Can (neo)rectal evacuation disorders be treated surgically in inflammatory bowel disease?

Besides the well-known perineal and anal manifestations of inflammatory bowel disease (abscess, ulcers, fissures and fistulae) anal stricture can develop in Crohn's disease. Usually anal dilation under general anaesthesia in one or two procedures is recommended as the treatment of choice. In the Leiden University Hospital 4 patients were seen in the period 1988-1993 with an anal stricture based on Crohn's disease after previous attempts at dilation. On physical examination and anal manometry it was judged that dilation in a single procedure was endangering faecal continence. It was decided to treat the patients with "self dilation" by means of custom made dilators over a period of several months. Three patients are very satisfied with the results and no longer have disordered defaecation. The fourth patient has only recently started this form of treatment but is experiencing clinical improvement. Anal stricture at the site of the anastomosis of the efferent limb of an ileal pouch in patients after restorative panproctocolectomy is most often the cause of obstructed defaecation. However, patients with such a pouch can develop obstructed defaecation caused by an efferent limb of the pouch that is compressed or intussuscepted on defaecation. Four patients with such a disorder were treated with a new operation to prevent repeated damage to the anal sphincter. In this operation the pouch was opened at the top and a stapling device was used to fuse the efferent limb with the pouch.(ABSTRACT TRUNCATED AT 250 WORDS)

Anal lymphoma presenting as a perianal abscess

A case of perianal abscess secondary to anal lymphoma affecting a human immunodeficiency virus negative patient is presented. Causes of perianal abscess other than anal glandular infection are important, although the proportion of abscesses reported to be secondary to these other causes is found to vary widely in the literature. A biopsy of the wall of an anorectal abscess should be taken when suspicion of an unusual cause arises.

Island flap anoplasty for anal canal stenosis and mucosal ectropion

Anoplasty is a technique used to treat patients with mucosal ectropion and anal canal stenosis. The island flap design has been demonstrated to have distinct advantages over the older forms of anoplasty. Few reports have addressed the long-term results of this procedure. A review of all patients undergoing island flap anoplasty between 1987 and 1992 was performed. Twenty-eight patients were identified. Indications for anoplasty included anal stenosis in 20 patients and mucosal ectropion in eight patients. Complications included five minor wound separations and one urinary tract infection with subsequent clostridium difficile enterocolitis. In-office follow-up averaged 7 months, at which time all patients were completely healed and significantly improved. Follow-up by phone was performed in 23 patients, extending their follow-up to 36 months. Based on the phone questionnaire, 91 per cent of the patients judged their symptoms as improved, and 9 per cent of patients judged their symptoms as unchanged. No patient judged their condition has worsened. Compared with the earlier forms of anoplasty, the island flap anoplasty is associated with a more simple design, less morbidity, and excellent long-term outcome. The island flap anoplasty should be the preferred design in cases of mucosal ectropion and anal stenosis.

[Update of anal-perineal and rectal lesions observed in AIDS]

Anorectal lesions in patients carrying the HIV virus are uncommon (13%, in our personal life, 1 women/15 men). The following raise the possibility of AIDS: Kaposi sarcoma, non Hodgkin's lymphoma and also with the young patients, intraepithelial dysplasia, in situ carcinoma or squamous carcinoma of the anus. Other anorectal lesions encountered in proctology, should lead to suspicion of HIV infection: anal involvement in STD, florid papillomatosis, the most frequent lesion in his serious form which recur on a interminable bases, extensive and chronic herpes, lesions refractory to standard treatment, megalovirus and ulcers. Date by history indicating sexual habits, toxicomania as well as the existence of chronic diarrhea and full physical examination scoking enlarged lymph nodes are all factors to be taken into consideration in support of the diagnosis. Apart from painful emergencies justifying immediate surgery, indications for surgery should be weighed in terms of the patient's general condition, the stage of advancement of the disease and expected benefit in terms of patient comfort.

[Tuberculous anal fistulas. 13 cases]

Our retrospective study concerns 13 cases of anal tuberculosis fistulas, studied over a period of 12 years, between January 1980 and December 1991. The mean age of our patients was 24 years and they were predominantly male. The diagnosis, which was suspected clinically, was confirmed histologically, either by ridge biopsies of the external orifice of the fistula or by surgical removal of the fistular passage in patients having undergone an initial surgical intervention. In 5 cases, we noted an associated pulmonary tuberculosis involvement. The treatment comprised 2 phases: an antibacillary medical treatment in all cases and a surgical treatment depending on whether the diagnosis was initially based on the ridge biopsies of the external orifice--6 cases (46.15%)--or after removal of the fistular passage--7 cases (53.85%). The outcome was good in all cases.

