Perianal Examination Research Articles

Aetiology, pathogenetic factors and prevalence of anal fissure in the Republic of Tajikistan

Aim. To study the aetiology, pathogenetic factors and prevalence of anal fissure in the Republic of Tajikistan.Materials and methods. Approximately 600 patients with anal fissure are treated annually in specialized coloproctology centres of the Republic. During 2018-2022, 3,065 patients were admitted with this pathology. All patients underwent perianal examination. Anal and rectal reflexes were measured, digital rectal examination, sphincterometry, manometry and sigmoidoscopy were performed.Results and discussion. The main factor in the pathogenesis is the formation of the so-called vicious cycle, in which the pain factor and spasm of the anal sphincter play an important role, as well as the formation of a caruncle, which was observed in 83% and 82% of the cases, respectively. Pectinosis of the anal sphincter occurred in 8% and thickening of the anal fissure margins in 115 cases.Conclusions. Anal fissure is a polyetiological disease and an important factor in its development is mechanical damage of the posterior wall due to chronic persistent constipation. In the pathogenesis of anal fissure there is a vicious circle in which pain factor and spasm of anal sphincter play an important role.

871 Audit on Compliance and Documentation of GMC Guidelines Regarding the Use of Chaperone During the Intimate Examination

Abstract Aim To assess the compliance of GMC guidelines with respect to chaperones during intimate examination and their appropriate documentation. Method Analysis of patient notes documented by members of the general surgery department in the surgical assessment unit, or ED, for the month of October 2022. We checked the patient notes for the following dataset: Chaperone - offered/not offered, name and position of chaperone and signature of chaperone.Area examined – Perineum, Abdomen, Breast or perineum and abdomenGender of patient, doctor and chaperone.Time of the day and place of examination The data was analyzed (results below). As part of the audit cycle, the results were shared with the department, and education on the seriousness of this issue was discussed. Stickers for chaperones with their name, position, and gender will be attached to the patient notes. Results 168 patients were reviewed totally. 9/168 (5.3%) – documentation present, 1/9 (11%) had complete documentation. 23 patients had perianal examination – 1 (4.3%) had documentation 141 patients had abdomen examination – 8 (5.6%) had documentation 9/9 (100%) documentation done by male doctors for female patients Conclusions We found a lack of adequate documentation for chaperone presence during the examination. It was agreed that chaperone presence was always adhered to, but documentation was lacking. Necessary changes have been initiated, and we are collecting prospective data after the intervention.

DIEULAFOY LESION CAUSING LOWER GI BLEEDING: A CASE OF COVID-19 CRITICAL ILLNESS PROMPTING UNUSUAL PRESENTATION OF A MORE RARE CONDITION

DIEULAFOY LESION CAUSING LOWER GI BLEEDING: A CASE OF COVID-19 CRITICAL ILLNESS PROMPTING UNUSUAL PRESENTATION OF A MORE RARE CONDITION

Comparison of contrast-enhanced fat-suppressed T1-3D-VIBE and T1-TSE MRI in evaluating anal fistula.

To evaluate the accuracy of contrast-enhanced (CE) fat-suppressed three-dimensional (3D) T1-weighted imaging with volumetric interpolated breath-hold examination (FS-T1-3D-VIBE) and fat-suppressed T1-weighted turbo spin echo (FS-T1-TSE) sequence in characteristics of anal fistula. One hundred and two patients underwent perianal CE-MRI examination on a 3T scanner including FS-T1-3D-VIBE and FS-T1-TSE sequences before surgery. The performance of each sequence was evaluated in terms of fistula classification, clarity of internal opening, number and position of internal openings including the distance between internal opening and anal verge, presence of secondary tracts and blind-ending sinus tracts. MRI findings were compared with surgical findings. Signal-to-noise ratios (SNRs) and contrast-to-noise ratios (CNRs) of fistula, gluteus maximus, and subcutaneous fat were compared between CE FS-T1-TSE and CE FS-T1-3D-VIBE. Compared with CE FS-T1-TSE, CE FS-T1-3D-VIBE displayed more accurate in secondary tract, lithotomy position of the internal opening and the distance between internal opening and anal verge (P < 0.05). CE FS-T1-3D-VIBE was found superior to CE FS-T1-TSE in the clarity of the internal openings and in the diagnostic accuracy of blind-ending sinus tracts and complex fistulas in Standard Practice Task Force classification (P < 0.05). CE FS-T1-3D-VIBE achieved higher SNRs and CNRs in fistula and gluteus maximus than CE FS-T1-TSE (P ≤ 0.001). CE-MRI of FS-T1-3D-VIBE might be a more valuable noninvasive technique than FS-T1-TSE to evaluate the anal fistula on evaluating the lithotomy position of internal opening, distance between internal opening and anal verge, clarity of internal opening, secondary tract, blind-ending sinus tract and classification of the complex fistula. The trial registration number for this prospective trial was Chi-TR1800020206 and the trial registration date was December 20, 2018.

