Anorectal necrosis induced by injection sclerotherapy for hemorrhoids

Abstract

N. Wasserberg (*) Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo Street, Suite 514, Los Angeles, CA 90033, USA e-mail: nwasserberg@gmail.com Tel.: +1-323-4426860 Fax: +1-323-4425756 Dear Editor: Nonsurgical treatment for hemorrhoidal disease includes fixating methods that induce inflammation and fibrosis by various means. Although they are generally safe, with nonsignificant morbidity, rare cases of post-treatment life-threatening pelvic sepsis have been reported, requiring some form of surgical intervention. We describe an 80-year-old man who underwent emergency abdominoperineal resection (APR) for anorectal necrosis after injection sclerotherapy for hemorrhoids. An 80-year-old man was admitted to the Department of Internal Medicine with abdominal pain, and fever of 2 days duration. His past medical history was remarkable for chronic renal failure, state post right nephrectomy for nephrolithiasis, hypertension, and hypothyroidism. One day before the systemic symptoms began, the patient had completed two courses of oily 5% phenol injection sclerotherapy, 3 weeks apart, for the treatment of symptomatic firstand second-degree hemorrhoids. Physical examination and laboratory tests revealed abdominal tenderness, fever, leukocytosis, and leukocyturia. The working diagnosis was urinary sepsis, and the patient was given intravenous antibiotics. However, his condition continued to deteriorate. Abdominal computed tomography scan revealed a small amount of fluid in the pelvis, opacity of the mesenteric and perirectal fat, and a solitary free air bubble adjacent to the rectum. The patient was transferred to the Department of Surgery for further treatment. On admission, he was febrile (38°C), hemodynamically stable (heart rate 100 beats/min, blood pressure 165/83 mmHg), with no respiratory distress. Physical examination revealed a distended abdomen, with localized lower abdominal peritoneal signs. The rectumwas filledwith feces, with no sign of bleeding. Necrotic hemorrhoids were noted. Laboratory investigation showed awhite blood cell count of 20.3×10/mm, predominantly neutrophils with a left shift. After fluid resuscitation and administration of parenteral antibiotics, laparotomy was performed. Operative findings were consistent with free peritoneal air, necrosis of the rectosigma, anus, and surrounding tissue, and lower abdominal peritonitis. The mesenteric vessels appeared thrombotic. Emergency APR was performed. The pathologic findings included large bowel with widespread areas of fibrinoid necrosis, mostly transmural, many vessels with fibrin thrombi at the bowl wall, widespread area of fat necrosis, microabscesses, and congestion of the pericolic fat. Postoperatively, the patient developed a wound infection, which was drained, and urinary sepsis, which (2007) 22: 997–998