Perianal ulcerative skin tuberculosis: A case report

RATIONALE

Ulcerative skin tuberculosis (TB) is a rare form of extrapulmonary TB.

CASE REPORT

We present a case of a 65-year-old patient with perianal ulcer, which had been present for 1 year. Anamnesis revealed he had been persistently coughing for the same period of time. Histological examination of perianal skin showed necrotizing granulomatous lesions, acid-fast staining in sputum samples was ++++, TB antibody in the blood was positive, TB DNA test was positive, and chest scan that showed secondary pulmonary TB accompanied by possible pulmonary cavity formation in the 2 upper lungs.

INTERVENTIONS

Anti-TB therapy with isoniazid, rifampicin, ethambutol, and pyrazinamide for 6 months. The skin ulcer completely healed after 6 months.

CONCLUSION

TB should be suspected for nonhealing ulcers. Pertinent studies should be done early during the lesion; finally, TB treatment should be initiated immediately after diagnosis is made.

[Treatment of anal fissures]

Anal fissure is a common ailment, however, the pathophysiology and optimal treatment strategy is unclear. Anal fissures may be classified as acute or chronic. Acute fissures are effectively treated and prevented with conservative measures, whereas chronic fissures typically require medical or surgical therapy. Invasive interventions have superior healing rates compared with local medical therapies, but may cause persistent incontinence. New interventions are constantly introduced and may be of value in patients with high risk of incontinence, but more evidence is currently needed.

[EXPEDIENCY OF THE INTRATISSUE ELECTROPHORESIS APPLICATION IN PREOPERATIVE PREPARATION OF PATIENTS, SUFFERING CHRONIC ANAL FISSURE]

The experience of preoperative application of the intratissue electrophoresis with the dioxysol solution was analyzed for the patients, suffering chronic anal fissure. In the patients, beginning from the first day, there was proved the reduction of the pain syndrome severity, hemodynamic disorders, an acute inflammatory reactions in the anal fissure tissue, the young granulations growth in the edge of the wound and resection. Application of the method proposed have promoted the inflammatory process severity reduction, the reparative processes in anal fissure stimulation, the operation wound epithelization acceleration, the anal sphincter muscle spasmelimination, which constitutes the main pathogenetic mechanism of the disease.

Anal fissure in children: a 10-year clinical experience with nifedipine gel with lidocaine

BACKGROUND

We aimed to evaluate efficacy and safety of the use of nifedipine gel with lidocaine in the treatment of acute anal fissures in children by reviewing the cases of 106 children with acute anal fissure treated conservatively by nifedipine gel with lidocaine between the years 2003-2012.

METHODS

The patients included in this study were 48 males and 58 females. Their clinical presentation consisted of constipation, rectal bleeding, anal pain, perianal itching, abdominal pain, irritability and rectal prolapse. Posterior, anterior, both anterior and posterior, multiple, both posterior and lateral locations were the main physical findings in 65, 23, 10, 7, and 1 cases.

RESULTS

Ninety-nine patients completed the 4-week treatment course of nifedipine gel with lidocaine successfully (93.40%), with complete healing of the fissure. The recurrence rate observed was very low (6.60%).

CONCLUSIONS

Topical 0.2% nifedipine with lidocaine appears an efficient mode of treatment for anal fissures in children, with a significant healing rate and no side effects.

[CHANGES OF HISTOSTRUCTURE OF CHRONIC ANAL FISSURE, DEPENDING ON DURATION OF THE DISEASE]

The results of histological investigation of the chronic anal fissure (AF) edges in 95 patients with the disease duration from 6 mo to 4.5 yrs were analyzed. Basing on estimation of severity of an acute inflammation signs and the granulation and cicatricial tissue presence there was established, that duration of an acute inflammation in the AF may constitute up to 6 - 7 mo; subacute--from 8 to 11 mo, chronic cicatricial process was observed in terms from 12 mo and more.

A rare case of myeloid sarcoma presenting as anal fissure

Myeloid sarcoma is a tumor composed of myeloblasts occurring at an extramedullary site. It may develop in patients with acute myeloid leukemia, myeloproliferative or myelodysplastic syndrome, sometimes preceding onset of the systemic disease. Frequent sites of myeloid sarcoma are bones or various soft tissues. Gastrointestinal involvement is very rare. We report a unique case of myeloid sarcoma presenting as a painful anal fissure, in a patient with a history of acute myeloid leukemia. The diagnosis was achieved by a surgical excisional biopsy and immunoistochemical staining.

