrow. For the same reason, the introduction of a dye element and the use of fistulography are not effective.

If there is a suspicion of illness

If you suspect your child has a parapractical fistula and do not observe acute pain, high fever and other symptoms in him acute onset, you should contact a pediatric surgeon.

If the children are young (less than six months), there is elevated temperature, roaring when passing feces - urgently need to call the ambulance. Do not under any circumstances take into account the advice of strangers, that this happens, it is an age thing and will go away on its own.

Your child will be taken to the emergency room, examined by a surgeon, and necessary tests. They will determine the causative agent of the infection and check how the child tolerates antibiotics. If doctors confirm the presence of a rectal fistula near the anus, the child will definitely undergo urgent surgery.

If the disease process has not started, the operation lasts no more than a quarter of an hour. General anesthesia is a prerequisite for its implementation. Surgeons will open the source of the infection and clean it of pus and infection. A parapractical fistula on the butt in children is not such a terrible thing. Upon achievements modern medicine he is being successfully treated.

In more advanced cases surgery may take longer. Then it will follow rehabilitation period, which will be carried out in a hospital, for about fourteen days. Typically, such cases are treated with antibiotics, physiotherapy, and antiseptics with bandages.

Doctors say that a pararectal fistula of the rectum at the anus cannot be cured at home.

No proven methods of “experienced” people will help if the source of infection itself is not removed. Conduct complete removal epithelial cover of the passage of the fistula. You should not self-medicate in such cases, and use methods alternative medicine. This can make life more difficult for your child and yourself.

If the child’s fistula is congenital, the operation is performed immediately, because there is a direct threat to life. They rarely heal on their own. Fistulas, called labiform fistulas, are removed using surgical intervention . If we talk about prevention, there are measures to prevent infectious diseases, as well as strict adherence

antiseptic rules.

How is it treated

In children, chronic paraproctitis is treated using conservative measures and surgical intervention. Conservative treatment eliminates inflammation and prevents it. For newborns, children and those who are already several months old, and older ones, it is carried out until the fistula entrance is completely formed.

It must be said that these measures are used as temporary and auxiliary measures before the start of surgery. In any case, the child will need surgery. It is only important to choose the right timing. The operation is performed by experienced pediatric surgeons. The fistula is cut off and the source of infection is localized.

After the operation, the child is admitted to the hospital, where he remains on a special diet for a week. On the seventh day, his intestines are cleansed with an enema and he is transferred to a normal diet. Sutures are removed after a week or a little later. Usually such operations give positive results. After them, the child begins to live full life, like all his peers.

Paraproctitis is a disease that occurs in men aged 20 to 50 years. However, although it is rare, it also occurs in babies some time after their birth. Today medicine has everyone possible methods, with the help of which this unpleasant pathological phenomenon is completely cured. The sooner parents apply for classified medical assistance, the faster the recovery in a small child.

So, what contributes to the development of this abnormal phenomenon in a baby, what you need to know about the disease, and what features of the treatment of paraproctitis in infants will be discussed in this article.

Paraproctitis

– a disease that affects fatty tissue lower rectum (sphincter area). In newborns and infants The disease most often occurs in two forms:

1. Spicy.
2. Chronic.

In addition, in the case of abscess formation, paraproctitis is determined by its location:

1. Subcutaneous.
2. Ischiorectal.
3. Submucosal.
4. Retrorectal.
5. Pelvic-rectal.

As shown medical practice, the most common form of the disease in children is acute subcutaneous form. The remaining varieties are observed very rarely.

According to medical statistics:

1. 66.6% of children from birth to 14 years old suffered from an acute form.
2. 33.3% – chronic.

At the same time, children under 6 months make up about 60% of the total number of those who have recovered from the disease.

For purulent paraproctitis:

1. 62% – from 0 to 6 months.
2. 20% – from 6 to 12 months.

Of the total number of patients, 95% are boys. This is due to the fact that in girls the pressure in the rectum is lower, so the risk of infection is negligible.

As you can see, after the first year of life, the likelihood of contracting this disease decreases significantly.

Why do young children suffer from paraproctitis?

In infants and adults, the disease is provoked by the same factors. Initially, the infection affects the rectal sinuses (crypts) or glands. Then the acute inflammatory process spreads to the cells of the anal area. Further damaged tissue begin to peel off from healthy ones, which contributes to the formation of an abscess (abscess).

In the absence of timely treatment, the abscess can spontaneously open either outward or in subcutaneous tissue, as a result, a fistula is formed.

Paraproctitis in a child

Factors contributing to the appearance of paraproctitis in newborns:

1. In adults the disease is caused coli, in children - staphylococci.
2. Irregular structure of the anal glands.
3. Frequent stools, which is typical for newborns.
4. Obstipation is a common phenomenon in children under one year of age.
5. Imperfect immune system.
6. Availability .
7. Transmission of respiratory diseases.

It is worth emphasizing that any infectious agents present in the baby’s body, for example, the presence of tonsillitis or sinusitis, can also provoke the disease. However, the most common cause of pathology is intestinal bacteria.

Symptoms of the disease

The course of the disease in young children is exactly the same as in adults, but with some peculiarities. Besides this, her symptomatic picture It also depends on what form of the disease manifests itself: acute or chronic.

Acute form

For acute paraproctitis characterized by a sudden onset, and its symptoms have a pronounced intensity, depending on how advanced the disease is, its location, the size of the inflammatory focus, the type of infection and the state of the protective properties of the small organism.

