Anal fissures: An update on treatment options

BACKGROUND

Anal fissure (AF) is the second most common anorectal complaint in healthcare settings. The presentation might be acute or chronic, characterised by severe pain with defaecation that persists for one to two hours. Non-surgical and surgical interventions are available based on the severity and persistence of the fissure.

OBJECTIVE

The aim of this article is to review the pathophysiology, clinical presentation and management of AF under current guidelines.

DISCUSSION

The aetiology of AF is unclear, although it is commonly associated with local trauma or associated chronic conditions. Acute AF is first treated with conservative therapy, including dietary fibre and sitz baths. Addition of topical nitrates, topical calcium channel blockers or botulinum toxin injection is indicated with failure of conservative treatment or at medical discretion. Surgical options are considered if AF persists despite treatment. Most present as hypertonic, but special consideration is needed for hypotonic or secondary presentations.

Natural History of Anal Ulcerations in Pediatric-Onset Crohn's Disease: Long-Term Follow-Up of a Population-Based Study

INTRODUCTION

Anal ulcerations are frequently observed in Crohn's disease (CD). However, their natural history remains poorly known, especially in pediatric-onset CD.

METHODS

All patients with a diagnosis of CD before the age of 17 years between 1988 and 2011 within the population-based registry EPIMAD were followed retrospectively until 2013. At diagnosis and during follow-up, the clinical and therapeutic features of perianal disease were recorded. An adjusted time-dependent Cox model was used to evaluate the risk of evolution of anal ulcerations toward suppurative lesions.

RESULTS

Among the 1,005 included patients (females, 450 [44.8%]; median age at diagnosis 14.4 years [interquartile range 12.0-16.1]), 257 (25.6%) had an anal ulceration at diagnosis. Cumulative incidence of anal ulceration at 5 and 10 years from diagnosis was 38.4% (95% confidence interval [CI] 35.2-41.4) and 44.0% (95% CI 40.5-47.2), respectively. In multivariable analysis, the presence of extraintestinal manifestations (hazard ratio [HR] 1.46, 95% CI 1.19-1.80, P = 0.0003) and upper digestive location (HR 1.51, 95% CI 1.23-1.86, P < 0.0001) at diagnosis were associated with the occurrence of anal ulceration. Conversely, ileal location (L1) was associated with a lower risk of anal ulceration (L2 vs L1 HR 1.51, 95% CI 1.11-2.06, P = 0.0087; L3 vs L1 HR 1.42, 95% CI 1.08-1.85, P = 0.0116). The risk of fistulizing perianal CD (pCD) was doubled in patients with a history of anal ulceration (HR 2.00, 95% CI 1.45-2.74, P < 0.0001). Among the 352 patients with at least 1 episode of anal ulceration without history of fistulizing pCD, 82 (23.3%) developed fistulizing pCD after a median follow-up of 5.7 years (interquartile range 2.8-10.6). In these patients with anal ulceration, the diagnostic period (pre vs biologic era), exposure to immunosuppressants, and/or anti-tumor necrosis factor did not influence the risk of secondary anoperineal suppuration.

DISCUSSION

Anal ulceration is frequent in pediatric-onset CD, with nearly half of patients presenting with at least 1 episode after 10 years of evolution. Fistulizing pCD is twice as frequent in patients with present or past anal ulceration.

Identification of a new syndrome: ASS-SSA or anal sphincter syndrome

AIM

The author proposes a new, original Syndrome, observing the relationship between some of the most frequent anal pathologies, apparently different from each other in terms of morphological aspect and symptomatologic expression, but united by the same pathogenic cause, represented by the hypertonicity of the anal sphincter apparatus. There are already descriptions of other "syndromes" of the pelvic floor, inaccurate and subject to different interpretations. The proposed syndrome, instead, called Anal Sphincter Syndrome - ASS (in Italian SSA - Sindrome dello Sfintere Anale) presents clarity on the determining cause (sphincter hypertonicity) and descriptive simplicity, including only two welldefined pathological conditions: anal fissure and anal thrombosis; other ancillary conditions or symptoms are inconstantly possible, but not decisive. The author will present, as soon as possible, in subsequent works, a retrospective study (still to be completed) on a wide personal case history, dating back to the 1990s.

