Perianal Discomfort Research Articles

Hemorrhoids, Anorectal Symptoms, and Related Risk Factors in Pregnancy and the Postpartum Period: A Follow-up Study

Purpose: To investigate the presence of hemorrhoids and anorectal signs/symptoms and to identify various risk factors including anthropometric/musculoskeletal contributors associated with hemorrhoids in pregnancy and the postpartum period. Background: Pregnancy and the postpartum period may predispose women to develop hemorrhoids and anorectal symptoms because of hormonal and musculoskeletal changes. Methods: Fifty-one pregnant women with no history of anorectal disease were included in the study. The occurrence of hemorrhoids and other anorectal signs/symptoms was examined at 4 different times: first, second, and third trimesters, and postpartum 6th week. The Rome III criteria and the Bristol Stool Scale were used to confirm the presence of constipation and to determine stool type, respectively. Waist and hip circumference (as anthropometric contributors), bi-iliac and bitrochanteric width (as diameter measurements), diastasis recti abdominis, joint hypermobility, and lumbar lordosis (as musculoskeletal contributors) were evaluated. Personal, demographic, and clinical characteristics of the patients as well as postpartum period information were also recorded. Results: Hemorrhoids, perianal discomfort, perianal pain, and protrusion were significantly more frequent at postpartum than at the first trimester (P < .008). According to the multivariate analysis, body mass index, the presence of constipation, joint hypermobility, and birth weight were significant determinants of hemorrhoids at the third trimester and postpartum (odds ratio = 1.25-2.67). Conclusions: Body mass index, constipation, joint hypermobility, and increased birth weight of the newborn were potential risk factors for the development of hemorrhoids during pregnancy and postpartum. Hemorrhoids and anorectal complaints should be kept in mind and managed to increase the quality of life during pregnancy and the postpartum period.

Perianal Paget's Disease Metachronically Associated with Adenocarcinoma

Abstract Introduction This article describes an unusual case of perianal Paget's Disease in a 42-year-old man, highlighting distinct characteristics about more typical cases. Case report 42-year-old male patient with persistent perianal lesion, recurrent abscesses, and discomfort. Magnetic resonance imaging indicated a possible fistulous path. Biopsy revealed secondary anal Paget's disease and adenocarcinoma. Chemotherapy and radiotherapy treatment demonstrated a positive response. Discussion Perianal Paget's Disease is a rare condition of the anal canal that is part of the Extramammary Paget's Disease (EMPD) group. Symptoms include itching, pain, perianal bleeding, and skin lesions. Diagnosis can be challenging and usually involves performing a histopathological biopsy associated with an immunohistochemical study. Treatment varies and may involve surgery, radiotherapy, and chemotherapy. Due to the rarity of the disease, the best therapeutic approach is not yet well defined, and follow-up is essential due to the risk of recurrence. Conclusion Perianal Paget's Disease is rare and requires differentiation from other conditions. Early detection is essential to prevent malignancy.

Fecal incontinence risk factors and pregnancy.

We conducted an analysis on 231 pregnant women. A proctologist examined the patients three times: in the 1st trimester (within the first 15 weeks), in the 3rd trimester (29-40 weeks), and 12 months after childbirth. The total number of fecal incontinence observations among women included in the study was 66 cases (28.6%), detected at the final visit. Risk factors for fecal incontinence with a high probability were age over 36 years (P = 0.001), low physical activity (P = 0.034), three or more pregnancies resulting in childbirth (P = 0.022), history of hemorrhoids (P = 0.027), perianal discomfort on the first visit (P = 0.045), and constipation on the first visit (P = 0.006). Factors such as being overweight, marital status, education, living conditions, living area, and infant size did not have significance for fecal incontinence. Pregnancy- and obstetric-related risk factors contributing to fecal incontinence are multifactorial, including factors such as multiple childbirths with trauma to the pelvic muscles or anal sphincter muscles, chronic constipation, age, and vaginal deliveries. However, currently, there is no clear concept for the prevention of fecal incontinence in pregnant women. The prevalence of fecal incontinence among pregnant women is 12.9%, which increases to 28.6% one year after childbirth. The most common complaint was involuntary passage of intestinal gas. Risk factors for fecal incontinence with a high probability included being over 36-years old, low physical activity, three or more pregnancies resulting in childbirth, a history of hemorrhoids, perianal discomfort, and constipation in the 1st trimester of pregnancy.

