Proctological Examination Research Articles

Anal Pathologies during Pregnancy and Postpartum: Diagnosis and Treatment at the Kalaban Coro Referral Health Center

Pregnancy and childbirth are generally considered to be happy episodes in women's lives, these events can be marred by anal affections. The exact epidemiology of anal pathologies is difficult to define, due to the reluctance of patients to discuss their symptoms and to be examined. In most cases, their diagnosis is delayed and their management is inadequate or inappropriate. Aim: To study anal pathologies during gravido-puerperality at the CS Ref of Kalaban Coro. Methods: This was a single-center descriptive and analytical prospective study with prospective data survey at the CS Ref of Kalaban Coro. The study was conducted over a 9-month period from January 1 to September 30, 2019. Results: During the study period, we identified 151 pregnant women. Of these pregnants, 88 or 58.27% had anal pathology. The different anal pathologies encountered were, hemorrhoidal disease (30.68%), anal fissure (30.68%) and anal incontinence (27.27%). The offending factors were dominated by constipation, a newborn weight > 3500g, a foetal expulsion time > 20 minutes. The clinic was conducted by interrogation and proctological examination. Clinical signs were anal pain, rectorrhagia, and pruritus. Treatment primarily includes the regulation of intestinal transit and topical topicals, analgesics, and those that improve blood circulation (Veinobiase, Daflon).

Buschke-Löwenstein Tumor: Ano-Perineal Location (About 4 Cases)

Buschke-Löwenstein tumor belongs to the group of verrucous carcinomas, a relatively rare condition and always precedes condyloma acuminata. This tumor is more common in men and immunocompromised people, it develops in the genital area, the perineum and the anus, creating a large budding lesion. The aim of our work is to analyze the epidemiological, clinical, paraclinical and therapeutic data of these tumors based on our 4 observations collected over 2 years and a review of the literature. The average age was 47.5 years with a male predominance. Sex ratio 3. The three men had spent time in a prison environment. All patients had had at least one anal coitus. Clinical signs are represented by anal swelling, rectal bleeding, moist anus and signs of anemia. Proctological examination revealed an ulcerative-budding cauliflower appearance in all patients. Immunodeficiency virus serology (HIV) was positive in 3 patients. The biopsy revealed a Buschke-Löwenstein tumor without signs of transformation in 3 patients with one case of squamous cell carcinoma. An abdominopelvic CT scan was performed in all patients revealing no signs of sphincter infiltration or other neighboring organs. The treatment consisted of a wide excision associated with analplasty in all patients. Eight months later, we noted a recurrence in one patient, but very minimal, who was treated by electrocautery. Surgical management of Buschke-Löwenstein tumor must be carried out by an experienced surgeon.

The lucky polyp: an unusual manifestation of chronic schistosomiasis.

A 23-year-old male from Brazil presented with bright red hematochezia. Proctological examination revealed grade II internal hemorrhoids, but flexible sigmoidoscopy uncovered a 6 mm-pedunculated polyp in the sigmoid colon, which was found to result from inflammatory reaction to Schistosoma mansoni egg deposition. The patient had no signs of portal hypertension and was successfully treated with praziquantel. This case underscores a rare presentation of chronic intestinal schistosomiasis and emphasizes the role of early diagnosis in preventing severe hepatic sequelae of chronic Schistosoma infection.

Anorectalis régiót érintő STI fertőzések

The authors present the case of a 20-year-old male patient, who was refered to their department by his family doctor with suspected drug allergy. He had several proctological examinations in the last half year, because of a chronic intermittently bleeding anal fissure, which has been treated with analgesic rectal cream and wound healing gel. During physical examination multiple maculopapular rash all over the body, infiltrated brownish papules on the soles and purulent discharge on the pharyngeal wall were detected. Differential diagnosis included secondary syphilis, viral exanthema and drug eruption. The syphilis serological tests confirmed the diagnosis of secondary syphilis. The patient received benzathine-penicillin treatment. Due to the non-healing anal fissure pelvic MR was performed, which did not reveal definitive fistula. Further STI screening tests showed Neisseria gonorrhoeae infection of the anus and after ceftriaxon administration the patient’s anorectal symptoms healed. Our case emphasizes the importance of sexually transmitted co-infections.