Persistent perianal “warts”

Persistent perianal “warts”

Evaluation of the role of anal tone and perianal sensation examination in the assessment of suspected cauda equina syndrome

Purpose Cauda equina syndrome (CES) can present with a varied constellation of clinical signs and symptoms, which together with the time-sensitive nature of the condition and risk of catastrophic clinical outcome, presents a significant challenge to those assessing patients with this suspected diagnosis. Anal tone is commonly tested during initial assessment using a digital rectal examination (DRE). This study aims to evaluate the diagnostic value of anal tone and perianal sensation assessment in patients with suspected CES and report modern prevalence data on CES within a neurosciences centre. Materials and methods Consecutive patients with suspected CES presenting over three years to the Emergency Department (ED) of a busy tertiary centre were included in the study. History and examination findings, documented in the ED notes, were assessed and these variables were correlated with the presence or absence of cauda equina compression on subsequent magnetic resonance imaging (MRI). Results Out of 1005 patients with suspected CES, 117 (11.6%) had MRI confirmed cauda equina compression (MRI + ve CES). 35% of MRI + ve patients and 31% of MRI -ve patients had reduced anal tone. Using univariate and multivariable logistic regression analyses, no associations were found between abnormal anal tone and MRI + ve CES for patients of all ages. The univariate logistic regression analysis identified altered perianal sensation to be significantly associated with MRI + ve CES in patients ≤42 years old. This association was no longer present when an adjusted multivariable logistic regression was performed. Conclusion The prevalence of MRI + ve CES was 11.6%. Our findings suggest that the clinical finding of reduced anal tone has no demonstrable diagnostic value for those with suspected CES, either in itself or in combination with other clinical findings. Further studies are needed to confirm the diagnostic efficacy of assessing perianal sensation in this context.

EP.TU.693A rare case of anal melanoma: An entity to be aware of

Abstract Aims Anal melanoma is a rare but aggressive malignancy representing a small percentage anorectal cancers. We report a rare case incidentally detected during bowel screening. Methods A 74-year-old female presented for endoscopy after a positive qFIT. She was asymptomatic. During endoscopy, perianal examination revealed a jet black naevus of approximately 3x3cm from 9 to 12’O clock position, overlying the perianal body, involving anal margin to the posterior vagina. General physical, abdominal and rectal examinations were unremarkable. During colonoscopy, a benign polyp was removed from the sigmoid colon. She underwent examination of rectum and vagina under general anaesthetic, and incisional biopsies were obtained. Histopathology confirmed an invasive, superficial spreading malignant melanoma, with a Breslow thickness of 1.5mm and Clark Level IV invasion. Staging CT scans did not reveal metastasis. Following loco-regional MDT discussion, a combined colorectal and plastic surgery was offered. She underwent wide local excision from the posterior vaginal fourchette to the anal canal, bilateral perforator flap reconstruction, and defunctioning sigmoid loop colostomy. Results There were no intraoperative complications. She recovered well post-operatively. After histopathology, her tumour was staged as pT2b, N0, M0. She did not require further treatment post-operatively as per MDTdiscussion. No disease recurrence has been detected yet with 30 months follow up, and she is awaiting reversal of colostomy. Conclusions Prognosis is generally poor in anal melanoma. This case report adds to the limited literature and emphasizs that despite no consensus on management, early detection and surgical resection offers the best chance for favorable outcomes.

