Perianal Ulceration Research Articles

A proper application of chemotherapeutic agent at the site of anal fissure: a major concern in healing anal fissure

Background: To show the efficacy of chemotherapeutic agent by special emphasis on its proper application at the site of anal fissure.Methods: All patients were seen in outpatient department and were initially started with 0.2% Glyceryl trinitrate ointment along with sitz bath and psyllium fiber as a primary treatment while 2% diltiazem cream reserved for refractory cases. The follow up visits were made weekly for perianal pain relief and ulcer healing rate.Results: Results in terms of healing of anal fissure and perianal pain relief in 2 or 4 weeks duration were recorded in SPSS version 17. 0.2% GTN ointment showed 75% results in 2 weeks. While complete response was achieved in 95% cases in 4weeks. 2% diltiazem responded in 98% cases in 2 weeks. Non-compliant (2%) abandoned the medical treatment early in the course and proceeded for surgery where 99.99% results were seen in 2weeks only.Conclusions: Conservative treatment is the gold standard for managing anal fissure. Effective counseling of proper application of ointment at the site of anal fissure is emphasized, which is usually failed by the patient due to intense, excruciating peri anal pain and spasmodic sphincter contraction which led them to proceed to surgery.

A rare case of methotrexate－associated lymphoproliferative disorder presenting as a perianal ulcer

A rare case of methotrexate－associated lymphoproliferative disorder presenting as a perianal ulcer

Cutaneous cytomegalovirus manifestations, diagnosis, and treatment: a review

The possible presentations of cytomegalovirus (CMV) are vast not only in its systemic manifestations, but also in the various cutaneous lesions that may result. Cutaneous cytomegalovirus is rarely reported in the literature because the clinical and pathologic features can be difficult to identify. Its identification, however, is vital as cutaneous human CMV infection can signal systemic disease and an unfavorable prognosis. The objective of this study is to aid in recognition, diagnosis, and treatment of CMV according to dermatological evidence. A complete literature search was performed within PubMed, resulting in the inclusion of 58 patient cases. The most common dermatologic manifestation was perianal or oral ulcers, but the locations and types of lesions noted throughout the review were numerous. Treatment is often simple, yet incorrect diagnoses along with concurrent illnesses can often complicate management. It is imperative for CMV to be detected early in its course to prevent mortality, especially in the immunocompromised. Dermatological presentations are often the first sign of this deadly virus' activity and it is essential that these diagnoses are made more efficient and accurate.

Extensive perianal basal cell carcinoma: a case report.

Introduction: Basal cell carcinoma is the most common skin cancer. It usually occurs in sun-exposed areas; perianal location is rare. The extension to the anal canal is exceptional, only a few cases were reported in the literature. Observation: we report the case of a 58 years old patient, referred for a chronic ulceration of the perianal area. Histopathology revealed an extensive basal cell carcinoma. a large excision was performed, with a favorable outcome. conclusion: the main lesson from this case is that although basal cell carcinoma is exceptional in the perianal region, a biopsy is mandatory for all chronic perianal ulcerations.

Extensive vulval and perianal ulceration due to genital herpes virus infection.

Extensive vulval and perianal ulceration due to genital herpes virus infection.

Current diagnosis and treatment of sexually transmitted infections

In recent years, there has been an increasing incidence of sexually transmitted infections (STI), which in turn play amajor role in urological clinical routine. Which STIs are relevant in urological clinical routine? What kind of recommendations for diagnosis and treatment exist? Review of evidence-based recommendations from the literature, current guidelines of the European Association of Urology and the Robert-Koch-Institute. STIs can be differentiated into those that cause genital, anal, perianal or oral ulcers from STIs that cause urethritis, cervicitis, or urethral or vaginal discharge. Asymptomatic courses are frequently observed. For diagnosis predominantly amplification methods are recommended. The local resistance situation should be considered. Special attention is paid to the worldwide increasing resistance of gonococci. The sexual partner should also be treated. In addition, diagnosis and therapy of other STIs should be made due to the high rate of co-infection. Due to the increasing incidence of STIs, the recognition and evidence-based treatment of these infections is essential to avoid ascending infections, long-term consequences, and further transmissions. It is important to assure the infectious material before initiating therapy to be able to switch from the initially initiated calculated therapy (also considering the local resistance situation) to atest-appropriate therapy.