(189) Sexual Abuse and Vesico-Sphincter Dysfunction

Abstract Introduction Even though urologists know that there may be an association between sexual abuse and urinary disorders, finding sexual abuse (SA) is often not part of their standardized questioning. Objective Evaluate the incidence of sexual abuse (SA) in women with vesico-sphincter dysfunction, to understand the cause-and-effect relationship in order to adapt their management. Methods A multi-parametric, cross-sectional study was conducted by a female doctor looking for sexual assault, the latter interviewed 214 women (42 years, extremes 19-75 years), followed by specialists between January 2017 and December 2019. All patients were evaluated by voiding schedule, MHU score (a measure of urinary disability), bladder fibroscopy, and urodynamic workup and spinal MRI to exclude neurological injury. The results are presented in Tables 1 and 2. Results The possible recollection of a memory of sexual abuse leads to a categorical refusal of the urogynecological clinical examination or an attitude of opposition during a urodynamic or proctological examination. No correlation between the painfulness of this memory and the seriousness of what induced it has been demonstrated; sometimes a simple examination may have been experienced as aggression. The observation of a "frozen" perimeter, which does not contract with the effort of restraint and does not relax with the push or the request for relaxation, will draw our attention even more to the fact that it is a hypertonic perimeter. Conclusions Sexual assaults are very frequent and their management is multidisciplinary due to the physical, psychological, or psychosomatic consequences. They concern men as well as women, regardless of the socio-economic context, and this has been shown in all epidemiological studies. This proves the strong causal link between LUTS and sexual abuse. Disclosure No

Sexual violence against women in southern Tunisia: Epidemiology and risk factors

IntroductionSexual violence (SV) against women represents a public health problem. Despite, the promulgation of the new Act of 2017-58, SV remains frequent in Tunisia. In this paper, we propose to determine the socio-demographic characteristics of women victims of SV and to identify risk factors related to serious SV. Material and methodsThis is a retrospective, descriptive and analytical study including all women victims of SV, examined at the Forensic Department of Sfax Hospital, between 1st March 2018 and February 29th, 2020. We defined serious SV as any sexual violence associated with genital or anal lesions. ResultsWe collected 269 cases of women victims of SV. This sexual violence was associated with extra-genital physical violence in 18.86 % of the cases. The average age of the victims was 21.23 years (+/−10.67 years). The consultation delay was relatively long. Only 11.52 % of victims consulted within 24 h. It was mainly an extra-family abuse. Vaginal examination revealed recent defloration in 9.29 % of the cases. The proctological examination was normal in most cases (61.63 %).Seven victims were pregnant.In the analytical study, we studied the risk factors of serious SV against women. A total of 150 cases were considered serious (55.8 %). Serious SV was statistically related to the age (over 18),the profession (housewives),the origin (urban),and the relationship with the aggressor (friend, neighbor, or family member).The risk of serious SV was greater when the victim didn’t have any traumatic extra-genital injury. ConclusionSexual violence is a serious problem worldwide and in Tunisia. The Tunisian legislation repressing SV has been strengthened by the promulgation of the 2017-58 Act. However, much effort remains to be deployed to fight against this form of violence.

Anorectal Function and Clinical Characteristics Associated with Faecal Incontinence in Patients with Crohn's Disease.

Faecal incontinence is an important complaint reported by patients with Crohn's disease [CD] and it is associated with several disease-related mechanisms, including anorectal functional disorders. This study aimed to assess the anorectal function and clinical characteristics to identify parameters associated with faecal incontinence in CD patients. This is a cross-sectional study of 104 patients with CD, aged 18 years or older, from a referral centre between August 2019 and May 2021. Patients responded to a specific questionnaire, and underwent medical record review, proctological examination and anorectal functional assessment with anorectal manometry. Of the 104 patients, 49% were incontinent. Patients with incontinence had a lower mean resting pressure [43.5 vs 53.1 mmHg; p = 0.038], lower mean squeeze pressure [62.1 vs 94.1 mmHg; p = 0.036] and lower maximum rectal capacity [140 vs 180 mL; p < 0.001]. Faecal incontinence was also associated with disease activity [p < 0.001], loose stools [p = 0.02], perianal disease [p = 0.006], previous anoperineal surgery [p = 0.048] and number of anorectal surgeries [p = 0.036]. This is the largest reported study describing manometric findings of Crohn's disease patients with and without faecal incontinence. Our results identified an association between faecal incontinence and functional disorders, in addition to clinical features in these patients. Functional assessment with anorectal manometry may help choose the best treatment for faecal incontinence in patients with CD.

Safety and efficacy of Levorag emulgel in the treatment of anal fissures using a validated scoring system.

