Anal sphincter fibrillation: is this a new finding that identifies resistant chronic anal fissures that respond to botulinum toxin?

AIM

Anal fissures can be resistant to treatment and some patients may undergo several trials of medical therapy before definitive surgery. It would be useful to identify predictors of poor response to medical therapy. This study assesses the role of anorectal physiological criteria to identify patients with anal fissure predicted to fail botulinum toxin (BT) treatment.

METHOD

A retrospective analysis of anorectal physiological data collected for patients with resistant chronic anal fissures, referred to one consultant surgeon between 2007 and 2011, was undertaken. These were correlated with treatment plans and healing rates.

RESULTS

Twenty-five patients with idiopathic chronic anal fissures underwent anorectal physiology studies and were subsequently treated with BT injection. Eleven had a characteristic high-frequency low-amplitude 'saw tooth' waveform or anal sphincter fibrillation (ASF) and higher anal sphincter pressures. Nine (82%) of these patients had resolution of their anal fissure symptoms following treatment with BT. Of 14 patients with no evidence of ASF and a greater range of anal sphincter pressures, only one (7%) had resolution following BT.

CONCLUSION

ASF appears to be an anorectal physiological criterion that helps predict response of anal fissures to BT injection. This could help streamline fissure management.

Defects in multiple complexes of the respiratory chain are present in ageing human colonic crypts

Mitochondrial DNA (mtDNA) mutations accumulate in a number of ageing tissues and are proposed to play a role in the ageing process. We have previously shown that colonic crypt stem cells accumulate somatic mtDNA point mutations during ageing. These mtDNA mutations result in the loss of the activity of complex IV (cytochrome c oxidase (COX)) of the respiratory chain in the stem cells and their progeny, producing colonic crypts which are entirely COX deficient. However it is not known whether the other complexes of the respiratory chain are similarly affected during ageing. Here we have used antibodies to individual subunits of complexes I–IV to investigate their expression in the colonic epithelium from human subjects aged 18–84. We show that in ∼50% of crypts with any form of respiratory chain deficiency, decreased expression of subunits of multiple complexes is observed. Furthermore we have sequenced the entire mitochondrial genome of a number of cells with multiple complex defects and have found a wide variety of point mutations in these cells affecting a number of different protein encoding and RNA encoding genes. Finally we discuss the possible mechanisms by which multiple respiratory chain complex defects may occur in these cells.

The quality of patient-orientated internet information on colorectal cancer

OBJECTIVE

The Internet provides an enormous amount of patient-orientated information on colorectal cancer. This study examined its accessibility and quality.

METHODS

Sites were identified using two search engines (Google and Hotbot) and the search terms 'bowel cancer' and 'colon and rectal cancer'. The first 100 sites in each search were visited and classified. Sites that contained patient information were assessed using the 'Discern' instrument for reliability and quality of information on treatment choices.

RESULTS

Google identified 55,700 sites for the search term 'colorectal cancer' and 214,000 for 'bowel cancer'. Hotbot produced 27,700 and 190,000, respectively. Four hundred sites were studied. Only 25 (6%) sites were duplicated in the searches. One hundred and eighteen (30%) provided information, 70 (18%) were lists of links, 27 (7%) were adverts, 22 (6%) promoted medical centres, 51 (13%) were dead links, 15 (4%) were message boards. Of the 118 that provided information 73 (62%) advised on treatment and 73 (62%) were designed for patients. The sources of information were clear in 55 (47%) and the date when this information was reported was given in only 63 (53%). By adapting the Discern instrument, sites were classified as excellent 18 (15.3%), very good 19 (16.1%), good 28 (23.7%), fair 8 (6.8%) and poor 45 (38.1%).

CONCLUSIONS

The Internet provides a wealth of information on colorectal cancer but the best sites are difficult for patients to distinguish from the thousands of sites returned by search engines. Clinicians should guide patients to quality sites to avoid confusion and misinformation.

Obstructive jaundice causes reduced expression of polymorphonuclear leucocyte adhesion molecules and a depressed response to bacterial wall products in vitro

BACKGROUND

Obstructive jaundice is associated with an increased incidence of infection and endotoxaemia, which may result from impaired host immunity. Neutrophil adhesion to vascular endothelium is a key part of the inflammatory response.

AIMS

To investigate neutrophil adhesion molecule expression and activation in obstructive jaundice.

PATIENTS

Nine adult patients with obstructive jaundice and 11 control subjects.

METHODS

The expression of the neutrophil adhesion receptors L-selectin, CD11a, CD11b, CD11c, and CD15 was determined using flow cytometry. CD11b expression in response to stimulation with fMLP and endotoxin was measured.

RESULTS

The basal expression of L-selectin, CD11a, and CD15 was significantly decreased in jaundiced patients (p < 0.05) and the expression of CD11b in response to stimulation with fMLP and endotoxin was significantly impaired in the jaundiced group. Endotoxin stimulation without plasma did not reverse the impaired response showing that it is not caused by endotoxin inactivation by plasma proteins.

CONCLUSIONS

Neutrophils from patients with obstructive jaundice show decreased adhesion receptor expression and an impaired response to stimulation with bacterial products. This cellular dysfunction may be responsible for the high incidence of septic complications in these patients.