190例犬肛囊炎的治疗、预后、复发及共病的回顾性研究 ...

王帆

A retrospective study of treatment, outcome, recurrence and concurrent diseases in 190 dogs with anal sacculitis

190例犬肛囊炎的治疗、预后、复发及共病的回顾性研究

Katinka Hvitman-Graflund | Tim Sparks | Katarina Varjonen

 

Abstract

Background: Few studies report the treatment and recurrence rate in anal sacculitis (AS).

Objectives: Retrospective study reporting the management, recurrence and concurrent diseases in dogs with AS in a primary care practice.

Animals: One hundred and ninety privately owned dogs in Sweden.

Materials and Methods: Clinical records of dogs diagnosed with AS between 2018 and 2021 were reviewed, and management, time until clinical resolution, number of recurrent episodes and comorbidites were recorded.

Results: The 190 dogs developed 290 episodes of AS. The most common management, in 235 of 290 (81.0%) episodes, was flushing±infusion of an antimicrobial product into the sacs±prescription of a nonsteroidal antiinflammatory drug (NSAID), providing resolution in 213 of 235 (90.6%) episodes. Median time to resolution was oneweek (range 1–16weeks), with resolution seen within oneweek in 205 of 290 (70.7%) episodes. A single episode of AS developed in 126 of 190 (66.3%) dogs. Dogs with concurrent cutaneous allergic disease were more likely (p＜0.001) to have recurrence of AS when compared to dogs with other comorbidities. Cutaneous allergic disease occurred more often (p＜0.001) in dogs with AS than in the practice population.

Conclusions and Clinical Relevance: Local treatment of the anal sacs±systemic NSAID was the most common treatment, inducing clinical resolution in the majority of dogs. Cutaneous allergic disease was the most common concurrent diagnosis, with higher recurrence rate of AS compared to other diseases and occurring in higher prevalence than in the practice population. Further studies are needed to determine if management of cutaneous allergic disease would reduce the risk of AS.

KEYWORDS

anal sacculitis, cutaneous allergy, management, primary practice

 

摘要

背景: 关于肛门囊炎(AS)的治疗和复发率的研究很少。

目标: 回顾性研究报告社区保健诊所中AS患犬的管理、复发和共病情况。

动物: 共计190只私家犬。

材料和方法: 回顾2018年至2021年之间被诊断为AS患犬的临床记录，并记录治疗方法、临床缓解时间、复发次数和共病。

结果: 这190只犬发生了290次AS。290次中的235次(81.0%)AS发作，使用了最常见的治疗方法，即冲洗±将抗微生物制剂注入肛门囊±处方非甾体抗炎药(NSAID)，并且235次中的213次(90.6%)AS发作获得了临床缓解。临床缓解的中位时 间为1周(范围1-16周)，290次AS发作的205次占70.7%，在1周内获得了缓解。在190只犬中有126只(66.3%)只发生了一次AS。与有其他共病的犬相比，皮肤过敏性疾病患犬更有可能(p ＜0.001)出现AS复发。与临床中的其他疾病相比，伴有AS的皮肤过敏性疾病患犬更常见(p ＜0.001)。

结论和临床相关性: 外部治疗肛门腺±全身用NSAID是最常见的治疗方法，可以使大多数犬获得临床缓解。与其他疾病相比，皮肤过敏性疾病是最常见的共病，使AS的复发率更高，且在临床中的患病率也更高。需要进一步研究以确定是否 管理皮肤过敏性疾病能降低AS的风险。

关键词:肛囊炎；皮肤过敏症；管理；初级诊所

 

INTRODUCTION

介绍

Discomfort, malodour and involuntary discharge from the anal sacs are common clinical signs suggesting anal sac disease in dogs. Between 4.4% and 15.7% of patients seeking primary veterinary care present with nonneoplastic anal sac disorders (ASD). These include anal sac impaction and anal sacculitis (AS), which may progress to anal sac abscessation and fistulous tract formation from the anal sacs to the skin surface.

不适、异味和肛门囊不自主排出分泌物是犬肛门囊疾病常见的临床症状。初级兽医诊所就诊的非肿瘤性肛囊疾病(ASD)中占4.4% ~ 15.7%。其中包括肛门囊阻塞和肛门囊炎(AS)，后者可进展为肛门囊脓肿和从肛门囊到皮肤表面形成瘘管。

 

There are no objective criteria available to differentiate between anal sac impaction and AS. A palpable distention of one or both anal sacs, with the sacs containing secretions that are variably difficult to express, occur in both conditions. However, in anal sac impaction, there is no inflammation of the anal sac walls or the surrounding tissue in contrast with AS where concurrent infection also may be present. Based on several studies, cytological and microbiological assessment of anal sac contents cannot be used to differentiate between dogs showing clinical signs of AS and healthy dogs because a marked overlap is seen. Keratin, keratinocytes, neutrophils, gram positive cocci, gram negative rods, gram positive large rods and yeasts may be seen on cytological evaluation in secretions from both healthy and diseased anal sacs, and microbial cultures show overlap with growth of a similar microbial flora including Streptococcus faecalis, Staphylococcus pseudintermedius, Escherichia coli, Proteus mirabilis, beta-haemolytic streptococci, Pseudomonas aeruginosa, Bacillus spp. and Malassezia spp.