P114 PERIANAL EXAMINATION AT TIME OF COLONOSCOPY - A MISSED OPPORTUNITY FOR IBD ASSESSMENT

Abstract Introduction The subtype of inflammatory bowel disease (IBD) is often not known at index colonoscopy and examining for perianal disease (PAD) can assist in establishing the diagnosis. PAD is common in Crohn’s disease (CD) but can also be seen in patients with ulcerative colitis (UC) in the form of fissures, abscesses and fistulae. Absence of perianal symptoms does not exclude PAD. Performing a routine perianal examination in a busy outpatient setting is not ideal and the endoscopy suite may be more appropriate. We hypothesise that perianal examinations are being omitted during IBD assessment colonoscopy. Methods Unisoft GI Reporting Tool was used to identify the last 70 consecutive CD and UC assessment colonoscopies performed over a 12 month period (August 2018 and July 2019) at a London-based district general hospital. Data was collected on demographics, known PAD, previous imaging and performance of perianal examination at colonoscopy. Results 140 patients undergoing colonoscopy for IBD assessment were included in this study (70 CD, 70 UC).Median age 42 (IQR 32 – 55), Female 66 (47.1%). 15 (10.7%) had known perianal disease. Pelvic MRI had previously been performed in 20(14.3%). Perianal examination was performed in only 3 (2%) patients at the time of their last clinic consultation. Although digital rectal examination (DRE) was performed in 132 (93.6%) of patients at the time of colonoscopy, only 9 (6.4%) had a perianal examination documented. Conclusion About 10% of patients in our cohort undergoing IBD assessment colonoscopy were known to have PAD but perianal examination was performed in only 2% of patients during clinic consultation and 6% during colonoscopy. Perianal examination at time of endoscopic assessment is an ideal setting to perform an intimate examination as you have an exposed, sedated and chaperoned patient. The omission of perianal examination at colonoscopy is a missed opportunity and improvement in this key element of disease assessment is required.

Nationwide Survey for Application of ROME IV Criteria and Clinical Practice for Functional Constipation in Children.

BackgroundThis study aimed to investigate the awareness and application of ROME IV criteria for functional constipation (FC) in real-world practices and assessed differences between pediatric gastroenterologists (PGs) and general pediatricians.MethodsA total of 239 (47.8%) out of 500 nationwide pediatricians answered a questionnaire for diagnosis and management of pediatric FC; 60 were PGs (75% of total PGs in Korea).ResultsA total of 16.6% of pediatricians were aware of the exact ROME IV criteria. Perianal examination and digital rectal examination were practiced less, with a higher tendency among PGs (P < 0.001). Treatment duration was longer among PGs for > 6 months (63.8%) than < 3 months among general pediatricians (59.2%, P < 0.001). Fecal disimpaction and rectal enema were practiced among 78.8% and 58.5% of pediatricians, respectively. High dose medication for initial treatment phase was prescribed by 70.7% of pediatricians, primarily within the first 2 weeks (48.3%). The most commonly prescribed medications in children aged > 1-year were lactulose (59.1%), followed by polyethylene glycol (PEG) 4000 (17.7%), and probiotics (11.8%). Prescription priority significantly differed between PGs and general pediatricians; lactulose or PEG 4000 were most commonly prescribed by PGs (89.7%), and lactulose or probiotics (75.7%) were prescribed by general pediatricians (P < 0.001). For patients aged < 1-year, lactulose (41.6%) and changing formula (31.7%) were commonly prescribed. Most participants recommended diet modification, and PGs more frequently used defecation diary (P = 0.002).ConclusionDiscrepancies between actual practice and Rome IV criteria and between PGs and general pediatricians were observed. This survey may help construct practice guidelines and educational programs for pediatric FC.