[SURGICAL TREATMENT OF POSTOPERATIVE STRICTURE OF ANAL CHANNELL]

The results of treatment of 50 patients, suffering postoperative stricture of anal channell (SACH), who were treated in Proctology Department of Ivano-Frankivskiy Rural Clinical Hospital in 2006-2014 yrs, were analyzed. After conduction of hemorrhoidectomy in accordance to Milligan-Morgan method for chronic hemorrhoids grades III-IV a SACH have occurred in 46 (92%) patients, excision of a chronic anal fissura was performed in 3 (6%) and excision of perianal pointed condylomas--in 1 patient. In 2006-2007 yrs 11 (22%) patients were operated in accordance to approaches, which were conventional at that time (comparison group). In 2008 - 2014 yrs 39 (78%) patients were admitted to hospital (main group), in whom new approaches for diagnosis, conservative and surgical treatment were applied, 30 (76.9%) of them were operated. The proposed method on isolated roentgen contrast investigation of anal channell have permitted to determine objectively a form, diameter and grade of the anal channel stricture, and it may be applied as a screening procedure, as additional objective criterion while choosing a surgical tactic. Application of the improved operative technique for SACH have permitted to lower its occurrence rate from 45.4 to 6.7%.

[MORPHOGENESIS OF THE ANODERM STRUCTURAL CHANGES IN PATIENTS WITH CHRONIC ANAL FISSURES]

The objective of the study is to find peculiarities of the anoderm structural changes of morphogenesis in patients with chronic anal fissures (CAF) for further substantiation of therapeutic methods. The material of the study was the tissues of dissected anal complex (bottom and margins of ulcer, hypertrophic anal papilla, sentinel pile) from 33 patients. Histological examination found the defect of the stratified squamous epithelium. The epidermis of the marginal area of the wound, hypertrophic with signs of parakeratosis and acanthosis, hanged over the bottom. The surface of the bottom and margins of the wound in 31 cases (94%) was with thickening of rough fibrous masses. The bottom of ulcer in 29 (88%) cases is presented by sclerosed connective tissue. An increased amount of collagen fibers was found forming fuchsinophil is bundles. In 24 (73%) cases the scar on the fuchsine bottom of fissure was 3,4 mm (0,3±0,02) in deep. There are separate complexes of newly formed blood vessels with prevailing localization in the lateral walls of the wound. The blood vessels were with main by fibrosis in deep areas of the wound. Moderate interstitial edema and focal interstitial inflammatory infiltration mostly of lymphocytes and fibroblasts were detected; the amount of macrophages was not substantial. Considering cicatrical rebuilding of the anoderm of ulcer bottom caused, first of all, by hypoxia leading to activation of collagen-producing function of fibroblastes and absence of the signs of epithelization, patients with CAF should be treated surgically dissecting the bottom and margins of fissure in the complex with hypertrophic anal papilla and sentinel pile.

Non-surgical treatments for anal fissure in adults

An anal fissure is defined as a linear tear or ulcer of the anal mucosa. Patients typically describe a sharp pain 'like passing broken glass' on defaecation, followed by a burning pain in the anus lasting a few hours. Pain and bleeding during and after the passage of stool are the usual presenting features. Fissures are most common in young to middle-aged adults and are also commonly seen in pregnant and postpartum women. The lifetime incidence of anal fissure is around 11%. Here, we review the evidence on the efficacy and safety of non-surgical treatments for anal fissure.

Anal fissures in infants may be a pathognomonic sign of infants with cow's milk allergy

OBJECTIVE

To study the association between analfissures and cow's milk allergy (CMA) in infants. METHODS AND METHOD: In a prospective study, 72 confirmed cases of CMA in infants were examined for anal fissure by pediatricians with five years' experience. A positive finding was defined as when an anal fissure was detected by at least two out of three examiners.

RESULTS

Of infants with CMA with and without gastrointestinal GI symptoms, 79% and 83% had anal fissures, respectively The prevalence of anal fissure in these infants is significantly higher than in normal infants.

CONCLUSION

Anal fissure may be a pathognomonic sign of cow's milk allergy in infants.

[Significance of nontraumatic anal sphincter relaxation for the success of plastic and miniinvasive interventions in coloproctology]

The investigation objective was to estimate the role of nontraumatic anal sphincter (AS) stretching, as a leading factor of success in minimally invasive and/or plastic proctological interventions. One-centre randomized investigation was performed in 83 patients: In 22 of them the AS fissura was revealed (in 16), suprasphincteric fistula (in 3) and coexistent rectocele 2-3 Ap (according to POP-Q classification) with thinning of the AS anterior segment, the degree III hemorrhoids and anterior AS fissure presence. Ninety units of botulotoxin preparation (Disport) were injected between internal and external AS portions 5-15 days preoperatively. The treatment results without botulotoxin injection were compared retrospectively. After botulotoxin injection performance the AS spasm elimination was noted, leading to the pain subsiding promotion before and postoperatively in all the patients observed. The spasm elimination have permitted to escape the anal high fistula recurrence as a result of the mucosal flap shift after intraluminal closure of the fistula or because of the fistula intermuscular electrowelding "suture" rupture, also have guaranteed the plastic sutures on AS, even while the stage II-III rectocele presence, not depending of performance of its simultant surgica correction.

