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Parasitic diseases. Other roundworms. Trichuris, hookworm, and Strongyloides.
Trichuriasis may be asymptomatic or, in heavy infection, lead to profuse, bloody diarrhea and rectal prolapse. Diagnosis is made by finding the distinctive barrel shaped eggs in the stool or in the heavily infested patient, by anoscopy and identification of worms attached to reddened and ulcerated rectal mucosa. Mebendazole is the drug of choice in treatment. Capillariasis, a parasitic infection encountered mainly in the Philippine Islands, is of interest in that the eggs may be confused with the eggs of trichuris. Hookworm disease is generally asymptomatic, but in heavy infection, leads to iron deficiency and hypochromic, microcytic anemia. Diagnosis is made by finding the characteristic hookworm eggs on a examination of a direct fecal film. Accidental invasion of humans by dog and cat hookworm leads to cutaneous larva migrans, also known as "creeping eruption." Human hookworm is treated most effectively with mebendazole, while the rash produced by creeping eruption responds to topical thiabendazole. Strongyloides is fairly common in rural areas of the southeastern United States and may be seen in the urban setting among inmates of mental institutions, prisons, and in immigrants who formerly resided in endemic tropical regions. Because of its remarkable capacity for dissemination of larvae throughout the body, this parasite is now recognized as a serious problem for the patient who is immunocompromised. Diagnosis is made by finding larvae in the stool or by the Enterotest. All infected patients should be treated with thiabendazole. I consider the issue on Drugs For Parasitic Infections, published annually or biannually by The Medical Letter on Drugs and Therapeutics, to be the single best source of information on the treatment of parasitic diseases for primary care physicians.
Cap polyposis--an unusual cause of diarrhoea.
'Cap polyposis' is a poorly recognised condition with distinct clinical, sigmoidoscopic, and pathological features that may be confused with other inflammatory conditions of the large intestine including pseudomembranous colitis and idiopathic chronic inflammatory bowel disease. The pathogenesis is unknown but on the basis of the characteristic histological appearances, which are similar to those seen in situations where mucosal prolapse is the underlying mechanism, it has been suggested that the latter may be an important aetiological factor. Two cases are described. Histological features in the first (presence of intramucosal elastin) and clinical features in the second (rectal prolapse) support the above hypothesis.
Spontaneous rupture of the rectosigmoid with small-bowel evisceration through the anus. Report of a case and review of the literature.
A patient with spontaneous rupture of the rectum and evisceration of small bowel through the anus is presented. To the authors' knowledge, this paper represents the third reported case of this type of spontaneous rectal rupture. A discussion of the pathogenesis and treatment of this rather unique complication is presented. It is suggested that rectal or rectosigmoid rupture be considered a rare complication of rectal prolapse.
[Defecography by spiral computed tomography].
PURPOSE: We investigated the possible role of helical CT defecography in pelvic floor disorders by comparing our results with those of conventional defecography. MATERIAL AND METHODS: Our series consisted of 90 patients, namely 62 women and 28 men, ranging in age 24-82 years. They were all submitted to conventional defecography, and 18 questionable cases were also studied with helical CT defecography. The conventional examination was performed during the 4 standard phases of resting, squeezing, Valsalva and straining; we used a remote-control unit. The parameters for helical CT defecography were: 5 mm beam collimation, pitch 2, 120 KV, 250 mAs and 18-20 degrees gantry inclination to acquire coronal images of the pelvic floor. The rectal ampulla was distended with a bolus of 300 mL nonionic iodinated contrast agent (dilution: 3 g/cc). The patient wore a napkin and was seated on the table, except for those who could not hold the position and were thus examined supine. Twenty-second helical scans were performed at rest and during evacuation; multiplanar reconstructions were obtained especially on the sagittal plane for comparison with conventional defecographic images. RESULTS: An unquestionable diagnosis could be made in all the 18 patients submitted to helical CT defecography. The diagnosis was in agreement with proctology results and added new information in all cases. Sixteen patients had constipation and 2 fecal incontinence--one from rectal prolapse and the other from a rectovaginal fistula. In this latter case helical CT defecography permitted to confirm the fistula and suggest its course. One patient had a previously undetected ovarian cancer metastatic to the anterior rectal wall. DISCUSSION AND CONCLUSIONS: Coronal helical CT defecography images permitted to map the perineal floor muscles, while sagittal reconstructions provided information on the ampulla and the levator ani. To conclude, helical CT defecography performed well in the study of pelvic floor disorders and can follow conventional defecography especially in questionable cases.