Empiric therapy of perianal lesions in a sexually abused child: medical and forensic implications

A two-year, eight-month-old boy was diagnosed clinically with perianal warts and treated with topical 5-Fluorouracil, with subsequent resolution of the lesions. The child disclosed sexual abuse, and subsequent physical abuse was also documented. Attempts to identify the perpetrator have been hampered by the child's young age and resolution of the skin lesions. The forensic implications of this case are discussed.

Ano-genital warts in consecutive male heterosexual patients referred to a CO2-laser clinic in Copenhagen

The relation between sexual practices and location of anogenital warts is discussed. Results were derived from clinical examination and interview of 56 consecutive male patients referred to CO2-laser treatment of therapy-resistant genital warts, at a clinic at the Department of Dermatovenereology, Gentofte Hospital, located in the northern area of Copenhagen. Twenty (100%) patients with anal warts and 36 (100%) patients with penile warts all claimed to be strictly heterosexuals. None of the patients interviewed had had anoreceptive coitus or been engaged in sexual practices with oro-anal contact. The study population otherwise had a heterosexual profile with approximately one fifth of the patients having had other sexually transmitted diseases, mainly chlamydia. The group of patients with anal warts had significantly fewer known sex partners with genital warts (25% versus 58%, p < 0.05) compared to the patients with penile warts. All patients received one or more CO2-laser treatments using local anesthesia, resulting in cure rates of 80% (16/20) and 89% (32/36) in men with anal warts and penile warts, respectively. Anal warts seem to be much more common in a heterosexual male population. There is a need to elucidate the nature and epidemiology of anal human papillomavirus infection in heterosexual males.

Clinical presentation of chronic anal fissures

Chronic anal fissures have a varied and often confusing clinical presentation. To clarify this picture, we retrospectively studied 172 patients to determine associations between patient characteristics and manifestations of these lesions. We found that anterior fissures and sentinel piles were significantly more common in women; pruritus and rectal drainage occurred significantly more often in men; and patients with a longer duration of symptoms and those with pruritus and drainage were more likely to have a fistula. Younger patients were more likely to report rectal bleeding. Patients with chronic anal pruritus or an anal abscess should be carefully evaluated for an anal fistula, since anorectal problems may recur if a fistula remains untreated.

Anogenital warts in prepubertal children; sexual abuse or not?

Forty-two prepubertal children presenting with anogenital (AG) warts (15 boys and 27 girls) were prospectively followed up (mean 15.9 months, SD 12.24). Most (73.8%) of these children had perianal condylomatous-type warts and 11 (26.2%) had concurrent non-genital (NG) warts. None had any other AG infections or sexually transmitted disease (STD). Twelve (28.6%) children acquired their AG warts by vertical transmission from an infected maternal birth canal, 3 (7.1%) by autoinoculation from common hand warts and 2 children (4.8%) through sexual abuse. In the remaining 25 children (59.5%) mode of acquisition of AG warts was uncertain but not thought to be sexual. Human papilloma virus (HPV) DNA (types 6/11, 16/18 or 31,33,35-31+) was detected in 10/32 (31.3%) of AG warts biopsied from these children, types 6/11 in the majority of positive biopsies (9/10). Detection of HPV DNA (types 6/11, 16/18 or 31+) in a child's AG warts was significantly associated with either vertical or sexual transmission (P < 0.02). Thirty-one children had their warts treated with a combination of scissor excision and electrocautery under general anaesthesia. Warts recurred in 10 (31.4%) of these children all within 4 months following treatment. Spontaneous resolution of AG warts was seen in 9 (21.4%) children. Of 42 children with AG warts 10 (23.8%) had at least one adult family member with AG warts, 13 (36.9%) on adult family member with another AG infection or STD, and 23 (62.2%) had a mother with cervical intraepithelial neoplasia (CIN). Twenty (47.6%) of these children had a family member with NG warts.(ABSTRACT TRUNCATED AT 250 WORDS)

Decision making in surgery: acute anorectal sepsis

Acute perineal inflammation is a common surgical emergency, presenting in most cases with an abscess arising from infection within the many tissue planes in this area. Simple drainage of such an abscess leads to immediate symptomatic relief but this should be accompanied by diagnostic manoeuvres that allow any underlying fistulae to be found and eradicated.

Management of the neurogenic bowel in patients with spinal cord injury

Bowel dysfunction in patients with spinal cord injury has a significant impact on quality of life as well as causing morbidity and death. This article reviews the pathophysiologic features of the neurogenic bowel of patients with spinal cord injury. Also discussed are the clinical manifestations, current options for management, and newer approaches that address this chronic and debilitating problem.

Severe lacerations after childbirth

We have reviewed the literature on third and fourth degree perineal lacerations, with respect to occurrence, risk factors, repair, short and long term morbidity, and secondary treatment. Suggestions of delivery procedures aiming to reduce the extent of perineal trauma are given. The long term sequelae of severe lacerations are clearly underestimated.

