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PubMed1980

[Pathogenesis, clinical aspects and conservative therapy of hemorrhoids].

Hemorrhoids are readily diagnosed by proctoscopy. They should not be treated without thorough examination, as carcinoma of the rectum or sigmoid may cause similar symptoms. The examination should include careful inspection of the anal region, digital palpation, proctoscopy and sigmoidoscopy. Once the diagnosis is established, instruction in anal hygiene should first be given. Local use of ointment and suppositories follows. If this symptomatic treatment fails, sclerosing injections are recommended. For this purpose various irritant solutions are used which may on occasion lead to complications such as local and, in rare cases, extensive necrosis of the rectal mucosa. In the search for a method which avoids any type of irritant substance, coagulation by infrared radiation using a special probe has been developed and found to be at least as successful as injection treatment. For prolapsing piles, however, rubber band ligature appears to be the most effective method.

Cold Temperature↗
PubMed1994

Pruritus ani. Causes and concerns.

PURPOSE: The aim of this study was to determine how frequently pruritus ani (PA) is a symptom secondary to benign or malignant colon and anorectal pathology. METHODS: One hundred nine patients with PA as the only presenting symptom were prospectively evaluated over a two-year period. All patients underwent anoscopy, rigid proctoscopy, and colonoscopy and were treated for PA. Patient data were entered into a computer data base and analyzed. RESULTS: The mean age was 52.1 years; males outnumbered females 2:1. The mean duration of symptoms was 6.1 weeks. Mean coffee intake was four cups per day. Forty-five percent of patients smoked and 45 percent drank alcohol daily. Thirty-five percent had an abnormal proctosigmoidoscopy or colonoscopy. Twenty-seven (25 percent) patients had primary pruritus and 82 (75 percent) patients had coexisting colon or anorectal pathology. The PA-associated neoplasia included rectal cancer (11 percent), anal cancer (6 percent), adenomatous polyps (4 percent), and colon cancer (2 percent). Hemorrhoids (20 percent) and anal fissures (12 percent) were the most common pruritus-related anorectal diseases. Among the 23 percent of patients with PA and neoplasia, pruritic symptoms were present longer compared with those with PA and anorectal disease < 0.001 and primary pruritus (P < 0.0001). All patients with primary PA were initially treated with dietary fibers, steroid cream, and drying agents. The recurrence rate for primary pruritus was twice that for anorectal disease (P < 0.0001). CONCLUSIONS: PA responds to treatment in 89 percent of patients, while 11 percent are refractory to treatment. Symptoms suggestive of pruritus ani, especially those of long duration, should alert the surgeon to the potential for proximal colon and anorectal neoplasia.

Adenomatous Polyps↗
PubMed1997

Feasibility study for use of brush cytology as a complementary method for diagnosis of rectal cancer.

UNLABELLED: Brush cytology has previously been described as a feasible method for accurately diagnosing colorectal cancer. PURPOSE: This study was designed: 1) to determine the sensitivity and specificity of brush cytology for the diagnosis of rectal cancer; 2) to prospectively assess the extent of interobserver variability with this technique; 3) to prospectively examine the cost impact of the addition of brush cytology as a routine method of confirming the diagnosis of rectal cancer. PATIENTS AND METHODS: Three hundred fifty-seven patients who attended a rectal clinica and who were found to have a lesion between January 1990 and March 1996 were assessed. Each patient underwent rigid proctoscopy, followed by brush cytology and tissue biopsy. Results were compared with the final histologic diagnosis in each patient. The brushings from the last 92 consecutive patients in this series were independently examined by four cytologists and a pathologist to determine the rate of interobserver variability. RESULTS: Rectal adenocarcinoma was confirmed from surgically resected specimens in 303 patients. Brush cytology accurately diagnosed 278 of them. Of the remaining 25 patients, two had brushings that were insufficient for diagnosis. There was one false-positive case. Forceps biopsy correctly identified cancer in 260 patients, with no false-positive interpretations. Brush cytology accurately identified 53 of 54 adenomas as being benign, and forceps biopsy correctly identified all as benign. Sensitivity of brush cytology in this series was 92 percent, with a specificity of 92 percent. Interobserver agreement was 84 percent. Actual costs incurred with this method was an additional $17.00 per patient. CONCLUSIONS: Brush cytology can accurately diagnose rectal cancer in a high proportion of patients. Interobserver variation is low and compares favorably with other forms of cytologic interpretation. The additional cost remains a concern but can be kept within acceptable proportion.