[Surgical treatment for cicatrix strictures of anal canal]

Classification of anal canal strictures with gradation of intensity, extent and localization is proposed. In 12 patients with compensated strictures combination of stenosis and anal fissure served as an indication for operation. These patients underwent fissure excision with dosed sphincterotomy. Anoplasty with displacement of island skin flaps to anal canal defects was carried out to 29 patients with sub-or decompensated strictures after dissection of scarry stricture. Good direct results were achieved in 38 patients. Compensated re-stenosis treated conservatively was observed in 3 patients after anoplasty. It is drawn a conclusion about necessity of differential approach to choice of treatment mode for anal scarry strictures. Anoplasty according to proposed method is considered to be optimal for marked strictures.

The effect of topical nifedipine in treatment of chronic anal fissure

Chronic anal fissure is the most common cause of anal pain associated with internal anal sphincter hypertonia. Reduction of hypertonocity is a special treatment for fissure healing. For this purpose chronic anal fissures were conventionally treated by anal dilatation or by lateral sphincterotomy. However, both of these methods may cause a degree of incontinence in some patients. The uptake of medical therapies that create a reversible chemical sphincterotomy has recently become widespread. The aim of this prospective clinical trial study was to assess the effectiveness of nifedipine in healing anal fissure, a calcium channel blocker that reduces sphincter pressure. A single-blind randomized comparative trial was setup to compare traditional treatment with stool softeners and 2% lidocaine cream against 0.5% nifedipine cream for 4 weeks. 110 patients were included in this study, 60 patients in the nifedipine group and 50 patients in the control group and the therapeutic outcome and side effects were recorded. Healing had occurred in 70% of patients in the nifedipine group and in 12% of patients in the control group after 4 weeks treatment (P < 0.005). Recurrence of symptoms occurred in four of healed patients in the nifedipine group and three patients in the control group in two months. The final result of nifedipine application after 12 months follow up was recurrence in 11 patients (26.19%). Mild headache occurred in four patients (6.6%) of the nifedipine group. Patients in the nifedipine group showed significant healing and relief from pain compared with patients in the control group. Recurrence rate with nifedipine use in spite of control of predisposing factors such as constipation was significant. Another finding was low complication rate with this treatment.

Early and late results of topical diltiazem and bethanechol for chronic anal fissure: a comparative study

BACKGROUND/AIMS

Late efficacy of medical treatment of chronic anal fissure remains controversial due to high recurrence. This study aimed at analyzing safety and efficacy of topical diltiazem and bethanechol regarding healing and symptoms relief, safety, recurrence, and need for surgery.

METHODOLOGY

This was a single-center nonrandomized trial. Outcomes of 30 patients with chronic anal fissure treated with 2% diltiazem were compared to 30 patients treated with 0.1% bethanechol, both for eight weeks. Patients were assessed after seven days and eight weeks.

RESULTS

In diltiazem group, after seven days, 31% were symptomatic; after bethanechol, 71% (p = 0.06). After seven days, fissure healing occurred in 19% after diltiazem and in 11% after bethanechol. After eight weeks, in both groups, 64% were asymptomatic; after diltiazem, 53% healed; after bethanechol, 50% (p = 0.80). Success was the same for both groups: 63.3%. Groups were similar regarding complications. After diltiazem, 9 (30%) patients were operated on; and 11 (36.7%) after bethanechol (p = 0.60). Recurrence occurred in 4 (13.3%) patients in both groups. Median time to recurrence after diltiazem was 15 (10-24) months and 7.5 (2-15) after bethanechol - p = 0.15.

CONCLUSIONS

Both treatments are safe and effective. Diltiazem may be associated to earlier relief and more sustained response.

Botulinum toxin A with fissurectomy is a viable alternative to lateral internal sphincterotomy for chronic anal fissure

Lateral internal sphincterotomy (LIS) is the gold standard surgical treatment for anal fissure. However, it carries potential complications, including fecal incontinence. The goal of this retrospective study was to compare the outcome of botulinum toxin A injection coupled with fissurectomy ([BTX + FIS) versus LIS. There were 59 patients who underwent BTX + FIS or LIS over a 5-year period. LIS was performed in the standard fashion without fissurectomy. BTX + FIS entailed internal sphincter injection with 80 units of botulinum toxin A coupled with fissurectomy. Forty patients underwent LIS and 19 had BTX + FIS. The choice of operation was based on the patient's preference. Primary healing rate was 90 and 74 per cent in the LIS and BTX + FIS groups, respectively (P = 0.13). The complication rate was 10 per cent in the LIS vs 0 per cent in the BTX + FIS groups (P = 0.29). Complications of LIS included anal sepsis in one patient and flatal and/or fecal incontinence in three patients. During a mean follow up of 19 months; recurrence rate was 0 and 5 per cent in the LIS and BTX+FIS groups, respectively (P = 0.32). The results of this study demonstrate that BTX + FIS is a viable alternative to LIS for patients with chronic anal fissure and should be considered as an alternative first-line surgical therapy.