At acute form Symptoms of paraproctitis in a child under one year old are characterized by:

1. Fever.
2. Chills.
3. Diarrhea or...
4. High temperature (up to 39 degrees).
5. Incorrect functioning of the urinary system.
6. Pain when urinating.
7. Weakness.
8. Headache.
9. Purulent discharge from the rectum.
10. Soreness in muscles and joints.
11. Pain in the rectum and pelvis, which increases during bowel movements.

Fistula in the anus of a baby photo

It is the manifestation of the latter symptom that indicates the development of this disease in the child. Paraproctitis in the child in the photo above has clearly defined symptoms.

It is also worth emphasizing that different forms of the disease manifest themselves with some differences, e.g. With subcutaneous paraproctitis, the following anomalies are observed:

1. Swelling.
2. The presence of seals near the anus.
3. Redness of the tissue in the sphincter area.
4. Pain on palpation.
5. Inability to assume a sitting position.
6. The inflammation is quite pronounced.

In the pelvic-rectal form, it is much more difficult to diagnose the pathology, since inflammation develops inside the pelvis, and its symptoms are general.

Often parents cannot determine the cause painful condition baby and attribute his anxiety and whims to respiratory infection. However, treatment with anti-cold medications does not provide positive result. The child's condition worsens, and the course of paraproctitis becomes more complicated.

In some cases, the baby's condition may suddenly improve and the temperature may return to normal. However, it begins from the rectum abundant leakage of pus with blood particles, which indicates independent rupture of the abscess into the intestine.

Ileorectal form of paraproctitis in initial stage in small children it is detected in isolated cases, while the disease of this form proceeds secretly in the first days, and only after a week can characteristic signs appear:

1. Redness of the skin.
2. Tissue swelling.
3. Incorrect (asymmetrical) size of the buttocks.

Note to parents: Under no circumstances should you open an abscess on your own or engage in any therapeutic measures. This is dangerous due to the development of a chronic form and various serious complications.

Chronic

Under no circumstances should you open an abscess yourself.

With this form, the presence of a fistula canal is noted, as well as two openings in it: external and internal.

Depending on their location, fistulas are:

1. Full (opens into the rectum and onto the skin).
2. Incomplete (open, that is, they extend to the skin, but do not affect the rectum, but end in the fat layer).

Some doctors believe that fistulas in young children are a congenital anomaly. After infection gets into them, incomplete fistulas transform into complete ones.

Chronic paraproctitis in newborns is indicated by the presence of a fistula tunnel. At the time of exacerbation of chronic paraproctitis, its symptoms are similar to the acute form, but are much milder, and periods of its exacerbation are quite active.

In some cases, the fistula may close spontaneously and not appear for a relatively long time.

Komarovsky about the disease

Komarovsky about paraproctitis in infants: in case of abscess formation, urgent surgical intervention. After the operation you should carefully adhere to the rules of personal hygiene, which will help avoid relapse of the disease, and also be sure to consult with a pediatrician, surgeon or pediatrician about further treatment measures.

Komarovsky for paraproctitis In children we strongly advise:

1. Apply Glycerin suppositories which have a complex effect.
2. Surgery is the most the best option getting rid of the disease.
3. Do not treat the child yourself in any way.
4. Although the disease is not fatally serious, it can provoke a number of complications that are life-threatening to the baby.

Treatment of paraproctitis in young patients

Treatment of paraproctitis in infants without surgery is possible, only in those episodes if the disease has not acquired advanced stage. In this case doctors recommend conservative therapy, in which the following are prescribed:

1. Antibiotics.
2. Ichthyol ointment.
3. Rectal suppositories.
4. Vishnevsky ointment.
5. Microclysters.
6. Ultraviolet radiation.

If all these measures do not produce a positive result, emergency surgery is prescribed.

Photo of paraproctitis

If a fistula tract is detected important point is the treatment of paraproctitis in children and preventive measures aimed at preventing infection by bacteria. For this purpose, the doctor recommends:

1. Careful hygiene of the anal area.
2. Timely elimination of feces and its residues after each act of defecation.
3. Sitting baths with a weak solution of potassium permanganate.
4. For newborns, bathing 2-3 times a day is recommended, and also with the addition of potassium permanganate.

In most cases, the above measures are quite sufficient and surgical intervention is cancelled. However, if conservative treatment does not give the expected effect, then the surgical method is performed after the fistula tract has fully matured, which can finally form only by the child’s second birthday.

During the operation, the fistula tract and scar tissue are removed, or the scars are excised with further ligation of the fistula tunnel. As a rule, after surgery there is a complete recovery.

Conclusion

If you suspect your baby has it, do not self-medicate and especially do not use folk remedies. All these experiments can lead to unexpected disastrous results.

Paraproctitis, like any other pathology in children, can only be treated under the supervision of a pediatrician. The sooner it is appointed effective therapy, the faster the child will recover.

Fistulas- these are channels consisting of epithelium and granulation tissue and connecting the pathological focus of the disease, hollow organs and the surface of the body with each other or with environment. This unpleasant phenomenon can appear spontaneously in both infants and adolescents. different parts body and become inflamed at any time. Fistulas can also arise artificially (surgically) as a result of an anastomosis by a surgeon to create additional ducts in the child’s body, to divert the contents of the fistula in the desired direction, to restore the patency of a hollow organ. In addition, there are congenital fistulas in children, which are a consequence of intrauterine malformations, for example, umbilical fistulas, neck fistulas, gill fistulas, etc., which are common among children.