The effect of physical therapy and mechanical stimulation on dysfunction of lower extremities after total pelvic exenteration in cervical carcinoma patient with rectovesicovaginal fistula induced by radiotherapy: a case report

BackgroundTotal pelvic exenteration is the ultimate solution for rectovesicovaginal fistula caused by radiation therapy, yet total pelvic exenteration frequently causes intraoperative complications and postoperative complications. These complications are responsible for the dysfunction of lower extremities, impaired quality of life, and even the high long-term morbidity rate, thus multidisciplinary cooperation and early intervention for prevention of complications are necessary. Physical therapy was found to reduce the postoperative complications and promote rehabilitation, yet the effect on how physiotherapy prevents and treats complications after total pelvic exenteration and pelvic lymphadenectomy remains unclear.Case presentationA 50-year-old Chinese woman gradually developed perianal and pelvic floor pain and discomfort, right lower limb numbness, and involuntary vaginal discharge owing to recurrence and metastasis of cervical cancer more than half a year ago. Diagnosed as rectovesicovaginal fistula caused by radiation, she received total pelvic exenteration and subsequently developed severe lower limb edema, swelling pain, obturator nerve injury, and motor dysfunction. The patient was referred to a physiotherapist who performed rehabilitation evaluation and found edema in both lower extremities, right inguinal region pain (numeric pain rate scale 5/10), decreased temperature sensation and light touch in the medial thigh of the right lower limb, decreased right hip adductor muscle strength (manual muscle test 1/5) and right hip flexor muscle strength (manual muscle test 1/5), inability actively to adduct and flex the right hip with knee extension, low de Morton mobility Index score (0/100), and low Modified Barthel Index score (35/100). Routine physiotherapy was performed in 2 weeks, including therapeutic exercises, mechanical stimulation and electrical stimulation as well as manual therapy. The outcomes showed that physiotherapy significantly reduced lower limb pain and swelling, and improved hip range of motion, motor function, and activities of daily living, but still did not prevent thrombosis.ConclusionStandardized physical therapy demonstrates the effect on postoperative complications after total pelvic exenteration and pelvic lymphadenectomy. This supports the necessity of multidisciplinary cooperation and early physiotherapy intervention. Further research is needed to determine the causes of thrombosis after standardized intervention, and more randomized controlled trials are needed to investigate the efficacy of physical therapy after total pelvic exenteration.

Application of platelet-rich-plasma in the postoperative treatment of perianal abscess pseudohealing: A case report.

Perianal abscess is a common disease of the anus and intestine. Surgery is an important treatment option for perianal abscess. However, some patients have a long healing time, poor healing effect after surgery, or even pseudo-healing. Platelet-rich plasma (PRP) is rich in platelets that can release a large number of factors when activated and promote wound healing. Moreover, there are few reports on the use of PRP for wounds that are difficult to heal after perianal abscess surgery. The patient had reported a complaint of perianal swelling and discomfort associated with anal pain, which was considered a perianal abscess. Ceftriaxone, fumigation, and sitz bath were administered after mixed hemorrhoid and perianal abscess surgeries were performed; however, the wound remained unhealed for more than 3 months, and there was a fistula under the skin. Perianal color ultrasonography revealed perianal abscess. Autologous PRP treatment was performed 5 times for each patient. The postoperative wound healed within 15 days after 5 times PRP treatments. PRP is a novel treatment option for pseudo-healing.