Laser therapy of solitary rectal ulcers: a new concept.
Fourteen cases of histologically proven benign solitary rectal ulcer were managed with Neodymium: Yttrium-Aluminium-Garnet (Nd:YAG) laser (contact mode) over a three-year period. All patients were symptomatic at presentation (bleeding, mucus or pus discharge per rectum, with or without diarrhoea). Thirteen of the 14 (93%) were relieved of symptoms after a mean of 2.3 sittings of laser (range 1-8). None of the patients had associated rectal prolapse. Successfully treated patients have been followed up for a mean of 14.2 months (two to 25 months) and are symptom free. There was minimal morbidity and no death. Nd:YAG laser excision of benign solitary rectal ulcers is a safe, new and patient-friendly technique.
Anal complaints in Nigerians attending Olabisi Onabanjo University Teaching Hospital (OOUTH), Sagamu.
The objective of this study was to determine prospectively the prevalence of anal complaints amongst Nigerians attending the General Out-patient Department (GOPD) of the hospital and review the records of those admitted to the surgical service with related complications. All the 272 patients attending the GOPD of OOUTH in November, 1999 were interviewed using a structured questionnaire. Information concerning age, sex, educational status, present or past history of at least one of the following symptoms viz recurrent bleeding per rectum, anal prolapse, anal/perianal pain, pruritus ani and anal discharge were obtained. Also obtained were reason(s) for current hospital attendance and any previous medical consultation. Those with at least one of the symptoms were classified as symptomatic. The symptomatic group had rectal examination including proctoscopy. The results showed that 82/272 (30.15% ) were symptomatic. Rectal examination on these 82 patients showed that 10(3.7% of 272) had haemorrhoids, 2(0.7% ) had rectal prolapse, 0.7% had peri-anal warts; 15(5.5% ) anal tags, 10(3.7% ) chronic anal fissure, 2 (0.7% ) perianal fistulae. In 29(10.4% ), the examination was normal and in 12 the rectum was too loaded with feaces to permit proctoscopy. However, only 5/272 (1.84% ) attended the clinic for the anal complaint, while 12(4.4% ) had previously consulted a physician for same. Fear of impotence following surgery in 24 males and belief in herbal remedies in 32 patients were the main reasons for not consulting a physician. During the year 1999, out of a total of 558 admissions into our surgical service, only 4(0.6% ) were for complications related to anal complaints. This study indicated the prevalence of anal complaints in the study population of Nigerians as 30.15% , haemorrhoids constitute 3.7% and anal fissure 3.7% , contrary to low rates reported for developing countries. While this result cannot be extended to represent prevalence amongst Nigerians, it may be a pointer to what is to be expected.
Pelvic floor disorders.
The pelvic floor conditions form a diverse array of primarily functional conditions that are rarely life-threatening but may be severely debilitating. Reassurance combined with initial medical and dietary management of most of these conditions greatly ameliorates the suffering of most patients. Surgical intervention is most successful in patients with demonstrable defects such as mechanical sphincter disruption or obvious complete rectal prolapse. Surgery should be offered only to patients with other functional pelvic floor disorders who manifest intractable symptoms.
Anatomy of the presacral venous plexus: implications for rectal surgery.