The fistula itself is even beneficial for the body, because... opens a way out for the formed pus and inflammation, but at the same time, when it appears, serious complications. If the fistula channel is narrow, this can lead to blockage, inflammation and, ultimately, secondary infection. If not done on time fistula drainage, the risk of infection with sepsis and damage to neighboring tissues increases.

In a multidisciplinary medical center"Medicentre" has opened a department of pediatric dermatology and surgery, where you can register your child for a consultation with a pediatric specialist with any skin problems. Our center, in particular, deals with the diagnosis, treatment and probing of fistulas in children.

Depending on the location on the child’s body, they are distinguished external And internal fistulas

External fistulas represent a channel between the source of infection, a hollow organ and the skin. This type is easier to tolerate by children and easier to treat, because... the contents come out spontaneously or with the help of drainage, thereby relieving inflammation.

Internal fistulas arise inside the body between two hollow organs as a result pathological processes. Often internal fistulas themselves are birth defects development.

The most common places for fistulas to occur in children are the gums, ears, navel, and large intestine.

Fistula on the gum child is a channel between oral cavity, gum, external environment, jaw. Most often it occurs as a result of periodontitis or poorly treated caries. The treatment of such a fistula is carried out by the dentist, who, depending on the cause of its occurrence, either treats caries and refills the tooth, or drains the fistula and then rinses it.

Parotid fistula forms a canal between the auricle, neck, middle ear and even the mouth. As a rule, this is a congenital defect that is noticeable externally, but if it does not become inflamed, forming a painful lump, it does not bother the child in any way. In this case, anti-inflammatory treatment and surgery are required.

Umbilical fistulas very common among infants and can be complete or residual results of the baby’s intrauterine development (incomplete fistulas). They are treated with hydrogen peroxide, and the child is also bathed in potassium permanganate. If treatment fails, surgery is required, as in the case of a complete fistula. Fistulas of the gallbladder, stomach, etc. may also occur in the peri-umbilical region.

Intestinal fistulas may be a consequence of birth injuries, postoperative complications, Crohn's disease, etc. The danger of intestinal fistulas for children lies in the possibility of infection in the genital organs, as well as transformation into malignant tumors.

No matter what part of the body a fistula occurs in a child, in no case should you self-medicate or expect it to go away on its own. You need to contact a pediatric specialist who will prescribe adequate treatment or hospitalize the child for surgical intervention.

Inflammation in the anal area in a baby is difficult to notice in the initial stage. One of dangerous pathologies– paraproctitis in infants. It is diagnosed more often in children under 14 years of age, 60% of whom experienced the disease before the age of 6 months. In boys, pathology occurs 5 times more often, because due to anatomical features structure, the pressure inside the rectum is higher in them than in girls.

general description

The disease occurs when pathogenic microbes enter the tissues of the lower rectum. In infants, especially when breastfeeding, inflammation is caused by staphylococcal bacteria. Initially, a small cyst forms, which, if the course is unfavorable, turns into an abscess.

Paraproctitis comes in three forms:

1. Subcutaneous, next to the anus - it can be seen without medical devices. This is a common type, observed in half of the cases;
2. Submucosa, located in the lower part of the rectum;
3. Subcutaneous-submucosal – mixed type.

The abscess can come out, near the anus and break through. If the process occurs inside the rectum, the infection provokes the formation of a fistula. When pus enters the abdominal cavity, there is a risk of peritonitis.

Reasons for appearance

The occurrence of paraproctitis is promoted by:

1. . Sensitive skin and mucous membrane of the lower rectum are injured during difficult defecation, straining, bacteria enter microcracks and cause inflammation;
2. – frequent bowel movements irritate the mucous membrane;
3. arising from prickly heat, improper wearing of a diaper, reduce local immunity, the skin is susceptible to microtraumas;
4. Improper hygiene – aggressive cosmetics for washing, untimely cleansing of the skin from feces;
5. An abnormal structure of the anal glands, into the ducts of which pathogenic microflora enters and begins to actively multiply;
6. Congenital abnormalities in the development of rectal mucosa.
7. Immunodeficiency conditions caused by infectious diseases, hypothermia. The body's defenses are reduced, creating favorable conditions for the proliferation of dangerous bacteria;
8. One of common reasons is proctitis - inflammation of the rectal mucosa. It occurs due to the body's rejection breast milk, artificial mixtures, . Undigested substances irritate the intestinal mucosa, and can be seen in the stool.

Proctitis often occurs in the first weeks of life.

Symptoms of acute paraproctitis

Characteristic signs of the disease:

1. Temperature rises to 39°;
2. The child becomes capricious, it is impossible to calm him down in the usual ways;
3. Decreased appetite, refusal to eat;
4. The baby becomes apathetic, reactions are reduced;
5. Defecation and release of gases are accompanied by intense crying;
6. Symptoms are painful in a baby when sitting;
7. Painful sensations lead to stool retention, bloating, and deterioration of the general condition;
8. When examining the anus, there is noticeable redness and compactions in the form of nodules that are easily palpable. The child's reaction increases when pressure is applied due to painful sensations. On early stage it feels like this area is hot even without general increase temperature.

Difference from hemorrhoids

Similar signs are observed when a baby develops hemorrhoids, but due to the non-infectious course of the disease, the child does not have a fever. He is quite active, there is no malaise, general health normal.