目前还没有客观的标准来区分肛门囊阻塞和AS。在这两种疾病中均可触及一个或两个扩张的肛门囊，囊内含有不同程度难以排出的分泌物。然而，在肛囊阻塞中，肛囊壁或周围组织没有炎症，而AS中也可能存在感染。根据几项研究，肛囊内容物的细胞学和微生物学评估不能用于区分有AS临床症状的犬和健康犬，因为可以同时发生。在细胞学评估中，健康和病变肛囊的分泌物中均可见角蛋白、角质形成细胞、中性粒细胞、革兰阳性球菌、革兰阴性杆菌、革兰阳性大杆菌和酵母菌，并且微生物培养显示与类似微生物菌群的同时生长，包括粪链球菌、假中间型葡萄球菌、大肠埃希菌、奇异变形杆菌、β溶血性链球菌、铜绿假单胞菌、芽孢杆菌属和马拉色菌属。

 

Multiple management protocols have been proposed in the literature for the treatment of AS. With an increasing antibiotic resistance worldwide, in recent years, there has been a movement away from the use of systemic antimicrobials towards local treatment in dermatological conditions to improve antimicrobial stewardship. Supporting this change, a recent study conducted at a university referral practice involving 33 cases of AS showed local treatment to be effective. However, most cases of AS are seen and managed in primary care practice. The aims of the current study were, in a primary care small animal practice, to retrospectively assess (i) how AS was managed in a larger group of patients, (ii) length of treatment, (iii) whether there was a difference in time to clinical resolution between different treatment protocols, (iv) frequency of recurrence and interval between episodes, (v) concurrent diseases and treatments in the affected dogs and (vi) if any concurrent disease(s) appeared over-represented in the group developing AS compared to the primary care population.

关于AS的治疗，文献中提出了多种治疗方案。近年来，随着世界范围内抗生素耐药性的增加，在皮肤病中已从全身性使用抗微生物药物转向局部治疗，以改善抗微生物药物管理。最近在一所大学转诊诊所进行的一项研究(涉及33例AS患犬)表明，局部治疗有效，这支持了这一变化。然而，大多数AS病例是在初级保健实践中发现和管理的。本研究的目的是，在一个初级保健小动物诊所中，回顾性评估(i)如何在更大的患犬病例中管理AS， (ii)治疗长度，(iii)不同治疗方案之间的临床缓解时间是否有差异，(iv)复发频率和发作间隔时间，(v)患病犬的共病和治疗;(vi)与初级保健病例相比，发生AS的犬中是否有任何共病的比例过高。

 

MATERIALS AND METHODS

材料与方法

The clinical records in a primary care practice in Sweden were searched and records of all cases diagnosed with non-neoplastic ASD during 2018–2021 were extracted and further assessed. In addition, for statistical purposes, the total number of dog visits to the practice in the same time frame was recorded, as well as the proportion of these with a diagnosis of cutaneous allergic disease. Obtaining owner consent was not necessary as this was a retrospective study in which all records were anonymised upon extraction of the clinical data.

检索瑞典一家初级保健机构的临床记录，提取并进一步评估2018—2021年诊断为非肿瘤性ASD的所有病例的记录。此外，统计同一时间段内犬的总就诊次数，以及诊断为皮肤过敏性疾病的犬所占比例。由于这是一项回顾性研究，在提取临床数据后，所有记录都是匿名的，因此不需要获得所有者的同意。

 

A diagnosis of AS was defined when the primary clinician had documented the following: (i) discomfort of the perianal area manifesting as excessive licking, biting/nibbling of the area or scooting; (ii) an erythematous and/or painful swelling of the anal sacs with or without palpable thickening of the anal sac walls; (iii) anal sacs containing yellow-to-brown secretions with or without haemorrhage and with or without involuntary discharge of the contents. Dogs described as having filled anal sacs, yet without clinical signs of swelling or erythema in the tissue surrounding the sacs and treated only with manual emptying of the sacs, were considered to have a diagnosis of anal sac impaction and were excluded. Additionally, anal sac abscessation or fistulation at the first visit, and cases that had a clinical history of anal sac disease present before 2018, were excluded. The remaining records were further assessed.

当初级临床医生记录以下情况时，诊断为AS:(i)肛周区域不适，表现为过度舔舐、咬/啃咬该区域或疾走;(ii)肛门囊有皮肤发红和/或胀痛，伴或不伴可触及的肛门囊壁增厚;(iii)含有黄色至棕色分泌物的肛囊，伴有或不伴有出血，伴有或不伴有分泌物的不自主排出。被描述为肛门囊充盈，但无肛门囊周围组织肿胀或皮肤发红的临床症状，并且仅进行了手动挤空肛门囊的治疗的犬，被认为有肛门囊阻塞的诊断，并被排除。此外，首次就诊时已发生肛囊脓肿或瘘道形成，以及2018年之前有肛囊疾病临床病史的病例被排除。对其余记录进行进一步评估。

 

An episode of AS was defined to include all visits and treatments used until the AS was considered clinically resolved and remission had been maintained for 30days. Clinical resolution was defined as the recorded resolution of all clinical signs of discomfort, erythema and swelling by the attending veterinarian together with reported resolution of clinical signs by the owner. The anal sac contents were at this point described in the records as normal, and, when applicable, involuntary discharge had ceased. Repeat signs of AS following a 30day remission period were considered as a new episode.