Anal fissure is one of the most common anal disease characterized by intense anal pain, and deterioration of patients quality of life. Treatment is mainly based on the topical administration of calcium antagonist or nitric oxide ointments, and in cases refractory to medical treatment patients can undergo surgery. This study aims to assess the efficacy and safety of Levorag emulgel in the treatment of acute and chronic fissures using of a validated scoring system. A prospective observational study was carried out on patients with anal fissures between February and May 2022. The efficacy of the treatment was evaluated using the REALISE score, a new validated scoring system that rates VAS for pain, NSAID use, pain duration, bleeding, and quality of life (QoL), recorded after 10, 20 and 30 days from the beginning of treatment. Forty patients (median age 46 years, IQR 29-57, 70% women) with acute (22, 55%) or chronic (18, 45%) anal fissures entered the study. The median anal pain score according to the VAS scale decreased significantly from 7 (IQR 4.7-8) at baseline to 1 (IQR 0-3.2, p = 0.05) after 20 days. At the 30-day proctological examination, 22 patients (61%) were pain free (median VAS of 0, IQR 0-1.2, p < 0.05). Pain duration after defecation measured according to the REALISE score, showed a significant decrease after 10 days, from a median value of 2 (IQR 1-4) to 1 (IQR 1-1.2) (p < 0.005). The median value of the REALISE score decreased significantly, from 15 (IQR 11-19.25) at first proctological evaluation to 4 (IQR 4-6, p = 0.139) after 30 days of treatment. At day 30, complete fissure healing was achieved in 30 patients (80%). The healing rate was 82% and 78% in patients with acute and chronic anal fissures, respectively. The use of Levorag® Emulgel may represent a safe and effective non-invasive first line treatment in patients affected by acute or chronic anal fissure.

Anogenital symptoms and lesions in a series of 20 patients infected with monkeypox virus.

Monkeypox virus (MPXV) has been spreading in many European countries, the USA and Canada since May 2022. General symptoms, skin and anoperineal lesions have been reported. Anal pain is often reported, but anal canal lesions have yet to be described in these patients. The aim of this study was to describe anoperineal lesions in patients infected with MPXV undergoing systematic margin and anal canal examination at a tertiary care centre in France. In this prospective descriptive study, systematic anal examination was performed in 20 patients diagnosed with MPXV infection at Bichat Hospital, Paris, France between 6 and 11 July 2022. Anal swabs were also obtained from all these patients for polymerase chain reaction testing for MPXV. All the patients were men that have sex with men (MSM). Sixteen patients had anal symptoms: 13 reported anal pain, and the other anal symptoms described were anal bleeding (n=12), pruritus (n=11), dyschezia (n=10), tenesmus (n=13), burning (n=3), swelling (n=9) and discharge of mucus (n=9). Proctological examination detected: (i) anal margin lesions in 14 patients (vesicles, n=8; pustules, n=6; ulceration, n=6); (ii) anal canal lesions in 16 patients (ulceration, n=13; ulcers, n=4; pustules, n=1), seven of whom presented anal hypertonia; and (iii) rectal lesions in 12 patients (congested rectum, n=6; erythema, n=10; ulcers, n=2; not seen in one case). the presence of mucus was noted in 10 patients and the presence of blood in six patients. This is the first study to describe anal canal lesions in patients infected with MPXV. Most of the observed lesions were ulceration, accounting for the pain reported.

P155 Natural history of anal stricture in pediatric-onset Crohn’s disease: a two-decades population-based study