Hemorrhoidal bumps appear after physical activity. The disease develops over several months, in contrast to paraproctitis, in which inflammation turns into an abscess in about 7 days (the timing varies from person to person). Hemorrhoids with untimely treatment can turn into an inflammatory form, causing paraproctitis.

What should parents be wary of?

The first symptoms appear at the end of the 1st day of disease development. On the 2nd or 3rd day possible purulent discharge from the formation, if it comes out, or discharge from the anus, if the abscess has broken through into the rectum. After this, a lot of mucus comes out along with the feces, which is formed during tissue healing.

It is difficult to identify pathology if the general background is decreased immunity and heat during teething. In such conditions, paraproctitis can be noticed by external signs or when pus appears from the anus.

Subcutaneous paraproctitis in newborns is easier to diagnose by external manifestations. In the submucosal form, the main symptom is a temperature not higher than 37.5°, the abscess is not visible, the diagnosis becomes more complicated, parents consult a doctor if acute phase. It is dangerous if the abscess breaks into the internal cavity, and sepsis may develop. It is characterized by an increase in temperature to 40°, increased heart rate, and possible vomiting due to general intoxication of the body. Immediate health care, if signs appear, you need to call an ambulance.

Chronic form

If acute paraproctitis breaks into the intestines, a fistula canal is formed and the cells become infected. A chronic form of paraproctitis occurs, exacerbation of which occurs several times a year. Spontaneous closure of the fistula for a long time is possible. According to their location, fistulas are:

• Complete - the passage connects the skin and the wall of the rectum;
• Incompletely open - there is no connection with the rectum, an abscess forms on the skin;
• Incompletely closed - they exit in the rectum and end in the fatty tissue.

Fistulas can be congenital and with acute paraproctitis they enlarge, turning into complete ones. Asymmetry of the buttocks and perineal tissue may be observed.

Diagnostics

The doctor examines the rectum by palpation, determines the location of the formation, its size, the degree of compaction (in the initial stage it is higher, when an abscess forms, the tissue becomes softer). When paraproctitis is located on inner wall of the rectum, external examination is ineffective; anoscopy is performed to examine the rectum. If a fistula has formed in a baby due to paraproctitis, an ultrasound and probing are performed to determine the location of its course.

A general blood test reveals signs inflammatory process in organism: increased content leukocytes and high speed erythrocyte sedimentation. Additionally carried out biochemical research blood, urine test. If pus is released, the bacteria that causes the infection are determined from it in order to prescribe antibiotic therapy. To find out the cause of the pathology, it is necessary to show the baby to an immunologist to rule out lactose intolerance and infectious diseases.

Features of treatment

Acute form

Acute purulent paraproctitis is subject to mandatory surgical intervention on the day the diagnosis is confirmed, since there is a danger of the spread of infection and general intoxication if the formation breaks through into the intestine. The operation is performed under general anesthesia and lasts about 20 minutes. If there is a fistula, it is carried out in two stages:

1. It is opened, cleaned of pus, washed and drainage is installed. To prevent infection, a 7-day course of antibiotics is prescribed;
2. When the baby's condition improves (after 3-4 days), the drainage is removed. After defecation, the child is given a sitz bath in a solution.

For three days after surgery, a slag-free diet is prescribed. Microenemas are administered for several days after bowel movements to cleanse the intestines. Physiotherapy is carried out to improve the baby's condition. Usually after two weeks the child is discharged for further treatment at home. Additionally, medications are prescribed that restore intestinal microflora. If there are no complications after the operation, the prognosis is good, the baby will fully recover.

Chronic

At chronic form may recommend ointments: ichthyol, Vishnevsky, levomekol, anti-inflammatory suppositories, antibacterial drugs. IN in rare cases Conservative treatment helps get rid of the fistula. If not, the child will undergo surgery after two years of age, since before this time, surgical intervention without a clear threat to the baby’s health is not recommended.

What not to do

Paraproctitis is often accompanied by constipation in a newborn; they are used to ease stool, and Dr. Komarovsky also recommends using them. You are more likely to notice signs of inflammation. However, the product has paraproctitis among its contraindications; you should consult a doctor before using glycerin suppositories.

You cannot use folk remedies to treat a baby without consulting a pediatrician and finding out the cause. Such therapy can lead to allergies and infectious complications.

Possibility of relapse

Reasons for recurrence of the disease:

• Prolonged course of the disease and late surgical removal;
• Independent opening of a purulent formation;
• Treatment of paraproctitis using conservative methods;
• Seals remaining at the site of suppuration.

Between relapses, the child feels normal, the signs of a relapse are similar to the symptoms of acute paraproctitis. The abscess opens on its own or is removed surgically.

Preventive measures

Following the rules helps to avoid repeated exacerbations:

• Strengthening the immune system by hardening, daily walks, establishing feeding and sleeping patterns, good nutrition. The baby should not be allowed to become hypothermic. Summer is a time of drafts, from which you need to protect a child, especially a sweaty one;
• Normalization of digestion, maintenance intestinal microflora to prevent diarrhea, prevent constipation, sufficient fluid intake;
• Careful hygiene of the baby - regular bathing, washing after each bowel movement;
• Sitz baths with potassium permanganate 2-3 times a day, the solution should be slightly pink, the temperature should not exceed 39°. The crystals are diluted in a separate container, filtered and added to bathing water. If infant can't sit yet, he gets a full bath. Additional moisturizing of the skin with baby cream is necessary, since manganese can dry it out;
• Gymnastics, rational physical exercise normalize blood flow, serve as a good prevention of hemorrhoids. You should avoid letting your baby lie in the crib for long periods of time.