Adenoma↗
PubMed2005

Retrorectal tumors: a diagnostic and therapeutic challenge.

PURPOSE: Tumors occurring in the retrorectal space are heterogeneous and uncommon. The utility of newer imaging techniques has not been extensively described, and operative approach is variable. This study examined the diagnosis, treatment, and outcome of retrorectal tumors at a tertiary referral center. METHODS: Patients with primary, extramucosal neoplasms occurring in the retrorectal space were identified using a prospectively maintained, procedural database of all adult colorectal surgical patients (1981-2003). Patients also were incorporated from the gynecologic oncology service. Exclusion criteria included inflammatory processes, locally advanced colorectal cancer, and metastatic malignancy. Medical records, radiology, and pathology reports were reviewed retrospectively. RESULTS: Thirty-four patients with retrorectal tumors were treated. Malignant tumors comprised 21 percent. Older age, male gender, and pain were predictive of malignancy (P < 0.05). Sensitivity of proctoscopy was 53 percent; this increased to 100 percent with the use of transrectal ultrasound. Accuracy of magnetic resonance vs. computed tomographic imaging for specific histologic tumor type was 28 vs. 18 percent, respectively. Surgical approach was anterior (n = 14), posterior (n = 11), and combined abdominoperineal (n = 9). Eleven patients required en bloc proctectomy. Patients undergoing posterior resection had lower blood loss and required fewer transfusions (P < 0.05). All benign tumors were resected with normal histologic margins and none recurred (median follow-up, 22 months). All patients with malignancy had recurrence/recrudescence of their disease. For these patients, median disease-free and overall survivals were 38 and 61 months, respectively. CONCLUSIONS: Retrorectal tumors remain a diagnostic and therapeutic challenge. Pain, male gender, and advanced age increase the likelihood of malignancy. Various imaging modalities are useful for planning resection but cannot establish a definitive diagnosis. Whereas benign retrorectal tumors can be completely resected, curative resection of malignant retrorectal tumors remains difficult.

Abdomen↗
PubMed2004

[The organisation and carrying-out of proctological examinations].

Coloproctology, a specialist field requiring specialist knowledge, experience and skill, is dealt with only marginally in current further education courses for doctors. A thorough anamnesis, and here a questionnaire is of great help in procuring rapid and complete information, and examination of the patient in the lithotomy position (being the most comfortable for the patient and the most practical for the doctor) ar vital. A thorough basic diagnosis, independent of the reported symptoms, is always required: 1. Abdominal examination. 2. Inspection and palpation of the anal region with and without abdominal muscular pressure. 3. Digital examination, including the prostate. 4. Rectosigmoidoscopy. 5. Proctoscopy, possibly with anal speculum examination. 6. Test for occult blood in the faeces. Depending on the anamnesis and findings, this basic diagnosis must be supplemented by further tests.

Anal Canal↗
PubMed1977

Anal pressures in hemorrhoids and anal fissure.

Maximal anal pressures have been measured after proctoscopy in 145 patients with hemorrhoids, 48 patients with anal fissure, and 78 asymptomatic control subjects. Anal pressures in patients with hemorrhoids (106 +/- 40 cm H2O) and anal fissure (130 +/- 43 cm H2O) were very significantly higher than those of controls (88 +/- 34 cm H2O) (P less than 0.001). Because patients with anal fissure have high anal pressures, these patients should benefit from manual dilatation of the anus or lateral subcutaneous sphincterotomy; however, only young male patients with hemorrhoids have anal pressures that are significantly higher than age- and sex-matched controls. Digital assessment and the two finger test are unreliable indicators of high anal pressure. These results indicate that measurement of anal pressure is useful in assessing the suitability of manual dilatation or sphincterotomy in the treatment of hemorrhoids.

Adolescent↗
PubMed1984

Piecemeal snare excision of large sessile colon and rectal polyps: is it adequate?

This study analyzes 28 consecutive patients with large sessile polyps snared piecemeal from the colon and rectum. The sections were examined to determine the adequacy of orientation and margin of excision. Orientation was judged excellent in five, good in 12, fair in six, and poor in five cases. The margin of excision was judged adequate in 23 of 28 cases. Five of eight patients with invasive carcinoma underwent bowel resection, and no residual tumor was found in the resected specimens. Of the remaining 20 patients without carcinoma, five had residual tumor or recurrences, with follow-up from 6 months to 6 years (average, 18 months). All of them underwent rebiopsies and electrocoagulation. None of the residual tumor or recurrences showed evidence of malignancy. Piecemeal snare excision of large sessile polyps of the large bowel appears to be an adequate procedure for most patients. A close follow-up with colonoscopy or proctoscopy is essential because residual tumor or recurrences are common.