Non-healing perianal ulcer: A rare presentation of cutaneous tuberculosis

Perianal tuberculosis is an extremely rare form of tubercular disease. We report here a case of chronic non-healing perianal tubercular ulcer associated with, asymptomatic pulmonary tuberculosis in a 16-year-old boy for its rarity and to emphasize the importance of considering tubercular etiology in the work up of persistent perianal ulcer.

Subcutaneous fissurotomy: a novel procedure for chronic fissure-in-ano. a review of 109 cases

PURPOSE

The constant presence of a narrow subcutaneous tract extending caudad to chronic fissures-in-ano is reported. The efficacy of surgically unroofing this tract (subcutaneous fissurotomy) without sphincterotomy was evaluated.

METHODS

By using a narrow-gauge, hooked probe, a constant, midline subcutaneous tract was identified extending from the caudad aspect of chronic anal fissures. These tracts are present within the sentinel tag, when present, and extend up to 1 cm caudad to the fissure in the subcutaneous plane. A proximal connection with the dentate line in the submucous plane also was identified. Surgically unroofing the tract (subcutaneous fissurotomy) resulted in significant widening of the distal anal canal, rendering internal sphincterotomy unnecessary. A 32-month prospective evaluation of this new technique was performed. Inclusion criteria included patients with chronic anal fissures that had failed conservative therapy, including topical agents. In each case, the tract was identified and surgically laid open along its entire length. No internal sphincterotomy was performed in any patient. Postoperatively, patients were instructed to apply topical 10 percent metronidazole t.i.d. The need for repeat surgery and/or subsequent internal sphincterotomy was recorded.

RESULTS

A total of 109 patients were enrolled during the study period. Median follow-up was 12 months. During the study period, two patients (1.8 percent) required repeat surgery for persistent symptoms at 3 and 12 months postoperatively. No change in continence was reported in any patient.

CONCLUSIONS

Laying open the subcutaneous tract has a very high success rate and a low incidence of repeat surgery. This finding introduces a new debate relating to the etiology of fissure-in-ano and makes routine internal sphincterotomy unnecessary.

Nicorandil related anal ulcer

BACKGROUND

Anal ulceration is uncommon. Patients are typically referred because of severe anal pain, bleeding, discharge, and ulceration. It is important to exclude anal carcinoma, and to consider more unusual causes.

METHODS

A 74-year-old lady presented with severe anal pain and ulceration. This was subsequently noted to be related to nicorandil, a potassium channel activator used in the treatment of angina. Discontinuation of nicorandil and faecal diversion allowed symptom relief and ulcer healing.

CONCLUSION

Knowledge of the association between nicorandil and anal ulceration is essential in order to appropriately diagnose and manage this condition.

Anal ulceration associated with Nicorandil: case series and review of the literature

BACKGROUND

Use of Nicorandil in the treatment of ischaemic heart disease has been associated with oral, ileal and more recently anal ulceration. We report a series of six cases of peri-anal ulceration in patients on nicorandil therapy, their response to withdrawal of the drug and review the literature.

METHODOLOGY

Systematic case note review of all patients with anal ulceration presenting to a single colorectal unit. Including detailed medical and drug history, morphological and histological appearances of the peri-anal ulcer after biopsy. Nicorandil therapy stopped in conjunction with physician and the progress of the ulcer monitored. Photographs taken before and after cessation of Nicorandil after informed consent. A literature search on Nicorandil combined with the key words: anal, peri-anal, ulceration and adverse drug effects was performed using the Cochrane Library Medline (January 1966 to June 2005) and Embase (January 1974 to June, 2005).

RESULTS

Six patients were identified from our hospital records. Histological examination of all ulcers revealed nonspecific chronic inflammation. Five patients demonstrated healing of ulceration within six weeks of withdrawal of Nicorandil, the remaining patient had circumferential involvement of the anal canal and has not improved at 3-month review. One patient was recommenced on Nicorandil after healing due to refractory angina and ulceration recurred.

CONCLUSIONS

We believe ulceration due to Nicorandil remains widely under diagnosed and the mechanism of ulceration is unclear. Despite diversion colostomy one of our patients continued with peri-anal ulceration, which may suggest a systemic mechanism rather than local irritation. Biopsy of these lesions is essential to exclude neoplastic process and inflammatory bowel disease.

Clinical and endoscopic features of acute hemorrhagic rectal ulcer

BACKGROUND

Acute hemorrhagic rectal ulcer (AHRU) has increasingly been reported in Japan, whereas it has rarely been reported in the English literature and is not yet established as a disease entity. The aim of this study was to elucidate clinical and endoscopic characteristics of patients with AHRU.

METHODS

We enrolled 20 patients with 26 ulcers diagnosed as AHRU in our department between January 2001 and October 2005. Clinical features such as the underlying disorder, Karnofsky performance status (PS), and presence or absence of anticoagulant or antiplatelet therapy, as well as endoscopic findings and type of bleeding, were evaluated. Strategies for hemostasis were also reviewed.

