Liver abscess after hemorrhoidectomy. Report of two cases

PURPOSE

Pyogenic liver abscess after hemorrhoidectomy is extremely rare. Only two such cases have been previously reported; the diagnosis in each was made intraoperatively. We report two additional cases of hepatic abscess after hemorrhoidectomy, both treated nonoperatively with a successful outcome.

METHODS

The two cases were analyzed for history, presentation, laboratory data, radiologic studies, and bacteriology.

RESULTS

In both cases, the patients presented within one week of the hemorrhoidectomy. Treatment with broad-spectrum intravenous antibiotics was successful in achieving significant clinical improvement. The liver function test values reverted back to normal and follow-up computed tomography (CT) scans of the liver revealed marked improvement of the abscesses. Laparotomy was avoided in both of the patients.

CONCLUSIONS

Increased awareness of this serious complication will afford earlier diagnosis. In addition, proper aerobic and anaerobic bacterial isolation techniques will allow appropriate nonoperative therapy, decreasing the high morbidity and mortality rates associated with this complication.

Ulcerative disease of the anorectum in the HIV+ patient

Ulcerative processes are the most disabling of anal diseases in HIV+ patients. The spectrum ranges from "benign" fissures to invasive ulcerative processes. It is important to recognize their salient features in order to effectuate proper management. Since 1989, 74 HIV+ patients with ulcerative anal disease were evaluated. Of 33 patients with benign fissures, 13 had sphincterotomy, with symptomatic relief in 12 and healing in 11. Ten had improvement with standard conservative treatment, and 10 did not return for re-evaluation. Of 41 patients with "idiopathic" anal ulcers, 34 underwent operative evaluation, biopsy, viral culture, and debridement. Thirty had significant pain relief, and 17 showed variable evidence of healing. Four patients with intractable pain had injection of Depo-Medrol (The Upjohn Co., Kalamazoo, MI) into the bed of the ulcer with significant pain relief. One patient was diverted. We propose that anal ulcerative disease be classified as benign lesions and therefore treated as if the patient were HIV negative. In those patients with HIV-associated anal ulcers, evaluation under anesthesia, biopsy, culture, and debridement should be performed and therapy directed against any neoplastic or viral agents found. Those patients with no identifiable agents may be helped with aggressive debridement or intralesional steroid therapy. This approach allows safe and effective treatment in most patients.

Anorectal surgery in the HIV+ patient: update

Anorectal surgery in HIV+ patients historically has been viewed with a great deal of nihilism. Advances in medical therapy and better understanding of unique pathophysiologic processes have afforded the colorectal surgeon the ability to treat better and sometimes cure the anorectal complications of AIDS. We present a series of 75 consecutive surgical procedures (1-year accrual) on HIV+ (40) and CDC AIDS (22) patients. Surgical procedures, perioperative T cell counts, and outcome will be presented; 53 percent of procedures resulted in complete healing of anal wounds; 30 percent resulted in partial healing with symptomatic relief; 17 percent resulted in symptomatic relief or tissue diagnosis without appreciable wound healing. The healing rate was significantly higher in the HIV+ group (69 percent) compared to the AIDS group (26 percent). Perioperative T cell counts did not have predictive value on outcome. No patients suffered significant unexpected morbidity, mortality, or incontinence. Pathophysiologic mechanisms of several disease processes unique to HIV+ patients and data from our ongoing investigation using RNA hybridization are presented.

Emergency colectomy for cytomegalovirus ileocolitis in patients with the acquired immune deficiency syndrome

The charts of all patients with the acquired immune deficiency syndrome (AIDS) who underwent emergency intra-abdominal surgery between January 1981 and July 1987 were reviewed. Eleven AIDS patients underwent 13 emergency laparotomies. Seven of these patients (64 percent) had cytomegalovirus (CMV) ileocolitis as the pathologic process requiring emergent surgical intervention. Four patients had hemorrhagic CMV proctocolitis and three had perforations of CMV ulcers of the ileum or rectosigmoid. The operations performed included three subtotal colectomies, two segmental resections, and two diverting stomas. The postoperative mortality rate in the CMV group was 28 percent at one day, 71 percent at one month, and 86 percent at six months. Furthermore, CMV ileocolonic pathology was directly responsible for 70 percent of the deaths in AIDS patients who underwent emergent exploratory laparotomy.