Preventing the disease helps to avoid negative consequences. It is necessary to regularly visit the pediatrician and independently examine the baby for redness and swelling near the anus. If signs appear, it is dangerous to treat the child yourself; you should consult a doctor.

Hydatids

Etiology:

Acute nonspecific testicular disease:

Orchiepididymitis:

Classification of orchiepididymitis:

Pathogenesis:

Gangrene of the scrotum (Fournier's disease).

Clinic and diagnosis of acute diseases of the scrotal organs:

The role of ultrasound in diagnosing the condition of the scrotal organs. Introduction

Private problems

Differential diagnosis of various forms of acute diseases of the scrotal organs:

Treatment of acute diseases of the scrotal organs:

The choice of treatment method for patients with acute inflammatory diseases of the epididymis and testicle

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Duodenal atresia (below the major duodenal papilla)

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Incomplete umbilical fistula

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4.2.1. Funnel chest deformity

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7. Phimosis. Paraphimosis. Balanoposthitis. Causes. Clinical manifestations. Diagnostics. Emergency care for acute urinary retention. Treatment methods. Prevention.

8. Anomalies in the development and location of the testicle. Classification. Clinical manifestations. Complications.

9. Cryptorchidism. Classification. Clinic, diagnosis of inguinal ectopia, inguinal and abdominal testicular retention. Complications. Indications, timing and methods of surgical treatment. Reproductive health forecast.

10. Dropsy of the membranes of the testicle and spermatic cord in children. Etiology. Classification. Clinical manifestations. Differential diagnosis. Age indications for surgical treatment.

11. Varicocele. Etiology. Pathogenesis. Classification. Clinical manifestations depending on the degree. Modern diagnostic methods. Methods of treatment. Dispensary observation.

Etiology and pathogenesis

Clinic.

Diagnostics.

Operation from mini access (Marmar).

Open surgery (performed according to Ivanissevich).

Endoscopic surgery.

Microsurgical revascularization of the testicle.

2. Clavicle fractures in children. Mechanogenesis of injury. Clinic. Diagnostics. X-ray diagnostics. Treatment methods in age groups.

3. Fractures of the bones of the forearm. Classification. Mechanogenesis of injury. Typical and special fractures. Clinic. Providing assistance at the prehospital stage. Principles of treatment.

4. Fractures of the humerus. Classification. Mechanogenesis of injury. Fractures in the elbow joint. Clinic, diagnostics. Complications. Choice of treatment method. Rehabilitation.

5. Fractures of the femur in children. Classification. Mechanogenesis of injury. Clinic. Types of fragment displacements. Principles of performing radiographs. Complications. Choice of treatment method.

9. Features of traumatic brain injury in children. Classification. Clinic and diagnosis of various types of head injuries. Treatment of acute and long-term periods. Complications. Outcomes.

1 Pathophysiology.

1. Treatment.

11. Frostbite. Classification. Clinic. Diagnostics. Principles of treatment.

12. Malformations of the hand. Polydactyly. Syndactyly. Classification. Diagnostics. Age indications for surgical treatment. Syndactyly

Polydactyly

13. Poor posture and scoliosis. Classification. Diagnostics. Therapeutic tactics. The role of a pediatrician in the prevention of spinal deformities.

I degree - the angle of curvature on the radiograph is up to 10° (170°) in a vertical position, in a horizontal position it decreases or disappears, moderate torsion of the vertebrae is characteristic;

II degree - angle of curvature up to 25° (155°), torsion is pronounced, there is a compensatory arch;

III degree - angle of curvature up to 40° (140°), deformation of the chest and rib hump appear;

IV degree - the angle of curvature is more than 40°, persistent deformation is expressed with the presence of anterior and posterior costal humps, stiffness

II test - the ossification nucleus extends to the middle third;

III test - the ossification nucleus covers the entire iliac crest;

IV test - complete fusion of the apophysis with the wing of the ilium; occurs on average in girls at 18 years old, in boys at 19 years old; Skeletal growth is completed, scoliosis does not progress.

14. Hip dysplasia Congenital dislocation of the hip. Etiology. Clinic. Diagnostics. Principles of X-ray diagnosis and treatment in children under 1 year of age.

15. Torticollis in childhood. Classification. Clinic. Differential diagnosis. Methods of conservative treatment. Age indications for surgery.

16. Congenital clubfoot. Etiology. Clinic. Stages and methods of conservative treatment. Indications for surgical treatment. Methods of surgical correction of foot abnormalities.

17. Osteochondropathies in children. Classification, typical localizations. Clinical manifestations depending on the location of the lesion. Modern methods of diagnosis and treatment.

Complete umbilical fistula

Complete umbilical fistulas occur in cases where the vitelline duct remains open along its entire length. In this condition, the contents of the ileum are released through the umbilical wound.

Clinic and diagnostics. In the case of an unobliterated vitelline duct, at the birth of a child, attention is paid to an abnormally thickened umbilical cord and a slightly dilated umbilical cord. ring. The fall of the umbilical cord is often delayed, and after this has happened, a fistula opening with bright mucous membrane and intestinal discharge is found in the center of the umbilical fossa.

In cases where the fistula is wide and long enough, if the child is worried, evagination of the intestine may occur, accompanied by intestinal obstruction. Early cutting of the umbilical cord on the 2-3rd day of life in the case of a non-obliterated vitelline duct is often complicated by eventration of intestinal loops through a peritoneal defect in the umbilical fossa. An intestinal loop strangulated in the umbilical ring can become necrotic.