Abstract Background The natural history of anal stricture complicating pediatric-onset Crohn’s disease (CD) is poorly known. The aims of this study were: to determine in a population-based study the risk of anal stricture in pediatric-onset CD; to identify risk factors for anal stricture; and to evaluate the natural history of anal stricture at the population level. Methods All patients with a diagnosis of CD made before the age of 17 years between 1988 and 2011 in a population-based registry were followed retrospectively until 2013. A specific collection of additional data was performed in patients with anal stricture at diagnosis or during follow-up. Variables collected included: proctological examination, diagnostic management and treatment. Multivariate Cox models were used to identify factors associated with anal stricture. Results Among the 1,007 included CD patients (females, 451 (44.8%); median age at diagnosis 14.4 years (IQR, 12.0-16.1), median follow-up 8.8 years (IQR, 4.6-14.2)), only one (0.1%) had anal stricture at diagnosis while 26 (2.6%) presented anal stricture during follow-up. Cumulative incidence of anal stricture at 5 and 10 years after diagnosis was 0.6% (CI95%, 0.1-1.1) and 1.4% (CI95%, 0.5-2.3), respectively. Among the 27 patients with anal stricture, 25 (92.6%) had already at least one episode of anal ulceration or fistulizing perianal CD (pCD). In multivariable analysis, the presence of extra-intestinal manifestations (Hazard Ratio (HR) 2.2, CI95% 1.0-4.8, p=0.027), colonic location (L1 vs L3 HR 0.0 (-); L2 vs L3 HR 1.2, CI95% 0.6-2.7, p=0.006) and history of fistulizing pCD (HR 9.9, CI95% 4.3-22.8, p&amp;lt;0.0001) were significantly associated with anal stricture. Eleven (41%) patients needed at least one dilation. After a median follow-up of 16.9 years (IQR, 11.5-20.2), healing of anal stricture was observed only once. One patient (3.7%) presented an anal cancer 7 years after the diagnosis of anal stricture. Nine (33.3%) patients needed a stoma. Among them, 8 already had a fistulizing pCD and 4 needed an abdominoperineal amputation. Anal stricture was significantly associated with an increased risk of stoma (HR 5.8, CI95% 2.3-14.3), p=0.0002). Conclusion Anal stricture is a rare event in pediatric onset CD, occurring in 1.5% of patients over a 10 year-period after diagnosis. However, anal stricture had a negative impact on disease prognosis with a five-fold increase of the risk of stoma.

Postpartum anal sphincter injury – overlap suturing. Case report

Injury to the anal sphincter is a challenging clinical problem that may be encountered by any doctor in their daily practice. The most common injuries are associated with complicated childbirth, traffic accidents and impalement-type injuries. Depending on their course, injuries with or without sphincter muscle disruption have been distinguished. We present a case of obstetric trauma in a primiparous woman aged 25 years with grade 3 perineal tear. The injury was repaired within 2 hours of delivery. The muscles were sutured using the overlap method with good functional and cosmetic outcomes. The patient reported no symptoms of incontinence in the following weeks after the injury, the anus was compact. A follow-up proctological examination showed normal sphincter tone and function. We would like to emphasise the importance of regular training in practical proctological knowledge. The ability to repair such a challenging injury requires continuous proctological practice. Grade 3-4 perineal injuries are relatively rare, most commonly managed by obstetric gynaecologists. Therefore, it is often impossible to acquire skills in this area as part of daily surgical practice.

Early and midterm results of radiofrequency ablation (Rafaelo® procedure) for third-degree haemorrhoids: a prospective, two-centre study.

BackgroundThe aim of this study was to evaluate the safety and efficacy of radiofrequency ablation (RFA) for treating third degree haemorrhoids, with a follow-up over 2 years.MethodsWe conducted a prospective, two-centre study to assess RFA of third-degree haemorrhoids in an outpatient setting. Treatment was performed under local anaesthesia, optionally in combination with sedation. The primary endpoint was analysis of a proctological symptom score ([PSS] bleeding, itching, pain, soiling) and proctological examination to detect recurrence at 1, 6, 12 and 24 months after surgery. The secondary endpoints were postoperative complications, incidence of postoperative pain, including administration of analgesics and time to return to daily routine.ResultsNinety-eight patients were included in the study. The mean age of the patients was 49.1 ± 10.9 (mean ± SD). 83 patients (84.7%) were male and 15 patients (15.3%) were female. The follow-up involved 100% (1 month), 95% (6 months), 86% (12 months) and 74% after 24 months. The individual symptom scores and overall PSS score decreased significantly in comparison to the initial score at each time point assessed. Prolapsed haemorrhoids decreased in comparison to the initial situation (100%) to 7.2% (1 month), 3.5% (6 months), 13.1% (12 months) and 13.7% (after 24 months). Thirteen patients (12.7%) required repeat haemorrhoid therapy during the 2-year follow-up period. The mean maximum pain score after the procedure was 2.5 ± 2.7 (determined with the visual analogue scale), while 33 (33.7%) patients reported having no pain. 59 (60.2%) patients did not take analgesics after the procedure. Eleven patients (11.2%) experienced minor complications (bleeding, fever, cramps, diarrhoea, anal venous thrombosis) but did not require additional treatment. Eight cases (8.2%) of major complications (infection, bleeding, severe pain) required treatment with antibiotics, a second intervention, analgesics or hospitalization.ConclusionsRFA is safe and effective for treatment of third-degree haemorrhoids. The main advantages of this new method are its use on an outpatient basis under local anaesthesia, a very low level of postoperative pain and significant control of haemorrhoid symptoms over 2 years.