An Unusual Cause of Perianal Ulceration in an HIV-Negative Patient

An Unusual Cause of Perianal Ulceration in an HIV-Negative Patient

Nicorandil-induced penile ulceration - surgical excision: case series and review of literature.

Nicorandil, a nicotinamide ester, is used in the prevention of angina pectoris. There is now a well-established association of perianal ulceration and the use of the drug. However, in the recent years, there have been reports of penile skin, vulval and even vaginal ulcers caused by nicorandil. We report three cases of nicorandil-induced penile ulcers which were surgically managed, and present a review of current literature.

Man with a perianal ulcer, what to think?

Man with a perianal ulcer, what to think?

Ectopic intestinal mucosa implanted on the perianal skin of a patient with Crohn disease

Intestinal mucosa implanted in skin is an exceedingly rare occurrence. Implantations are thought to occur during the creation of ostomy sites or other surgical procedures in which suture goes through bowel mucosa and then skin. Current ostomy literature reports this as a very uncommon complication. We present a 54-year-old man diagnosed with Crohn disease with severe perianal involvement who was referred to our outpatient clinic because of two persistent perianal cutaneous ulcerations. He previously underwent several interventions to drain complex perianal fistulas and abscesses, the last of them involved placing seton stitches to ensure continuous draining during the healing process. Physical examination revealed two painful ulcerations with bleeding on contact. A skin biopsy was performed, revealing ectopic intestinal mucosa with crypts, villi, and goblet cells. Perianal ulcerations characteristic of Crohn disease might be difficult to differentiate from ectopic implant of bowel mucosa secondary to a surgical procedure in the perianal area. Therefore, we believe a high degree of suspicion and skin biopsy are key to the diagnosis.

MRSA in the Blood From MRSA in the Gut: A Rare Presentation of MRSA Bacteremia From a Gastrointestinal Source

MRSA causes a wide variety of diseases in humans ranging from benign skin infections to life-threatening sepsis. Blood stream infections (BSI) secondary to MRSA have high mortality rates of 20-40%. Immunocompromised patients are at risk of acquiring health care associated MRSA BSI. Most common sources for MRSA BSI are intravascular inoculation, urinary tract infection and pneumonia. We report a case of MRSA BSI originated from gastrointestinal tract. A 23-year-old African-American male with a history of HIV presented with odynophagia, weight loss and hematochezia. Subsequently, he developed septic shock due to MRSA bacteremia. The initial physical examination was significant for cachexia, oral thrush, grade III systolic murmur in mitral area, perianal ulcers, painful digital rectal exam with few stains of blood on the gloved finger. Laboratory data was significant for CD4 count of 21 cell/mm3, hemoglobin of 9.9 g/dl, creatinine of 1.53 mg/dl. Bactrim and Azithromycin was started for HIV prophylaxis. Upper GI Endoscopy was positive for severe candida esophagitis. Colonoscopy showed multiple superficial ulcers in the transverse colon and terminal ileum with the biopsy negative for IBD. Subsequently he developed fever and watery diarrhea. Stool cultures were positive for MRSA. Blood cultures were obtained which grew MRSA with similar sensitivity pattern as of the gut MRSA. He was successfully treated with IV Vancomycin for MRSA bacteremia. TEE did not show any evidence of endocarditis. Repeat blood and stool cultures were negative. The patient was subsequently discharged with initiation of HAART therapy. HIV/AIDS patients are at increased risk for infections and MRSA is one of the most common pathogens in hospital settings. The common sites of MRSA carriage are nose, throat and rectum. There have not been convincing case reports of gastrointestinal origin of MRSA BSI in the past. However, it has been demonstrated in an immunocompromised mice model that MRSA BSI could be originated from the gut derived bacteria and the proposed mechanism was the migration of bacteria from the intestinal lumen to blood stream. MRSA in the blood from MRSA in the gut could account for a portion of 10-20% of cases when the sources remain unidentified. Early diagnosis and treatment of MRSA infection of GI tract may prevent serious complications including MRSA bacteremia and septic shock in severely immunocompromised patients.

Anoperineal lesions in Crohn's disease: French recommendations for clinical practice.