AS发作的定义包括所有的就诊和治疗，直到AS被认为是临床恢复和缓解维持了30天。临床缓解被定义为主治兽医记录的所有不适、皮肤发红和肿胀的临床症状的缓解，以及宠主报告的临床症状的缓解。在这一点上，肛囊内容物在记录中被描述为正常，并且，在适用的情况下，非不自主分泌物已经停止。30天缓解期后再次出现AS症状视为新发作。

 

For each dog and at every AS visit, one of five treatment protocol options (A–E) was recorded: Treatment A, no additional treatment or a systemic nonsteroidal anti-inflammatory drug (NSAID); Treatment B, instillation of an antibiotic or a combination product containing an antibiotic, antifungal and glucocorticoid, with or without a systemic NSAID; Treatment C, instillation of a combination product containing an antibiotic, antifungal and glucocorticoid and systemic treatment with either glucocorticoids (GCS), ciclosporin A (CsA) or oclacitinib, and no analgesia; Treatment D, instillation of a combination product containing an antibiotic, antifungal and glucocorticoid with additional systemic antibiotics with or without systemic NSAIDs; Treatment E, surgical extirpation of the anal sacs. Expression and flushing of the sacs were included in treatments A–D, with or without sedation. Sedation when used was induced with a combination of low-dose dexmedetomidine and butorphanol, afterwards reversed with atipamezole. None of the patients needed full anaesthesia for the procedure.

对于每只犬，在每次AS就诊时，记录5种治疗方案(A - E)中的一种:治疗A，不进行其他治疗或不用全身性非甾体抗炎药(NSAID);治疗B:滴注抗生素或含有抗生素、抗真菌药和糖皮质激素的复方制剂，伴或不伴全身性NSAID;治疗C:滴注含有抗生素、抗真菌药和糖皮质激素的复方制剂，并使用糖皮质激素(GCS)、环孢素A(CsA)或奥拉替尼进行全身性治疗，使用或不使用镇痛;治疗D:滴注含有抗生素、抗真菌药和糖皮质激素的联合制剂，以及其他全身性抗生素，联用或不联用全身性NSAID;治疗E，手术摘除肛门囊。A-D治疗包括在镇静或不镇静的情况下，挤和冲洗肛门囊。联合使用小剂量右美托咪定和布托啡诺诱导镇静，随后使用阿替美唑逆转镇静。所有患犬均无需全程麻醉。

 

Information on breed, sex, age and weight at first presentation, with body condition score, treatment(s) used and prescribed at each visit, the number of visits made during an episode of AS, time to clinical resolution, time to recurrence of clinical signs following treatment, the total number of episodes of AS, and concurrent diseases and treatments were extracted from the records. Management included information about flushing products, local and systemic medications given, and length of treatment prescribed.

从记录中提取了有关品种、性别、年龄和首次就诊时体重、体况评分、每次就诊时使用和规定的治疗方法、一次AS发作期间的就诊次数、到临床缓解的时间、治疗后临床症状复发的时间、AS发作的总数、共病和治疗的信息。管理包括冲洗产品、给予的局部和全身药物以及规定的治疗时间的信息。

 

Data from all episodes from all dogs were used for the description of the study population including signalment, treatment, number of visits, episodes, recurrences and concurrent diseases. The total number of episodes were recorded. The episodes were further divided into episodes where clinical resolution was achieved using the same medical treatment protocol (consistent treatment protocol), and episodes where a change of treatment protocol had been made within the episode (mixed treatment protocol).

来自所有犬的所有发作的数据被用于描述研究病例，包括特征、治疗、就诊次数、发作、复发和共病。记录了总集数。这些发作被进一步分为使用相同的治疗方案(一致的治疗方案)获得临床解决的发作，以及在发作期间改变治疗方案的发作(混合治疗方案)。

 

Data from the consistent medical treatment episodes were subject to statistical analysis to investigate the relative performance of the four main medical treatments A–D. As detailed under statistical analysis (see the Statistics section below), some analyses are restricted to the first episode per dog to avoid repeat records per dog.

对一致性治疗事件的数据进行统计分析，以调查四种主要药物治疗的相对效果。如统计分析(见下面的统计部分)所述，一些分析仅限于每只犬的首次发作，以避免每只犬重复记录。

 

The time to clinical resolution, time to recurrence (if applicable) and total number of episodes of AS were separately compared to the parameters of age, weight, sex, concurrent diseases and consistent treatment protocol (to avoid the complexity posed by a limited number of mixed treatment episodes).

将AS的临床缓解时间、复发时间(如适用)和总发作次数分别与年龄、体重、性别、共病和一致治疗方案的参数进行比较(以避免有限数量的混合治疗发作所带来的复杂性)。

 

Statistics

统计分析

Raw data are summarised, as appropriate, either as percentages or rates, median and ranges. The number of visits in the first episode, the time to resolution in the first episode, the time to first recurrence (when present), and number of episodes were each compared to multiple explanatory variables (age, weight, sex, consistent treatment protocol and presence of the most frequent concurrent diseases) in general linear models (GLMs). The use of data from the first episode was both for consistency and to ensure that each dog (the basic unit for analysis) was represented only once. Success at the first episode (i.e. dogs without recurrence of AS) was compared to age, weight, sex, consistent treatment protocol and presence of the most frequent concurrent diseases in a binary logistic regression. The restriction to consistent treatment protocol for formal statistical testing was used to compare only constant parameters and to simplify comparisons between what would otherwise be a complex suite of treatments.