Prevalence of syphaciosis in laboratory rodents with emphasis on species identification, treatment and Th2 cytokine response

Prevalence of syphaciosis (pinworm infection) in laboratory rats and mice, species identification, chemotherapy with ivermectin and its effect on pinworm infection, and Th2 cytokine response was studied. Using perianal tape test examination, the highest rate of pinworm infection was found in male Wistar rats (69.44%) followed by female Wistar rats (62.50%), male Balb C mice (60.60%), female Swiss Albino mice (51.42%), male Swiss Albino mice (33.33%) and female Balb C mice (32.69%). Wistar rats had maximum infection (65.97%) followed by Balb C mice (46.64%) and Swiss albino mice (42.37%). Overall, males had higher infection (54.45%) compared to females (48.87%). Syphacia obvelata in mice and S. muris in rats were the pinworms identified morphologically and confirmed with polymerase chain reaction and sequencing. No mixed infection was found in rats and mice. Ivermectin (2.5 mg/kg) as oral gavage as well as in drinking water continuously for five days was highly effective in eradicationof pinworms in rats and mice. Down regulation of Th2 cytokines, viz. IL4, IL5 and IL13 was observed after ivermectin treatment in both male and female Wistar rats.

Issue Highlights

Issue Highlights

Forensic Examination Findings among Child Victims in Pekanbaru, Indonesia (2010–2016)

The role of forensic examination is very important to collect evidence on violence against children (VAC). To know the incidence of child victim, describe victim and forensic examination findings, we conducted retrospective study in Emergency Department Bhayangkara Hospital Pekanbaru. The medicolegal report of the child victims from January 2010 to December 2016 was reviewed. Out of 2071 child victims, two-third were physical assault. Average incidence number was 295.8 per year. Physical assault was more prevalent among boy (75.4%) with ratio 3.1. Sexual assault was predominant among girl (92.7%). Adolescent is main victims of child physical and sexual assault, diminishing with decrease age. Bruise and abrasion were more frequent found with head as common site. Almost boy has no abnormal finding on genital examination. Perianal examination showed no abnormal finding. Both of boy and girl have the same risk of becoming victims.

A Pilot Study of the Prevalence of Anal Human Papillomavirus and Dysplasia in a Cohort of Patients With IBD.

Defective cell-mediated immunity increases the risk of human papillomavirus-associated anal dysplasia and cancer. There is limited information on anal canal disease in patients with IBD. The purpose of this study was to assess anal/vaginal human papillomavirus and anal dysplasia prevalence in patients with IBD. Patients had an anal examination before routine colonoscopy. The study was conducted at a tertiary IBD referral center. We studied a convenience sample of sexually active male and female patients with IBD who were not on biological therapy. Anal examination, anal and vaginal human papillomavirus testing, anal cytology, and high-resolution anoscopy/biopsy were carried out. Anal and vaginal human papillomavirus types, anal cytology, and biopsy grade were measured. Twenty-five male and 21 female evaluable participants, 31 with Crohn's disease, 14 with ulcerative colitis, and 1 with indeterminate colitis, were predominantly white (91.3%), treatment experienced (76.1%), an average age of 38.1 years (range, 22.0-66.0 y), and had an average length of IBD diagnosis of 9.3 years (range, 1.0-33.0 y). Eighteen (39.1%) had an abnormal perianal examination and 3 (6.5%) had an abnormal digital examination. Forty-one (89.1%) had anal human papillomavirus, 16 with a single type and 25 with multiple types (range, 2-5 types). Human papillomavirus type 16 was most common (65.2%), followed by human papillomavirus types 11 and 45 (37.0% each). Nineteen of 21 (90.5%) women had vaginal human papillomavirus. Overall, 21 (45.7%) had abnormal anal cytology. Thirty three (71.7%) had ≥1 anal biopsy (9 had multiple), with dysplasia diagnosed in 28 (60.9%) and high-grade and low-grade squamous intraepithelial lesions diagnosed in 4 (8.7%) and 24 (43.5%). No control group was included, and no detailed sexual history was taken. A high prevalence of anal and vaginal human papillomavirus and anal dysplasia was demonstrated in the study population outcomes. See Video Abstract at http://links.lww.com/DCR/A379.