Clinical, Endoscopic, and Histologic Characteristics of Patients with Solitary Rectal Ulcer Syndrome at a Tertiary Care Center

Abstract Objective Solitary rectal ulcer syndrome (SRUS) is a chronic disorder of defecation presenting with bleed per rectum, mucorrhea, tenesmus, perianal discomfort, etc. We aim to report clinical, endoscopic, and histologic features of SRUS in patients who underwent either colonoscopy or sigmoidoscopy at our center. Materials and Methods We performed retrospective analysis of all patients diagnosed with SRUS on endoscopy and confirmed by histopathologic examination at our center between January 2010 and June 2022. Data retrieved included demographic details, clinical features along with endoscopic, and histopathological findings of SRUS patients. Results The study included 132 patients with SRUS with mean (± standard deviation) age of 45 (± 20.6) years and male to female ratio of 1.5:1. While most of the patients presented with a combination of symptoms, the most common clinical presentation was bleeding per rectum (82%). Rectal ulcers, either single or multiple, were the predominant findings on endoscopy followed by polypoidal lesions. Histology showed fibromuscular obliteration and crypt distortion in all patients. Biofeedback training, lifestyle changes, and sucralfate enema were successful in about 87% of the patients at the end of 6 weeks and about 76% at the end of 12 weeks with surgery for rectal prolapse being performed in two of our patients. Conclusion SRUS presents with a myriad of symptoms and requires a high index of suspicion by the treating physician(s). While the most common presenting symptom in our study was rectal bleed rectal bleed; ulcers, either solitary or multiple, ulcers, either solitary or multiple, were the commonest endoscopy findings. Endoscopic findings along with histopathology confirm the diagnosis.

EFFICACY OF INJECTION 3% POLIDOCANOL IN TREATMENT OF 1STAND 2ND DEGREE INTERNAL HEMORRHOIDS

Internal Haemorrhoids has been the most common condition since ages and wide variety of treatment modalities are available to make it an equally enigmatic disease to approach. Polidocanol is the recent sclerosants in the surgeon's armamentarium for its treatment. This prospective study included 80 patients with rst or second degree internal haemorrhoids. Internal haemorrhoids had sexual predilection towards males in our study in the ratio of approximately 2:1 with a age range of 25-60 yrs. Fifty ve of 80 patients had rst degree haemorrhoids and the rest 25 had second degree haemorrhoids. Bleeding Per rectum was the most common complaint followed by constipation, perianal discomfort and perianal itching. Response to rst dose of 3% polidocanol was seen in 60% of patients, 27.50% patient responded to second dose and 12.50% patients responded to the third dose of sclerotherapy. Sclerotherapy with inj 3% polidocanol has been an effective agent in the treatment of rst and second degree haemorrhoids in this study.

Post-Episiotomy Self-Care Practice among Primiparous Women attending Maternity Teaching Hospital in Sulaimani/ Iraq

Background and Objectives: Episiotomy care is very essential, if neglected it can lead to serious complications such as infections, open wounds, etc. Therefore, it is very important to pay special attention to maintaining perineal hygiene and caring for episiotomy. The present study aimed to determine the effect of perineal self-care instructions on pain and healing of episiotomy in women after childbirth. Method: descriptive-analytic (Cross-sectional) study of 260 Primiparous Womenin Maternity Teaching Hospital/Sulaimani City. Data have been collected using a questionnaire by direct interview lasted 4 consecutive months from June 2021 to October 2021. The questionnaire consists of: Maternal Demographic Characteristics, Episiotomy History, Post episiotomy Self-care practice. Results there is a statistically significant association between age and level of education with Post episiotomy Self-care practice, moreover, primiparous women in the current study reported a poor level of Self-Care Practice with Perineal Hygiene, Reducing Perianal discomfort and pain, Positioning and movement, and Pelvic floor muscle exercises, but thankfully, they have a good level of self-care practice concerning dealing with episiotomy complications or risks and eat healthy nutrition. Conclusion According to the study's findings, only a tenth percent of the puerperal women has good practice regarding post-episiotomy Self-care, while the rest of the participant have fair practice and poor practice. Recommendation Women must be informed and guided during their prenatal care concerning the episiotomy procedure.

Successful treatment of giant anogenital condyloma accuminata with combined cryotherapy and intralesional tuberculin purified protein derivative: a case report

To show the effectiveness of combined cryotherapy and intralesional tuberculin purified protein derivative (PPD) in the treatment of giant condyloma accuminata. A 57-year-old female was presented with an extensive verrucous, ulcerated, cauliflower-like 10 × 5 cm mass of the perianal area with extension to labia majora. The mass had evolved progressively for 2 years and resulted in perianal discomfort, itching and bleeding. Histopathological examination ruled out the presence of malignancy and confirmed the diagnosis of condyloma accuminata.The lesions were treated by 6 sessions of combined cryotherapy (2 freeze thaw cycles 25 seconds each) and intralesional PPD with a dose of (0.3 ml each session) at two-week interval. The mass resolved completely after 3 months and the quality of life of the patient has improved dramatically. There was no recurrence within 1 year of follow-up. Although most case reports suggest surgical excision as the treatment of choice of giant condyloma accuminata, our case was successfully treated with a highly effective and safe combined modality of cryotherapy and intralesional PPD, with the advantage of preserving the normal anatomy and avoidance of post-surgical disfigurement. No conflict of interest to declare.