OP35 Natural history of anal ulcerations in pediatric-onset Crohn’s Disease: A population-based study

Abstract Background Anal ulcerations are frequently observed in Crohn’s disease (CD). Their natural history remains poorly known, especially in pediatric-onset CD. The aims of this study were: to determine in a population-based study the risk of anal ulcerations in pediatric onset CD; to identify risk factors for anal ulcerations; to evaluate the risk of progression towards suppurative lesions; to evaluate the risk factors of progression towards suppurative lesions. 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. A specific collection of additional data was performed in patients with anal ulcerations at diagnosis or during follow-up. The variables collected included: proctological examination, diagnostic management (perineal MRI, endoscopic ultrasound, examination under general anaesthesia) and treatment (medical or surgical). Multivariate Cox models were used to identify factors associated with anal ulcerations and factors of progression towards suppurative lesions. An adjusted time-dependent Cox model was used to evaluate the risk of progression of anal ulcerations towards suppurative lesions. Results 1005 patients were included (females, 450 (44.8%); median age at diagnosis 14.4 years (IQR, 12.0–16.1)). 257 (25.6%) had anal ulceration at diagnosis. Cumulative incidence of anal ulceration at 5 and 10 years from diagnosis was 38.4% (CI95%, 35.2–41.4) and 44.0% (CI95%, 40.5–47.2). The presence of extra-intestinal manifestations (HR 1.46, CI95% 1.19–1.80, p=0.0003) and upper digestive location (HR 1.51, CI95% 1.23–1.86, p&amp;lt;0.0001) at diagnosis were associated with the occurrence of anal ulceration. Conversely, ileal location at diagnosis was associated with a lower risk of anal ulceration (L2 vs L1 HR 1.51, CI95% 1.11–2.06, p=0.0087; L3 vs L1 HR 1.42, CI95% 1.08–1.85, p=0.0116). Among the 352 patients with at least one episode of anal ulceration, 82 (23.3%) developed perianal suppuration after a median follow-up of 5.7 years (IQR, 2.8–10.6). The risk of perianal suppuration was doubled in patients with anal ulceration compared to those who did not have any ulceration (HR 2.0, CI95% 1.45–2.74, p&amp;lt;0.0001). In patients with anal ulceration, the diagnostic period (before or since the “biologic era”), exposure to immunosuppressants and/or anti-TNF did not influence the risk of perianal suppuration. Conclusion Anal ulceration is frequent in pediatric-onset CD, with nearly half of patients presenting with at least one episode after 10 years of evolution. Perianal suppurations are twice as frequent in patients with present or past anal ulceration. These results plead for a proactive therapeutic approach in case of anal ulcerations.

P692 Clinical, therapeutic and evolutionary profile of fistulizing ano-perineal lesions in Crohn’s disease

Abstract Background Ano-perineal lesions (APLs) during Crohn’s disease (CD) are frequent and varied. Ano-perineal fistulas (APF) are the most common and severe manifestations. They are associated with increased morbidity and considerable impairment of quality of life. Their management is not always easy despite therapeutic advances, particularly anti-TNFα.The aim of our work was to describe the epidemiological profile, the therapeutic modalities and the evolutionary aspects of APF during CD. Methods This was a retrospective, descriptive, single-center study collecting records of patients followed for CD with APF between January 2010 and December 2020. The patients had a proctological examination and a perineal MRI. We recorded clinical, endoscopic, radiological data, therapeutic management and clinical response to the initial therapeutic regimen. Complete remission was defined as closure of all initially productive fistulas, partial response was defined as closure of more than 50% of fistulas. Therapeutic failure was defined as closure of less than 50% of the initially productive fistulas. Results 83 patients followed up for CD with APLs were collated of which 38 had APF (45.7%). The mean age was 42 years [26 - 73] with a sex ratio of 0.4. Active smoking was noted in six patients (15.8%). In 55.3% of cases, PAF was present at the time of diagnosis of CD (n=21).17 patients had developed one or more PAFs during the course of their disease with a mean delay of seven years [1 - 29]. APFs were associated with luminal involvement in 94.7% of cases, with ileal location in 10 patients (26.3%), colonic location in 13 patients (34.2%) and ileocolic location in 13 patients. The APFs were perianal in 34cases, vulvovaginal in five cases and gluteal in one case. There were complex fistulas in 92.1% of cases. The number of external orifices at the time of diagnosis was respectively: 1 orifice in 63.2% of cases, 2orifices in 26.3% of cases and more than two orifices in 10.5% of cases. A perineal abscess was associated in 44.7% of cases and anorectal stricture was observed in 7.9% of patients. Seton drainage was performed in 86.6% of patients. All patients with complex APF had received anti-TNFα after disappearance of collections if initially present (infliximab (92.1%), adalimumab (7.9%)) combined with thiopurines in 97.4% of cases. After a mean follow-up of 40 months, a complete remission was observed in 14 patients (36.8%), a partial response was noted in 13 patients (34.2%). 11 patients (28.9%) were in therapeutic failure. Conclusion In our study, APFs during CD account for almost half of all APLs.Thus, the development of local therapeutic means proves to be of necessity in order to increase the efficacy of biotherapies and to accelerate the healing of APFs.