The presacral venous plexus results from anastomoses between the lateral and median sacral veins, and courses into the pelvic fascia covering the anterior aspect of the body of the sacrum. The presacral venous plexus is not directly visible during rectal surgery, and injuries to this plexus may be life-threatening. Dissection of the retrorectal plane or anchoring of the rectum to the sacral promontory as in rectal prolapse surgery exposes the patient to the risk of injury to the presacral venous plexus. The aim of this study was to identify some avascular areas in the anterior aspect of the sacrum in order to lower the occurrence of such injuries during rectal surgery. The pelvis of 10 fresh cadavers was dissected after injection of a colored resin into the inferior vena cava, and the presacral venous plexus was studied. Four avascular tetragonal areas were common to all the specimens. The corners of a square with a side of 3 cm, centered on the anterior aspect of the body of sacrum, were always contained in the avascular areas. The upper side of this square was parallel to a line passing through the sacral promontory, at a 3 cm distance from it. Staples or sutures should be placed in the avascular areas to avoid injuries to the presacral venous plexus.
[Radiologic diagnosis of anal incontinence].
Defaecography was performed in 47 consecutive patients with faecal incontinence. A gap in the anal canal with spontaneous leakage of contrast medium was observed in 19 patients and demonstrated a severe disturbance of sphincteric function. In 13 cases, an anorectal angle of more than 120 degrees that did not change during voluntary sphincter contraction and the missing dorsal impression of the anorectal junction indicated a damage of the puborectalis muscle. A rectocele was detected in 18 patients, an intussusception in 14 patients, and a complete rectal prolapse in 3 patients. Thus, mechanisms of faecal incontinence can be elucidated radiologically in more than one half of the patients examined. However, the high prevalence of a rectocele or an intussusception in patients with faecal incontinence causes doubt whether these alterations of rectal morphology are functionally relevant in the majority of patients with faecal incontinence.
[Inverted polypoid hamartoma of the rectum].
The inverted polypoid hamartoma of the rectum (IPHR) is characterized by polypoid masses composed of ectopic glands of Lieberkühn invaginated within the mucosal muscle to form a conglomeration in the submucosa, hence the term "inverted polyp". It produces an unremarkable rectal syndrome, more suggestive, when abundant glairy exudate is observed, in young subjects. It causes a unique sessile polypoid lesion, occasionally multilobular or a stenotic, approximately circular, ring. Diagnosis is made using deep surgical biopsies. Two theories, dysgenetic or acquired, attempt to explain the pathogenesis of this lesion. The predominant acquired theory includes IPHR in the "solitary rectal ulcer" syndrome which is related to the traumatism of rectal prolapse. Transanal ablation is the predominant treatment.
Anorectal physiology and pathophysiology.
The anatomy and physiology of the external anal sphincter, puborectalis muscle, internal anal sphincter, and rectum are described. Measurement techniques are reviewed emphasizing those which can be carried out by the gastroenterologist in independent office practice, and the range of normal values for each test is given. A protocol for diagnostic evaluation of anorectal disorders is recommended which includes testing for rectal prolapse and for descent of the perineum by having the patient strain while seated on a commode chair, evaluating the external and internal anal sphincters by recording EMG with an anal plug, or recording pressures with a perfused catheter or balloon probe, using a rectal balloon to evaluate the maximum tolerable volume of rectal distension and the minimum (threshold) volume of a bolus injection which can be subjectively perceived, and arranging with a radiologist to perform a proctogram--a radiograph of the rectum and anal canal during rest and when the patient strains to defecate--in order to evaluate the anorectal angle (puborectalis muscle) and to detect rectocele and intussusception. These objective tests should be supplemented by a careful clinical history and physical examination.
Solitary rectal ulcer syndrome (colitis cystica profunda) in spinal cord injury patients: 3 case reports.