Colonic Polyps↗
PubMed2000

Acute radiation proctitis: a sequential clinicopathologic study during pelvic radiotherapy.

PURPOSE: Rectal toxicity is often dose limiting during pelvic radiation therapy. This prospective study examined the sequential development and associations of clinical, endoscopic, and histopathologic rectal toxicity during ongoing radiation therapy. METHODS AND MATERIALS: Thirty-three patients with nongastrointestinal pelvic carcinomas underwent proctoscopy with biopsy before radiation therapy, after 2 weeks treatment, and toward the end of the treatment course (6 weeks). Symptoms of acute toxicity were recorded, and endoscopic changes were graded. Histologic changes in the surface epithelium, glandular layer, and lamina propria were assessed using an ad hoc scoring system. Macrophage accumulation was evaluated in anti-CD68 stained sections. RESULTS: Pretreatment endoscopy and biopsies were unremarkable. Clinical symptoms progressed toward the end of the treatment course. In contrast, endoscopic pathology was maximal at 2 weeks. Biopsies obtained during treatment exhibited atrophy of the surface epithelium, acute cryptitis, crypt abscesses, crypt distortion and atrophy, and stromal inflammation. Histologic changes, particularly those in the surface epithelium, were consistently more pronounced at 2 weeks than they were at 6 weeks. CONCLUSION: In contrast to clinical symptoms, endoscopic changes stabilize and histologic changes regress from the 2nd to the 6th week of treatment. These results may have implications for the design and timing of prophylactic and therapeutic interventions to reduce radiation proctitis.

Acute Disease↗
PubMed1976

Surgical treatment of colovesical fistula: the value of a one-stage procedure.

The records of all patients (43) with colovesical fistulas at Ochsner Clinic were reviewed retrospectively. The presenting symptoms are more often related to the bladder and not to the colon; fecaluria and pneumaturia are almost pathognomonic. The diagnosis may be difficult to obtain on proctoscopy, cystography, or intravenous pyelograms. Roentgenograms after barium enema and cystoscopy are the best means of diagnosis, though operation is necessary in some instances for definitive diagnosis. Primary resection and anastomosis with closure of the bladder has been successful in our experience with little morbidity and only one postoperative death. The controversy regarding primary colon resection in treatment of colovesical fistulas is perplexing. We do not believe that it is "foolhardy" to save the patient extra time, morbidity, and expense by doing one instead of three procedures. Primary resection of the colon with simple closure of the bladder is our recommended treatment for chronic colovesical fistula. We have had no recurrences.

Adult↗
PubMed1999

Referral for anorectal function evaluation: therapeutic implications and reassurance.

AIM: To determine the impact of anorectal function evaluation (AFE) on patients and referring specialists. PATIENTS AND METHODS: In one year, 135 patients were referred for AFE, which consisted of proctoscopy, anal manometry, rectal compliance, anal sensitivity measurement and anal endosonography. Questionnaires were sent to the patients and referring specialists. RESULTS: In 70% of the 135 patients there was total agreement about the referring and final diagnosis. The response rate of the patients was 78% (n = 100) and that of the specialists was 91% (n = 117). The experience with regard to pain and embarrassment during AFE was good. Of the women, 13% preferred a female investigator. Fifty-nine patients answered that they had received one or more treatments after referral: surgery (n = 32), medication (n = 16), diet (n = 5), physiotherapy (n = 1) or a combination of the above (n = 5). Of the 41 patients who did not receive another treatment, 29 were reassured and 12 did not experience any benefit from the visit, thus bringing the total benefit of the referral to 88%. The anorectal complaints before AFE and at follow-up improved significantly in the treated group (P < 0.0001). The advice given was followed by the referring specialist in 98 cases (84%). The quality of the advice given was considered good in 98 (84%). The opportunity of referral for AFE was considered useful in 108 cases (93%). In 71 patients, information from both the specialist and the patient was obtained. Three patients had therapies that were not advised and 19 patients did not follow the advice (mainly dietary). In the 135 patients, AFE changed the management in 34 patients (25%). In the other 101 patients, endosonography was of value in determining the size of sphincter defects or the fistula tracks. CONCLUSION: AFE was well tolerated and changed the management in 25% of patients. Additional advice and reassurance were given in many patients; only 12% of patients claimed to have no benefit from the referral. Anal endosonography seems the most valuable test.

Adolescent↗
PubMed1980

Diagnosis and management of anorectal gonorrhoea in women.