P325 Performance of new MRI scores: the modified Van Assche Index and the MAGNIFI-CD in the evaluation of the response to anti-TNFα in anoperineal fistulas in Crohn’s disease

Abstract Background Despite considerable therapeutic advances over the last two decades in the management of Crohn’s disease(CD), complex anoperineal fistulas(APF) still constitute a real therapeutic challenge for the practitioner. Treatment is mainly medico-surgical, combining seton drainage and biotherapy. The ultimate goal is to obtain a deep remission, which combines clinical remission and a normal perineal MRI. Thus, several MRI scores have been proposed to assess the therapeutic response of APF to biotherapy. The aim of this study was to investigate the reliability of the new MRI scores: the modified Van Assche Index(mVAI) and the MAGNIFI-CD in the evaluation of the response of APF to anti-TNFα, by comparing them to the old version of the Van Assche Index(VAI). Methods We conducted a retrospective study, including all patients followed up for CD with APF treated with anti-TNFα over a, 10-year period [2010–2020]. Clinical, biological, morphological and evolutionary data were collected. VAI, mVAI and MAGNIFI-CD scores were calculated from data provided by perineal MRI: number, locations, extensions and lengths of fistulous tracts, characteristics of collections. Clinical response to anti-TNFα was assessed by proctological examination, at the end of which the patients were classified into two groups: • Responders(26): having a complete remission (closure of all initially productive fistulous orifices) or partial response (closure of more than, 50% of orifices) • Non-responders(12): closure of less than, 50% of the initially productive fistulous orifices A statistical study was carried out to compare the performance of the different scores in assessing the response to treatment by calculating the area under the ROC curve with a, 95% confidence interval. Results A total of, 38 patients were included. The mean age was, 42 years [26–73] and the sex-ratio M/F was, 0,4. All patients had received anti-TNFα after disappearance of perineal collections if initially present (Infliximab in, 35 cases(92,1%) and Adalimumab in, 3 cases(7,9%)) combined with thiopurines in, 97,4%. The average duration of anti-TNFα therapy was, 46 months [5–180] The means of the different scores were calculated in responders and non-responders before and after anti-TNFα treatment respectively: A decrease in all three scores was observed after anti-TNFα treatment in the responders, in contrast to the non-responders, thus confirming therapeutic failure. Furthermore, the AUROC of the VAI, mVAI and MAGNIFI-CD scores in the assessment of response to anti-TNFα in APF were, 0,925, 0,908 and, 0,869 respectively. Conclusion Our results suggest that the old version of the VAI, as well as the mVAI and MAGNIFI-CD, are reliable scores with comparable performance in the assessment of response to treatment in APF in CD.

Epidemiological and clinical profile of primary anal fissures in the hospital of Sikasso

Anal fissure is a superficial attack of the anal canal between the skin-mucosa junction, located preferentially at the anal commissure. The objective of this study is to highlight the epidemiological and clinical profile of primary anal fissures in the hospital of Sikasso. This was a cross-sectional study that took place from February 2018 to January 2020 and included patients admitted to the hospital of Sikasso for primary anal fissure. Other cases of anal fissures were not included in this study. A total of 71 patients were collected during the study period. The mean age of our patients was 42.12 years (extremes 20 and 60 years) and a male/female sex ratio of 1.95. The symptoms were dominated by proctalgia (84%) followed by rectal pain (24%), constipation (12%), anal discharge (8%) and anal pruritus (0.71%). On proctological examination, the following were noted: presence of a sentinel mark (32%), sensitivity to palpation (45%), and moderate (56%), posterior (88%), anterior (8%), and lateral (0.71%) location. The fissure was at its first episode in 52% of cases (37 patients) and had recurred in 48% of cases (34 patients). Reflex sphincter hypertonia was noted in 26 patients (36%). The associated pathologies were internal hemorrhoids (45%), erythematous rectitis (0.71%) and rectal polyps (0.71%). The management was based on hygienic-dietary, medical and surgical aspects. Healing of the lesions was observed in 56% of cases after four weeks of medical treatment. The short and medium term satisfaction rate after surgery in 17 patients was 95%. Primary anal fissure is a common proctological pathology in Sikasso. Surgery remains the most effective, curative and definitive treatment, even if medical treatment associated with hygienic and dietary measures plays a major role in healing. Surgery is often ignored by the patient and surrounded by taboo in our environment.