原始数据根据情况总结为百分比或比率、中位数和范围。在一般线性模型(GLMs)中，与多个解释变量(年龄、体重、性别、一致的治疗方案和最常见的共病)进行比较，首次发作的就诊次数、首次发作缓解的时间、首次复发的时间(当存在时)和发作次数。使用首次发病的数据既是为了一致性，也是为了确保每只犬(分析的基本单位)只出现一次。在二分类逻辑回归中，我们将首次发病的成功率(即没有AS复发的犬)与年龄、体重、性别、一致的治疗方案和最常见的共病进行了比较。在正式统计学检验中，治疗方案必须一致，这一限制被用于仅比较恒定参数，并简化了一套复杂的治疗方案之间的比较。

 

Models were checked for collinearity in the independent variables [this is typically assumed when variance inflation factors (VIFs) exceed 5]. Model selection by backwards elimination also was undertaken to check if conclusions would vary.

检查模型中自变量是否共线性[这通常是在方差膨胀因子(VIF)超过5时假设的]。还进行了反向消去法的模型选择，以检查结论是否会有所不同。

 

Kruskal–Wallis tests and Fisher exact tests were used to compare continuous/ordinal and categorical variables (respectively) between groups.

Kruskal-Wallis检验和Fisher精确检验分别用于组间连续/序数和分类变量的比较。

 

The incidence of AS and the most frequent concurrent disease categories in the study sample were compared to those in the practice population for the years 2018–2021 using 95% exact confidence intervals (CI) and one-sample tests of proportion.

使用95%精确置信区间(CI)和单样本比例检验，将研究样本中AS的发病率和最常见的共病类别与2018-2021年的实践病例进行比较。

 

Analysis was undertaken in Minitab 19 and R 3.6.2. Significance was taken as p＜0.05.

在Minitab 19和r3.6.2中进行分析。p＜0.05为显著性。

 

RESULTS

结果

Animals

动物

Non-neoplastic ASD was diagnosed in 299 dogs within the study period. Following application of the inclusion and exclusion criteria, the records of 190 dogs were further assessed.

在研究期间，299只犬被诊断为非肿瘤性ASD。按照纳入和排除标准，对190只犬的记录进行进一步评估。

 

Sixty-four breeds were represented, with Labrador retrievers, German shepherd dogs, golden retrievers and springer spaniels constituting the largest groups with 11, 10, 9 and 8 dogs, respectively; 38 dogs were of mixed breed (Table 1).

共有64个品种，其中拉布拉多猎犬、德国牧羊犬、金毛猎犬和史宾格猎犬最多，分别有11只、10只、9只和8只;杂交犬38只(表1)。

 

The female-to-male ratio was 1:1.8 (67 females, 123 males). The majority of dogs (142 dogs, 74.7%) were intact (Figure S1). The median age at first presentation of AS was four years (range threemonths to 13years).

雄：雌比例为1:8 .8(雌犬67只，雄犬123人只)。大多数犬(142只，74.7%)未节育(图S1)。首次出现AS的中位年龄为4岁(范围为3个月至13岁)。

 

Body condition scores (BCS, scale 1–9) were recorded as 5 or 6, with 121 of 190 (63.6%) dogs having BCS 5 and 69 of 190 (36.3%) dogs having BCS 6. Median weight was 16.8kg (range 2.4–71.5kg). The most common concurrent disease was cutaneous allergic disease in 118 dogs (62.1%) (Table 2).

体况评分(BCS，评分1-9)记录为5或6,190只犬中有121只(63.6%)为BCS 5, 190只犬中有69只(36.3%)为BCS 6。中位体重为16.8kg(范围2.4-71.5kg)。最常见的共病是皮肤过敏性疾病，118只犬(62.1%)(表2)。

 

Treatments

治疗

In the 190 dogs, 290 episodes of AS were recorded, encompassing 576 visits for assessment and treatment of the disease. At each visit, the anal sacs of all dogs, except those categorised into the Treatment E group, were manually expressed followed by flushing with either saline or an antiseptic solution or both. Additional treatments at visits were as follows: A (none or NSAIDs) in 34 of 576 (5.9%) visits, B (local treatment with or without NSAIDs) in 421 of 576 (73.1%), C (local treatment with systemic immunomodulatory medication) in 78 of 576 (13.5%), D (local treatment with systemic antibiotics with or without NSAIDs) in 27 of 576 (4.7%) and E (surgical extirpation of the anal sacs) in 16 of 576 (2.8%), respectively.

在190只犬中，记录了290次AS发作，包括576次疾病评估和治疗。每次访视时，除治疗E组的犬外，所有犬的肛囊均人工挤空，然后用生理盐水或消毒剂或两者都用进行冲洗。就诊时的其他治疗如下:A(不用药或不使用NSAID)(576例中的34例(5.9%))，B(局部治疗+/-NSAID的)(576例次中的421例(73.1%))，C(局部治疗+全身免疫调节剂)(576例中的78例(13.5%))，D(局部治疗+/-全身抗生素+/-NSAID)(576例中的27例(4.7%))和E(手术摘除肛门囊)(576例中的16例(2.8%))。

 

The treatment inducing remission of AS – or used last within an episode if a change of treatment had been made within the episode – was most commonly B in 197 of 290 (67.9%) episodes, followed by C in 47 of 290 (16.2%), A in 16 of 290 (5.5%) and D in 14 of 290 (4.8%) episodes, respectively. Treatment E, surgery, was performed in 16 of 290 (5.5%) episodes (Table 3).