KEY WORDS

Anal sphincter hypertonia, Anal thrombosis, Anal fissure, Syndrome, Proctology, Somatization.

Recommendations of the Crohn's Disease and Ulcerative Colitis Spanish Working Group (GETECCU) for the treatment of perianal fistulas of Crohn's disease

Recommendations are advice that is given and considered to be beneficial; however, they are still suggestions and are therefore open to different interpretations. In this sense, the final objective of the review has been to try to homogenize, with the evidence available, the approach to the diagnosis and medical/surgical treatment of one of the most complex manifestations of Crohn's disease, such as simple and complex perianal fistulas.

[Proctology for internists]

In proctology patients can often be helped with very little effort. With knowledge of the most common disease symptoms the treating physician can in many cases correctly recognize the cause of the complaints and initiate the appropriate therapy or arrange referral to a proctological institution. This article aims to briefly and succinctly present the most common diseases in proctology (e.g. mariscae, hemorrhoids, anal fissures, perianal venous thrombosis, abscesses and fistulas, condyloma acuminatum and anal carcinoma) and to provide the treating internist, even outside of gastroenterology, assistance with the management of proctological symptoms.

Elaboration and validation of Crohn’s disease anoperineal lesions consensual definitions

AIM

To establish consensual definitions of anoperineal lesions of Crohn’s (APLOC) disease and assess interobserver agreement on their diagnosis between experts.

METHODS

A database of digitally recorded pictures of APLOC was examined by a coordinating group who selected two series of 20 pictures illustrating the various aspects of APLOC. A reading group comprised: eight experts from the Société Nationale Française de Colo Proctologie group of study and research in proctology and one academic dermatologist. All members of the coordinating and reading groups participated in dedicated meetings. The coordinating group initially conducted a literature review to analyse verbatim descriptions used to evaluate APLOC. The study included two phases: establishment of consensual definitions using a formal consensus method and later assessment of interobserver agreement on the diagnosis of APLOC using photos of APLOC, a standardised questionnaire and Fleiss’s kappa test or descriptive statistics.

RESULTS

Terms used in literature to evaluate visible APLOC did not include precise definitions or reference to definitions. Most of the expert reports on the first set of photos agreed with the main diagnosis but their verbatim reporting contained substantial variation. The definitions of ulceration (entity, depth, extension), anal skin tags (entity, inflammatory activity, ulcerated aspect), fistula (complexity, quality of drainage, inflammatory activity of external openings), perianal skin lesions (abscess, papules, edema, erythema) and anoperineal scars were validated. For fistulae, they decided to follow the American Gastroenterology Association’s guidelines definitions. The diagnosis of ulceration (κ = 0.70), fistulae (κ = 0.75), inflammatory activity of external fistula openings (86.6% agreement), abscesses (84.6% agreement) and erythema (100% agreement) achieved a substantial degree of interobserver reproducibility.

CONCLUSION

This study constructed consensual definitions of APLOC and their characteristics and showed that experts have a fair level of interobserver agreement when using most of the definitions.

A rare case of myeloid sarcoma presenting as anal fissure

Myeloid sarcoma is a tumor composed of myeloblasts occurring at an extramedullary site. It may develop in patients with acute myeloid leukemia, myeloproliferative or myelodysplastic syndrome, sometimes preceding onset of the systemic disease. Frequent sites of myeloid sarcoma are bones or various soft tissues. Gastrointestinal involvement is very rare. We report a unique case of myeloid sarcoma presenting as a painful anal fissure, in a patient with a history of acute myeloid leukemia. The diagnosis was achieved by a surgical excisional biopsy and immunoistochemical staining.

