Giant fecaloma in an adult with severe anal stricture caused by anal imperforation treated by proctocolectomy and ileostomy: report of a case

Although fecalomas are relatively common in patients who are elderly, constipated, or who have spinal injuries, a giant fecaloma formation unresponsive to conservative treatment is a rare condition that sometimes requires surgery for complications. Herein we report a case of a long-lasting (46 years) giant fecaloma associated with severe anal stricture after surgery for anal atresia and resulting in severe malnutrition, bone structural changes, and severe impairment of quality of life. Eight months after treatment by total proctocolectomy and ileostomy, the patient was on a free diet and had gained more than 10 percent of his postoperative body weight; improvements were observed in the tone of the abdominal muscles and in his quality of life.

[Treatment of fistulating pouchitis with tumour necrosis factor-alpha-inhibitor (infliximab)]

The surgical first choice treatment for patients with ulcerative colitis (UC) involves total proctocolectomy with ileal pouch-anal anastomosis (IPAA). Postoperative development of pouch-related fistula is a rare complication, but it is associated with significant morbidity, a high recurrence rate and is a major cause of pouch failure. We report the use of infliximab, a monoclonal antibody to tumour necrosis factor-alpha, in three patients who developed pouch-related fistula after undergoing IPAA surgery for UC.

[Sexually transmissible infections of the anus and the rectum]

A recent increase of sexually transmitted infections (STI) of rectum and anus has been observed in France, particularly in men who have sex with men. Symptoms of STI are not specific and sometimes patients have no symptom, which implies a high risk of contamination. Ulcerations, vegetant lesions and proctitis are the main anorectal lesions observed. Infection by multiple germs is frequent. STI, particulary those including ulceration, facilitate the transmission of HIV. New therapeutic strategies have to be established as antimicrobial resistance of several sexually transmitted pathogens is increasing. The treatment of sex partners of patients diagnosed with an STI is essential. Education and counseling (use of condom) taking into account each patient's individual risk factors, are the main strategies in the prevention and control of STI.

[Anorectal Leśniowski-Crohn's disease]

Authors retrospectively reviewed results of surgical treatment of the patients with anorectal Leśniowski-Crohn's (LC) disease, operated in the Department of General and Gastroenterological Surgery in Warsaw.

MATERIAL AND METHODS

In years 1987-2007 we treated 110 patients with LC disease. The anorectal localization of lesions was noticed in 24 patients (13 women, 11 men, average age of fall--28 year), i.e. 21.8% of all patients. The operations performed in other hospitals were taken into account. Results were compared with literature data.

RESULTS

Anorectal lesions were the first signs of LC disease in 16/110 patients (14.5%), and there were most often: perianal fistulas (multiple) in 12, perianal abscesses in 2, and rectovaginal fistula in 2 patients. In the remaining 8 patients (7.3%), anorectal lesions emerged in later period of the disease, formerly placed in other part of digestive tract. The primary local surgical treatment (incision/excision offistulas, abscess drainage) was performed in 20/24 patients. Most frequent indications were: perianal fistulas--13, perianal abscesses--6, and rectovaginal fistula--1. Primary abdominal operations were performed in 4/24 patients: Hartman procedure in 2 patients with rectovaginal fistulas and in other 2 patients with severe colitis--subtotal colectomy and restorative proctocolectomy. The follow-up in 23/24 patients exceeded 5 years, only in 1 patient was 4 years. The surgical recurrences were noticed in 19/24 (79.1%) patients. Recurrences of fistulas were noticed in 11 patients, in addiction in 5 patients we noticed anal stenosis, in 3 rectal/sigmoidal stenosis and in 3 proctitis of the remaining rectal stump. Surgical recurrences of LC disease after 5, 10 and 15 years of observation were 18/23--78.2%, 14/15-93.3%, and 7/7--100% respectively. Two patients (8.3%) died from severe general complications of the disease. The primary local surgical treatment was sufficient only in 2 patients. In 18/22 patients 28 abdominal operations were carried out in later period of the disease. In all 24 patients we performed 46 extended abdominal operations. In result of them 13/24 patients have definitive and 1 temporary stoma.

CONCLUSIONS

1. Surgical treatment of anorectal LC disease should be sparing and performed in the proper time. 2. Surgical treatment of anorectal LC disease is difficult and should be carried out in reference centers. 3. Anorectal LC disease has poor prognosis in terms of fecal and gas continence and creates the risk of proctectomy in up to 20% of cases.