RESULTS

The most prevalent underlying disorder was diabetes mellitus, and the number of bedridden patients with PS 4 was relatively high. In addition, more than half of the patients had been treated with anticoagulant or antiplatelet agents. Endoscopically, ulcers were characteristically solitary and irregularly shaped, and they did not show any typical localization pattern. As a hemostatic strategy, clipping alone showed a favorable result, with a hemostatic success rate as high as 76.9%.

CONCLUSIONS

This study may support the establishment of AHRU as a new clinical entity. In aged patients being treated with anticoagulant or antiplatelet agents, especially bedridden patients using aspirin, the possible appearance of this disease should be kept in mind.

Nitric oxide deficiency in the internal anal sphincter of patients with chronic anal fissure

Anal fissure is a common condition affecting young to middle-aged adults. It causes severe pain on defecation and rectal bleeding. The aetiology remains uncertain. Spasm of the internal anal sphincter is a constant feature. Nitric oxide (NO) is the major inhibitory neurotransmitter of the internal anal sphincter (IAS). In other spasmodic conditions of the GI tract a lack of normal nitric oxide synthase (NOS) activity has been reported. The aim of this preliminary study was to compare the presence of NOS in the internal sphincters of patients with and without chronic anal fissure. Internal anal sphincter biopsies were taken under general anaesthesia from patients having lateral internal sphincterotomy for chronic anal fissure and from sphincter of patients having abdominoperineal resections as controls. Sections of IAS were stained to show the presence of NADPH diaphorase (and hence presence of NOS). Internal anal sphincter was taken from 6 patients with chronic anal fissure and 6 controls. IAS taken from patients with chronic anal fissure showed little NOS presence compared with controls. It may be that there is an abnormal failure of relaxation of internal sphincter in those patients who develop chronic anal fissure caused by an intrinsic lack of neural NOS in the internal anal sphincter.

[Endosonographic and manometric assessment of the internal anal sphincter in patients with chronic anal fissure]

INTRODUCTION

High anal resting pressures have been implicated in the pathophysiology of chronic anal fissure. It is not known, however, whether altered function is associated with any morphological abnormalities of the internal anal sphincter (IAS). The aims of the present study were to determine IAS thickness in patients with chronic anal fissure and to investigate the correlation between IAS thickness and anal resting pressure.

PATIENTS AND METHOD

Patients with chronic anal fissure were prospectively included between November 1999 and December 2002. Patients with a history of inflammatory bowel disease, anal surgery, and those previously treated with nitroglycerine ointment or botulinum toxin were excluded. Anal endosonography and manometry were performed. IAS thickness was considered to be increased when it was > 2.5 mm in patients < 50 years and > 3 mm in patients > or = 50 years. Anal resting pressure was considered to be increased when it was higher than 80 mmHg.

RESULTS

Sixty-three patients were analyzed. An abnormally thick IAS was observed in 58 patients (92%). The mean IAS thickness was 3.7 +/- 0.7 mm. IAS hypertonia was found in 47 patients (66%). The mean anal resting pressure was 91 +/- 28 mmHg. No correlation was found between IAS thickness and anal resting pressure (r = 0.05; p < 0.68).

CONCLUSIONS

Most of the patients with chronic anal fissure had an abnormally thick IAS. However, increased thickness of the IAS did not correlate with increased anal resting pressure.

Stapled endorectal mucosectomy for high extrasphincteric fistula-in-ano: preliminary report

PURPOSE

There is no optimum surgical method of repair for high extrasphincteric fistula-in-ano. We describe a relatively simple procedure for surgery of extrasphincteric fistula, which entirely preserves the anal sphincter, does not interfere with anal function, and does not preclude the possibility of further surgery, if necessary.

METHODS

Five patients have been treated for high extrasphincteric fistula with a stapled endorectal flap by using a circular hemorrhoidal stapler gun. The procedure involved two 180 degrees pursestrings placed above the dentate line and 3 cm apart, proximal and distal to the internal opening. On firing, the result was the excision of a 180 degrees rectal flap, containing the internal ostium, and including rectal mucosa and submucosa.

RESULTS

No perioperative complications were encountered. There was some temporary difficulty in controlling flatus and/or defecatory urgency in two patients, which spontaneously reversed with no treatment within the first two postoperative months. The mean Cleveland Clinic Score of Incontinence did not vary significantly after surgery. Overall anal manometry did not register any significant differences between preoperative and postoperative values. With up to 26 months of follow-up, none of the fistulas recurred.

CONCLUSIONS

These preliminary promising results suggest that the stapled endorectal flap could have a role in the management of high extrasphincteric fistula-in-ano.