A retrospective assessment of 159 female patients who had undergone proctoscopy was carried out between January and September 1977. One hundred and twenty-seven (80%) were known contacts of gonorrhoea; of these, 63 (49.6%) were found to be infected with Neisseria gonorrhoeae. Of these, 29 (46%) harboured gonococci in the rectum as well as in the urethra and cervix while four (6.3%) harboured gonococci only in the rectum. Gram-stained smears gave positive results in only 12 of the 29 cases of rectal gonorrhoea, which indicates the importance of culturing rectal material. It is recommended that the management of anorectal gonorrhoea should be similar to that already established for urogenital infection.

Anus Diseases↗
PubMedDate not supplied

The predictive value of clinical evaluation of response to neoadjuvant chemoradiation therapy for rectal cancer.

INTRODUCTION: Multimodality therapy has become the standard treatment for patients with locally advanced (T3 and T4) rectal carcinoma. Accurate preoperative staging of the patients with rectal cancer has increased in importance because the selection of patients with transmural rectal cancer (T3 or T4) or node-positive disease leads to a previous nonsurgical neoadjuvant treatment. The purpose of this study was to evaluate the predictive value of the clinical response to neoadjuvant therapy on the basis of pathological results obtained on rectal cancer patients treated by chemoradiotherapy and surgery. METHODS: From 1994 to 2003, 58 patients with a primary diagnosis of rectal cancer were studied at our department and enrolled in a neoadjuvant protocol of chemoradiotherapy followed by surgery. All patients were treated by 30 days of chemoradiotherapy. At the end of the chemoradiotherapy, each patient underwent clinical examination, including digital rectal examination, proctoscopy and abdominal-pelvic computerized tomography to define the clinical response to the chemoradiotherapy. Surgical resection was performed in all patients three weeks after the end of chemoradiotherapy, and histological analysis was performed on all resected specimens. RESULTS: The clinical complete response rate corresponded to the pathological complete response rate, whereas the clinical evaluation overestimated partial response and stable disease. The pathologic examination revealed that 3.5% of clinical partial responses and 3.4% of clinical stable disease were really pathological progressive disease. Clinical partial response and clinical stable disease positive predictive values were 92.8% and 90.9%, respectively, whereas the clinical progressive disease negative predictive value was 20%. Then, 6.9% of patients believed to have responded to the therapy, or not to have responded or worsened, actually had worsened by the end of the chemoradiotherapy. CONCLUSIONS: Positive and negative predictive values, in particular for partial response and stable disease, of clinical evaluation of the response to chemoradiotherapy were not high enough to consider clinical evaluation accurate enough to make treatment decisions.

Adult↗
PubMed1995

Has the use of cervical, breast, and colorectal cancer screening increased in the United States?

This report describes trends in reported breast, cervical, and colorectal cancer screening within the US population from 1987 to 1992. Data from the 1987 and 1992 Cancer Control Supplements of the National Health Interview Survey were analyzed to determine use of Pap smears by women aged 18+; of mammography and clinical breast examination by women aged 50+; and of proctoscopy, digital rectal examination, and fecal occult blood testing among men and women aged 50+. Use of mammography doubled between 1987 and 1992 while Pap smear use changed very little. Use of the three colorectal cancer screening modalities increased but levels remained low. Usage trends were also assessed in relation to several sociodemographic factors. Disparities in screening reported in 1987 according to income and education persisted in 1992.

Aged↗
PubMed2000

[Severe obstipation due to eating unshelled sunflower seeds].

In two boys aged 13 and 6 years respectively obstipation and a paradoxical diarrhoea developed four days after consumption of unshelled sunflower seeds. The cause was impaction of the unshelled sunflower seeds in the rectum. Both patients required general anaesthesia to remove the sunflower seeds via proctoscopy. It is known that eating unshelled sunflower seeds can cause impaction of the shells in the rectum (causing a bezoar). Removing the seeds under general anaesthesia is practically always necessary. Considering the serious symptoms and the invasive consequences which are not without risks, parents and children should be warned about the danger of eating unshelled sunflower seeds.

Adolescent↗
PubMed2001

Experience with a one-stop colorectal clinic.