[When is it too early or too late for surgery in Crohn's disease? ]

The surgical boarding of Crohn's disease (CD) admitted as a last effort of treatment against behavior in those the therapy prescribes it has failed, it supposes a loss on perspective that can postpone the delay in the recovery of patients and it retracts them of a better quality of life when it is considered that 50% of patients maintain inactive illness during years after selected surgical procedures; some rate no reached by the most effective treatments. The risk to specify surgical procedure in the course of CD rises to 75% of payees, more than 50% in the first year from the diagnosis, and practically 100% patients in the evolution when it is contemplated to attend perianal lesions. Therefore gastroenterologist should be trained in the selection who, when and why these patients should be operated. To retard the surgery to advanced illness phases increases morbidity, and if it is certain that the new biological therapy allow induction of remissions it is also it that to increase the duration of the process and the patient s age and contributes to face bigger surgical risk and worse perspectives in the treatment of their acute complications and also chronic manifestations often clinically inconsiderate as: Retractile mesenteritis, the states of hipercoagulability and the appearance of malignizations phenomena. Saving absolute indications for initial selective surgery in management of CD patient like: Massive intestinal bleeding, toxic megacolon or free perforation, other surgical conditions they should be reevaluated on light of our current knowledge. Patient s genotyping constitutes a clinical element that contributes to the identification of its specific risks and it facilitates the therapeutic selection. Unfortunately until these analyses can be routinely used the precocious employment of CD surgery it will be based on the consideration clinical data: The patient age, its nutritional state, smoking, and the necessities of steroids. To differ among inflammatory or fibrous stenosis is crucial for the election of their treatment, because the therapeutic employment of surgery it supposes to accept its irreversibility and makes indispensable to conjugate clinical manifestations of chronic obstruction: Pain, distension bacterial overgrowth and hipoalbuminemia with demonstration of their aperistaltic character, local hipovascularity or the submucosae muscularization submucosa in the stenosis. On the other hand, the medical treatment of fistulous behaviors CD in proximal gastrointestinal tracts offers results that they cannot be considered valid and this condition should be assumed as absolute indication for the surgical treatment. The image methods diagnoses also they don't offer absolute effectiveness in the characterization on penetrating modalities in which the effectiveness of the new ones biological it is controversial to recommend its therapeutic handling for what the surgical option seems to acquire a high-priority significance under conditions as coloenteric and colovesical fistulae. The under anesthesia surgical exam for anatomical characterization of lesions in perineal CD it demands a surgical attendance precociously carried out and it is constituted in the gold standard for definition that can be supplemented with image techniques. After characterization perianal CD they should be attended considering the presence or absence of proctitis and the phenotype of underlying illness. Some authors had intended to stratify the patients as: Simple fistula without proctitis; Affections with simple fistula associated to rectal illness; or associated complex fistulae. The first group they will be candidates to an antibiotic therapy and immunosupressors in the beginning, the second group to protocols for biological therapy added to the previous program, and the third group to previous surgical exploration to any later medical performance. The cumulative relative risk to the ten years from the diagnosis gives the CD it is relatively low (3%) for the development he/she gives a cancer colorrectal. But it ascends until 33.2% (15.9-60.9) on the small intestine, with rate no modified in the last 30 years that accentuate the necessity of screening programs or indication for surgery against their mere suspicion the poor later presage he/she gives these patient.

Medical options for treating perianal Crohn's disease

Perianal Crohn's disease can cause significant morbidity for patients affected by the disease. However, diagnostic modalities and treatment options have progressed changing the goals of treatment from fistula "improvement" to complete cessation of drainage. Fistula closure and fibrosis of the fistula track is achieved in some patients. Furthermore, treatment has become a combined effort between medical physicians and surgeons. Simple disease can be treated with medical therapy alone consisting of antibiotics and immunomodulators. Infliximab should be added to refractory simple disease or simple disease with the presence of inflammation. If complex fistula disease is evident a surgical evaluation should also be done to determine if intervention is indicated. Complex disease should be treated with antibiotics, immunomodulators and biologic therapy from the onset. This review will summarise current data regarding medical options for treatment of fistulising Crohn's disease.