治疗包括AS缓解-或在发作期间改变治疗的最后一次使用——最常见的是在290次发作中有197次(67.9%)为B，其次是在290次发作中有47次(16.2%)为C, 290次发作中有16次(5.5%)为A, 290次发作中有14次(4.8%)为D。290例患犬中有16例(5.5%)采用手术治疗(表3)。 

 

In 253 of 290 (87.2%) episodes a consistent medical treatment protocol was used at each visit within the episode until remission. In 36 of 290 (12.4%) episodes a mixed treatment protocol was used, with 15 of 36 (41.7%) ending with Treatment E, surgery (Table 3), which also was conducted in one additional episode (0.3%) at the first visit in the affected dog's second episode (Table 4). In the mixed treatment protocol episodes, there were one to several changes of medical treatments between visits, amongst them A or B to D in eight, and from D to A or B in five episodes, respectively (Table 3). For the consistent treatment protocol episodes clinical remission was achieved in all (100%) (Tables 3 and 4), with B used to induce remission in 187 of 253 (73.9%) episodes, C in 46 of 253 (18.2%), A in 12 of 253 (4.7%) and D in eight of 253 (3.2%), respectively (Tables 3 and 4).

在290例发作中，253例(87.2%)在发作期间的每次就诊中使用一致的药物治疗方案，直至缓解。290例中36(12.4%)例使用混合治疗方案,治疗E组，15/36 (41.7%)以手术治疗(表3),这也统计为一次复发(0.3%)在患犬复发时首次就诊时(表4)。在混合治疗组,就诊中有一种至几种的药物治疗改变,其中8例从A或B至D,5例从D至A或B（表3）。对于一致的治疗方案，所有患犬(100%)均达到了临床缓解(表3和表4)，B诱导缓解的患犬比例为187/253 (73.9%)，C诱导缓解的患犬比例为46/253 (18.2%)，A诱导缓解的患犬比例为12/253 (4.7%)，D诱导缓解的患犬比例为8/253(3.2%)。

 

Number of visits and time to clinical resolution

就诊次数和临床恢复时间

The number of visits for the 190 dogs in the first episode were not significantly affected by weight (p=0.773), sex (p=0.300) or presence of cutaneous allergic disease (p=0.195). However, age (p=0.024) was significant, with more visits seen in younger dogs. Additionally, amongst dogs on a consistent treatment protocol, more visits were noted in cases receiving Treatment B (p=0.001), with the mean number of visits 1.9 compared to 1.1–1.4 in the other three. All VIFs were＜0.001) with an odds ratio for success of 0.17 (95% CI 0.07–0.42). There was no significant effect of age (p=0.219), weight (p =0.488), sex (p=0.821) or consistent treatment protocol (p=0.646). In the group of dogs with cutaneous allergic disease 55 of 118 (46.6%) experienced recurrence of AS. Nine of 72 dogs (12.5%) without concurrent cutaneous allergic disease developed repeat episodes of AS (Tables 2 and 6). In the fitted statistical model of the number of episodes there was no significant effect of age (p=0.652), weight (p=0.834), sex (p=0.928) or consistent treatment protocol (p=0.278). However, the presence of a cutaneous allergic disease was significant (p＜0.001); affected dogs required a mean of 1.8 episodes of treatment compared to those without (mean 1.1). All variance inflation factors (VIFs) were＜3.The significance of age was borderline, and indeed, model selection by backwards elimination left only age (p=0.047) as a significant effect; younger dogs needed more time before achieving clinical remission during the first episode of AS.

190只首次发病的犬的就诊次数不受体重(p=0.773)、性别(p=0.300)或皮肤过敏性疾病(p=0.195)的显著影响。然而，年龄(p=0.024)是显著的，更年轻的犬的就诊次数更多。此外，在接受一致治疗方案的犬中，接受治疗B的犬的就诊次数更多(p=0.001)，平均就诊次数为1.9，而其他3只犬的平均就诊次数为1.1-1.4。所有VIF均<0.001)，成功的比值比为0.17 (95% CI 0.07 ~ 0.42)。年龄(p=0.219)，体重(p= 0.488)，性别(p=0.821)或一致的治疗方案(p=0.646)没有显著影响。皮肤过敏性疾病组118只犬中55只(46.6%)AS复发。72只犬中有9只(12.5%)没有并发皮肤过敏性疾病，出现AS的重复发作(表2和6)。在发作次数的拟合统计模型中，年龄(p=0.652)、体重(p=0.834)、性别(p=0.928)或一致的治疗方案(p=0.278)没有显著影响。然而，皮肤过敏性疾病的存在是显著的(p<0.001);患犬平均需要1.8次治疗，而未患犬平均需要1.1次治疗。方差膨胀因子(VIF)均<3。年龄的显著性是临界的，事实上，通过向后消除的模型选择只留下年龄(p=0.047)作为显著效应;年轻的犬在AS首次发作期间需要更多的时间才能达到临床缓解。

 

Looking at each medical treatment protocol separately across all episodes (i.e. including both consistent and mixed treatment protocols), remission was achieved within one week in 13 of 16 (81.2%) episodes with A, in 143 of 197 (72.6%) with B, in 38 of 47 (80.9%) with C and in seven of 14 (50.0%) with D. The proportions of first episodes with consistent treatment protocol, which achieved clinical resolution within one week were nine of nine (100.0%) of dogs with A, 99 of 127 (78.0%) of dogs with B, 23 of 28 (82.1%) of dogs with C and four of four (100.0%) of dogs with D, respectively. The median time to clinical resolution per episode was one week (range 1–16 weeks), with resolution in ≤1 week in 70.7% of all treatment episodes and in 78.7% of consistent treatment protocols.

