Problems of diagnosis and treatment caused by ingested foreign bodies

An ingested foreign body often passes the gastrointestinal tract without any complications. Foreign bodies, such as fish bones, chicken bones and toothpicks, have been known to cause perforation of the gastrointestinal tract. We present 4 cases: the first 2 of a 27-year-old male and a 48-years-old female respectively, with acute abdomen, diffuse purulent peritonitis, with ileum perforation, both caused by accidentally ingesting a wire, 1 case of a 64-year-old male with sigmoid perforation, caused by accidentally ingesting a toothpick and 1 case of a 52-year-old female presented with left buttock painful swelling for 1 week associated with fever,physical examination revealed an ischiorectal abscess.During incision and drainage a 3 cm chicken bone was found inside the abscess cavity. Evolution was favorable in all 4 cases.

Rectal hyposensitivity and functional anorectal outlet obstruction are common entities in patients with functional constipation but are not significantly associated

BACKGROUND/AIMS

The causes of functional anorectal outlet obstruction (outlet obstruction) include functional defecation disorder (FDD), rectocele, and rectal intussusception (RI). It is unclear whether outlet obstruction is associated with rectal hyposensitivity (RH) in patients with functional constipation (FC). The aim of this study was to determine the association between RH and outlet obstruction in patients with FC.

METHODS

This was a retrospective study using a prospectively collected constipation database, and the population comprised 107 patients with FC (100 females; median age, 49 years). We performed anorectal manometry, defecography, rectal barostat, and at least two tests (balloon expulsion test, electromyography, or colon transit time study). RH was defined as one or more sensory threshold pressures raised beyond the normal range on rectal barostat. We investigated the association between the presence of RH and an outlet obstruction such as large rectocele (> 2 cm in size), RI, or FDD.

RESULTS

Forty patients (37.4%) had RH. No significant difference was observed in RH between patients with small and large rectoceles (22 [44.9%] vs. 18 [31%], respectively; p = 0.140). No significant difference was observed in RH between the non-RI and RI groups (36 [36.7%] vs. 4 [30.8%], respectively; p = 0.599). Furthermore, no significant difference in RH was observed between the non-FDD and FDD groups (19 [35.8%] vs. 21 [38.9%], respectively; p = 0.745).

CONCLUSIONS

RH and outlet obstruction are common entities but appear not to be significantly associated.

[3.0T MRI with a high resolution protocol for the study of benign disease of the anus and rectum. Part 2: Anorectal inflammatory disease. Postsurgical anatomy and complications after treatment]

Benign anorectal disease comprises a broad group of processes with very diverse origins; these processes may be congenital or acquired as well as inflammatory or tumor related. However, benign anorectal disease has received less attention in the scientific literature than malignant disease. In this second part of this image-based review of benign anorectal disease, we describe the most common inflammatory and fistulous diseases, the postsurgical anatomy, and complications that can occur after surgical treatment or radiotherapy for anorectal disease.

[3.0 T MRI with a high resolution protocol for the study of benign disease of the anus and rectum. Part one: High resolution protocol for 3.0 T MRI, anatomic review, benign tumors, and congenital or acquired alterations of the sphincter complex]

Benign anorectal disease comprises a broad group of processes with very diverse origins; these processes may be congenital or acquired as well as inflammatory or tumor related. However, benign anorectal disease has received less attention in the scientific literature than malignant disease. We present an image-based review of the most common benign diseases of the anus and rectum. In this first part, we review the anatomy of the region and provide a brief description of the peculiarities of the high resolution protocol that we use with 3.0 T MRI. We go on to describe the most common benign anorectal tumors and developmental cystic lesions, together with their differential diagnoses, as well as congenital and acquired anomalies of the anorectal sphincter complex.

[Abdominal tuberculosis in a young immigrant patient: a clinical case]

In developing countries, tuberculosis (TBC) is commonly associated with inadequate socio-economic and sanitary conditions. Currently, in Western countries, TBC is often linked with HIV infection, an ageing population or trans-global migration. Approximately two out of ten TB cases worldwide are extra-pulmonary, of which abdominal tuberculosis accounts for 11%-16%. The Mycobacterium tuberculosis complex involves the abdomen as primary or secondary localization (hematogenous spread or from pulmonary foci or infected neighbouring organs). Abdominal TBC can infect the gastrointestinal tract, peritoneum, mesentery, abdominal lymph nodes, liver, spleen, and pancreas. Diagnosis of abdominal tuberculosis is difficult because of vague and non-specific clinical features and due to the differential diagnosis with other granulomatous diseases such as Crohn's Disease. It is of great importance for clinicians to pay great attention to tubercular aetiology as a possible cause of gastrointestinal symptoms. Here we describe the clinical case of a young immigrant patient with intestinal TB for whom the wrong initial diagnosis led to a delay in the correct diagnosis and a worsening of the already serious general conditions.