Diagnosis complete umbilical fistula is not difficult and in case of a wide fistula it is placed on the basis of characteristic discharge. Fistulography is a valuable diagnostic technique.

Treatment. The only way to treat complete umbilical fistulas is surgery, which is performed immediately after diagnosis to avoid complications (evagination, infection, bleeding).

The operation consists of excision of the fistula tract along its entire length from the navel to the ileum using a laparoscopic approach.

Incomplete umbilical fistula

Incomplete umbilical fistulas are formed when the obliteration of the distal vitelline duct is disrupted and are observed much more often than complete ones.

Clinic and diagnostics. Scanty discharge from the umbilical fossa is typical, as a result of which children are treated for a long time for a “wet navel.” When an infection occurs, the discharge becomes purulent. Examination of the umbilical fossa reveals a pinpoint fistula opening with scanty discharge among the sparse granulations. To confirm the diagnosis, probing of the fistula tract is performed. If the button probe can be passed to a depth of 1-2 cm, the diagnosis of a fistula becomes undoubted.

Differential diagnosis must be made with umbilical fungus, which is characterized by the proliferation of granulation tissue at the bottom of the umbilical fossa due to infection and delayed epithelization.

Treatment incomplete umbilical fistula always begins with such conservative measures as daily baths with a weak solution of potassium permanganate, treatment of the fistulous tract with a solution of hydrogen peroxide and 3% tincture of iodine, bandages with antiseptics (1% solution chlorophyllipt). In case of ineffective conservative treatment, surgery is indicated starting from 6 months of age.

9. Developmental defects manifested by acute respiratory failure. Diaphragmatic hernia. Classification. Congenital lobar emphysema. Clinical and radiological picture. Pathanatomical substantiation of the concept of “asphyxial strangulation.” Medical tactics. Indications for preoperative preparation. Timing and methods of surgical correction of defects. Postoperative management.

Diaphragmatic hernia

Diaphragmatic hernia refers to the displacement of organs abdominal cavity into the chest through a defect in the diaphragm. Unlike other hernias, they do not always have a hernial sac.

In children, congenital hernias are mainly detected - malformations of the diaphragm. The incidence of diaphragmatic hernia varies widely - from 1 in 2000 to 1 in 4000 newborns; this does not take into account a large group of stillborns with malformations of the diaphragm.

Classification

The defect begins to form in the embryo at the 4th week of gestation, when the rudiment of the septum forms between the pericardial cavity and the body of the embryo. Underdevelopment of muscles in certain areas of the thoraco-abdominal barrier leads to the appearance of hernias with a sac, the walls of which consist of serous covers - the peritoneal and pleural layers. Such hernias are called true. At false In hernias, there is a through hole in the diaphragm, formed as a result of underdevelopment of the pleuroperitoneal membrane or due to its rupture due to overstretching.

Congenital diaphragmatic hernia:

diaphragmatic-pleural (false and true);

parasternal;

phrenopericardial;

hernia hiatus.

Acquired hernias are traumatic.

Most often in children, diaphragmatic-pleural hernias and hiatal hernias occur. Parasternal hernias are encountered much less frequently, and phrenopericardial hernias, in essence, can be considered casuistry.

Paresis of the diaphragm is a separate nosological form of the disease that is not included in this classification.

Diaphragmatic-pleural hernia

Diaphragmatic-pleural hernias can be either true or false. More often they are left-sided. False hernias on the right are observed very rarely. True hernias can occupy a limited part of the diaphragm, be large and complete. In the latter cases, when a high standing of the entire dome of the diaphragm with the absence of the muscle layer is detected, this type of diaphragmatic hernia is called relaxation of the diaphragm.

With false hernias, the defect in the diaphragm is most often slit-like, located in the costovertebral region (hernia

Bochdalek). As a result of the absence of a hernial sac in these types of diaphragmatic hernias, the organs of the abdominal cavity move into the thoracic cavity without restriction, which often leads to intrathoracic tension syndrome. A similar situation is typical for true hernias, when a high position of the diaphragm is noted.

Parasternal hernias

Parasternal hernias usually have a hernial sac and are divided into retrosternal and retrosternal-costal. These hernias penetrate into the chest cavity through a thinned section of the diaphragm in the anterior section (Larrey's fissure). A hernia that is located more to the right of the sternum is called Morgagni's hernia by some authors.

Phrenopericardial hernia

Phrenopericardial hernia -* false hernia with a defect, dis- ! located in the tendon part of the diaphragm and the adjacent pericardium. Through this defect, intestinal loops can move into the pericardial cavity; sometimes the opposite phenomenon is possible - dislocation of the heart into the abdominal cavity.

Hiatal hernia

Hiatal hernias are divided into two large groups - paraesophageal and esophageal. Paraesophageal hernias are characterized by upward displacement of the stomach with its location next to the esophagus. In esophageal hernias, the esophagogastric junction is located above the level of the diaphragm. In this case, the degree of displacement of the stomach can be different and even change depending on the position of the child and the volume of filling of the stomach.

Associated defects

The severity of the condition and the severity of clinical manifestations are determined not only by the degree and volume of organs displaced into the chest cavity, but also by associated developmental defects. With diaphragmatic-pleural hernias, underdevelopment of the lungs, heart defects, central nervous system and gastrointestinal tract diseases are often encountered. Particular severity is determined by the degree of underdevelopment of the lungs and morphofunctional disorders in them, leading to impaired circulation in the pulmonary circle with the development of hypertension and the occurrence of a right-to-left shunt with blood discharge at the level ductus arteriosus or intracardiac. It is possible that blood will be shunted in the lungs due to functioning fetal communications. Children with such severe developmental defects are often stillborn or die soon after birth.