分别观察所有发作的每种药物治疗方案(即包括一致治疗方案和混合治疗方案)，A组16次发作中的13次(81.2%)、B组197次发作中的143次(72.6%)、C组47次发作中的38次(80.9%)和D组14次发作中的7次(50.0%)在1周内达到缓解。B组127只犬中99只(78.0%)，C组28只犬中23只(82.1%)，D组4只犬中4只(100.0%)。每次发作至临床缓解的中位时间为1周(范围1 ~ 16周)，所有治疗发作的70.7%和一致治疗方案的78.7%在≤1周内缓解。

 

Recurrence of anal sacculitis

肛门囊炎复发

One single episode of AS was seen in 126 of 190 dogs (66.3%, 95% CI, 59.1–73.0%), with the remaining 64 dogs (33.7%) having two to six episodes before end of recurrences in the studied time frame (Table 5). The median number of episodes per dog was one (range 1– 6). The median time to relapse was 4.5months (range 1–36months).

190只犬中有126只(66.3%，95% CI, 59.1-73.0%)出现了一次AS发作，其余64只犬(33.7%)在研究时间框架内复发结束前有2至6次发作(表5)。每只犬发作的中位数为1次(范围1 - 6)。复发的中位数时间为4.5个月(范围1 - 36个月)。

 

In the binary logistic regression model of success of treatment at the first episode (i.e. dogs experiencing a single episode of AS), dogs with cutaneous allergic disease had a significantly higher risk of experiencing more than one episode of AS (p＜0.001) with an odds ratio for success of 0.17 (95% CI 0.07–0.42). There was no significant effect of age (p=0.219), weight (p =0.488), sex (p=0.821) or consistent treatment protocol (p=0.646). In the group of dogs with cutaneous allergic disease 55 of 118 (46.6%) experienced recurrence of AS. Nine of 72 dogs (12.5%) without concurrent cutaneous allergic disease developed repeat episodes of AS (Tables 2 and 6). In the fitted statistical model of the number of episodes there was no significant effect of age (p=0.652), weight (p=0.834), sex (p=0.928) or consistent treatment protocol (p=0.278). However, the presence of a cutaneous allergic disease was significant (p＜0.001); affected dogs required a mean of 1.8 episodes of treatment compared to those without (mean 1.1). All variance inflation factors (VIFs) were＜3.Model selection by backwards elimination did not change these conclusions.

在首次发病治疗成功的二元逻辑回归模型中，患有皮肤过敏性疾病的犬发生多次AS的风险显著升高(p＜0.001)，成功的比值比为0.17 (95% CI 0.07 ~ 0.42)。年龄(p=0.219)，体重(p= 0.488)，性别(p=0.821)或一致的治疗方案(p=0.646)没有显著影响。皮肤过敏性疾病组118只犬中55只(46.6%)AS复发。72只犬中有9只(12.5%)没有并发皮肤过敏性疾病，出现AS的重复发作(表2和6)。在发作次数的拟合统计模型中，年龄(p=0.652)、体重(p=0.834)、性别(p=0.928)或一致的治疗方案(p=0.278)没有显著影响。然而，皮肤过敏性疾病的存在是显著的(p＜0.001);患犬平均需要1.8次治疗，而无共病患犬平均需要1.1次治疗。方差膨胀因子(VIF)均＜3。通过向后消除法进行的模型选择并未改变这些结论。

 

Of the subset of dogs with more than one episode there was no significant effect on time to first recurrence of clinical signs when compared to age (p=0.844), weight (p= 0.324), sex (p= 0.569), consistent treatment protocol (p=0.695) or presence of cutaneous allergic disease (p=0.966). All VIFs were＜4.Model selection by backwards elimination did not change these conclusions.

与年龄(p=0.844)、体重(p= 0.324)、性别(p= 0.569)、一致的治疗方案(p=0.695)或是否存在皮肤过敏性疾病(p=0.966)相比，在一次以上发作的犬群中，临床症状首次复发的时间没有显著影响。所有VIF均＜4。通过反向消去选择模型并没有改变这些结论。

 

Concurrent diseases

共病

During the studied time frame 36,555 dog visits were recorded in the primary practice. A diagnosis of canine atopic dermatitis (cAD) was recorded in 1561 (4.3%), cutaneous adverse food reaction (CAFR) in 173 (0.5%), and a combination of both cAD and CAFR in 558 (1.5%) of these visits.

在研究期间，在初级诊所中记录了36555只犬就诊。1561例(4.3%)诊断为犬特应性皮炎(cAD)， 173例(0.5%)诊断为皮肤食物不良反应(CAFR)， 558例(1.5%)诊断为cAD和CAFR兼有。

 

The most common concurrent disease in the study population of 190 dogs was cutaneous allergic disease in 118 dogs (62.1%). These dogs were diagnosed with allergic dermatitis by the primary author, either before developing AS or subsequently during the study period. The diagnoses were based on compatible clinical cutaneous signs, exclusion of other pruritic skin disease and performance of a dietary trial with provocation according to published criteria. Thirty-one (16.3%, 95% exact CI 11.4%–22.4%) had a diagnosis of cAD, whilst 19 (10.0%, 95% exact CI 6.1%–15.2%) had CAFR, and 68 (35.8%, 95% exact CI 29.0%– 43.0%) had been diagnosed with a combination of both (Tables 2 and 6). Dogs with AS and cutaneous allergic disease were overrepresented compared with the primary practice population in each category (cAD, CAFR and cAD+CAFR, each comparison p＜0.001).There were 49 dogs (25.8%) in the category No concurrent disease and 23 dogs (12.1%) in the category Miscellaneous disease, in which 20 different diseases/ clinical signs were represented, with one to two dogs per disease/clinical signs (Table 6).