Hemorrhoids and anal fissures in inflammatory bowel disease

Perianal disease is a common complication of inflammatory bowel disease (IBD). It includes different conditions from more severe and potentially disabling ones, such as abscesses and fistulas, to more benign conditions such as hemorrhoids, skin tags and fissures. Most literature has been focused on anal sepsis and fistulae, as they carry the majority of disease burden and often alter the natural course of the disease. Hemorrhoids and anal fissures in patients with IBD have been overlooked, although they can represent a challenging problem. The management of hemorrhoids and fissures in IBD patients may be difficult and may significantly differ compared to the non-affected population. Historically surgery was firmly obstructed, and hemorrhoidectomy or sphincterotomy in patients with associated diagnosis of IBD was considered harmful, although literature data is scant and based on small series. Various authors reported an incidence of postoperative complications higher in IBD than in the general populations, with potential severe events. Considering that a spontaneous healing is possible, the first line management should be a medical therapy. In patients non-responding to conservative measures it is possible a judicious choice of surgical options on a highly selective basis; this can lead to acceptable results, but the risk of possible complications needs to be considered. In this review it is analyzed the current literature on the incidence, symptoms and treatment options of hemorrhoids and anal fissures in patients with Crohn's disease and ulcerative colitis.

[SURGICAL TREATMENT OF POSTOPERATIVE STRICTURE OF ANAL CHANNELL]

The results of treatment of 50 patients, suffering postoperative stricture of anal channell (SACH), who were treated in Proctology Department of Ivano-Frankivskiy Rural Clinical Hospital in 2006-2014 yrs, were analyzed. After conduction of hemorrhoidectomy in accordance to Milligan-Morgan method for chronic hemorrhoids grades III-IV a SACH have occurred in 46 (92%) patients, excision of a chronic anal fissura was performed in 3 (6%) and excision of perianal pointed condylomas--in 1 patient. In 2006-2007 yrs 11 (22%) patients were operated in accordance to approaches, which were conventional at that time (comparison group). In 2008 - 2014 yrs 39 (78%) patients were admitted to hospital (main group), in whom new approaches for diagnosis, conservative and surgical treatment were applied, 30 (76.9%) of them were operated. The proposed method on isolated roentgen contrast investigation of anal channell have permitted to determine objectively a form, diameter and grade of the anal channel stricture, and it may be applied as a screening procedure, as additional objective criterion while choosing a surgical tactic. Application of the improved operative technique for SACH have permitted to lower its occurrence rate from 45.4 to 6.7%.

[The experience of treatment with medicines of botulinum toxin of type A Lantox of chronic anal fissure with sphincter spasm]

The original material of monitoring of 118 patients with chronic anal fissure is presented in the article. Patients' mean age was 48.9+-10.5 years. It was used injections of medicine of botulinum toxin of type A (Lantox) by its introduction in internal anal sphincter in all patients. There was granulating wound with signs of marginal epithelialization in 59.3% of cases on the 10th day after injection. It was detected complete epithelialization of dermis defect in 93.2% of cases on the 21st day, after six weeks - in 100% of cases. According to anorectal profilometry the index of maximal and average pressure in the anal canal at the level of the internal sphincter in patients at rest decreased to norm. Lantox introduction leads to rapid and persistent reduction of pain intensity. "Lantox" use in ambulatory practice permits to minimize the indications for surgical treatment.

[Patients with a therapy-resistant anal fissure: beware of malignancies]

In this article we describe three patients aged 53, 39 and 70 with a therapy-resistant anal fissure. Each patient was inspected under anaesthesia. In all three cases a suspicious lesion or swelling was observed and all biopsies taken showed anal malignancies. Although anal malignancies are rare, their incidence has increased significantly over the past 22 years in the Netherlands (from 71 patients in 1989 to 215 in 2012). It is important to be aware of the possibility of malignancies among patients with a therapy-resistant anal fissure. Therefore, we recommend performing an inspection under anaesthesia in these patients to obtain tissue for histological analysis.

Operative strategy for fistula-in-ano without division of the anal sphincter

INTRODUCTION

The treatment of perianal fistulas is diverse because no single technique is universally effective. Fistulotomy remains the most effective way of eradicating the pathology but it renders the patient at some risk of faecal incontinence, which many patients are reluctant to take. There are no data in the literature to indicate the healing rate of perianal fistulas when using an operative strategy that routinely avoids division of any part of the anal sphincter. The aim of this paper is to present the long-term results with an operative strategy that aims to avoid division of any part of the anal sphincter complex when treating all types of perianal fistulas, thereby minimising/eliminating the risk of postoperative incontinence.