Managing Perianal Crohn’s Disease

Perianal Crohn’s Disease (CD) is a significant cause of morbidity in CD patients. Accurate identification of perianal involvement requires advanced imaging techniques in addition to physical exam. Treatment of the disease is aimed at improving both the perianal and intestinal manifestations. Proper treatment depends upon the severity of the disease and combines current medical and surgical therapies to maximize response. The ability to improve perianal disease has grown significantly since the introduction of anti-TNF agents which are now a mainstay of treatment along with antibiotics and immunomodulators. New experimental therapies are limited by lack of research to support their use.

Evaluation and management of common anorectal conditions

The prevalence of benign anorectal conditions in the primary care setting is high, although evidence of effective therapy is often lacking. In addition to recognizing common benign anorectal disorders, physicians must maintain a high index of suspicion for inflammatory and malignant disorders. Patients with red flags such as increased age, family history, persistent anorectal bleeding despite treatment, weight loss, or iron deficiency anemia should undergo colonoscopy. Pruritus ani, or perianal itching, is managed by treating the underlying cause, ensuring proper hygiene, and providing symptomatic relief with oral antihistamines, topical steroids, or topical capsaicin. Effective treatments for anal fissures include onabotulinumtoxinA, topical nitroglycerin, and topical calcium channel blockers. Symptomatic external hemorrhoids are managed with dietary modifications, topical steroids, and analgesics. Thrombosed hemorrhoids are best treated with hemorrhoidectomy if symptoms are present for less than 72 hours. Grades I through III internal hemorrhoids can be managed with rubber band ligation. For the treatment of grade III internal hemorrhoids, surgical hemorrhoidectomy has higher remission rates but increased pain and complication rates compared with rubber band ligation. Anorectal condylomas, or anogenital warts, are treated based on size and location, with office treatment consisting of topical trichloroacetic acid or podophyllin, cryotherapy, or laser treatment. Simple anorectal fistulas can be treated conservatively with sitz baths and analgesics, whereas complex or nonhealing fistulas may require surgery. Fecal impaction may be treated with polyethylene glycol, enemas, or manual disimpaction. Fecal incontinence is generally treated with loperamide and biofeedback. Surgical intervention is reserved for anal sphincter injury.

[Magnetic resonance imaging study of perianal abscess]

OBJECTIVE

To investigate magnetic resonance imaging(MRI) manifestations of perianal abscess and to evaluate MRI diagnosis for perianal abscess.

METHODS

Fifty cases of perianal abscess between July 2007 and March 2009 were included in this study. MRI was performed using T1 weighted sequence in axial plane, T2 weighted sequence with fat saturation in axial, coronal and/or sagittal plane, and T1 weighted enhanced sequence with fat saturation in axial, coronal and/or sagittal plane. The location, size, shape, signal characteristics, and enhancement patterns of perianal abscess were analyzed.

RESULTS

Fifty cases with 51 perianal abscesses were identified. The abscess appeared slight hypo- or isointense signal on T1 weighted imaging, obviously hyperintense signal at cavity and isointense signal at wall on T2 weighted with fat saturation imaging, and marked enhancement at wall. The largest diameters ranged between 0.5 cm and 9.0 cm (mean 3.4±1.7 cm ) in abscess, between 0.2 cm and 8.0 cm(mean 2.7±1.7 cm) in cavity. The abscess was round, oblong and crescent in 23, 18 and 7 cases respectively, and was unilocular in 41 cases and multilocular in 10 cases. The abscess located between levator ani and intersphincteric groove in 23 cases, under intersphincteric groove in 3 cases, across levator ani and intersphincteric groove in one case, on levator ani in 7 cases, on intersphincteric groove in 16 cases and above levator ani in one case.

CONCLUSION

MRI is a noninvasive, convenient and highly accurate procedure for diagnosing perianal abscess, which can demonstrate the anatomical relationship between abscess and anal canal.