A case report of pneumo-retro-peritoneum: An unusual presentation of ischio-rectal abscess

IntroductionAno-rectal abscesses are common. They however usually do not present with abdominal symptoms. CT although useful is not routinely carried out. Finding of Pneumo-retro-peritoneum with ischio-rectal abscess is rare.Case presentationWe present the case of a diabetic gentleman who presented with abdominal pain and distension and was found to have ischio-rectal abscess on perianal examination. Although initially suspected to have acute abdomen due to perforated viscus, CT scan revealed pneumo-retro-peritoneum which appeared to arise due to the abscess. Patient underwent incision and drainage of the abscess followed by serial debridement. He made a complete recovery.ConclusionAbdominal symptoms are rare in ischio-rectal abscess, but they must be kept in mind. Proper diagnosis may avoid a negative laparotomy.

Perianal Crohn Disease in a Large Multicenter Pediatric Collaborative.

Although perianal complications of Crohn disease (CD) are commonly encountered in clinical practice, the epidemiology of perianal CD among populations of children is poorly understood. We sought to characterize the prevalence of perianal disease in a large and diverse population of pediatric patients with CD. We conducted retrospective analyses from a prospective observational cohort, the ImproveCareNow Network (May 2006-October 2014), a multicenter pediatric inflammatory bowel disease quality improvement collaborative. Clinicians prospectively documented physical examination and phenotype classification at outpatient visits. Perianal examination findings and concomitant phenotype change were used to corroborate time of new-onset perianal disease. Results were stratified by age, sex, and race and compared across groups with logistic regression. Cumulative incidence was estimated using Kaplan-Meier analyses and compared between groups with Cox proportional hazard regression models. The registry included 7076 patients with CD (41% girls). Missing/conflicting entries resulted in 397 (6%) patient exclusions. Among the remaining 6679 cases, 1399 (21%) developed perianal disease. Perianal disease was more common among boys (22%) than girls (20%; P = 0.013) and developed sooner after diagnosis among those with later rather than early onset disease (P < 0.001). Perianal disease was also more common among blacks (26%) compared with whites (20%; P = 0.017). Asians with later onset CD developed perianal disease earlier in their disease course (P = 0.01). There was no association between disease location or nutritional status at diagnosis and later development of perianal disease. In this large multicenter collaborative, we found that perianal disease is more common among children with CD than previously recognized. Differences in the development of perianal disease were found across racial and other subgroups. Treatment strategies are needed to prevent perianal disease development.

Occult Blood and Perianal Examination

Occult Blood and Perianal Examination

Occult Blood and Perianal Examination: Value Added in Pediatric Inflammatory Bowel Disease Screening.

Pediatric inflammatory bowel disease (IBD) often presents insidiously and standard blood tests are normal in 20% of patients. We hypothesize that fecal occult blood testing (FOBT) and the perianal examination in addition to blood tests provide important information during the screening process for IBD. The aim of the present study was to measure the diagnostic value of adding FOBT and perianal examination to standard screening laboratories in evaluating children and adolescents for IBD. The medical records of consecutive patients undergoing ileocolonoscopy for IBD were reviewed. Laboratory test results, FOBT, and perianal examination before the decision to perform the ileocolonoscopy were recorded. Standard limits of laboratory tests were used. Multivariate logistic regression was performed on a discovery cohort and applied to an independent validation cohort. The discovery cohort included 335 patients (85 IBD and 250 non-IBD). A total of 61.2% had FOBT and perianal examination performed before the decision to perform the ileocolonoscopy. A total of 119 patients had complete blood testing, FOBT, and perianal examination available for full analysis. The sensitivity of the laboratory testing was 80.5% for IBD, and the sensitivity of FOBT with perianal examination was 66.9%. The combined sensitivity of laboratory testing and FOBT with perianal examination was, however, 97.6%. The most predictive model included C-reactive protein, platelet counts, and FOBT with perianal examination and was superior to the laboratory value-only model (P < 0.001) that was validated in a separate cohort. Perianal examination and FOBT improve sensitivity in screening children for IBD.