190只犬的研究病例中，最常见的共病为皮肤过敏性疾病(118只，62.1%)。这些犬在发展为AS之前或随后的研究期间被第一作者诊断为过敏性皮肤病。诊断是基于一致的临床皮肤症状，排除其他瘙痒性皮肤病，以及根据已发表的标准进行了食物排查激发试验。31只犬(16.3%，95%确切可信区间11.4%-22.4%)被诊断为cAD, 19只犬(10.0%，95%确切可信区间6.1%-15.2%)被诊断为CAFR, 68只犬(35.8%，95%确切可信区间29.0% - 43.0%)被同时诊断为CAFR(表2和6)。在每一类(cAD、CAFR和cAD+CAFR，每一种比较p＜0.001)中，患有AS和皮肤过敏性疾病的犬都比初级诊所病例多。无共病类别有49只犬(25.8%)，其他疾病类别有23只犬(12.1%)，其中有20种不同的疾病/临床症状，每种疾病/临床症状1 ~ 2只犬(表6)。

 

Within the three cutaneous allergic disease categories, cAD, CAFR and cAD+CAFR, there was no significant difference in the proportion having a single episode (Fisher exact test, p=0.141), time to resolution of first episode (Kruskal–Wallis H=5.28, p= 0.071), time to first relapse (H=0.57, p=0.571) or number of episodes (H=2.04, p=0.360). Dogs with AS with concurrent CAFR or cAD+CAFR, were significantly younger (median threeyears vs. fiveyears, Kruskal–Wallis H=14.45, p＜0.001) than dogs without allergic skin disease.

在cAD、CAFR和cAD+CAFR三种皮肤过敏性疾病类别中，单次发作比例(Fisher精确检验，p=0.141)、首次发作缓解时间(Kruskal-Wallis H=5.28, p= 0.071)、首次复发时间(H=0.57, p=0.571)和发作次数(H=2.04, p=0.360)无显著差异。AS合并CAFR或cAD+CAFR的犬明显比没有过敏性皮肤病的犬年轻(中位3岁对比5岁，Kruskal-Wallis H=14.45, p＜0.001)。

 

There were recurrent episodes in 11 of 31 (35.5%) dogs with cAD, in seven of 19 (36.8%) dogs with CAFR and in 37 of 68 (54.4%) dogs with cAD+CAFR (Tables 2 and 6). Only seven of 42 (14.3%) dogs in the No concurrent disease and two of 23 (8.7%) dogs in the Miscellaneous disease categories had more than one episode of anal sacculitis.

31只cAD犬中有11只(35.5%)复发，19只CAFR犬中有7只(36.8%)复发，68只cAD+CAFR犬中有37只(54.4%)复发(表2和表6)。42只无共病犬中只有7只(14.3%)，23只(8.7%)其他疾病犬中只有2只(8.7%)有不止一次肛囊炎发作。

 

DISCUSSION

讨论

This retrospective study describes treatment of AS in a primary care practice. Based on data from the clinical records, we assessed treatments used, time to clinical resolution, recurrence of AS and concurrent diseases in the study population.

本研究是对初级诊所治疗AS的回顾性研究。根据临床记录的数据，我们评估了研究病例中使用的治疗方法、达到临床缓解的时间、AS的复发和共病。

 

The highly skewed preference towards use of local treatment is likely to be a reflection of the practice's antibiotic stewardship guidelines, aiming to reduce the use of systemic antibiotics. Additionally, by using locally applied products in the anal sacs higher concentrations of medications can be achieved, improving local antimicrobial and often anti-inflammatory effects. In a recent retrospective study of 33 dogs with AS at a referral dermatology centre, local treatment of AS, consisting of flushing the anal sacs using sterile saline followed by instillment of a poly-pharmaceutical product into the sacs, induced remission in the majority of treated dogs. It is not possible to compare the efficacy of the treatment protocols used in that study with the current study; however, the current study provides supporting evidence for the effectiveness of local treatment in the management of AS and supports that systemic antibiotics are rarely required to resolve AS. Time to clinical resolution varied between one and 16weeks. Remission was seen within oneweek in 70.7% of all episodes and in 78.5% of episodes with a consistent medical treatment protocol. A longer time to clinical resolution in mixed treatment protocol episodes might reflect more severe disease.

对局部治疗的高度偏向可能反映了诊所的抗生素管理指南，该指南旨在减少全身性抗生素的使用。此外，通过在肛门囊内局部使用产品，可以达到更高浓度的药物，改善局部抗菌和通常抗炎的效果。在最近的一项对33只患有AS的犬的回顾性研究中，AS的局部治疗，包括使用无菌生理盐水冲洗肛门囊，然后向囊内灌注一种复合药物，诱导了大多数接受治疗的犬的缓解。无法比较该研究中使用的治疗方案与本研究的疗效;然而，目前的研究为局部治疗在管理AS中的有效性提供了支持证据，并支持很少需要全身抗生素来解决AS。至临床缓解的时间为1 ~ 16周。所有发作中有70.7%在1周内缓解，采用一致药物治疗方案的发作中有78.5%在1周内缓解。在混合治疗方案中，较长的临床缓解时间可能反映了较严重的疾病。

 

The number of visits were significantly higher in younger dogs. Younger dogs also were more commonly diagnosed with concurrent CAFR or cAD+CAFR. The higher number of visits recorded in the younger dogs until clinical resolution of AS were possibly a consequence of concurrent unmanaged allergic inflammation, which needed to be investigated following application of diagnostic criteria whilst treating AS. We speculate that the undiagnosed cAD and/or CAFR, might contribute to and delay the resolution of AS.