The natural history of perianal Crohn's disease

Perianal lesions are exceedingly common in Crohn's disease and many patients have more than one type of lesion. Skin tags, fissures and haemorrhoids may persist over time and are usually managed expectantly or with topical therapy. Perianal and rectovaginal fistulas and associated abscesses often require both local and systemic therapy, and recurrence is common. In general, the clinical course of Crohn's disease is more aggressive in patients with perianal involvement. Established risk factors for perianal disease include colonic disease and young age at disease onset. Classification schema now recognize perianal fistulas as distinct from other forms of penetrating Crohn's disease. Genetic susceptibility factors for perianal disease may exist, but they remain incompletely delineated at present. There is hope that immunosuppressive and biotechnology medications will influence the natural history of perianal disease by preventing invasive surgeries, disease complications and recurrence, but this needs to be confirmed. Cancer, a rare complication of perianal disease, must be suspected when lesions persist despite therapy.

Surgical therapy of perianal Crohn's disease

The surgical management of perianal Crohn's disease is complex with a wide range of operations being described. The initial emergency treatment is to drain any source of underlying sepsis. A loose seton drainage or a defunctioning stoma can then be used as a 'bridge' to definitive treatment allowing both adequate assessment of the condition and preventing further sepsis. The likelihood of success of any surgical repair must be weighed against the risk of faecal incontinence. Improved results of a local surgical repair are seen with optimal surgical and medical management of perianal Crohn's disease.

Perianal Crohn's disease: classification and clinical evaluation

Perianal manifestations are common in patients with Crohn's disease and include skin tags and haemorrhoids, fissures, ulcers, abscesses, fistulas, stenosis or cancer. Primary lesions include Crohn's fissures and cavitating perianal ulcers. Secondary lesions include deep abscesses, fistulas and strictures. A good classification and anatomical description of these conditions is crucial before embarking on any kind of (medical or surgical) therapy, as this greatly influences management. This review analyses and discusses current classifications of any perianal form of Crohn's disease.

Imaging of perianal Crohn's disease

Perianal fistulas and abscesses are common complications of Crohn's disease, affecting up to 50% of patients during their disease course. Accurate diagnosis and classification of perianal disease is crucial before and during treatment to plan an adequate approach for each patient and to avoid irreversible functional consequences. Although examination under anaesthesia has been considered the gold standard for diagnosis and classification of Crohn's disease perianal fistulas, taken alone it does not have perfect accuracy, stressing the need for concomitant or alternative, non-invasive, methods of evaluation. In this context, imaging modalities assessed for diagnosis, classification and monitoring of Crohn's disease perianal fistulas include pelvic magnetic resonance imaging, anorectal endoscopic ultrasonography, transcutaneous perianal ultrasound, fistulography and computed tomography. In particular, magnetic resonance imaging and endoscopic ultrasonography findings have shown the best accuracy, and the ability to influence therapeutic management of these patients. For transcutaneous perianal ultrasound too, good preliminary data have been reported. This paper reviews the available data on imaging methods for the management of perianal Crohn's disease.

Risk factors for sonographic internal anal sphincter gaps 6-12 months after delivery complicated by anal sphincter tear

OBJECTIVE

The objective of the study was to identify risk factors for internal anal sphincter (IAS) gaps on postpartum endoanal ultrasound in women with obstetric anal sphincter tear.

STUDY DESIGN

This prospective study included 106 women from the Childbirth and Pelvic Symptoms Imaging Supplementary Study who had third- or fourth-degree perineal laceration at delivery and endoanal ultrasound 6-12 months postpartum. Data were analyzed using Fisher's exact and t tests and logistic regression.

RESULTS

Mean (+/- SD) age was 27.7 (+/- 6.2) years. Seventy-nine women (76%) were white and 22 (21%) black. Thirty-seven (35%) had sonographic IAS gaps. Risk factors for gaps included fourth- vs third-degree perineal laceration (odds ratio [OR] 15.4, 95% confidence interval [CI] 4.8, 50) and episiotomy (OR 3.3, 95% CI 1.2, 9.1). Black race (OR 0.23, 95% CI 0.05, 0.96) was protective.

CONCLUSION

In women with obstetric anal sphincter repairs, fourth-degree tears and episiotomy are associated with more frequent sonographic IAS gaps.

Anogenital Warts Knowledge and Counseling Practices of US Clinicians: Results From a National Survey

OBJECTIVES

To examine messages US clinicians use when counseling patients diagnosed with anogenital warts.