The safety and efficacy of a mixture of honey, olive oil, and beeswax for the management of hemorrhoids and anal fissure: a pilot study

We have found that a mixture of honey, olive oil, and beeswax was effective for treatment of diaper dermatitis, psoriasis, eczema, and skin fungal infection. The mixture has antibacterial properties. A prospective pilot study was conducted to evaluate the therapeutic effect of topical application of the mixture on patients with anal fissure or hemorrhoids.Fifteen consecutive patients, 13 males and 2 females, median age 45 years (range: 28—70), who presented with anal fissure (5 patients) or first- to third-degree hemorrhoids (4 with first degree, 4 with second degree, and 2 with third degree), were treated with a 12-h application of a natural mixture containing honey, olive oil, and beeswax in ratio of 1:1:1(v/v/v). Bleeding, itching, edema, and erythema were measured using a scoring method: 0 = none, 1 = mild, 2 = moderate, 3 = severe, and 4 = very severe. The pain score was checked using a visual analog scale (minimum = 0, maximum = 10). Efficacy of treatment was assessed by comparing the symptoms' score before and after treatment; at weekly intervals for a maximum of 4 weeks. The patients were observed for evidence of any adverse effect such as appearance of new signs and symptoms, or worsening of the existing symptoms. The honey mixture significantly reduced bleeding and relieved itching in patients with hemorrhoids. Patients with anal fissure showed significant reduction in pain, bleeding, and itching after the treatment. No side effect was reported with use of the mixture. We conclude that a mixture of honey, olive oil, and beeswax is safe and clinically effective in the treatment of hemorrhoids and anal fissure, which paves the way for further randomized double blind studies.

A study of suppurative pathologies associated with chronic anal fissures

BACKGROUND

Suppurative pathologies associated with chronic anal fissures are common but not well documented. Fissure abscess, post-fissure fistula, and post-fissure antibioma are but a few of them. These pathologies increase the complications and morbidity of the primary lesion and need a comprehensive approach.

METHODS

From the hospital case record of 532 patients treated for chronic anal fissures, 88 patients (16.5%) were found to have one of these pathologies. This retrospective study describes such pathologies in terms of demographics, clinical presentation, pathological features, operative technique and outcome.

RESULTS

Of the 88 patients who presented with pain and discharge per anus, 90% could resume their duties within a week of the surgical procedure. Wound healing took between 2 weeks and 2 months. At the last follow- up at 18 months, three patients had a recurrence (3.4%).

CONCLUSIONS

Suppuration in chronic anal fissure seems to be more frequent than described. While dealing with the anal fissure, it is desirable to look for and attend to these associated pathologies, especially to avoid complications and morbidity of the primary disease.

[A Dutchman from Mali with a perianal ulcer caused by cutaneous amoebiasis]

A 66-year-old Dutchman, living in Mali, presented with an extensive progressive perianal ulcer despite local and antibiotic treatment. Microscopic examination of the stool revealed Entamoeba histolytica/dispar cysts and phagocytosing trophozoites were seen in fresh scrapings of the ulcer, a diagnostic feature of infection with E. histolytica. The diagnosis was cutaneous amoebiasis and the patient was effectively treated with metronidazole and local debridements. Primary cutaneous amoebiasis is a rare disease. Diagnosis and treatment are relatively simple but lack of familiarity with the disease may lead to misdiagnosis or diagnosis at a late stage ofthe infection.

Relation between botulinum toxin and nitric oxide donors in the treatment of chronic anal fissure

Although the pathogenesis of fissure is not fully understood, we do know that surgical and/or pharmacological sphincterotomy promotes the healing of chronic anal fissures. A number of studies support the hypothesis that local ischemia is the reason for failure to heal in anal fissure. Therefore, sphincterotomy may work because it decreases anal canal resting pressure and enhances microcirculation at the fissure site. The vasomotor tone of arterioles controlled by metabolic and endothelial factors determines perfusion of tissue and fissure healing. In a novel approach, this paper proposes mechanisms for nitric oxide synthesis, regulation and action in the internal anal sphincter. The design demonstrates the direct interdependence between the activity mechanisms of botulinum toxin and nitric oxide. Endothelial lining can modulate not only vascular tone but also internal anal sphincter (IAS) tone. The application of botulinum toxin likely releases the blockage in glyceryl trinitrate bioactivation in smooth muscle cells and suppresses basal continuous sympathetic activity, causing IAS relaxation. Sufficient distension of the IAS during defecation also reduces the risk of trauma during defecation and complication after the trauma. Both eruption of tissue in the fissure region and release of contraction vessel mediators tend to arrest fissure healing.

[Crohn's disease with anoperineal lesions: use of MRI]

The authors report a case of perineal Crohn disease with three anal fissures. Because of a persistant fever without any clinical aspect of abscess they practiced MRI examination that discovered an abscess of the recto-vaginal wall. The patient was operated under general anaesthesia. This clinical case shows the interest of radiologic exams, particularly pelvic MRI for the precise lesional diagnosis of anoperineal lesions of Crohn's disease, that is still complex and difficult to treat.

Radiation-induced rectal ulcer--prognostic factors and medical treatment

BACKGROUND/AIMS

We conducted this study in order to investigate prognostic factors, and the difference of efficacy of three medical regimens, in the treatment of radiation-induced rectal ulcer.