Injection Sclerotherapy with 3% Polidocanol in 1st and 2nd degree Internal Haemorrhoids – A Prospective Study

Internal Haemorrhoids has been the most common disease since ages and wide variety of treatment modalities available make it an equally enigmatic disease to approach. Polidocanol is the recent sclerosants in the surgeon’s armamentarium for its treatment. This prospective study included 86 patients with first or second degree internal haemorrhoids. Internal haemorrhoids had sexual predilection towards males in our study in the ratio of 2:1 with a age range of 24-68 yrs. Sixty-one of 86 patients had first degree haemorrhoids and the rest 25 had second degree. Bleeding P/R was the most common complaint followed by constipation and perianal discomfort. Response to first dose of 3% polidocanol was seen in 59.3% of patients, 29.07% patient responded to second dose and 11.63% patients responded to the third dose of sclerotherapy. Sclerotherapy is an effective option in the treatment of first and second degree haemorrhoids and 3% polidocanol has been an effective agent in this strategy.

PERSONALIZED APPROACH TO ACUTE PERIANAL VENOUS THROMBOSIS TREATMENT DEPENDING ON CLINICAL MANIFESTATIONS

Aim: to investigate the time period and reasons for seeing a doctor of patients with acute thrombosis and to assess treatment satisfaction.Methods: The main complaints, symptom duration, pain severity and pathological process characteristics of patients with acute perianal venous thrombosis were recorded. The treatment strategy was determined by the doctor and the patient: the surgical thrombosed hemorrhoid removal or conservative treatment with analgesics, venotonics, drugs for stool softening. Pain severity on days 3, 7, 30 and overall satisfactions on day 30 were evaluated.Results: 62 patients were included. The main symptoms were pain (69.4%) and discomfort (16.1%). During the first 72 hours from the disease onset 21.5% of patients saw a doctor and 66.7% of all patients underwent the surgery, on day 4–7 — 50% saw a doctor and 77% underwent the surgery, > 8 days — 28.5% and 33% respectively. During the appointment pain was 4 points according to VAS, 3 days after surgery — 5.9 points, 4–7 days — 3.9 points, > 8 days — 2.5 points. 64% of patients underwent the surgery with average pain level of 5 points, in the conservative group — of 4.5 points (p = 0.014). On day 30 80.6% of all patients were completely satisfied. Having the pain severity > 4points nobody was satisfied with conservative treatment, while 80% of surgical patients were satisfied.Conclusion: Considering the symptom duration, pain continuing > 3 days, perianal discomfort ora «bump» the treatment tactics should be accepted by the doctor and the patient together for achieving a high treatment satisfaction.

Clinical and diagnostic profile of patients with anal fistula: a cross sectional study from Vilasrao Deshmukh Government Institute of Medical Sciences, Latur, Maharashtra

Background: Anal fistulas are one of the commonest causes for a persistent discharge seropurulent in nature that irritates the skin in the neighbourhood and leads to discomfort. Fistula-in-ano is seen quite frequently in perirectal perianal suppuration. The objective of this study to study the clinical profile and diagnosis of anal fistula at surgical OPD of VDGIMS.Methods: The present cross-sectional observational study was carried out in patients with fistula-in-ano admitted at surgical department of VDGIMS, Latur during the period of 2017-19 in 50 diagnosed patients. Data was analysed by using SPSS 24.0 version IBM USA.Results: Majority of the patients with anal fistula were from 41-50 years age group i.e. 15 (30%) and males were predominantly affected 40 (80%) compared to females i.e. 10 (20%). Male to female ratio was 4:1. Perianal discomfort was the commonest symptom in all patients i.e. 100%. It is followed by perianal discharge complained by 54% and perianal itching in 38% cases. The anterior position of external opening is found to be significant (p<0.05). Fistulogram showed external opening in all patients i.e. 50 cases whereas internal opening in 46 (92%) cases. Findings of MRI revealed that anal fistula was intra sphincteric in 28 cases i.e. 56%, extra sphincteric in 2 cases i.e. 4% and trans sphincteric in 20 cases i.e. 40%.Conclusions: Commonest age group affected in our study was 40-50 years with male predominance. Perianal discomfort and discharge were the commonest symptom. E. coli was the predominant organism isolated. Fistulogram and MRI is useful in detecting the aetiology of fistula in ano.