Anoperineal lesion (APL) occurrence is a significant event in the evolution of Crohn's disease (CD). Management should involve a multidisciplinary approach combining the knowledge of the gastroenterologist, the colorectal surgeon and the radiologist who have appropriate experience in this area. Given the low level of evidence of available medical and surgical strategies, the aim of this work was to establish a French expert consensus on management of anal Crohn's disease. These recommendations were led under the aegis of the Société Nationale Française de Colo-Proctologie (SNFCP). They report a consensus on the management of perianal Crohn's disease lesions, including fistulas, ulceration and anorectal stenosis and propose an appropriate treatment strategy, as well as sphincter-preserving and multidisciplinary management. A panel of French gastroenterologists and colorectal surgeons with expertise in inflammatory bowel diseases reviewed the literature in order to provide practical management pathways for perianal CD. Analysis of the literature was made according to the recommendations of the Haute Autorité de Santé (HAS) to establish a level of proof for each publication and then to propose a rank of recommendation. When lack of factual data precluded ranking according to the HAS, proposals based on expert opinion were written. Therefore, once all the authors agreed on a consensual statement, it was then submitted to all the members of the SNFCP. As initial literature review stopped in December 2014, more recent European or international guidelines have been published since and were included in the analysis. MRI is recommended for complex secondary lesions, particularly after failure of previous medical and/or surgical treatments. For severe anal ulceration in Crohn's disease, maximal medical treatment with anti-TNF agent is recommended. After prolonged drainage of simple anal fistula by a flexible elastic loop or loosely tied seton, and after obtaining luminal and perineal remission by immunosuppressive therapy and/or anti-TNF agents, the surgical treatment options to be discussed are simple seton removal or injection of the fistula tract with biological glue. After prolonged loose-seton drainage of the complex anal fistula in Crohn's disease, and after obtaining luminal and perineal remission with anti-TNF±immunosuppressive therapy, surgical treatment options are simple removal of seton and rectal advancement flap. Colostomy is indicated as a last option for severe APL, possibly associated with a proctectomy if there is refractory rectal involvement after failure of other medical and surgical treatments. The evaluation of anorectal stenosis of Crohn's disease (ARSCD) requires a physical examination, sometimes under anesthesia, plus endoscopy with biopsies and MRI to describe the stenosis itself, to identify associated inflammatory, infectious or dysplastic lesions, and to search for injury or fibrosis of the sphincter. Therapeutic strategy for ARSCD requires medical-surgical cooperation.

Enhancement of Wound Healing by the Traditional Chinese Medicine Herbal Mixture Sophora flavescens in a Rat Model of Perianal Ulceration.

Hemorrhoidectomy is often associated with significant postoperative complications that may result in slow wound healing. The traditional Chinese medicine (TCM) compound Sophora flavescens (CSF) has shown efficacy on many inflammatory disorders. The aim of the present study was to examine the efficacy of CSF on wound healing in a rat model of perianal ulceration. A rat model of perianal ulceration was induced by subcutaneous injection of 75% glacial acetic acid. The animals with induced perianal ulcer received topical treatment of low, medium, and high doses of CFS twice daily. Potassium permanganate (PP); 0.02%) was given to the animals for comparison. Macroscopic and histological assessments of the ulcerated area were performed after treatment. The expression of pro-inflammatory cytokines prostaglandin E2 (PGE2) and interleukin-8 (IL-8) was detected by immunohistochemical analysis. Topical administration of medium- and high-dose CSF significantly enhanced perianal ulcer healing as compared to the untreated control (p<0.05). The macroscopic ulceration score was significantly reduced only in the high-dose CSF-treated group as compared to the control (p<0.01). All doses of CSF and PP ameliorated histological damages in the rats with induced perianal ulceration. High-dose CSF or PP significantly reduced the expression of PGE2 and IL-8 as compared to the control (p<0.01). No treatment-related toxicity was found in either the CSF- or the PP-treated mice. CSF enhances wound healing in a rat model of perianal ulceration. The inhibitory effect of CSF on pro-inflammatory cytokines PGE2 and IL-8 may be involved in the mechanism of enhanced wound-healing.

