Anorectal disorders

Anal skin tags in inflammatory bowel disease: new observations and a clinical review

BACKGROUND

The association between intestinal Crohn's disease (CD) and specific perianal abnormalities called anal skin tags (AST) has been recognized but not well defined. Skin tags have been classified into 2 types: 1) raised, broad, or narrow, single or multiple, soft or firm, and painless, often referred to as "elephant ears"; or 2) edematous, hard, often cyanotic, tender or not, and typically arising from a healed anal fissure, ulcer, or hemorrhoid. The aims of this study were to i) better characterize those skin tags identified by the term "elephant ears" and differentiate them from other types of AST; ii) compare their prevalence in patients with CD and ulcerative colitis (UC); iii) observe the relationship of the skin tags to the location of the primary bowel disease; and iv) to discuss the value of these typical AST in making an early diagnosis of CD.

METHODS

Photographs of all AST were taken when present at lower endoscopy in 170 consecutive patients with inflammatory bowel disease (IBD) seen in the private office of the senior investigator and Lenox Hill Hospital. Data was gathered with respect to major differences between the 2 types of AST. The location of the primary bowel disease for these patients was obtained from an extensive IBD computer database and review of details from charts.

RESULTS

Specific features of AST were described and served to favor type 1 versus type 2. AST were found more frequently in patients with CD (75.4%) as compared to patients with UC (24.6%), confirming previous observations that they are more diagnostic of CD (P = 0.005). Subset analysis revealed a trend with a greater incidence of AST in patients with colitis (46.9%) as compared to patients with ileitis (36.7%) and ileocolitis (16.3%) (P = 0.067).

CONCLUSIONS

We provide photographs with the most characteristic features of AST and attempt to separate elephant ears (type 1) from less typical AST (type 2) in CD. Our study confirms previous reports that AST are more commonly found in association with CD as compared with UC and more so in the presence of disease limited to the colon as compared to disease elsewhere in the bowel. Our observations support the diagnostic significance of AST heralding the diagnosis of CD when they are discovered on physical exam, especially in young people with diarrhea, abdominal pain, and/or growth retardation.

Systemic antibiotic regimens for acute cholecystitis treated by early cholecystectomy

A total of 203 patients were randomized into a prospective trial to compare short (SC) versus long courses (LC) of systemic antibiotic for acute cholecystitis treated by early cholecystectomy. The initial pre-operative management was the same and all patients received 2 g of cefamandole intravenously just before operation. Two further doses of cefamandole 500 mg were given 6 and 12 h later for patients on SC while the antibiotic was continued at 500 mg at 6 h intervals for 7 days for patients on LC. Seven patients developed wound infection on SC compared with five patients with wound infection and an additional patient with a subphrenic abscess on LC (P greater than 0.05). Thrombophlebitis related to intravenous antibiotic injections was more common in patients on LC (P less than 0.05). Also, patients on LC had to stay statistically longer in hospital in order to complete the course of antibiotic (P less than 0.05). We therefore recommend a SC to be used, as it is more cost-effective and causes fewer complications.

Trauma and other noninfectious problems in homosexual men

Homosexual men are at risk for problems unique to their sexual orientation, and the management of even standard problems must often be altered. The recognition and management of problems related to the anorectum, breasts, and external genitalia in homosexual men are discussed.

Keyhole deformity. Fact and fiction

The purpose of this paper is to show whether there is a keyhole deformity, its surgical significance, and how often it occurred following surgery for ulcer-in-ano. To do this, a retrospective study, over a 16-year period, of all patients admitted to the Ferguson Clinic with chief complaints of anal incontinence was undertaken. Of this group of patients, seven were identified as having questionable keyhole deformities, three of whom probably had classic defects. There were six females and one male. Only two of the deformities were associated with surgery for ulcer-in-ano. One of these was easily repaired and the other patient had a full rectal prolapse. In addition, of 186 patients undergoing fistula surgery, 77 who had posterior midline transsphincteric fistulas were studied and ten of these patients went on to complete recovery without any permanent problems resulting from severance of the sphincter. It can generally be concluded that, although there is such a defect as the keyhole deformity, it occurs only rarely, especially after surgery for ulcer-in-ano, and that many times it is not associated with anal incontinence.

Fissurectomy with superficial midline sphincterotomy. A viable alternative for the surgical correction of chronic fissure/ulcer-in-ano

A series of 121 patients with chronic fissure-in-ano who underwent fissurectomy with superficial midline sphincterotomy was studied. The mean follow-up was 8.1 years. Minor problems with anal competence occurred after the operation in 30 patients (25 per cent). Within two months, this problem had resolved in all patients. One patient (0.8 per cent) had a true recurrence. Five patients (4.1 per cent) had recurrent acute anal abrasions as the result of passage of a hard stool. These healed spontaneously. Twelve patients (9.9 per cent) had fragile scars, but this was a significant problem in only five (4.1 per cent). No patient had significant stricture formation, keyhole deformities, or major persistent problems with anal competence. The patients graded their operations with regard to satisfaction: 118 (97.5 per cent) reported satisfactory results and three (2.5 per cent) reported unsatisfactory results. This study shows that fissurectomy with superficial midline sphincterotomy is a viable approach to the surgical management of chronic fissure-in-ano.