Hemorrhoidal Artery Ligation Operations-Recto-Anal Repair (HALO-RAR) Procedure for Recurrent Haemorrhoids: Excellent Patient Satisfaction.

BackgroundHaemorrhoid is the most common anal canal disease. Treatments may vary from non-invasive to invasive depending on the symptoms. Haemorrhoidectomy has been widely used. However, it has some drawbacks like severe postoperative pain, longer time to return to daily activities and complications such as anal stenosis. To overcome these, various new treatment methods have been introduced. Doppler-guided hemorrhoidal artery ligation operations (HALO) are becoming popular among surgeons. HALO has been reported to have a lower recurrence rate of less than 10% and higher patient satisfaction of approximately 90% with minimal postoperative pain. It achieves very good postoperative outcomes in the treatment of early haemorrhoids where per rectal bleeding and/or perianal discomfort are main symptoms. Nevertheless, it has a limitation in the treatment of prolapsing haemorrhoids. To tackle this, simultaneous recto-anal repair (RAR) has been recently introduced. HALO, in combination with RAR, has been reported to achieve good postoperative outcomes and excellent patient satisfaction.This is a two-stage open operation. The stages are: - Doppler-guided HALO and - RAR (recto-anal repair)MethodsWe are presenting a single-centre one-year experience of Doppler-guided haemorrhoidal artery ligation operation and recto-anal repair (DG-HALO and RAR) conducted on haemorrhoidal patients to evaluate the outcomes and effectiveness of the procedure. Retrospective data were collected for the patients who underwent HALO over one year period from June 2018 to August 2019. A total of 10 patients were treated with the HALO-RAR procedure.ResultsThe male to female ratio was 7:3, median age was 47.98 (28.38 - 61.7) years, median body mass index (BMI) was 30.23 (23.8 - 39.1). Eight patients were American Society of Anesthesiologists (ASA) Grade II, one patient was ASA I and one was ASA III. Time from initial consultation to the HALO procedure was 9.90 (3.5 - 19.8) months. All patients complained of preoperative bleeding and six of them complained of pain or discomfort. Nine patients underwent previous bandings in the clinic and one patient declined banding. The average time of the procedure was 57 mins. The average number of ligations was 10 (0-21). In one case, the proctoscope did not pair with the speaker. The average number of plications was three (2-4). Postoperatively, nine patients had no immediate complications; one patient had acute urinary retention. Seven patients were discharged on the same day. One patient had to stay overnight for monitoring prior to restarting apixaban, one patient for his learning difficulties and one patient had an unplanned overnight stay due to acute urinary retention requiring catheterization. Eight patients had their first follow-up; improvement of symptoms was found in 100% patients on the first follow-up.ConclusionHALO-RAR should be considered as a treatment option for recurrent symptoms after banding for haemorrhoids. The study showed good overall results with no immediate surgical complications. Excellent patient satisfaction was found even in long-term follow-up.