PTU-198 Systematic review of the assessment and management of anal intraepithelial neoplasia grade iii

Introduction Anal Intraepithelial Neoplasia (AIN) is dysplasia in the squamous epithelium of the anus and is a precursor for anal squamous cell carcinoma. AIN is associated with many risk factors particularly infection with the Human Papilloma Virus (HPV), which is found in 90% of cases. There is ambiguity with regards to the optimal management of AIN III and there are significant variations in the published guidelines produced by official bodies. Therefore the optimal treatment and long term management of AIN III is yet to be standardised. The aim of this review is to assess the evidence behind national society guidelines currently available in the literature available on AIN III management, surveillance and treatment. Method An electronic search of Pubmed was performed using the search terms ‘anal intraepithelial neoplasia’, ‘AIN’, ‘anal cancer’, ‘guidelines’, ‘surveillance’ and ‘management’. Literature reviews and guidelines or practice guidelines in peer reviewed journals from 1 st January 2000 to 31 st December 2014, assessing the treatment, surveillance or management of patients with AIN related to HPV were included. The guidelines identified by the search were assessed for the quality of evidence behind them using the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence. Results The database search identified 4473 articles and 2 guidelines were sourced from official body guidelines (ACPGBI and ASCRS). After inclusion criteria were applied, 22 abstracts were reviewed and 10 were excluded as they were not relevant to AIN III or anal cancer, and a further 6 were excluded as they were earlier versions of current guidelines. Three guidelines (American College of Radiology, NCCN and the European Society for Medical Oncology) were excluded as they were recommendations for anal cancer leaving three guidelines for review. Guidelines published by ACPGBI, ASCRS Italian Society of Colorectal Surgery (SICCR) were included for the systematic review. Conclusion All 3 guidelines agree that a high index of clinical suspicion is necessary for diagnosing AIN III. A disease specific history focussing on signs, symptoms and predisposing risk factors as well as a perianal examination, digital rectal examination and anal cytology is essential for assessment. However, there is significant variation amongst the guidelines with regards to surveillance, medical treatment, surgical excision and follow-up of patients with AIN III. The quality of evidence used to form the guidelines is of a low level with the majority based on Level 3 or 4 evidence. This review highlights that the current guidelines available are based on out-dated evidence of low quality and standardised registry data is needed to standardise assessment, treatment and surveillance to improve overall outcome. Disclosure of interest None Declared.

An Uncommon Combination of Polyps

Question: A 43-year-old woman, with an unremarkable medical history, was admitted for chronic diarrhea. Colonoscopy was performed to evaluate the diarrhea. Perianal examination before the procedure revealed a 2.5 2 1.5-cm lesion extruding from the anus (Figure A) but reducible on digital examination. On top of the lesion was a 5-mm patch of a different appearing surface with a granular pattern (Figure B). Subsequent colonoscopy was otherwise normal, although the polyp was confirmed on retroflexion (Figure C). What is your diagnosis for this lesion? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Anal carcinoma and HIV infection: Is it time for screening?

Abstract A 38-year-old white man had a 10-year history of human immunodeficiency virus (HIV) infection (A3), with no episodes of opportunistic diseases and in good immunologic recovery (CD4 cell count: 450 and indetectable HIV viral load) while on HAART. He presented with a two-month history of mild anal symptoms, including pruritus and episodic bleeding. He referred past episodes of anal warts, self-treated with several topical compounds, all proven unsuccessful. Perianal examination showed erythema and scratching. A 0.5 cm sized tumor, with infiltration at the base was detected on digital exam, located at 15 mm from the anal margin. Local biopsy driven by high-resolution anuscopy (AAR) yielded a final diagnosis of infiltrative epidermoid carcinoma. Might that neoplasia have been prevented?