METHODOLOGY

We enrolled 38 pts, with different ages, the free interval from radiation to the appearance of symptoms, and the rectal ulcer size. Medical regimens were 1) sucralfate enema, 2) salasopyrine + hydrocortisone enemas, 3) combination of regimens. We analyzed the difference of frequency of ulcer healing and the time necessary for ulcer healing, between the patients in the different groups.

RESULTS

The patients with late appearance of symptoms had significantly shorter time to ulcer healing than the patients with early appearance of symptoms (p=0.032). The patients who received sucralfate alone significantly more frequently achieved ulcer healing, than the patients with salasopyrine and hydrocortisone (p=0.046), and combination regimen (p=0.003). The patients with sucralfate (p=0.009), and with salasopyrine + hydrocortisone (p=0.0387), demanded significantly shorter time to ulcer healing than the patients who received combination treatment.

CONCLUSIONS

The free interval may be an important prognostic factor, in patients with rectal ulcer concerning treatment duration. It seems that treatment with sucralfate alone may be the treatment of choice, for patients with radiation-induced rectal ulcer.

[Perianal ulceration revealing Langerhans cell histiocytosis]

Langerhansian histiocytosis is a rare and heterogenous disease. Skin localisation is common but the lesion usually have typical aspect and topography. Peri anal localisation is rare. We report a case of isolated peri anal ulceration revealing a Langerhansian histiocytosis in a young patient.

Diseases of the rectum and anus: a clinical approach to common disorders

Diseases of the rectum and anus are common, and the prevalence in the general population is probably much higher than that seen in clinical practice since most patients with symptoms referable to the anorectum do not seek medical attention. The examination and diagnosis of certain anorectal disorders can be challenging, and the physical examination of the anorectum is often inadequately performed in clinical practice. This article reviews the important features of the anorectal examination and the diagnosis and treatment of benign anorectal disorders such as hemorrhoids, fissures, fistulas, solitary rectal ulcer syndrome, fecal incontinence, and pruritus ani. Approaches to staging and managing malignant neoplasms of the anus and rectum are outlined.

Sphincterotomy with radio frequency surgery: a new treatment technique of fissure in ano and associated pathologies

BACKGROUND

Anal fissures are dealt with using traditional approaches aiming at relieving the anal spasm and minimizing the anal sphincter pressure. Nevertheless, pathologies like sentinel tags, anal papillae, anal polyps, or small hemorrhoids which are often associated with chronic fissures are either considered innocuous, therefore left untreated, or are removed by conventional techniques.

MATERIAL AND METHODS

In this retrospective, non-randomized study, we performed lateral internal sphincterotomy, which was followed by radio frequency surgical procedures to eliminate the associated pathologies mentioned above.

RESULTS

In all, 283 patients were studied. All the patients treated by the method of lateral subcutaneous internal sphincterotomy followed by radio frequency surgical procedure for aforesaid associated pathologies were made comfortable on account of the reduction in pain and irritation during defecation, the pricking or foreign body sensation in the anus and pruritus or wetness around the anal verge. A follow up after 18 months showed that only 7 % of patients had recurrence of symptoms or local signs.

CONCLUSION

This combined approach has been found to be an effective, easy and quick way of treating chronic fissure in ano with associated pathologies

Anal condyloma and HIV-associated anal disease

Although there are a large variety of anal diagnoses associated with the HIV population, anal condyloma and anal ulcerations make up the vast majority. A large percentage of individuals having multiple concurrent pathologies should also be noted. Thus, this article concentrates on anal condyloma, anal ulceration and HIV, making note of other significant issues.

Perianal acquired tufted angioma associated with pregnancy: case report

Tufted angiomas are rare lesions described as slowly growing/spreading erythematous macules especially located in the upper trunk and neck. Herein we report the case of perianal location of a tufted angioma in a young pregnant woman. She came to our observation complaining of perianal pain accompanied by bleeding at defecation. A lesion resembling a perianal fissure was observed. Mild hypertonia of the internal sphincter was confirmed at manometry. After one week of ineffective medical treatment, surgery was planed at the end of the sixteenth week under local anaesthesia. The lesion was excised and a minimal sphincterotomy was performed; histopathology report described features of a tufted angioma. The pregnancy proceeded regularly, without anal symptoms, followed by normal vaginal delivery at the thirty-eighth week. This case showed three peculiar features: the association of tufted angioma and pregnancy, the perianal location, and the clinical appearance suggestive of an anal fissure. The clinical manifestation of a perianal tufted angioma, mimicking an anal fissure, is of utmost importance to the differential diagnosis and treatment plan, especially in a pregnant woman.