METHODS

We report 54 consecutive cases of anal fistula that presented electively and as an emergency. Patients with known or subsequently diagnosed inflammatory bowel disease or malignancy were excluded from the study.

RESULT

Overall, 46 patients (37 male and 9 female) with a median age at presentation of 42 years (range: 19-73 years) were treated by lay-open of the subcutaneous tract of the perianal fistula and insertion of a loose seton for the part of the fistula tract related to the sphincter complex. The types of fistula treated were intersphincteric (89%), transsphincteric (4%) and high suprasphincteric (7%). The median length of time that the seton was left in place was 7 months (range: 1.5-24 months). The healing rate was 86% with a recurrence rate of 19% and a median follow-up duration of 42 months.

CONCLUSIONS

Patients who are reluctant to take any risk of faecal incontinence could be treated using an operative strategy that routinely avoids division of any part of the anal sphincter complex as this has a recurrence rate that compares well with other treatment modalities.

Medical and surgical treatment of haemorrhoids and anal fissure in Crohn's disease: a critical appraisal

BACKGROUND

The principle to avoid surgery for haemorrhoids and/or anal fissure in Crohn's disease (CD) patients is still currently valid despite advances in medical and surgical treatments. In this study we report our prospectively recorded data on medical and surgical treatment of haemorrhoids and anal fissures in CD patients over a period of 8 years.

METHODS

Clinical data of patients affected by perianal disease were routinely and prospectively inserted in a database between October 2003 and October 2011 at the Department of Surgery, Tor Vergata University Hospital, Rome. We reviewed and divided in two groups records on CD patients treated either medically or surgically according to the diagnosis of haemorrhoids or anal fissures. Moreover, we compared in each group the outcome in patients with prior diagnosis of CD and in patients diagnosed with CD only after perianal main treatment.

RESULTS

Eighty-six CD patients were included in the study; 45 were treated for haemorrhoids and 41 presented with anal fissure. Conservative approach was initially adopted for all patients; in case of medical treatment failure, the presence of stable intestinal disease made them eligible for surgery. Fifteen patients underwent haemorrhoidectomy (open 11; closed 3; stapled 1), and two rubber band ligation. Fourteen patients required surgery for anal fissure (Botox ± fissurectomy 8; LIS 6). In both groups we observed high complication rate, 41.2% for haemorrhoids and 57.1% for anal fissure. Patients who underwent haemorrhoidectomy without certain diagnosis of CD had significantly higher risk of complications.

CONCLUSIONS

Conservative treatment of proctologic diseases in CD patients has been advocated given the high risk of complications and the evidence that spontaneous healing may also occur. From these preliminary results a role of surgery is conceivable in high selected patients, but definitve conclusions can't be made. Further randomized trials are needed to establish the efficacy of the surgical approach, giving therapeutic recommendations and guidelines.

[Surgical treatment for cicatrix strictures of anal canal]

Classification of anal canal strictures with gradation of intensity, extent and localization is proposed. In 12 patients with compensated strictures combination of stenosis and anal fissure served as an indication for operation. These patients underwent fissure excision with dosed sphincterotomy. Anoplasty with displacement of island skin flaps to anal canal defects was carried out to 29 patients with sub-or decompensated strictures after dissection of scarry stricture. Good direct results were achieved in 38 patients. Compensated re-stenosis treated conservatively was observed in 3 patients after anoplasty. It is drawn a conclusion about necessity of differential approach to choice of treatment mode for anal scarry strictures. Anoplasty according to proposed method is considered to be optimal for marked strictures.

Doppler-guided haemorrhoidal artery ligation with recto anal repair: a new technique for the treatment of symptomatic haemorrhoids

PURPOSE

Doppler-guided haemorrhoidal artery ligation (DGHAL) is a minimally invasive surgical technique used to treat symptomatic haemorrhoids. In 2005, the DGHAL proctoscope was redesigned to incorporate a window through which a recto anal repair (RAR) could be performed to improve the outcome in patients with significant prolapse symptoms. The aim of this study was to observe the outcome of a series of consecutive DGHAL-RAR procedures.