BACKGROUND AND OBJECTIVE: Colorectal services have traditionally been arranged for the convenience of hospitals rather than patients. This model is not ideal, particularly for minor interventions and diagnostic procedures. In order to address this a one-stop colorectal clinic was set up. PATIENTS AND METHODS: Weekly clinics ran from 6.00 to 9.30 p.m. on Wednesdays for a period of 6 months. Patients with rectal bleeding, altered bowel habit, anorectal symptoms and those requesting screening advice were seen by a consultant or specialist registrar. Patients were asked to fill in a questionnaire at the end of their clinic attendance. RESULTS: 197 patients were seen in 17 clinics; 134 underwent proctoscopy, 72 had a rigid sigmoidoscopy and 85 had a flexible sigmoidoscopy carried out. Twenty-four patients subsequently had a barium enema and 3 were listed for colonoscopy. The main diagnosis was haemorrhoids (n = 104); 14 colorectal neoplasms were discovered (5 cancers and 9 polyps). During the study period the number of patients waiting for lower gastrointestinal endoscopy fell from 119 to 63; 2 months after ending the pilot scheme, the number had risen to 108. CONCLUSION: The clinic was found to have significantly improved patient care. The majority of patients were satisfied with an evening clinic. Flexible sigmoidoscopy without sedation was well tolerated and the ability to perform this at initial assessment had a marked effect on the number of patients awaiting lower gastrointestinal endoscopy.

Ambulatory Care Facilities↗
PubMedDate not supplied

Anal dilatation, lateral subcutaneous sphincterotomy and haemorrhoidectomy for the treatment of second and third degree haemorrhoids. A prospective randomized study.

Patients with second or third degree haemorrhoids were randomized for treatment by anal dilatation, lateral subcutaneous sphincterotomy or haemorrhoidectomy. The patients were studied by means of proctoscopy, anal manometry and symptom grading preoperatively, two months and one year after the procedure. After one year, more than half of the patients were symptomless in each treatment group. Both anal dilatation and sphincterotomy gave poor results in 25% of the patients, compared with 9% after haemorrhoidectomy. Young age was related to good results in anal dilatation or sphincterotomy, but not in haemorrhoidectomy. Results of anal dilatation and sphincterotomy in treating haemorrhoids are unpredictable, so they cannot be recommended as routine procedures. Maximal basal pressure was reduced after all three procedures, but neither the preoperative nor postoperative anal pressures were able to predict the result of the different treatment techniques.

Adult↗
PubMed1991

Closed lateral subcutaneous sphincterotomy under local anaesthesia in the treatment of chronic anal fissure.

We studied 65 consecutive ambulatory patients with chronic anal fissure that were treated by sphincterotomy under local anaesthesia. The patients were allowed to leave the clinic immediately after the operation. Healing rate was determined three to four months postoperatively by clinical examination and proctoscopy. Fifty-seven patients (88%) were free of symptoms and the fissure was healed. Eight unhealed patients were subjected to a repeated procedure under local anaesthesia, leaving two unhealed patients, that were operated with open sphincterotomy under general anaesthesia. We conclude that local anaesthesia can be recommended for the closed lateral subcutaneous sphincterotomy in ambulatory treatment of chronic anal fissure.

Adolescent↗
PubMed1990

Evaluation and therapy of the patient with fecal occult blood loss: a decision analysis.

We performed a decision analysis to evaluate cost per cancer detected, cost per neoplasm detected, and cost per treatable lesion of two common diagnostic strategies, barium enema-proctoscopy or colonoscopy as the first diagnostic test, for patients with fecal occult blood loss. The prevalence of polyps, cancer, and angiodysplasia, and the colonoscopy success rate were obtained from consecutive colonoscopy records. Costs were estimated from hospital charges; sensitivity and specificity of barium enema and colonoscopy were obtained from the literature. For treatable lesions (cancer, polyps, and angiodysplasia), the colonoscopy first strategy had a higher sensitivity (80% vs. 57%) and a higher specificity (95% vs. 80%) than the barium enema first strategy. Cost effectiveness measures were similar for the two strategies. Colonoscopy as the first diagnostic test had a lower cost per treatable lesion ($2,319 vs. $2,895) and a lower cost per neoplasm detected ($2,694 vs. $2,896), whereas the barium enema first strategy had a lower cost per cancer detected ($10,050 vs. $10,297). The lower cost per treatable lesion of the colonoscopy first strategy was not affected by changes in the prevalence of lesions, test characteristics, costs of tests, or colonoscopy success rate over clinically relevant ranges. The higher cost of colonoscopy was offset by its greater sensitivity and its capacity for biopsy and therapy. Therefore, since the cost per treatable lesion is lower and the sensitivity, specificity, and predictive value is superior, colonoscopy is recommended as the preferred initial test in evaluating a patient with fecal occult blood loss.

Barium Sulfate↗