Evaluation of the Efficacy and Safety of a Compound of Micronized Flavonoids in Combination With Vitamin C and Extracts of Centella asiatica, Vaccinium myrtillus, and Vitis vinifera for the Reduction of Hemorrhoidal Symptoms in Patients With Grade II and III Hemorrhoidal Disease: A Retrospective Real-Life Study

Background and Aim: Several evidences have shown how, in hemorrhoidal disease, phlebotonic flavonoid agents such as quercetin reduce capillary permeability by increasing vascular walls resistance, how rutin and vitamin C have antioxidant properties, and that Centella asiatica has reparative properties towards the connective tissue. A retrospective study was designed in order to evaluate the efficacy and safety of a compound consisting of micronized flavonoids in combination with vitamin C and extracts of C. asiatica, Vaccinium myrtillus, and Vitis vinifera for grade II and III hemorrhoidal disease. Patients and Methods: Data of 49 patients, over 18, who were following a free diet regimen, not on therapy with other anti-hemorrhoid agents, treated with a compound consisting of 450 mg of micronized diosmin, 300 mg of C. asiatica, 270 mg of micronized hesperidin, 200 mg of V. vinifera, 160 mg of vitamin C, 160 mg of V. myrtillus, 140 mg of micronized quercetin, and 130 mg of micronized rutin (1 sachet or 2 tablets a day) for 7 days were collected. Hemorrhoid grade according to Goligher’s scale together with anorectal symptoms (edema, prolapse, itching, thrombosis, burning, pain, tenesmus, and bleeding) both before treatment (T0) and after 7 days of therapy (T7) were collected. Primary outcomes were the reduction of at least one degree of hemorrhoids according to Goligher’s scale assessed by proctological examination and compound safety. The secondary outcome was the reduction of anorectal symptoms assessed by questionnaires administered to patients. Results: Forty-four patients (89.8%) presented a reduction in hemorrhoidal grade of at least one grade (p < 0.001). No adverse events with the use of the compound were noted. A significant reduction was observed in all anorectal symptoms evaluated (p < 0.05). No predictors of response to the compound were identified among the clinical and demographic variables collected. Conclusion: The compound analyzed was effective and safe for patients with grade II and III hemorrhoidal disease according to Goligher’s scale.

The results of sphincterometry in patients after sorgion treatment of extrasphintery anal fistula

More than 30% of patients with chronic paraproctitis have complex forms. They are most often complicated by external sphincter insufficiency due to deformation of the anal canal and scarring of the sphincters. The main principle of substantiation of surgical treatment of extrasphincteric pararectal fistulas is the individual choice of method in each particular patient. It is based on a comprehensive assessment of such factors as the etiology of the fistula, its distance from the edge of the anus, the relationship of the defect or fistula with the sphincter muscles apparatus, the severity of the scarring process, the functional state of the rectum.&#x0D; Aim. Evaluation of the functional state of the sphincter apparatus of the rectum in patients with extrasphincteric pararectal fistulas in the preoperative, early and late postoperative periods.&#x0D; Materials and methods. To determine the average indicators of anal sphincter function, basal tone and maximal compression force were measured using a sphincterometer "Sphinctometer STM-0164-SM" in 114 healthy individuals (68 men and 46 women) of different ages (16 to 80 years) who objectively had no signs of anal incontinence. In all patients, sphincterometry was preceded by a thorough proctological examination, and proctological pathology was excluded. Therefore, hemorrhoids or anal fissures, which lead to increased basal tone at rest, were excluded so as not to lead to falsified values.&#x0D; Results. Indicators of the maximum compression force in the early postoperative period, ie the compression force of the external anal sphincter, in both groups were significantly lower than preoperative and ranged from 55 to 154 mm Hg, respectively. and from 63 to 137 mm Hg. This can be explained by the presence of a granulating wound in the pararectal tissue, edema and partial injury of the external anal sphincter during surgery.&#x0D; In the late postoperative period, 6-12 months after surgery, the indicators of basal tone in both groups approached the preoperative indicators. In the main group, the study was performed in 22 patients. In these 22 patients, the tone of the internal anal sphincter did not differ significantly from the preoperative and ranged from 20 to 37 mm Hg. In the control group, in all 32 patients, the basal tone of the anal sphincter was significantly lower than before surgery - from 17 to 28 mm Hg. There were no clinical manifestations of incontinence at rest in either main or control groups.&#x0D; In the late postoperative period in both groups a decrease in the maximum compression force of the external anal sphincter was revealed. In the main group the maximum compression force of the external anal sphincter varied from 71 to 186 mm Hg, and in the control group from 77 to 135 mm Hg, respectively.&#x0D; Conclusion. Surgical treatment of patients with extrasphincteric pararectal fistulas significantly reduces the contractile function of the external anal sphincter in the postoperative period, regardless of the choice of surgery.