METHOD

Seventy-seven consecutive patients (49 male) underwent DGHAL-RAR for symptomatic haemorrhoids and were reviewed for a minimum of 6 months post-surgery.

RESULTS

Fifty-seven (74%) of patients presented with both prolapse and bleeding symptoms. The median number of DGHALs performed was six, and the median number of RARs was two. Most (96%) patients were discharged the same day. At follow-up, 11 patients complained of recurrent symptoms, five of prolapse, four of bleeding and two of pruritus. Eight patients suffered with post-operative anal fissures. The procedure is recommended by 84.4% of patients 6 weeks post-surgery.

CONCLUSION

DGHAL-RAR is safe, effective and well tolerated. It reduces the need for potentially dangerous excisional procedures. The RAR component is an effective addition to DGHAL in the short term for the treatment of prolapse, but longer follow-up will be required to demonstrate durability of the technique.

[The role of laser CO2 in proctology]

There is presented our experience in surgical hemorrhoids and condylomata acuminata treatment using CO2 laser. There were 289 operations on 198 patients in outpatient clinic. There were 4 cases of anal fissure and no postoperative bleeding during postoperative period. This work is demostrating that adaptation of the laser CO2 makes many advantages to the classic operation of Milligan ad Morgan: simplification of the surgical technique easy post-operative course, no hospitalisation and quicker return to work. Complications are rare and excellent results are noted. Laser CO2 treatment is considered one of the alternatives to conventional treatment, but the surgeon needs to be aware of laser hazards.

[Primary anal tuberculous fissure]

The anal tuberculous (TBC) fissure is infrequent. For this reason diagnosis is difficult. A case of a female adult patient with anal TBC fissure that consults for bleeding and perianal pain is presented. The perianal tuberculosis is a rare manifestation of the general disease. A routine biopsy must be performed, with the corresponding histopathologic study. A specific origin should be suspected when an anal chronic fissure, painful and bleeding, without response to the habitual treatment, is found. The primary TBC fissure can be cured with the administration of three drugs during 3 to 4 months.

Risk factors special to eastern culture for the development of anal fissure

AIM

To reveal the effect of diet, bowel functions and toilet habits on the development of anal fissure.

METHODS

One hundred patients complaining of anal fissure were included to the case group; and one hundred age- and gender-matched patients referred for other reasons except for anorectal complaints were included to the control group. The information was obtained by face to face interviews using questionnaires.

RESULTS

Statistically significant differences were found in coffee, fruit, and meat consumption between the groups. The patients suffering from anal fissure avoided paprika consumption. The rate of anal fissure incidence was higher in squat toilet users.

CONCLUSION

This study is the first study which evaluates the risk factors such as paprika consumption and squat toilet usage that are specific to Eastern culture. Further studies including large numbers of population are needed to evaluate different risk factors for anal fissure development (Tab. 2, Ref. 11). Full Text (Free, PDF) www.bmj.sk.

Hemorrhoids and fissure in ano

Hemorrhoids and anal fissures are common benign anorectal conditions that form a significant part of a colorectal surgeon's workload. This review summarizes and evaluates the current techniques available in their management.

[The role of glyceryl trinitrate in the treatment of anal fissure]

Anal fissure is a small linear tear in the lining of the distal anal canal below the dentate line. Treatment is aimed at reducing internal sphincter spasm. This can be achieved with surgery (lateral internal sphincterotomy) or pharmacological sphincterotomy applying topical medication, which relaxes the sphincter muscle. Glyceryl trinitrate is the most widely used topical agent. This is a nitric oxide donor which reduces the increased anal canal pressure caused by the hypertonic internal anal sphincter, improving anodermal blood flow. Although headache is a frequent side-effect, it is usually transient and glyceryl trinitrate does not seem to have any long-term adverse effects.

Stapled hemorrhoidopexy for prolapsed hemorrhoids in patients with liver cirrhosis; a preliminary outcome for 8-case experience

PURPOSE

To investigate the efficacy and safety of stapled hemorrhoidopexy in treating prolapsed hemorrhoids in patients with liver cirrhosis.