2035 Small Cell Carcinoma of Rectum: A Rare Cause of Hematochezia

INTRODUCTION: Small cell carcinoma (SmCC) is a subtype of neuroendocrine tumor that has commonly been associated with lung malignancy. However, it has been seen in <1% of colorectal malignancies. Majority of neuroendocrine tumors are asymptomatic and non-functioning, but about 75% have metastatic disease by the time of diagnosis. We present a case of SmCC of the rectum in a patient who presented with intermittent hematochezia. CASE DESCRIPTION/METHODS: A 65-year-old female with a medical history of Diabetes Mellitus Type II, Hypertension, and Hyperlipidemia, was referred for endoscopic evaluation of intermittent hematochezia ongoing for several months with the following associated symptoms: change in bowel habits, constipation, perianal discomfort increased upon defecation, urinary frequency, and dysuria. She was not on anticoagulation or NSAIDs. She had no personal or family history of GI malignancy or IBD, and she denied tobacco, alcohol, or illicit drug use. Screening colonoscopy ten years ago had been negative for any abnormalities. Laboratory data was unremarkable for anemia or liver disease, but did reveal a mildly elevated CEA 4.8 ng/mL. Subsequent colonoscopy revealed large ulcerated rectal mass at 15 cm with luminal narrowing concerning for rectal malignancy. Follow up imaging with CT of the abdomen and pelvis with contrast showed a large rectal mass with multiple enlarged peri-rectal lymph nodes, 1.5 cm right adrenal nodule, 3 mm non-calcified nodule of left lower lobe and multiple sub-centimeter hypodense lesions in left liver lobe. Biopsy with histological staining suggested neoplastic cells consistent with rectal small cell carcinoma. Patient was treated with neoadjuvant chemotherapy and radiation therapy followed by abdominoperineal resection. Ultimately, she could not tolerate adjuvant therapy and enrolled in hospice. DISCUSSION: To date, fewer than 1000 cases of GI SmCC have been reported with prevalence of 0.1% to 1% of all GI tumors. Seventy- five percent of patients present with metastasis at the time of diagnosis. Six-month survival rate is 58%, and five-year survival is 6%. Clinical presentation generally mimics the usual presentation of colorectal malignancies. Workup is also similar. However, there is no standard treatment approach for SmCC as none has been developed due to low incidence. Given the paucity of literature, cases should be reported to influence future prospective studies to establish standard diagnostic and treatment regimens and to improve the overall prognosis.

Diagnostic delay in inflammatory bowel disease increases the risk of intestinal surgery.

AIMTo investigate the factors affecting diagnostic delay and outcomes of diagnostic delay in inflammatory bowel disease (IBD)METHODSWe retrospectively studied 165 patients with Crohn’s disease (CD) and 130 patients with ulcerative colitis (UC) who were diagnosed and had follow up durations > 6 mo at Korea University Ansan Hospital from January 2000 to December 2015. A diagnostic delay was defined as the time interval between the first symptom onset and IBD diagnosis in which the 76th to 100th percentiles of patients were diagnosed.RESULTSThe median diagnostic time interval was 6.2 and 2.4 mo in the patients with CD and UC, respectively. Among the initial symptoms, perianal discomfort before di-agnosis (OR = 10.2, 95%CI: 1.93-54.3, P = 0.006) was associated with diagnostic delays in patients with CD; however, no clinical factor was associated with diagnostic delays in patients with UC. Diagnostic delays, stricturing type, and penetrating type were associated with increased intestinal surgery risks in CD (OR = 2.54, 95%CI: 1.06-6.09; OR = 4.44, 95%CI: 1.67-11.8; OR = 3.79, 95%CI: 1.14-12.6, respectively). In UC, a diagnostic delay was the only factor associated increased intestinal surgery risks (OR = 6.81, 95%CI: 1.12-41.4).CONCLUSIONA diagnostic delay was associated with poor outcomes, such as increased intestinal surgery risks in patients with CD and UC.

Pouchitis: a tridimensional view

The preferred surgical treatment of ulcerative colitis (UC) and familial adenomatous polyposis (FAP) is represented by proctocolectomy with ileal pouch-anal anastomosis (IPAA). However, patients with UC who have undergone IPAA are prone to develop several complications, which include surgery related/mechanical complications; inflammatory or infectious disorders; functional disorders; dysplasia or neoplasia; and systemic or metabolic disorders. Pouchitis, which is defined as the acute and/or chronic inflammation of the ileal reservoir, represents the most common long-term adverse sequela after IPAA. Gut microbiota play a pivotal role in the initiation and disease progression of pouchitis. Pouchitis can be classified according to the activity of the disease, the duration of the symptoms, the pattern of the disease or response to antibiotic therapy. Patients with IPAA for UC tend to experience a variety of symptoms, ranging from mild pelvic or perianal discomfort to a debilitating complex of symptoms that may eventually lead to pouch excision thereby necessitating the construction of a permanent ileostomy. To date, the etiology, the diagnosis and the medical management of pouchitis represent a clinical challenge. In fact pouchitis range from a disease with an acute antibiotic-responsive presentation to a chronic antibiotic-refractory form, with subsequent different disease mechanisms and clinical course. A tridimensional and multidisciplinar approach, including endoscopy, histology, and laboratory testing is widely helpful to identify the different phenotypes of the disease and to manage correctly its treatment.