Clinically indicated endoscopic examinations of 56 patients with spinal cord injury (SCI) (31 for bleeding) were performed over a 3-year period, of which 3 (6%) showed solitary rectal ulcer syndrome (SRUS). The presentation was rectal bleeding or mucoid discharge. The endoscopic appearance was multiple pseudopolyps and occasional mucosal ulcers extending proximally 8 to 40cm from the anus. Mucosal biopsy specimens showed distorted mucosal glands and displaced smooth muscle fibers wrapping around the glands, the hallmark of SRUS. The affected patients had routinely used suppositories and digital stimulation for bowel care and had been paralyzed 7 to 50 years. None had rectal prolapse. These cases show that SRUS (colitis cystica profunda) can be found among patients with SCI.
Clinicopathologic comparison of eroded polypoid hyperplasia and solitary rectal ulcer syndrome.
We experienced two unusual cases of tumor-like polypoid lesions involving the rectosigmoid colon. They could not be readily classified into any well known polypoid tumors of the rectosigmoid colon, but appeared to have some similarities to the previously documented "eroded polypoid hyperplasia (EPH)". A collective review of our seven cases of solitary rectal ulcer syndrome (SRUS), which proved to be due to paradoxically over-reactive muscle tone of the puborectalis, was performed, and clinicopathologic comparisons between EPH and SRUS were carried out. They shared histopathologic characteristics such as vascular congestion, crypt hyperplasia, and eroded surface, but they were different from each other in clinical symptoms, location of lesions and gross features. Furthermore, in one EPH case there was an altered much profile which was similar to that seen in SRUS and complete rectal prolapse. Conceivably, the pathological features of both EPH and SRUS were thought to have a possible connection with mucosal prolapse syndrome (MPS). Considering that MPS is a group of diseases encompassing SRUS and the related disorders of the colorectum and the anus, it is speculated that EPH of the rectosigmoid colon might be the proximal analogue of SRUS, a mucosal prolapse of the more distal colon.
The natural history of benign ulcer of the rectum.
The cause of benign ulcer of the rectum is obscure, and there are varying views as to its pathogenesis. It is usually found to have a clinical onset in young adults of either sex. On sigmoidoscopy, the lesion has a characteristic appearance. The ulcers are, most often, solitary but more than one ulcer can be present. Diagnosis at biopsy is not essential, but distinctive changes can be seen in tissue from both the ulcer itself or the mucosa adjacent to the ulcer. Clinically and histologically recognizable preulcerative and nonulcerative phases are seen. Despite the benign nature of the ulcer, it may persist unchanged for many years, often associated with rectal prolapse. In general, medical and surgical methods of treatment have proved unsatisfactory.
Diagnosis and assessment of sigmoidoceles.
OBJECTIVE: This study analyzed the clinical presentation, incidence, characteristics as demonstrated by defecating proctography, and surgical outcomes of sigmoidoceles. STUDY DESIGN: Defecating proctograms were obtained on all women with clinical evidence of pelvic floor defects between June 1, 1991, and June 30, 1995. The proctograms were retrospectively reviewed for the presence of a sigmoidocele and concomitant pelvic hernias. The distance between the maximum point of sigmoid descent with strain and the perineal body was measured. A chart review was performed to obtain clinical history, physical examination results, surgical treatment, and outcome. RESULTS: Nine sigmoidoceles (4.0%) were noted in 234 defecating proctograms. The leading edge of the sigmoid hernia ranged from 3.8 cm beyond the perineal body to 8 cm above the perineal body. All nine patients were found to have concomitant rectoceles by proctography, whereas only three were found to have enteroceles. Physical examination before proctography suggested that six patients had vaginal vault prolapse with enterocele, one patient had uterine prolapse with an enterocele, and two patients had rectoceles alone. Five of the seven patients clinically diagnosed with an enterocele showed no small bowel herniation on defecography. No sigmoidoceles were suspected by physical diagnosis alone. All rectoceles were diagnosed by clinical examination. All patients except one, who had concomitant rectal prolapse, complained of constipation. Two patients required manual pressure to the perineum or vagina to defecate. Seven of the nine patients underwent pelvic reconstructive surgery. The surgical procedure for sigmoidocele was determined by severity of constipation, degree of prolapse, and sigmoid redundancy at the time of surgery. Two patients underwent sigmoid resection with sigmoidopexy, one patient had sigmoidopexy alone, and four patients had Halban obliteration of the cul-de-sac. Two patients are successfully using pessaries. Follow-up from 4 months to 2 years (mean 12 months) showed no recurrence of an apical defect by clinical examination. One patient had a recurrent rectocele to the hymenal ring with strain. Five patients had no complaints of constipation, whereas two noted improvement but continued symptoms. Both these patients had Halban procedures only, and one had the recurrent rectocele. CONCLUSIONS: Sigmoidoceles are an uncommon but not rare finding with apical support defects. Physical examination alone does not make the diagnosis. All patients had a rectocele, which substantiates a posterior vaginal support defect. In these patients there was a strong association with constipation that responded to surgical correction, but the degree of anatomic distortion did not always correlate with functional impairment.