年轻患犬的就诊次数明显更高。年轻的犬也更常被诊断为并发CAFR或cAD+CAFR。在AS临床消退之前，年轻犬的较高就诊次数记录可能是并发未处理的过敏性炎症的结果，这需要在治疗AS的同时应用诊断标准进行调查。我们推测，未确诊的cAD和/或CAFR可能导致AS，以及使之恢复变慢。

 

Most dogs [126 of 190 (66.3%)] had a single episode of AS, whilst fewer [64,190 (33.7%)] developed between two and six recurrent episodes. Time to recurrence of AS varied greatly from slightly more than a month to threeyears. Several conditions have been proposed as potentially associated with development of non-neoplastic ASD, including dermatological and gastrointestinal diseases, obesity and anatomical abnormalities. In this study two dogs had been diagnosed with concurrent gastrointestinal disease, neither of which had recurrence of AS. Weight was not associated with a higher recurrence rate. Obesity was not a risk factor of AS in this population as none of the dogs included were obese, and anatomical abnormalities were not detected. Concurrent cutaneous allergic disease was, however, quite common (62.1%) in this study population, with cAD diagnosed in 16.3%, CAFR in 10.0% and cAD+CAFR in 35.8% of the dogs. When compared to the prevalence in the practice population (cAD 4.3%, CAFR 0.5%, cAD+CAFR 1.5%) allergic diseases appeared markedly over-represented in AS dogs. Atopic dermatitis was the most common form of cutaneous allergic disease in the practice population, which is consistent with previous reports on prevalence of allergic disease. A high prevalence of concurrent cutaneous allergic diseases in dogs with AS has been shown in two recent publications, with one based on the results of a questionnaire amongst private practice veterinarians reporting CAFR in 37.9% and cAD in 30.1% of 67 dogs with ASD, which is similar to our findings, and the other smaller study based on retrospective analysis of AS in 33 dogs at a referral centre reporting 42.4% diagnosed with concurrent cAD. Future studies are needed to assess if appropriate control of the allergic disease would reduce the risk of developing recurrencies of AS.

大多数犬[126/190(66.3%)]有一次AS发作，而较少[64,190(33.7%)]2-6次复发。AS的复发时间从一个多月到3年不等。一些疾病被认为可能与非肿瘤性ASD的发生相关，包括皮肤病和胃肠道疾病、肥胖和解剖异常。本研究中2只犬被诊断为合并胃肠道疾病，均未出现AS复发。体重与较高的复发率无关。肥胖不是该AS患犬的危险因素，因为纳入的犬均不肥胖，且未检测到解剖异常。然而，在本研究犬群中，并发皮肤过敏性疾病的情况相当常见(62.1%)，其中16.3%的犬被诊断为cAD, 10.0%的犬被诊断为CAFR, 35.8%的犬被诊断为cAD+CAFR。与临床患犬(cAD 4.3%， CAFR 0.5%， cAD+CAFR 1.5%)相比，过敏性疾病在AS犬中明显偏高。特应性皮炎是临床病例中最常见的皮肤过敏性疾病，这与之前关于过敏性疾病患病率的报道一致。最近的两项研究表明，AS患犬并发皮肤过敏性疾病的患病率较高，其中一项基于对私人执业兽医的问卷调查结果，报告67只患有ASD的犬中，有37.9%的犬并发CAFR, 30.1%的犬并发cAD，这与我们的发现相似，另一项较小的研究基于对转诊中心33只犬的AS的回顾性分析，报告42.4%的犬被诊断并发cAD。未来的研究需要评估是否适当控制过敏性疾病会降低AS的复发风险。

 

A best treatment protocol for AS cannot be determined based on this study. Limitations include the heterogenous nature of treatments, highly unequal number of dogs per treatment protocol, the use of both consistent and mixed treatment protocols within episodes, and the diverse treatments for concurrent diseases as well as diverse signalment of the studied dog population. Selection of different treatment protocols could be skewed because it is possible that only flushing was used in dogs considered to have milder disease compared to dogs selected to receive other treatments. However, use of systemic antibiotics appeared not to be required in the majority of dogs and episodes in this study, and avoiding such treatment as first line medication appears justified.

基于本研究尚不能确定AS的最佳治疗方案。局限性包括治疗的异质性、每个治疗方案的犬数量高度不均等、在发作期间使用一致的和混合的治疗方案、对共病的不同治疗以及研究病例的不同特征。不同治疗方案的选择可能有偏差，因为与选择接受其他治疗的犬相比，可能只对被认为疾病较轻的犬使用冲洗。然而，在本研究中，大多数犬似乎不需要使用全身性抗生素，因此避免这种作为一线用药的治疗似乎是合理的。

 

CONCLUSIONS

结论

Local treatment of AS was successful in obtaining clinical remission in most dogs treated in this study. Cutaneous allergic diseases, cAD and/or CAFR, were the most common concurrent diseases and were higher in prevalence in the studied population compared to the practice population. Dogs with cutaneous allergic disease additionally showed a significantly higher recurrence rate of AS than dogs with other concurrent diseases.

在本研究中治疗的大多数犬中，局部治疗AS成功获得临床缓解。皮肤过敏性疾病，cAD和/或CAFR，是最常见的共病，在研究病例中的患病率高于临床发病率。此外，患有皮肤过敏性疾病的犬的AS复发率明显高于患有其他共病的犬。

 

 

 

 

 

 

 

 

 

 

杨先生