Clinical picture

Each type of diaphragmatic hernia has quite specific symptoms, although two leading symptom complexes can be distinguished: cardiopulmonary disorders that occur with diaphragmatic-pleural hernias, accompanied by intrathoracic tension, and gastroesophageal reflux with hiatal hernias.

With false diaphragmatic-pleural hernias or true hernias with significant bulging of the hernial sac into the pleural cavity, when almost the entire intestine moves there, clinical manifestations of respiratory failure occur early. Shortness of breath and cyanosis develop immediately after birth or within a few hours. Skin and the mucous membrane is dark blue and even “cast iron” in color. Acute respiratory failure progresses very quickly. On examination, in addition to cyanosis, asymmetry attracts attention chest with bulging of the affected side (usually on the left) and lack of excursion of this half. Very characteristic symptom- sunken navicular abdomen. By percussion over the corresponding area of ​​the chest, tympanitis is determined, and by auscultation - a sharp weakening of breathing. Heart sounds (with a left-sided hernia) on the left are almost not detectable, but on the right they are loud, which indicates a displacement of the heart to the healthy side. Sometimes through the chest wall it is possible to listen to the peristalsis of displaced intestinal loops and the sound of splashing.

With smaller hernias, clinical manifestations are less pronounced; respiratory disorders in the form of cyanosis and shortness of breath more often develop when the child is restless, screaming, feeding, or changing position. Sometimes a deterioration in the condition occurs in children of toddler and even school age against the background of apparent complete health, when the gastric wall is pinched in a hernia.

the gate or its inversion. In this case, the child complains of vague abdominal pain, nausea and vomiting appear, and anxiety gradually increases.

With true small diaphragmatic hernias, especially with protrusion of a limited part of the diaphragm on the right, when the contents constitute the embedded portion of the liver, there are no clinical symptoms. Children are no different from healthy ones; they develop well, keeping up with their peers. With such hernias localized on the left, despite the absence of visible clinical manifestations, there is some displacement of the heart with its rotation, which can cause hidden cardiovascular disorders. To identify them, tests with functional loads and additional research methods should be carried out.

With parasternal hernias, the symptoms are not pronounced and inconsistent; they are more often detected in children of toddler or school age,

when they begin to complain of painful discomfort in the epigastric region. Sometimes nausea and vomiting occur. Respiratory and cardiovascular disorders are not typical for this type of hernia. In almost half of all cases, children do not complain. With the help of percussion and auscultation, it is possible to determine tympanitis and weakening of heart sounds in this area.

In case of hiatal hernia, especially in the esophageal form, clinical manifestations are associated with the presence of gastroesophageal reflux, resulting from dysfunction of the cardiac part of the esophagus (reflux esophagitis occurs). In the paraesophageal form, the symptoms of the disease are often not associated with the presence of gastroesophageal reflux, but depend on a violation of the evacuation of food from the stomach, its inflection, volvulus, or injury; Cardiovascular disorders are possible due to displacement and compression of the heart. Sometimes paraesophageal hernias are detected by chance during X-ray examination.

Diagnostics

Diagnosis of diaphragmatic hernia is not always simple. The greatest importance should be given to x-ray examination. Diaphragmatic-pleural hernias are characterized by ring-shaped clearings over the entire left half of the chest, usually having a spotted pattern; the transparency of these cavities is more pronounced at the periphery (Fig. 4-47). Characteristic is the variability of the position and shape of the areas of clearing and shading, which can be seen when comparing two radiographs taken at different times.

The mixing of the organs of the mediastinum and the heart depends on the number of intestinal loops that have prolapsed into the chest cavity. In newborns and children in the first months of life, the confusion is so significant that it is not even possible to identify the shadow of a collapsed lung.

Distinguish false diaphragmatic hernia from the true one it is difficult, especially if the pleural cavity is filled with embedded loops of intestines. Usually, with true hernias, it is possible to radiologically trace the upper contour of the hernial sac, limiting the prolapsed loops of intestine into the chest cavity.

If the patient’s condition allows and there are difficulties in differential diagnosis with diseases such as polycystic lung disease or limited pneumothorax, contrasting the gastrointestinal tract with barium sulfate should be performed. In this case, it is clearly established which part of the intestine is located in the chest cavity. Sometimes gastric catheterization is sufficient. Such a manipulation can alleviate the patient’s condition to some extent, since it decompresses the stomach.

When a true hernia is located on the right, usually its contents are part of the liver, so radiologically the shadow of the hernial protrusion will have a dense intensity, merging into lower parts with the main shadow of the liver, and the upper contour of the hernia will be spherical, i.e. one gets the impression of having a dense, round lung tumor adjacent to the diaphragm.

Differential diagnosis

Ultrasound and CT can be used for differential diagnosis. In case of parasternal hernia of the diaphragm, a semi-oval or pear-shaped shadow with large-celled ring-shaped clearings projected onto the shadow of the heart in a direct projection is revealed. In the lateral projection, the shadow of the hernia seems to be wedged between the shadow of the heart and the anterior chest wall. It is not possible to differentiate a parasternal hernia from a phrenopericardial hernia radiographically. In case of parasternal hernias, to establish the hernial contents, an X-ray contrast examination of the gastrointestinal tract with a barium suspension is performed. It is better to start with irrigography, since most often the contents of the hernia are the transverse colon.

