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PubMed1994

Endoanal ultrasonography in the follow-up of anal carcinoma.

As the modern treatment for anal carcinoma is either radiotherapy alone or combined radiochemotherapy, an exact histological staging is impossible. Therefore we have to depend on an accurate preoperative staging method. Endoanal ultrasonography enables imaging of the normal anal canal and its pathologies. In a prospective investigation we were able to confirm the histological proven diagnosis of an anal epidermoid carcinoma in 12 patients with a 10-MHz transducer covered with a sonolucent plastic cone. The depth of infiltration can be determined in relation to the normal layers of the anal canal. Six patients treated with radiotherapy alone or combined radiochemotherapy were followed and the success or failure of the treatment was documented. Endosonography of the anal canal allows an exact staging of a primary anal carcinoma and the follow-up in irradiated carcinomas. Besides digital palpation and proctoscopy with biopsy, endosonography complements the preoperative staging of anal carcinomas.

Anal Canal↗
PubMed1989

Soiling: anorectal function and results of treatment.

Forty-five patients with soiling but without faecal incontinence were evaluated by means of anorectal function investigations (anal manometry, rectal capacity and saline infusion test). The causes of soiling and the effect of treatment on both soiling and anorectal function were studied. The results were compared with a control group of 161 patients without soiling or incontinence. The diagnoses were haemorrhoids (10), mucosal prolapse (7), rectal prolapse (6), fistulae (5), proctitis (3), faecal impaction (2), rectocele with intussusception (2), scars after fistulectomy (2) and others (8). Simple inspection and proctoscopy were generally sufficient to establish a diagnosis. For two patients the diagnosis rectocele was made after defaecography. Anorectal test results did not differ between the soiling and control group, did not contribute to establish a diagnosis and did not change after treatment. Only patients with a rectal prolapse had abnormal results in anorectal function tests: a low basal sphincter pressure and a limited continence reserve. Appropriate therapy resulted in complete recovery (44%) or improvement of symptoms (29%).

Anal Canal↗
PubMed1995

Ergotamine-induced complex rectovaginal fistula. Report of a case.

PURPOSE: This report stresses the importance of local complications caused by ergotamine abuse for the treatment of migraine headaches. METHODS: We present an unusual case of a complex rectovaginal fistula (RVF) caused by long-term ergotamine suppository abuse. RESULTS: A 39-year-old female was referred after she had undergone a transverse colostomy for temporary fecal diversion. Evaluation, including proctoscopy, gastrograffin enema, vaginogram, and pelvic computerized tomography revealed a RVF 6 cm proximal to the dentate line with distal rectal stricture. Surgical intervention included take down of the transverse colostomy with reanastomosis, proctectomy with excision of the fistula, creation of a colonic "J-pouch" with a coloanal anastomosis, and construction of a temporary loop ileostomy. The patient had an uneventful recovery, and her ileostomy was closed three months later. Pathologic examination of the surgical specimen failed to reveal any specific etiology of the RVF. However, her ten-year use of up to five ergotamine suppositories per day for migraine treatment is associated with a local ischemic effect. Pathophysiology of this rare cause of RVF and the surgical procedure are discussed. CONCLUSION: If evidence of any side effects of ergotamine suppositories is seen, early discontinuation of the drug should be considered to avoid complications such as RVF and/or strictures.

Administration, Rectal↗
PubMed1997

Symptoms in chronic constipation.