STUDY DESIGN

In mid-2004, we conducted a confidential mail survey of nationally representative samples of physicians practicing internal and adolescent medicine, family/general practice, obstetrics/gynecology, urology, or dermatology; nurse midwives; physician assistants; and nurse practitioners. The survey assessed knowledge and counseling practices of clinicians who had diagnosed anogenital warts.

RESULTS

After adjusting for survey eligibility, 81% responded. Most (89%) were aware that human papillomavirus (HPV) causes anogenital warts, but only 48% were aware that oncogenic and wart-related HPV genotypes usually differ. Most (>95%) clinicians reported telling patients with warts that warts are an STD, are caused by a virus, or that their sex partners may have or may acquire warts. Many clinicians (>/=85%) also reported discussing STD prevention or assessing STD risk with such patients. Most reported addressing ways to prevent HPV (89%), including using condoms; limiting sex partners or practicing monogamy; or abstinence. Many also reported recommending prompt (82%) or more frequent (52%) Pap testing to female patients with anogenital warts. Potential barriers to counseling included providing definitive answers on how HPV infection was acquired, dealing with patients' psychosocial issues, and inadequate reimbursement.

CONCLUSIONS

Most surveyed clinicians appropriately counseled patients about the cause and prevention of anogenital warts. However, many clinicians were unaware that oncogenic and wart-related HPV types usually differ, and this may explain why many reported recommending more aggressive cervical cancer screening for female patients with warts.

Risk factors for perianal Crohn's disease: the role of genotype, phenotype, and ethnicity

OBJECTIVES

Perianal disease (PD) is a frequent complication of Crohn's disease (CD). The lack of association between PD and development of intestinal penetrating disease may suggest that PD is a distinct phenotype with specific genetic or clinical risk factors. This study was undertaken to evaluate the role of genotype, clinical, and demographic characteristics with PD.

METHODS

Phenotypic data on 121 CD patients with PD and 179 patients without PD were carefully characterized. The patients were genotyped for disease-associated OCTN1/2 and NOD2/CARD15 variants and the TNF-alpha promoter polymorphisms. Analysis was performed to evaluate the differences in phenotype and genotype frequencies between the PD group and the non-PD group.

RESULTS

PD was associated with rectal involvement (odds ratio [OR] 2.27, 95% CI 1.32-3.91) and with Sephardic (non-Ashkenazi) Jewish ethnicity (OR 1.71, 95% CI 1.02-2.9). No association was found among the studied OCTN, NOD2, TNF-alpha variants and the risk for PD.

CONCLUSIONS

The strongest factor associated with PD is rectal inflammation. OCTN1/2, NOD2/CARD15, and TNF-alpha promoter variants do not play a role in the risk to PD in the Jewish Israeli population. The association of ethnicity with PD may suggest that there are as yet unknown genetic variants that are associated with PD.

Risk factors for genital and anal warts in a prospective cohort of HIV-negative homosexual men: the HIM study

OBJECTIVE

The objective of this study was to determine the prevalence, incidence, and risk factors for genital and anal warts in HIV-negative homosexual men in Sydney.

STUDY DESIGN

The authors conducted a prospective cohort study. Participants were asked whether they had had genital and anal warts at each interview. Details of lifetime sexual contacts and sexual behaviors in the last 6 months were collected.

RESULTS

Among 1,427 men recruited, 8.9% and 19.6% reported a history of genital and anal warts at baseline, respectively. Incidence rates for genital and anal warts were 0.94 and 1.92 per 100 person-years, respectively. In multivariate analysis, both incident genital and anal warts were associated with younger age. In addition, incident genital warts was associated with insertive fingering (P trend = 0.018), whereas incident anal warts was associated with insertive fingering (P trend = 0.007) and insertive fisting (P trend = 0.039).

CONCLUSIONS

Anal warts were twice as common as genital warts. Fingering and other manual sexual practices may be an important transmission route for both.

Case report: perianal necrotizing fasciitis in a near-term neonate

Necrotizing fasciitis in the neonatal period is a rare, life-threatening condition. Previous cases of neonatal necrotizing fasciitis in the perianal region were speculated to have been initiated by rectal mucosal trauma secondary to rectal temperature measurements. We observed a case of fatal perianal necrotizing fasciitis in a neonate where the process began as a red ring surrounding the anus and guiac-positive stools, detected after a rectal temperature measurement. We speculate that the perianal necrotizing fasciitis that subsequently developed might have been initiated by a minor rectal mucosal injury, and we investigated the instrument used for the rectal temperature measurement to assess any potential areas on the probe sheath cover that might cause a minor injury. Each probe sheath cover examined had three areas that, in our opinion, could possibly generate a minor mucosal injury.