The radiographic appearance of hiatal hernias depends on their shape. With paraesophageal hernias in the chest cavity to the right or left of the midline, a cavity with a fluid level is detected, while the gas bubble of the stomach located in the abdominal cavity is reduced or absent. A contrast study with a barium suspension reveals an “hourglass” type stomach, upper section which is located in the chest cavity, and the lower one in the abdominal cavity, and the barium suspension can flow from one part of the stomach to another. An esophageal hernia, as a rule, can be detected only with contrasting of the gastrointestinal tract.

Treatment

Treatment of congenital diaphragmatic hernias is surgical. The exception is asymptomatic small hernias localized on the right, when the contents are part of the liver. The urgency of treatment depends on the severity of symptoms of respiratory failure and cardiovascular disorders.

Usually, with false diaphragmatic-pleural or true large hernias, respiratory and cardiovascular disorders are so pronounced that quite lengthy preoperative preparation is necessary, consisting of decompression of the stomach with a catheter, nasotracheal intubation, transfer of the child to mechanical ventilation with the creation of positive expiratory pressure, which should be minimal - no more than 20 cm water column, otherwise pneumothorax may develop . Eliminate metabolic disorders. Infusion and drug therapy should be aimed at improving the rheological properties of the blood and restoring homeostasis. In this case, it is very important to use medications that reduce pressure in the pulmonary circulation (dopamine). It should be emphasized that children with such disorders tolerate transportation very poorly, so this therapy should begin in the maternity hospital and continue in special machines. Only after homeostasis has improved, cardiovascular disorders and hypoxia have been eliminated, the child can be operated on.

The principle of surgical intervention is to bring down the organs into the abdominal cavity, suturing the diaphragm defect for false diaphragmatic hernias and diaphragm repair for true hernias. Sometimes, with aplasia of the diaphragmatic muscles and the presence of only a pleural layer, plastic material is used. The operation can be performed either through the abdominal or through the thoracic cavity, but it is extremely important that there is no significant intra-abdominal pressure in the postoperative period, so gastrointestinal CT decompression is performed during the operation. In the postoperative period, fairly long-term mechanical ventilation is carried out until hemodynamics and homeostasis improve.

The results of the operation are mainly related to the severity of the patient’s condition upon admission and the degree of lung underdevelopment. Besides, great importance has the quality of transporting and preparing a newborn for surgery. In case of severe cardiovascular and respiratory disorders, children are taken to the clinic on the first day after birth, and the prognosis in more than 50% of cases is unfavorable.

In case of hiatal hernia, the urgency of surgery depends on the severity of clinical manifestations and the effectiveness of conservative treatment. For paraesophageal hernias in the absence of obvious clinical symptoms, surgery can be performed even after the child reaches toddler age. In children with gastroesophageal reflux if there is no improvement after conservative treatment Surgical treatment is indicated within 2-3 weeks. Currently, these interventions are performed during laparoscopy.

Congenital localized emphysema

This malformation is characterized by stretching (emphysema) of part of the lung (usually one lobe). The terms “congenital lobar emphysema”, “localized emphysema”, “obstructive emphysema”, “hypertrophic emphysema” are also used to designate it. The true causes of the defect remain unclear. However, some authors associate its occurrence with aplasia of the cartilaginous elements of the bronchi, hypoplasia of elastic fibers and smooth muscles of the terminal and respiratory bronchioles and other disorders in the structural units lung tissue. These factors create the prerequisites for the emergence of a valve mechanism that promotes excessive inflation of the corresponding part of the lung and the development of respiratory disorders.

Clinical picture and diagnosis

Clinical disorders are caused by the presence and severity of symptoms of respiratory and cardiovascular failure. The following factors play a role in the pathogenesis of respiratory failure: exclusion of a large volume of lung tissue from the respiratory function (lack of respiratory function in the viciously developed part of the lung and collapse of normally formed parts as a result of compression of them by overstretched parts of the vicious lung), as well as shunting of blood in the collapsed part of the lung .

Increased intrathoracic pressure and mediastinal confusion, often found with this malformation, become another pathogenetic mechanism causing cardiovascular disorders in such patients.

There are decompensated, subcompensated and compensated forms of congenital lobar emphysema. In the decompensated form, the defect manifests itself from birth. Quite often, general cyanosis, shortness of breath, respiratory asymmetry (lag in the act of breathing of the swollen half of the chest), child anxiety, frequent dry cough, and attacks of asphyxia during feeding can be expressed.

X-ray examination becomes decisive in diagnosis, in which it is possible to detect an increase in the transparency of the lung tissue up to the complete disappearance of the pulmonary pattern, displacement of the mediastinum, sometimes with the presence of a “mediastinal hernia”, compression of healthy parts of the lung in the form of a triangular shadow of atelectasis. The last sign is extremely important in the differential diagnosis of pneumothorax (Fig. 4-23). Most Convincing signs of the localization of emphysema are detected with CT and radioisotope studies of the lungs In the compensated form of congenital lobar emphysema, the listed symptoms can be extremely mild, inconsistent, and noticeable only to an experienced clinician. Often, only the occurrence of inflammatory changes in the vicious part of the lung or collapse in other parts becomes the reason for an X-ray examination, which makes it possible to make an accurate diagnosis.

Treatment

The only correct method of treating this malformation is surgical (removal of the malformed lobe).

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