OBJECTIVES: This study was designed to evaluate whether detailed symptom analysis would help to identify pathophysiologic subgroups in chronic constipation. METHODS: In 190 patients with chronic constipation (age, 53 (range, 18-88) years; 85 percent of whom were women), symptom evaluation, transit time measurement (radiopaque markers), and functional rectoanal evaluation (proctoscopy, anorectal manometry, defecography) were performed. Patients were classified on the basis of objective data from all tests in four different groups ("disordered defecation," "slow gastrointestinal transit," "disordered defecation combined with slow-transit stool," and "no pathologic finding"). RESULTS: In 59 percent of patients, disordered defecation was found, and 27 percent had slow-transit stool. In 6 percent of patients, a combination of both was found; in only 8 percent of patients, there were no pathologic findings. Straining was reported by the vast majority in all groups (82-94 percent). Infrequent bowel movements and abdominal bloating were more common in slow-transit stool (87 and 82 percent vs. 69 and 55 percent, respectively; both P < 0.01). Feeling of incomplete evacuation was more common in disordered defecation (84 vs. 46 percent; P < 0.0001). However, specificity of these symptoms was discouraging (for slow-transit stool: infrequent bowel movements had a sensitivity of 87 percent and a specificity of 32 percent and abdominal bloating had a sensitivity of 82 percent and specificity of 45 percent; for disordered defecation: feeling of incomplete evacuation had a sensitivity of 84 percent and a specificity of 54 percent). Only the sense of obstruction and digital maneuvers were acceptably specific (79 and 85 percent, respectively) for disordered defecation, but sensitivity was low. CONCLUSIONS: Definition of chronic constipation by infrequent bowel movements alone is of little value; the symptom "necessity to strain" is much better suited (94 percent sensitivity). Specificity of infrequent bowel movements for slow-transit stool was discouraging. Sense of obstruction and digital manipulation for evacuation are relatively specific for disordered defecation but insensitive. Therefore, symptoms of chronically constipated patients are not well suited to differentiate between the pathophysiologic subgroups suffering chronic constipation.

Adolescent↗
PubMed1997

Clinical and genomic influence of sulindac on rectal mucosa in familial adenomatous polyposis.

PURPOSE: A study was performed to evaluate the antiproliferative effects of low doses of the nonsteroidal drug, sulindac, on adenomas and rectal mucosa in familial adenomatous polyposis and to analyze the influence on tumor-suppressor genes and on apoptosis. METHODS: This was a prospective, controlled, nonrandomized Phase II dose-finding study for sulindac. The study group (n = 28) and control group (n = 10) underwent colectomy and ileorectal anastomoses, with repeated proctoscopy with endoluminal ultrasound and biopsies every three months. Dose-reduction of sulindac according to adenoma reversion was predetermined. Proliferation marker, Ki-67 (MIB1 and 5), on frozen or paraffin sections evaluated the antiproliferative effects; mutant p21ras, pantropic p53, mutant p53, and anti-bcl-2 were performed as enzyme-linked immunosorbent assay procedures and/or immunohistochemistry on paraffin sections. RESULTS: All patients responded to sulindac after 24 weeks (at the latest). There was a significant reduction of adenomas and dose reduction to 67 mg/day after three years of therapy (Mann's test for trend, P < 0.001). Results consisted of 78 percent complete reversions, 22 percent partial reversions of adenomas at latest re-examination, and no influence on upper gastrointestinal tract adenomas. No influence was detected on repeated hemograms, liver, or renal function at high or low doses. There was a permanent antiproliferative effect (Ki-67) of low-dose sulindac, significant blocking of ras mutation activation, and a significant difference of untreated and treated mucosa in mutant p53 content (Wilcoxon's or Kruskal-Wallis each, P < 0.05). Reverse correlation of anti-bcl-2 and p53 immunostaining on mucosa sections was an indication of adenoma relapse. CONCLUSIONS: Low-dose antiproliferative sulindac therapy is highly effective in adenoma reversion in familial adenomatous polyposis patients. Sulindac shows influence on tumor-suppressor genes and on apoptosis markers. An immunostaining correlation indicates adenoma relapse in flat microadenomas in advance of macroscopic appearance. Low-dose sulindac treatment may develop into an additive permnanent therapy for colectomized familial adenomatous polyposis patients.

Adenomatous Polyposis Coli↗
PubMed1999

Use of anal endosonography in diagnosis of endometriosis of the external anal sphincter: report of a case.