Risk of sphincter damage and anal incontinence after anal dilatation for fissure-in-ano. An endosonographic study

Follow-up was performed two to six years after anal dilatation for fissure-in-ano in 32 consecutive patients who had not undergone additional anal surgery. All patients were interviewed and asked specifically about impairment of flatus or fecal control and its possible relation to the anal dilatation. Anal dilatation was followed by minor anal incontinence in 12.5 percent of the patients. Anal endosonographic follow-up was accepted by 20 patients, and sphincteric defects were found in 13 (65 percent) of those. Two patients with anal incontinence had internal sphincter defects. Sphincteric defects were also found in 11 of the 18 continent patients who underwent sonography: internal sphincter defects in nine, external sphincter defect in one, and combined defects of both sphincter muscles in one. In conclusion, anal dilatation results in sphincter damage in more than half of patients, but few of them develop anal incontinence.

Anal stenosis with megarectum: an unusual complication of a perineal burn

A case of a 3-year-old boy with anal stricture and megarectum is described. Overflow incontinence and soiling were corrected by local flaps and skin graft and were maintained by frequent dilatations after downward traction of the whole anus was performed. The options of immediate and late treatment of such burns and the colostomy procedure are discussed.

Possible role of the autonomic nervous system in sphincter impairment after restorative proctocolectomy

Peroperative manometry was performed in 12 patients operated on with endoanal proctectomy and a hand-sewn pouch-anal anastomosis and in 12 in whom proctectomy was performed entirely from above, with the ileal pouch stapled to the top of the anal canal. Results from both groups showed that division of the superior rectal artery reduced the median (95 per cent confidence interval (c.i.)) resting anal pressure from 77.5 (69.9-83.3) mmHg to 64.5 (55.2-70.0) mmHg (P < 0.01). Complete rectal mobilization to the pelvic floor decreased resting pressure by an additional 22 per cent, to a median of 50.0 (95 per cent c.i. 40.1-53.5) mmHg (P < 0.01). After completion of anastomosis, irrespective of the operative technique used, a further decline in median pressure to 35.0 (95 per cent c.i. 26.0-47.7) mmHg could be demonstrated (P < 0.05). This study indicates that anal sphincter pressure is reduced to a similar extent after hand-sewn and stapled anastomoses. Injury to the autonomic nervous supply to the anal sphincter mechanism might be the major cause for this reduction.

Is aggressive management of perianal ulcers in homosexual HIV-seropositive men justified?

A study was undertaken to assess the etiology, optimal diagnostic method, and incidence of healing of perianal ulcers in HIV-seropositive men. Between March 1990 and December 1991, 26 HIV-seropositive homosexual or bisexual males were referred with perianal ulcerations. According to CDC criteria, three (12 percent) were Class II, six (23 percent) were Class III, and 17 (65 percent) were Class IV. Eighteen patients had one ulcer, five had two ulcers, and two had three ulcers. In one patient the ulcer was circumanal. Patients with superficial erosions were not included. Biopsies were obtained in 23 patients for routine microscopy, HIV, cytomegalovirus, herpes simplex virus, and acid-fast bacilli. Biopsy revealed an immunoblastic lymphoma in one patient. A comparison of microscopy and culture results revealed culture to be more helpful in determining the etiology of these ulcers. Medical treatment included reverse transcriptase inhibitors (zidovudine, dideoxyinosine, and dideoxycytosine), oral and topical Zovirax (Burroughs Wellcome, Research Triangle Park, NC), ganciclovir, and oral broad-spectrum antibiotics. Surgical treatment included lateral internal sphincterotomy in three patients and seton placement in one patient. Follow-up for at least four weeks was obtained in 22 patients. Overall, healing occurred in 15 patients (68 percent): three (20 percent) were Class II, four (27 percent) were Class III, and eight (53 percent) were Class IV. Healing occurred in all four patients who underwent surgical treatment. In conclusion, aggressive diagnostic maneuvers allow the use of both medical and conservative surgical measures to successfully treat the majority of perianal ulcers in this patient population.

[Rubber band ligation in the management of hemorrhoids]

During one year from November 1990 to October 1991, 1005 patients of hemorrhoids visited VGH-Kaohsiung. Among different treatments of hemorrhoid, rubber band ligation was most commonly used, with which 66% patients were treated. The follow-up at least one month in duration, discovered much improvement with this ligation in patients symptoms such as prolapse, anal bleeding and anal soiling, etc. The success rate reached higher than 90% for the first, second and third degree of hemorrhoids. About one third of 4th degree hemorrhoid got improved after ligation of their internal hemorrhoids. Except for pain feeling in the anus, the occurrence rate of other complications such as hemorrhage, anal thrombosis, constipation or dysuria was very low. With the exception of hemorrhoid of 4th degree or with large skin tag, this simple and highly successful management is the first choice for the treatment of hemorrhoids.