[Infantile perineal protrusion is a harmless condition with multiple differential diagnoses]

Among girls the frequency of infantile perineal protrusion (IPP) is 13%. The skin-coloured protrusion is thought to represent a congenital weakness in the perineum and usually resolves spontaneously. We report a case of a 13 year-old girl who for nine years had been examined and treated for haemorrhoids and other relevant differential diagnoses before being diagnosed with IPP. During this time she developed iatrogenic contact allergy after frequent application of ointment for haemorrhoids. Recognition of this common and harmless condition renders further examination and treatment unnecessary.

Development and psychometric evaluation of a dutch questionnaire for the assessment of anorectal and lower urinary tract symptoms

BACKGROUND AND STUDY AIMS

Epidemiological studies have shown a frequent coexistence of symptoms and diseases affecting the anorectum and lower urinary tract. To further investigate combined symptoms and pathology of both pelvic viscera we developed a self-reported questionnaire, in Dutch, which extensively evaluates habits, complaints and symptoms of both viscera. We describe the construction and the psychometric properties of this questionnaire.

PATIENTS AND METHODS

This prospective study was conducted in 56 patients with anorectal symptoms, 41 patients with lower urinary tract symptoms and in a control group of 91 people. The following psychometric properties of the questionnaire were evaluated: content validity, construct validity, criterion validity, test-retest reliability and internal consistency.

RESULTS

The questionnaire covered all important domains, was well interpreted and showed good acceptability (content validity). The questionnaire clearly differentiated the patient populations (construct validity). The criterion validity of the questionnaire was excellent. The test-retest reliability of the questionnaire was acceptable in all three the study populations (overall median kappa: 0.64; Inter Quartile Range: 0.56-0.75; mean agreement: 88%). The internal consistency of both anorectal and lower urinary tract symptom questions was high (Crohnbach's alpha of 0.78 and 0.80 respectively).

CONCLUSIONS

This questionnaire is a valid and reliable instrument for the assessment of anorectal and lower urinary tract symptoms. It can provide further insights into the epidemiology of concomitant bowel and bladder disorders and, accordingly, can contribute to a more efficient diagnostic and therapeutic approach in patients with such disorders.

Perianal giant condyloma acuminata in an infant: an alarming lesion for a pediatric surgeon

Condyloma acuminatum (CA), which is a large cauliflower-like tumor, has been linked to human papilloma virus (HPV) types associated with skin warts. It is an uncommon condition in children, and there is no consensus regarding the optimal treatment. HPV may be acquired via sexual transmission, vertical transmission or extragenital contact. We report herein a 1.5-year-old girl with perianal giant CA, which developed due to extragenital contact and consisted of HPV types 6 and 18, to emphasize the effectiveness of surgical excision.

[Anogenital warts in children: the importance of a multidisciplinary approach]

INTRODUCTION

Anogenital warts are caused by human papillomavirus (HPV) infection. Its presence in children raises concern of a possible sexual abuse. A multidisciplinary team approach is essential to clarify the mode of infection's transmission.

CASE-REPORT

Female child, three years of age referred to pediatrician for perianal warts. A history of similar lesions in another location in the child, parents or cohabiting was denied and possible sexual abuse refused. Gynecologic assessment of mother and daughter lead to identification of HPV type 6 at the child's lesions and negative studies results in the mother. Evaluation of the child in psychology showed no signs of possible abuse and social assessment concluded there was no context of risk. After two cycles of topical treatment with imiquimod 5%, complete regression of lesions was achieved, with no recurrence to date.

DISCUSSION

No evidence of sexual abuse emerged from the set of clinical evaluations performed. The strategy of an extended follow-up is mandatory, and comes from the required prudence in this context, in order to ensure timely identification of risk situations which might have been previously unnoticed.

CONCLUSION

Authors emphasize the dichotomy between a simple clinical diagnosis and the complex multidisciplinary approach which is crucial to elucidate a situation with potential socio-medico-legal implications.

Role of magnetic resonance imaging in evaluation of the activity of perianal Crohn's disease

AIM

To evaluate the diagnostic ability of contrast-enhanced Magnetic Resonance Imaging (MRI) in assessment of the activity of perianal fistulas in Crohn's disease (CD) patients, compared to clinical data.