Anorectal diseases in patients with Antiphospholipid syndrome: a cross-sectional study

BackgroundHemorrhoid disease (HD) is one of the most common gastrointestinal complaints worldwide, affecting 4.4% of the general population in the United States. Since antiphospholipid syndrome (APS) may lead to intra-abdominal thrombosis, one may expect that this condition can impact the risk for HD development. Additionally, as APS patients are more prone to thrombosis and treatment with anticoagulants may increase risk of bleeding, one may also infer that rates of HD complications may be higher in this scenario. Nevertheless, no data in these regards have been published until now. The objective of the present study is to evaluate frequency of HD and describe its complications rates in antiphospholipid syndrome APS patients.MethodsWe consecutively invited patients who fulfilled APS criteria to undergo proctological examination. After examination, patients were divided in two groups, based on the presence of HD, and compared regarding different clinical manifestations and antiphospholipid profile. We performed the analysis of the data, using chi-square and Mann Whitney U when applicable and considering a significance level of 0.05. Multivariate regression analysis included age and variables with p < 0.10 in the bivariate analysis.ResultsForty-one APS patients agreed to undergo proctological examination. All were female and overall median age was 43 (36–49). Seventeen (41.4%) patients were diagnosed with HD, with the following frequency distribution: 7 internal (41.2%), 4 external (23.5%) and 5 mixed hemorrhoids (29.4%). Of the internal hemorrhoids, 5 patients were classified as grade I (71.4%), 1 grade II (14.3%), and 1 grade IV (14.3%). Prior gestation (p = 0.067) and constipation (p = 0.067) correlated with a higher frequency of HD. In multivariate analysis, constipation remained as an important risk factor (OR 3.92,CI95% 1.03–14.2,p = 0.037). Five out of 17 patients (29.4%) reported anal bleeding, but it did not correlate with warfarin dose (p = 0.949). Surgical treatment was indicated for 10 patients (58.8%). Other anorectal findings were anal fissure, plicoma, condyloma and one chlamydial retitis.ConclusionWe found an unexpected high frequency of hemorrhoids in APS patients, with a great proportion requiring surgical treatment.

Analyzing the prevalence of proctological diseases in HIV-positive and -negative patients

ObjectiveTo compare proctological diseases in HIV-positive and -negative patients. MethodProspective study conducted in the proctology outpatient clinic at Instituto de Infectologia Emílio Ribas from 2013 through 2019. All of them underwent anamnesis and proctological examination and were divided into two groups (HIV+ and HIV−). The groups were then compared with regard to age, sex, diagnosis, and whether or not there was any indication for surgery. Results485 HIV + patients (41.9%) (Group I) and 672 HIV− (58.1%) (Group II). The mean age in Group I was 42.8 years, and 404 (83.3%) of the patients were males. In Group II, the mean age was 48.3 years, and 396 (59%) patients were females. In comparing the groups, a statistically significant difference was found regarding sex, age, and diagnosis. The incidence of hemorrhoid and anal skin tags was higher in group II and that of condyloma acuminata was higher in in Group I (p < 0.001). In Group I, condyloma acuminata was more prevalent, but in those with CD4 levels above 500 cells/mm3, the diagnoses were more similar to those in the population without HIV. ConclusionsProctological diseases were found to be similar but have different incidences. The incidences of diseases in HIV− and + patients tend to approach each other as CD4 level increases.