Side effects of botulinum toxin injection for benign anal disorders

BACKGROUND

Botulinum toxin A (BT-A) is a powerful biological toxin. Nevertheless, it has proved to be a remarkable therapeutic agent for the treatment of benign anal disorders. Higher doses of BT-A could change the outcome of treatment. It is not known whether doses of BT-A higher than 20 units of Botox (or corresponding doses of Dysport) are as safe for patients as lower doses of BT-A.

METHODS

The side effects of BT-A injections in the treatment of chronic anal fissure (105 patients) and functional outlet obstruction (34 patients) were analysed prospectively. The patients received at least 25 units of Botox or 150 units of Dysport.

RESULTS

The patients with chronic anal fissure complained of incontinence of flatus (one severe case and eight mild cases), incontinence of faeces (five mild cases), anal haematoma (five cases), flu-like syndrome (three cases), an acute inflammation of external anal varices (two cases), epididymitis (one case) and haemorrhoid prolapse (one case). Patients with anismus suffered from intertrigo (one case); the pain after injection lasted for 2-4 days (four cases). No life-threatening side effects after 181 injections of BT-A were observed. Most of the side effects were only transient symptoms. No significant interdependence between injection methods (injection into one or two sites) and the risk of side effects was found.

CONCLUSION

Treatment with BT-A is safe. Despite the application of higher doses of BT-A in the treatment of benign anal disorders so far, no severe side effects were observed.

Treatment of anal fissure with glyceryl trinitrate in patients referred for surgical management

BACKGROUND

A number of recent studies indicate that anal fissure may be treated by applying glyceryl trinitrate (GTN) ointment. The present study aims to determine the effectiveness and patient acceptability of GTN treatment for patients referred to a consultant surgeon.

METHODS

A prospective study of 65 consecutive patients referred to one surgeon (ALP) over a 12-month period was undertaken. All patients were offered 0.2% GTN ointment to be applied intra-anally four times daily for 4 weeks. Informed consent was obtained and review planned for 4 weeks.

RESULTS

Fourteen patients declined treatment and nine of the 14 (64%) subsequently underwent lateral sphincterotomy. Twelve of the 51 patients (18.5%) who accepted treatment could not complete it due to headache or persisting severe anal pain. Thirty-nine of the 51 patients (77%) were able to complete 4 weeks of treatment. Twenty-two of the 39 reported an improvement in symptoms. A total of 22 patients (43%) who started GTN treatment subsequently underwent lateral sphincterotomy.

CONCLUSIONS

Evidence from the present study suggests that GTN ointment has a place in the management of referred patients with severe and/or chronic anal fissure, but sphincterotomy remains an important treatment option for the majority.

Fissurectomy and isosorbide dinitrate for chronic fissure in ano not responding to conservative treatment

BACKGROUND

Although lateral sphincterotomy heals chronic fissure in ano in over 90 per cent of cases it is a surgical technique with inherent complications. To avoid such complications, chronic fissure in ano was treated by fissurectomy in this study. To enhance postoperative tissue perfusion allowing stable wound healing, fissurectomy was combined with temporary chemical sphincterotomy by a nitric oxide donor cream.

METHODS

Seventeen consecutive patients (ten women) with chronic fissure in ano not responding to conservative management underwent diathermy fissurectomy. After operation patients used a 1 per cent isosorbide dinitrate cream. Postoperative follow-up continued until wounds had healed, at which time anal endosonography was performed. A telephone inquiry into fissure recurrence and continence status was made.

RESULTS

Seventeen patients underwent fissurectomy, without postoperative complications. All wounds had healed within 10 weeks. No fissure recurrence was seen after a median follow-up of 29 months. Histopathology showed non-specific scar tissue without signs of internal anal sphincter fibrosis. Postoperative endosonography showed no evidence of new internal sphincter defects.

CONCLUSION

In the treatment of chronic anal fissure not responding to chemical sphincterotomy with nitric oxide donors, fissurectomy in combination with isosorbide dinitrate cream may be a sphincter-sparing surgical technique.

Topical mononitrate treatment in patients with anal fissure

AIM

To assess the efficacy and patient compliance of topical mononitrate hydrogel for the treatment of anal fissure.

MATERIALS AND METHODS

Nineteen patients with symptomatic chronic anal fissures were randomly allocated to receive either active (10 patients) or placebo (nine patients) gel treatment. Rectal administration of hydrogel containing 0.2% isosorbide-5-mononitrate was prescribed. Patients were instructed on its application to the anal canal twice daily for 3 weeks. A questionnaire was used to determine patient compliance with therapy. Anal manometry was performed before and after therapy.

RESULTS

At the end of therapy, the fissures were healed in 80% of actively treated patients compared with 22% of the control group. There was a mean reduction of 28% in mean resting anal pressure. Two actively treated patients (20%) suffered from mild headache relieved with oral analgesics and menthol lozenges. Faecal incontinence was not observed. There were no recurrences during at least 3 months of follow-up.

CONCLUSIONS

Topical mononitrate gel therapy of anal fissures is an effective and safe approach. In this study, the few cases of headache were rapidly relieved with oral analgesia and menthol lozenges.