MATERIALS AND METHODS

Fifty CD patients (25 men; mean[SD] age: 40.4[12.6] years) with known or suspected perianal fistulas underwent perianal space MRI. Radiological activity of disease was measured as the percentage increase (PI) of ROI values of fistulas in relation to ROI values of healthy local fat, after contrast administration. Clinical activity of disease was defined according to Perianal Disease Activity Index (PDAI) and Fistula Drainage Assessment (FDA).

RESULTS

Forty-two patients presented perianal disease at MRI (55 fistulas identified). An association between both fistula's PI and PDAI (Pearson's coefficient 0.512, p<0.0001) and between PI and FDA (p=0.003) was demonstrated. Areas under ROC curves of PI values in relation to PDAI and FDA were respectively 0.876 [95%CI=(0.743-1.00), p<0.001] and 0.784 [95%CI=(0.588-0.980), p=0.003]. A cut-off value of PI, calculated on these preliminary data, correctly classified more than 90% of fistulas.

CONCLUSIONS

Contrast-enhanced MRI with PI calculation offered practical information about activity of perianal fistulas and might be helpful in providing a comprehensive evaluation of CD perianal disease.

[Internal and external haemorrhoids]

In this article, we present 3 cases of patients with different types of haemorrhoidal disease. The first patient is a 27-year-old woman who had been experiencing incidental rectal blood loss without pain during defecation for 3 months. The second patient is a 76-year-old woman who had been bothered by varying degrees of pain from a swelling nearby the anus for 1 year. The third case involves a 31-year-old man who had had continuous severe pain in the anal area for 3 consecutive days. The first patient appeared to have internal hemorrhoids, whereas different forms of external hemorrhoids affected the patients in the other 2 cases. Internal haemorrhoids develop from the intraluminal corpus cavernosum recti; external haemorrhoids from the perianal marginal veins. Patients with internal haemorrhoids present with symptoms that include blood loss and prolaps feeling during defecation. In patients with external haemorrhoids pain is the prominent symptom. Internal haemorrhoids are treated either conservatively or surgically, depending upon their severity. Considering external haemorrhoidal disease surgical treatment provides the most rapid and persistent relief of symptoms.

[Epidemiology and management of patients with ano-genital warts in Italy]

PURPOSE

Overview of the impact of ano-genital warts in Italy.

COMMENTS

In Italy, the HPV infection is not subject to mandatory reporting, the available epidemiological data come from sentinel surveillance of STIs and show a high spread among young people under 25 years and an increase in reports after 2004. Although ano-genital warts are a benign disease, nonetheless they are characterized by a big relational and psycho-sexual impact, due also to high recurrence rates.

CONCLUSIONS

It is extremely useful to promote information activities, education in safe sex, early diagnosis and treatment of genital warts. In this context, primary prevention through vaccination represents a valid tool of protection.

Anal cytology as a screening tool for early detection of anal dysplasia in HIV-infected women

BACKGROUND AND AIM

HIV-infected patients show a high rate of anal dysplasia and anal carcinoma but there is no gold standard for early detection. Therefore, the objectives of this prospective study were: a) evaluation of an anal screening using anal/perianal cytology; b) in case of a positive result to investigate its relation to immune status, clinical symptoms of HIV infection and antiretroviral therapy.

PATIENTS AND METHODS

In every HIV-infected woman visiting our gynaecological outpatient clinic, an anal and perianal swab for anal cytology was taken. One experienced cytologist examined all specimens. Relevant details of the HIV-related history such as CDC classification, CD4 count, viral load, actual antiretroviral therapy etc. were documented.

RESULTS

Altogether, 104 HIV-infected women were enrolled on this study. The results of 13 (13.5%) anal cytologies were classified as suspicious for low-grade or high-grade anal dysplasia and 6 of these were confirmed in an anal biopsy. A total of 9 out of 13 also had a cervical dysplasia and 12 were positive for high-risk HPV at the cervix. Ten of these women had already experienced clinical symptoms of their HIV infection and 8 showed a nadir of the CD4 count below 200 cells/microl. All but one took a highly active antiretroviral therapy.

CONCLUSION

In this pilot study, anal screening using anal cytology showed 13.5% suspected anal dysplasia in HIV-infected women. All performed biopsies revealed the presence of a high-grade anal lesion. The majority of these women already had an advanced disease and/or immune defect related to their HIV infection. In summary, we found anal cytology to be a useful tool to early detect anal dysplasia of high-risk patients such as HIV-infected women. How far this screening method contributes to the prevention of anal cancer has to be evaluated in further investigations.