PATIENTS AND METHODS

Eight consecutive cases of patients with prolapsed hemorrhoids comorbid with liver cirrhosis, who had intractable response to other interventions, were enrolled in this retrospective study between January 2002 and June 2006 at our institute. Six patients (75%) had Child-Pugh class A liver cirrhosis, whereas only two patients (25%) had class B disease. Rectal varices were identified in three patients (37.5%), and esophageal varices were identified in six patients (75%). Concurrent rectal and esophageal varices existed in three patients (37.5%). The patients underwent stapled hemorrhoidopexy with Proximate PPH-03 in a lithotomy position under spinal/intravenous general anesthesia.

RESULTS

There was no procedure-related mortality or major complications except hemorrhage. Two patients (25%) were complicated with postoperative staple-line bleeding, which was managed with conservative treatment without reoperation. There were no leading symptoms of relapsing during a follow-up period of at least 6 months.

CONCLUSIONS

This study may prove that stapled hemorrhoidopexy is a feasible and safe approach for prolapsed hemorrhoids concurrent with liver cirrhosis.

Perianal Crohn's disease

Perianal Crohn's disease in children is a potentially debilitating condition that can precede or follow the intestinal disease component. The perianal abnormalities are varied and can include lesions of the perianal skin or anal canal, abscesses or fistulas, and malignancies. The appropriate management of these problems is predicated on a thorough evaluation of the perineum and anus as well as the remainder of the alimentary tract. Therapy usually includes a combination of antibiotics, immunomodulators, and biologic agents as well as conservative operative procedures. The surgical options are intended to safely ameliorate disease-related symptoms without compromising function or continence.

[Tuberculosis ulcerosa of the anus and anal fissure accompanied by pulmonary tuberculosis]

Dermal tuberculosis is being rarely diagnosed and its incidence in Poland is less than I % of all registered cases of this disease. A case of the alcohol abusing patient with diagnosed tuberculosis ulcerosa of the anal fissure and pulmonary tuberculosis has been described. Bacteriological confirmation has been achieved using PCR and Bactec 460 methods. Complete healing of the cutaneous lesions and regression of radiological titers in lungs has been achieved as a result of applied typical antituberculotic treatment. Delayed diagnostics of the patient (6 months from occurrence of the cutaneous lesions) endangered other persons, including healthcare employees' health to infection with tubercle bacillus. This speaks for a need of continuous reminding physicians that infection with tuberculosis may manifest itself from various organs.

Systematic review: the treatment of anal fissure

BACKGROUND

Anal fissure is one of the most common anorectal conditions encountered in clinical practice. Most patients experience anal pain with defecation and minor bright red rectal bleeding, allowing a focused history to direct the evaluation.

METHODS

A systematic medical literature search of NIH, Pubmed, and MEDLINE using the search terms anal fissure, sphincterotomy, anal surgery and anal fissure medical therapy. English language was not a restriction. Cited references were used to find additional studies.

RESULTS

No single treatment is the best choice for all patients. Because pharmacological therapy is not associated with permanent alterations in continence, a trial of either a topical sphincter relaxant or botulin toxin injection, along with adequate fluid and fibre intake, is a reasonable option. However, because pharmacological therapy has lower healing and higher relapse rates, surgery can be offered in the first instance to patients without incontinence risk factors who have severe, unrelenting pain and are willing to accept a small risk of incontinence, for the highest likelihood of prompt healing and the lowest risk of recurrence.

CONCLUSIONS

Both non-operative and operative approaches currently exist for the management of anal fissure. Improved non-surgical therapies may continue to lessen the role of sphincter-dividing surgery in future.

Why the most potent toxin may heal anal fissure

An anal fissure is a painful linear ulcer in the lower part of the anal canal. It is very often referred to as an ischemic ulcer. Anodermal blood flow is negatively correlated with resting pressure of the anus. Increased activity of the internal anal sphincter may decrease the anodermal blood supply by compressing arterioles. Surgical procedures and botulinum treatment for patients with chronic anal fissure produce a temporary reduction in anal pressure, reverse sphincter spasm, and promote fissure healing. However, recent studies have shown that fissure healing does not appear to be dependent on reduction in mean resting anal pressure. On the basis of the published literature, this article attempts to explain this phenomenon in detail. The mechanism of action of botulinum toxin on the internal anal sphincter is not yet fully understood. This review focuses on problems associated with anal fissure treatment and presents them from the wider angle of science about botulinum toxin. In our opinion, anodermal blood flow depends not only on the "mechanical" force of sphincters but also on biochemical processes that occur in the fissure region.