Diagnosis and management of pouch outlet obstruction caused by common anatomical problems after restorative proctocolectomy

Background and aimsEfferent limb syndrome (ELS) after S pouch and pouch-rectal anastomosis (PRA) after J pouch are common anatomical problems after restorative proctocolectomy that lead to pouch outlet obstruction. This study was aimed to evaluate the frequency, diagnosis and management of ELS and PRA. MethodsConsecutive patients diagnosed with ELS or PRA at our Pouch Center from 2002 to 2011 were included. Demographic, clinical, endoscopic, and radiographic features together with its management and outcomes were studied. ResultsA total of 26 patients met the inclusion criteria, 17 (65.4%) were male. Eleven patients (42.3%) had ELS and 15 (57.7%) had PRA. The median length of the efferent limb/rectal stump for all patients was 6.0 (interquartile range [IQR]: 5.0–8.8) cm, 7.0 (IQR: 5.0–9.0) cm and 6.0 (IQR: 5.0–10.5) cm for S and J pouch patients, respectively (P=0.025). Dyschezia (n=15, 57.7%) was the most common presenting symptom, followed by bloating (n=9, 34.6%), abdominal pain (n=9, 34.6%), the sense of incomplete evacuation (n=7, 26.9%) and perianal discomfort (n=3, 11.5%). A greater number of patients in the ELS group had dyschezia compared to the PRA group (90.9% vs. 33.3%, P=0.005). More patients in the ELS group had a sense of incomplete evacuation than those in the PRA group (45.5% vs. 13.3%, P=0.10). Ten patients (90.9%) in the ELS group and 5 patients in the PRA group (33.3%) required surgical intervention (P=0.005). After a mean follow-up of 3.4±1.4years, 7 (87.5%) of the 8 patients, who underwent redo pouch construction with efferent limb/rectal stump excision, maintained a functional pouch. ConclusionsPatients with ELS or PRA often presented with debilitating symptoms. ELS occurred more frequently in S pouch patients than PRA in J pouch patients. Surgical intervention might be needed, especially for the ELS patients.

A Hemorrhoid by Any Other Name

A 92-year-old man with dementia presented with perianal discomfort and fecal incontinence of 1 week duration. He denied pain, pruritus, bleeding, or sensation of a mass. Physical examination was notable for a raised verrucous mass (0.75 cm) extending from the dentate line distally for 7 cm, circumferentially covering 75% of the anal margin. Punch biopsy specimens were obtained for diagnosis. Histology revealed intraepithelial cells with prominent nucleoli and abundant clear cytoplasm. Surgical options were explained to the patient, but given his decline in function and overall poor life expectancy, radiation therapy was offered. He successfully completed a regimen of 44 Gy in 11 fractions. On follow-up examination, no appreciable perianal mass was observed; the patient denied anal discomfort, pain, bleeding, or symptoms of obstruction. Perianal Paget disease is uncommon, with fewer than 300 cases reported in the literature.1,2 Classically described as involving the breast, Paget disease has been shown to affect areas containing apocrine glands, including the perianal region, vulva, penis, scrotum, thighs, buttocks, and axilla.2 Perianal Paget disease typically presents in the sixth decade of life with pruritus ani, bleeding, excoriation, pain with defecation, anal pain, or mass sensation.2 Lesions are characterized as slightly raised, erythematous, and well-demarcated.3 Treatment is predominantly surgical, consisting of local excision, wide local excision with skin grafting or flap reconstruction, or in severe cases abdominoperineal resection.4,5 Radiation therapy can be offered in select patients with good outcome.