Ulceras herpéticas perianales en pacientes inmunodeprimidos. Presentación de dos casos

Ulceras herpéticas perianales en pacientes inmunodeprimidos. Presentación de dos casos

Painful Hematochezia in HIV-Positive Male

A 37 year old male presented to the emergency room with complaints of sudden onset, progressively worsening painful hematochezia and abdominal cramping for 1 week. The patient had formed stool coated on the outside with fresh blood and clots. He denied similar symptoms in the past, local trauma, fever or diarrhea. His only medication was efavirenz/emtricitabine/tenofovir combination (Atripla) which he started taking for human immunodeficiency virus (HIV) infection in 2007. His CD4 count was 1069/mm3 and he had recently been treated for syphilis. His physical exam was unremarkable except for streaks of fresh blood and pain on rectal examination. His lab parameters were normal. A contrast enhanced CT scan showed mild rectal wall thickening possibly from proctitis or underdistension. Stool cultures were negative for ova and parasites. Urine and culture examinations were negative for Neisseria gonococcus and Chlamydia trachomatis. A flexible sigmoidoscopy showed noncircumferential diffusely erythematous mucosa with bleeding on contact, extending contiguously from 5 cm to 20 cm from the anal verge (Figure 1). Biopsies showed non-specific chronic inflammation in the lamina propria. When questioned, the patient disclosed that he recently had anal receptive intercourse. A rectal swab tested positive for Chlamydia trachomatis Lymphogranuloma venereum (LGV). He was treated with Doxycycline 100 mg BID for 21 days with resolution of symptoms. C. trachomatis is the most commonly reported sexually transmitted infection in the United States and an important cause of proctitis and proctocolitis in men who have sex with men. LGV serovars L1, L2, L3 produce a more aggressive infection manifest by perianal, anal or rectal ulceration with resulting pain and discharge. Since itis an obligate intracellular organism, diagnostic samples should contain cellular material to permit detection. This often necessitates the use of a rectal swab and subsequent microbiological assessment.Figure 1Figure 2

Refractory Perianal Ulcers in a Neonate. Beyond the Diaper Rash

Refractory Perianal Ulcers in a Neonate. Beyond the Diaper Rash

Sexually Transmitted Infections: Experience in a Multidisciplinary Clinic in a Tertiary Hospital (2010-2013)

BackgroundThe number of consultations for sexually transmitted infections (STIs) is increasing in Spain. The aim of this study was to describe and analyze the epidemiological, behavioral, clinical, and microbiological characteristics of patients registered at the STI unit of a tertiary hospital. MethodsThis was a retrospective, single-center descriptive study carried out between 2010 and 2013 in a multidisciplinary unit specialized in STIs, situated in a tertiary hospital. Epidemiological, clinical, and behavioral data were gathered using a face-to-face interview and a standardized questionnaire. Samples were collected for microbiology analysis. ResultsThe study included 546 patients: 96% were men, 41% had human immunodeficiency virus (HIV) infection, and 56% were men who have sex with men. The reasons for consultation were the following: urethritis; genital, anal, or perianal ulcers; proctitis; oral ulcers; sexual contact with a person with a known STI; and high-risk sexual contact. The most common microbiological diagnoses were Neisseria gonorrhoeae in urethritis, Treponema pallidum in genital and anal or perianal ulcers, and Chlamydia trachomatis lymphogranuloma venereum serovars in proctitis. The highest prevalences of the main STIs studied occurred in homosexual men with HIV infection. ConclusionThis study confirms the increase in the incidence of STIs in recent years and the epidemiological characteristics of the HIV/STI epidemic in Spain.

The Presentation, Diagnosis, and Treatment of Sexually Transmitted Infections.

The reported incidence of sexually transmitted infections (STIs) in Germany is rising. For example, the number of new reported cases of syphilis rose from 3034 in 2010 to 4410 in 2012. This review is based on pertinent articles retrieved by a selective search in MEDLINE, and on guidelines and systematic reviews from Germany and abroad. We discuss sexually transmitted infections presenting with genital, anal, perianal, or oral ulcers, urethritis, cervicitis, urethral or vaginal discharge, or genital warts. We also discuss sexually transmitted infection with HIV and the hepatitis C virus (HCV). Acquired sexually transmitted infections elevate the risk of transmission of other sexually transmitted infections; thus, patients presenting for the diagnosis or treatment of any kind of sexually transmitted infection should be evaluated for others as well. For most of these diseases, treatment of the patient's sexual partner(s) is indicated. Diagnostic nucleic acid amplification techniques are over 90% sensitive and specific and are generally the best way to detect the responsible pathogen. Factors impeding effective treatment include antibiotic resistance (an increasing problem) and the late diagnosis of HIV and HCV infections. Sexually transmitted infections are common around the world, and any such infection increases the patient's risk of contracting other types of sexually transmitted infection. Molecular genetic diagnostic techniques should be made widely available.