The demographics of anal cancers are changing. Identification of a high-risk population

One hundred fifty-six consecutive cases of carcinoma of the anal canal and margin diagnosed between 1959 and 1986 were reviewed. There were 27 cases between 1959 and 1967, 41 between 1968 and 1976, and 88 between 1977 and 1986. Although the female-to-male ratio remained constant at 1.5:1, a high-risk group emerged, consisting of male patients with admitted homosexuality, bisexuality, or a history of anal condylomata acuminata. During the earliest period, 8 percent of male patients were in this group; this subset rose to 72 percent during the latest period (P less than .05). While the number of anal margin cancers has decreased, there has been a steady rise in the number of anal canal and in situ carcinomas, especially in the high-risk group.

The surgical management of anorectal diseases in AIDS and pre-AIDS patients

The charts of 340 patients with Acquired Immunodeficiency Syndrome (AIDS), AIDS-related complex (ARC), or AIDS-prodrome (AIDS-P), treated between January 1982 and April 1986 at the Roosevelt Division of the St. Luke's-Roosevelt Hospital Center, were reviewed. The incidence of anorectal disease was 34 percent. Fifty-two patients (15 percent) presented with anorectal complaints prior to the diagnosis of AIDS, ARC, or AIDS-P. Over 50 percent of these patients were dead within 7.4 months. Fifty-one patients (15 percent) underwent 73 anorectal surgical procedures. Twenty-two of these patients (43 percent) were dead within six months, and only six patients had satisfactory wound healing 30 days after surgery. In addition to an 88 percent rate of poor healing, there was a 16 percent rate of major complications. Identification of these high-risk groups prior to any anorectal surgery is imperative to avoid unacceptable surgical complications. Aggressive surgical intervention should be reserved only for patients who did not fall into the high-risk groups presented.

The initial management of left lower quadrant peritonitis

The majority of patients admitted to the hospital with left lower quadrant peritonitis and suspected acute diverticulitis are treated empirically without colon radiography either for the duration of their hospital course, or until such time as it is deemed safe to perform a barium enema to confirm this diagnosis. Unlike barium, a water-soluble contrast agent such as Gastrografin can be used safely and accurately immediately on hospitalization. Early establishment of an accurate diagnosis can help eliminate complications, morbidity, mortality, and lengthy hospitalizations. Seventy-one patients admitted with left lower quadrant peritonitis, temperatures above 99.5 degrees F, and leukocytosis were evaluated. Treatment either was based on a diagnosis established by results of a barium enema or water-soluble contrast enema, or was empiric in nature. The early use of a water-soluble contrast enema in the elucidation of the cause of left lower quadrant peritonitis proved to be the most accurate and also the most cost-effective means of diagnosis.

The diagnosis and treatment of acute appendicitis in the aged

Since the turn of the century, the elderly population, particularly those over the age of 80, has been increasing steadily. Consequently, the surgeon will be confronted frequently with the diagnostic challenge of acute appendicitis in this population. Over the past ten years, 13 patients over the age of 80 were treated for acute appendicitis at the St. Lukes-Roosevelt Hospital Center. The mean duration of symptoms was 2.4 days; all patients complained of abdominal pain, with 72 percent of patients having right lower quadrant involvement. Ninety-two percent had perforated prior to surgery, and 23 percent did not survive the disease. This high mortality rate is attributed to both a delay in presentation to the physician and a further delay in proper treatment due to misdiagnosis. This is a disease with which every physician must be familiar and be continually vigilant, as correct diagnosis and prompt treatment are the keys to averting high morbidity and mortality rates.

Spontaneous rupture of the distal colon with evisceration of small intestine through the anus: report of two cases and review of the literature

Two cases of evisceration of the small intestine through a spontaneous perforation of the distal large bowel are presented, and the literature is reviewed. The condition is associated with a sudden increase in intra-abdominal pressure and a past history of rectal prolapse. The etiology and management of this problem are discussed.

Spontaneous rupture of colic-artery aneurysms: report of two cases

Two cases of spontaneous rupture of colicartery aneurysms are presented, one involving the left colic artery and the other the right colic artery, and the literature on abdominal apoplexy and visceral arterial aneurysms is reviewed. In view of the potential for life-threatening hemorrhage, it is urged that, whenever feasible, visceral arterial aneurysms be resected prophylactically when discovered by angiography or at celiotomy.