[Colorectal cancer. A study of 133 surgical cases].
The author studied the medical records of 133 patients who underwent surgery for adenocarcinoma of the colon or rectum in the Metropolitan Hospital Complex Arnulfo Arias Madrid from June 1972 to July 1992. In 9 (6.7%) the tumor was staged as Dukes A, in 49 (36.8%) as Dukes B; in 60 (43.1%) as Dukes C and in 10 (16.7%) as Dukes D. The anatomical location of the tumor was the cecum in 9 (6.7%), the ascending colon in 3 (2.3%), the sigmoid colon in 44 (33%) and the rectum in 41 (31.6%). Of the rectal carcinomas 24 (58.5%) were in the inferior one third, 10 (24.3) were in the middle and 7 (17%) in the superior third. It is evident that nearly two thirds of the tumors were within reach of the digital rectal examination of the sigmoidoscopic examination. The parents ranged from 21 to 89 years of age and their median age was 63 years. 73 patients were women and 60 were men. 60.5% of the women and 39.5% of the men had carcinoma of the colon. The sexual prevalence of carcinoma of the rectum was different: 5% were in men and 43% were in women. 2.2% of the tumors were synchronous and 4% were metachronous. The author discusses the number, type and indications for the surgical procedures used. There were no perioperative deaths. The 5 year survival for adenocarcinomas of the colon was 100% for those patients with tumors staged as Dukes A, 78.5% for the Dukes B, 61.1% for the Dukes C and 0% for those staged as Dukes D. For the rectal adenocarcinomas the 5 year survival was 100% for those patients with tumors in Stage Dukes A, 57.1%, for those in Dukes B, 33.3 for those in Dukes C and 0% in those in Dukes D. These results indicate that these patients are seen in an advanced stage and point to the urgent need to make the diagnosis in early, curable stages. The low incidence of tumors in stage Dukes A indicates an indifference of the patients and/or the doctors to the symptoms and signs of this disease. The most frequent symptoms, in descending order were: bleeding on defecation (all types), change in bowel habits (diarrhea or constipation), abdominal pains, tenesmus and anemia (with its different clinical manifestations). Other symptoms were a palapable abdominal mass, feces with bloody mucus and rectal prolapse on defecation.(ABSTRACT TRUNCATED AT 400 WORDS)
Intussusception of the rectum-internal procidentia: treatment and results in 90 patients.
A series of 90 patients with intussusception of the rectum (internal procidentia) has been studied. In 11 per cent of the patients there was also an enterocele and in 3 per cent, a large proctocele. Forty patients were operated upon by the Ripstein procedure. Indications for operation were, in most cases, incontinence for gas and/or feces. Seventy-five per cent of the preoperatively incontinent patients were, at follow-up 2 to 10 years after operation, continent. When indications for surgery were pain and or a sensation of obstruction, the results were poor; most of these patients had unchanged symptoms postoperatively, and some even had increased symptoms. There was one postoperative death. Of 50 patients treated conservatively during a period of 2 to 10 years, only two had to be operated upon: one due to the development of a rectal prolapse and the other due to severe pain and an increased sensation of obstruction.