Trans-anal protrusion of ventriculo-peritoneal shunt catheter with silent bowel perforation: report of ten cases in children

Ventriculo-peritoneal (VP) shunting used in the treatment for hydrocephalus is associated with several complications. Mechanical failure of shunt is the commonest complication of all. Visceral/bowel perforation is an unusual but serious complication of VP shunting. This article reports our experience in the management of ten children who had VP Shunt catheter protrusion from anus. This is a retrospective study of ten patients who had VP shunt catheter protrusion from anus, admitted in the department of paediatric surgery between Jan 1996 and Dec 2005. The records of above ten cases were reviewed for their clinical presentation and management, etc. We had performed 398 VP shunt operations in the last 10 years. Two hundred and seventy one (68.09%) VP Shunts were done for congenital hydrocephalus of which 164 were done in infancy/neonatal period and 107 VP shunts were done in the age group of >1-12 years. One hundred and twenty-seven (31.90%) VP shunt operations were done for patients who had hydrocephalus as a complication following tubercular meningitis (TBM). Out of 398 VP shunts, ten patients (2.51%) had protrusion of the distal end of peritoneal catheter from anus without causing/leading to peritonitis. We observed a 08.29% mortality of all VP shunt operations. Protrusion of VP shunt catheter per rectum can occur without producing peritonitis. Formal exploration and localization of entry of VP shunt catheter in bowel is not mandatory. Mini laparotomy and revision of peritoneal part of shunt can be done if there is no shunt infection.

[Frequent and rare dermatological diseases in HIV patients]

HIV patients develop a variety of infectious and non-infectious diseases of the skin and mucous membranes. Some of these serve as indicator diseases for a weakening immune system. While none of the dermatological complications is pathognomonic, conditions such as oral hairy leukoplakia, herpes zoster, thrush, and eosinophilic folliculitis should make physicians consider the possibility of underlying HIV disease. Moreover, one has to consider HIV if these skin diseases take an atypical or severe course, or if they do not respond properly to appropriate medication. Frequent and rare dermatoses occurring in HIV infection are discussed.

Management of Fournier's gangrene--report of 7 cases and review of the literature

Fournier's gangrene is a rare infection characterized with fast-progressing myonecrosis, that affect regions of perineum, genitalia and perianal area. This retrospective study presents authors' experiences and their principles in early diagnosis and treatment of Fournier's gangrene. The goal of this paper is to point out numerous diagnostically and therapeutic difficulties that lead to a high mortality if not recognized in time. We here describe seven male patients with myonecrosis and necrotising fasciitis in scrotal, perianal and perineal regions. Average age was 61 years (form 57 to 66 years of age), and average length of treatment was 25.8 days (from 14 to 36 days), with lethality of 14% (one case). We have recognised diabetes mellitus as risk factor, together with urethrostenosis, and other diseases of the perianal region (hemorrhoids, anal fissure, abscesses). Our hypothesis is that the key of the successful treatment is to treat as soon as symptoms onset, early and aggressive necrectomy under broad antibiotic protection. We also emphasize the possibility of recurrence of this disease even several years after treatment.

Perianal fistulas in Crohn's disease: MRI diagnosis and surgical planning: MRI in fistulazing perianal Crohn's disease

Crohn's disease is a chronic, transmural inflammatory process of the gastrointestinal tract. It often affects the colon with the perianal area. The most common intestinal manifestations include external and/or internal fistulas and abscesses. Assessment of the activity of perianal fistulas in the course of Crohn's disease seems to be an important factor influencing therapeutic approach. Fistula's activity is evaluated by such methods as magnetic resonance imaging, anal ultrasound and examination under anaesthesia. Usefulness of imaging methods in the diagnosis of fistulas still remains to be defined.MRI is used to present a wide spectrum of perianal fistulazing Crohn's disease. Additionally, it is an important instrument revealing location, extent and severity of inflammation. It is also very helpful to detect clinically silent sepsis related to small, local inflammation. The most common method used in MR imaging to assess topography of a fistula's track, is Parks' classification.Clinical indications to MRI may include follow-up studies of a diagnosed disease, classification of fistulas' subtypes in the course of Crohn's disease, determination of the extent of fistulas' tracts and spread of an inflammatory process what can guide surgical procedures.