A toddler with recurrent oral and genital ulcers

In western countries, when a child presents with recurrent oral ulcers and colitis, the diagnosis of Crohn's disease is mostly made. In our patient, the diagnosis was Behçet's disease with gastrointestinal manifestations. Behçet's disease with gastrointestinal manifestations has a similar clinical presentation to Crohn's disease, but there is more organ involvement and the prognosis is more severe in the former. Because there is limited experience in the treatment of Behçet's disease in the paediatric population, successful and unsuccessful treatment modalities in both paediatric and adult populations should be reported.

Magnetic resonance imaging of perianal fistulas

Most cases of fistula-in-ano are nonspecific and result from inflammation of anal glands and crypts (cryptoglandular). The classification of cryptoglandular fistulas depends on the degree of involvement of the anal sphincter complex and determines the type of treatment. Studies have shown that preoperative MR imaging revealed important additional information compared with surgery alone and better predicts clinical outcome of patients with fistula-in-ano than initial surgical exploration. With the emergence of novel surgical treatments like MRI-guided surgery, laser, and adhesive treatments, MR imaging is a mainstay for preprocedural and intraoperative evaluation to ensure the adequacy of the procedure.

Fístula anal de origen criptoglandular. Opciones terapéuticas

Anal fistula is a frequent condition. The most commonly accepted origin is infectious. The most widely used classification is based on cryptoglandular theory and on the position of the fistulous tract in relation to the anal sphincter. Physical examination will help to identify the type of fistula and allow its treatment to be planned. The most widely used complementary tests are endoanal ultrasound and magnetic resonance imaging. We review the various therapeutic options and their results, especially fistulotomy, endorectal advancement flap, use of sedal, anodermal advancement flap, sphincterorrhaphy with sphincter repair, and fibrin glue.

Pharmacological advancements in the treatment of chronic anal fissure

Chronic anal fissure is a tear in the lining of the anal canal that, if not treated appropriately at an early stage, causes considerable anal pain during defaecation. Surgery is no longer considered the first-line treatment of this common condition, as recent advancements in medical treatment has produced promising results in the healing of fissures, thus avoiding the unwanted complications that frequently occur following operative treatment. This review looks at those pharmacological agents used commonly in the treatment of chronic anal fissures and explores alternative therapies that may be of benefit in the future.

Constipation as a feature of anogenital lichen sclerosus in children

OBJECTIVE

To call attention to constipation as a frequent sign of lichen sclerosus (LS) in girls.

METHODS

A focused questionnaire was sent to parents of 24 girls with anogenital LS seen in the pediatric dermatology clinic at the Children's Hospital of Wisconsin between January 2001 and May 2004.

RESULTS

Eighteen of 24 questionnaires were completed and returned. The average age of onset of LS was 4.2 years, but average age at diagnosis was 5.2 years; only 1 patient was diagnosed correctly by her primary care physician. Itching was the most common symptom (78%). Severe constipation was reported in 67% of patients, and 89% had at least 1 gastrointestinal complaint (bleeding with bowel movements, fissuring, soiling, fecal impaction, or constipation).

CONCLUSIONS

Childhood anogenital LS often presents with recalcitrant constipation or some other gastrointestinal complaint. Primary care physicians need to consider the diagnosis of LS and perform a thorough examination by looking for anogenital lesions when a female pediatric patient presents with unexplained constipation or other severe gastrointestinal complaints.

[Crohn's disease with anoperineal lesions: use of MRI]

The authors report a case of perineal Crohn disease with three anal fissures. Because of a persistant fever without any clinical aspect of abscess they practiced MRI examination that discovered an abscess of the recto-vaginal wall. The patient was operated under general anaesthesia. This clinical case shows the interest of radiologic exams, particularly pelvic MRI for the precise lesional diagnosis of anoperineal lesions of Crohn's disease, that is still complex and difficult to treat.