Squamous cell carcinoma of the anus in a patient with perianal Crohn’s disease

Dear Editor Anal cancer is a rare disease and accounts for approximately 1.86% of all carcinomas originating in the digestive system. The American Cancer Society estimates that in 2008, there will be 5,070 new cases of anal cancer and 680 deaths from anal cancer in the USA. Anal cancer arising in patients with Crohn’s disease is also rare. The incidence or prevalence of anal carcinoma in Crohn’s disease is not sufficiently reported. According to Slater et al., the percentage of anal cancer in colorectal cancer in patients with Crohn’s disease is higher than that in patients with non-inflammatory bowel disease (IBD; 14% versus 1.4%, respectively, p<0.005). On the other hand, Frisch et al. reported one case of anal squamous cell carcinoma (SCC) among 2,723 Crohn’s patients with a median follow-up of 10.2 years and concluded that the rate of anal SCC is not significantly increased, even in IBD patients, as compared with the general population. Incidence rates of IBD diverge geographically. Traditionally, Northern Europe, the UK, and North America have a high prevalence of IBD. The incidence and prevalence rates of IBD in Asia are low compared with the West. According to a recently published epidemiologic study by Thia et al., incidence rates of Crohn’s disease in Japan, South Korea, and Hong Kong are similar, ranging from 1.00 to 1.34 cases per 10 person-years over a combined time period from 1998 to 2005, and interestingly, the incidence of Crohn’s disease is increasing in these areas. Approximately 40 cases of carcinoma that developed from anal lesions or in association with anal or rectal fistulas arising in patients with Crohn’s disease were reported in English literature from 1980 to 2008. Most of these cases were reported from Northern Europe or North America, and as far as we know, reports from East Asia are very rare. Our hospital is a tertiary referral center in South Korea. From 1991 to 2008, 843 patients were treated for IBD. We report the first case of SCC arising in a patient with perianal Crohn’s disease in our hospital. A 43-year-old woman had an 11-year history of Crohn’s disease. She underwent large loop excision of the transformation zone due to cervical cancer (carcinoma in situ) in 1997. Despite regular follow-up with sulfasalazin, steroid, or intermittent infliximab treatment, the patient developed enteroenteric fistulas as well as an anal stricture and multiple perianal fistulas. Even though the patient received conservative medical treatment, a small-bowel fistula did not resolve, and the patient suffered an increasing frequency of low abdominal pain with an engrowing palpable mass in the right lower abdomen. She underwent laparoscopic assisted right hemicolectomy, segmental resection of the small bowel, end ileostomy, and seton drainage for the rectovaginal fistula in January 2008. Fecal diversion was performed to relieve the perianal discomfort induced by J. Kang : B. S. Min :K. Y. Lee :N. K. Kim (*) Department of Surgery, Yonsei University Health System, Yonsei University College of Medicine, 250 Seongsanno (134 Sinchon-dong), Seodaemun-gu, Seoul, South Korea 120-752 e-mail: namkyuk@yuhs.ac

Are screen detected colorectal cancers asymptomatic?

Colorectal cancer (CRC) screening aims to detect asymptomatic disease and thus provide the opportunity for early diagnosis and treatment. This study assesses the prevalence of significant symptoms in patients found to have CRC detected through the NHS National Bowel Cancer Screening Programme (NHS NBCSP) pilots. All patients in the NHS NBCSP pilots with a positive faecal occult blood completed a standardized symptomatology questionnaire before colonoscopy. This data was entered into the NHS BCS pilot database, data from the English arm has been analysed retrospectively. There were 200 patients diagnosed with colorectal cancer. Of these, 28.5% were Dukes A, 35% Dukes B, 31% Dukes C1 and 5.5% Dukes C2. Some 81.5% reported experiencing GI symptoms. Symptoms considered significant included rectal bleeding, change in bowel habit, tenesmus and peri-anal discomfort, reported in 47.7%, 24%%, 36.5% and 15.5% of patients respectively. In addition to this, 27% reported urgency, 20.5% reported abdominal pain and 29% reported upper GI symptoms. This data suggests a high prevalence of significant symptoms amongst patients with screening-detected CRC. It is possible that these patients would have presented via routine colorectal services if the awareness of symptoms of colorectal cancer were increased.