Infecciones de transmisión sexual: experiencia de una consulta multidisciplinar en un hospital terciario (2010-2013)

IntroductionThe number of consultations for sexually transmitted infections (STIs) is increasing in Spain. The aim of this study was to describe and analyze the epidemiological, behavioral, clinical, and microbiological characteristics of patients registered at the STI unit of a tertiary hospital. MethodsThis was a retrospective, single-center descriptive study carried out between 2010 and 2013 in a multidisciplinary unit specialized in STIs, situated in a tertiary hospital. Epidemiological, clinical, and behavioral data were gathered using a face-to-face interview and a standardized questionnaire. Samples were collected for microbiology analysis. ResultsThe study included 546 patients: 96% were men, 41% had human immunodeficiency virus (HIV) infection, and 56% were men who have sex with men. The reasons for consultation were the following: urethritis; genital, anal, or perianal ulcers; proctitis; oral ulcers; sexual contact with a person with a known STI; and high-risk sexual contact. The most common microbiological diagnoses were Neisseria gonorrhoeae in urethritis, Treponema pallidum in genital and anal or perianal ulcers, and Chlamydia trachomatis lymphogranuloma venereum serovars in proctitis. The highest prevalences of the main STIs studied occurred in homosexual men with HIV infection. ConclusionThis study confirms the increase in the incidence of STIs in recent years and the epidemiological characteristics of the HIV/STI epidemic in Spain.

Herpetic Whitlow as a Clue to HSV Colitis in a Patient With Ulcerative Colitis: A Case Report

55-year old woman, diagnosed with ulcerative colitis (UC) proctitis, received rectal mesalamine for one week, followed by one month of hydrocortisone enemas and oral prednisone 20 mg daily. Her symptoms did not improve and repeat colonoscopy one month after diagnosis showed colitis involving two thirds of the colon. Prednisone was increased to 80 mg BID and Infliximab (IFX) 5 mg/kg and 6-mercaptopurine 50 mg daily were started. After three doses of IFX she developed worsening rectal bleeding. On admission she had normal vital signs. Physical exam was notable for circumferential perianal ulcers extended 5 cm onto the intergluteal fold and cleft. A group of coalesced vesicles with ulceration was noted on her right index finger. Labatory findings: hemoglobin 10.5 g/dL, ESR 53 mm/hr, CRP 0.7 mg/L. Infectious stool studies were negative. Intravenous (IV) methylprednisolone started on admission. Colonoscopy revealed a large ulceration in the descending colon and several circular superficial clean-based ulcers throughout the sigmoid colon which were biopsied. Dermatology biopsied the perianal ulcerations. The sigmoid and perianal biopsies showed multiple herpes simplex viral (HSV) inclusions and a single CMV inclusion. The patient's finger ulceration was clinically consistent with herpetic whitlow. IV ganciclovir was started to treat HSV and CMV colitis. The patient's symptoms of hematochezia improved within 7 days of IV ganciclovir. She was discharged on oral valgancyclovir and a prednisone taper. Both IFX and 6-MP were stopped indefinitely given the opportunistic infection. HSV colitis is rare with only a few reported cases, but it can cause major morbidity especially in patients with IBD. 2009 ECCO guidelines recommended against routine screening for latent HSV prior to starting immunomodulating IBD therapy. However, we believe that patients should routinely be asked if they have a history of orolabial, genital, or ophthalmic HSV infection prior to starting immunomodulating therapy. Patients with recurrent attacks should also be considered for prophylactic antiviral therapy. This is the first reported case of HSV colitis presenting with herpetic whitlow and perianal ulcerations. Our patient's unique presentation stresses the importance of a thorough physical exam, including skin and the perianal area, in all patients with suspected IBD relapse as it may suggest an easily overlooked opportunistic infection.Figure 1