PURPOSE: Perianal endometriosis is an infrequent form of extragenital endometriosis and is usually situated in episiotomy scars. METHODS: We report a rare case involving the external anal sphincter in a 24 year-old female. The precise anatomical location of the endometriotic lesion was confirmed using preoperative and intraoperative anal endosonography. CONCLUSION: We believe this procedure to be essential when history, digital examination, and proctoscopy are not conclusive in the differential diagnosis of perianal pain or mass. Although hormonal suppression often is the therapy of choice in extrapelvic endometriosis, we think surgical excision, respecting the anatomical fiber architecture of the anal sphincter, is the best treatment for perianal endometriosis. Surgical excision is required for histological diagnosis, which is imperative in view of the albeit rare development of malignancy in extragenital endometriosis.

Adult↗
PubMed1999

Nifedipine for local use in conservative treatment of anal fissures: preliminary results of a multicenter study.

PURPOSE: This study was performed according to a prospective, randomized, double-blind, multicenter design. The aim was to test the efficacy of local application of nifedipine gel" in healing acute anal fissure by relaxing the internal anal sphincter. METHODS: Two hundred eighty-three patients who gave informed consent were recruited; they received a clinical examination. A questionnaire to evaluate the symptoms and the pain was administered, and a proctoscopy and anorectal manometry were performed. Patients treated with nifedipine (n = 141) used topical 0.2 percent nifedipine gel every 12 hours for three weeks. The control group, consisting of 142 patients, received topical 1 percent lidocaine and 1 percent hydrocortisone acetate gel during therapy. Manometry was performed before and on Days 14 and 21. Anal pressures were measured by recording resting and squeeze pressures. RESULTS: Results obtained were as follows: total remission from acute anal fissure was achieved after 21 days of therapy in 95 percent of the nifedipine-treated patients (P < 0.01), as opposed to 50 percent of the controls (P < 0.01), and previously elevated maximum resting anal pressures decreased from a mean value +/- standard deviation of 72.5 +/- 10.07 mmHg to 50.5 +/- 10.03 mmHg in the nifedipine group. This represents a mean reduction of 30 percent (P < 0.01). We also observed a significant decrease in squeeze pressures in nifedipine-treated patients (from a mean +/- standard deviation of 130.5 +/- 19.25 mmHg to 108.5 +/- 18.55 mmHg, a mean reduction of 16.8 percent; P < 0.01). No changes in anal pressures were observed in the control group. We did not observe any systemic side effect or significant anorectal bleeding in patients treated with nifedipine. CONCLUSIONS: Our study clearly demonstrates that the therapeutic use of nifedipine, which at present is used only in cardiovascular pathologies, should be extended with local use to the conservative treatment of anal fissures.

Administration, Topical↗
PubMed2000

Diagnosis of enteroceles by dynamic anorectal endosonography.

PURPOSE: Enteroceles are herniations of the lining of the peritoneum and intestinal loops into the pouch of Douglas. They may accompany other pelvic and anorectal disorders or cause outlet obstruction. So far they are only diagnosed by defecography. We investigated the use of dynamic anorectal endosonography to detect this disorder. METHODS: Seventeen female patients with a defecation disorder were investigated by proctoscopy and endoluminal ultrasonography. In 14 patients defecography followed. Endosonography was performed using the curved array 7.5 MHz scanner directed to the ventral rectal wall. Dynamic studies were undertaken during rest and during maximal straining. The minimal distance between the inner verge of the anal canal and the peritoneal cavity was determined. RESULTS: Dynamic endosonography detected enteroceles in six patients in which the pouch of Douglas opened during straining and intestinal loops moved toward the anus. The diagnosis of enteroceles was confirmed in all patients by defecography giving a specificity of 100 percent. No enterocele was detected in the remaining eight patients with defecography, leading to a 100 percent sensitivity for endosonography. Comparing the 6 patients with enteroceles with the 11 patients without enterocele, the peritoneal-anal distances were at rest 3.9 +/- 0.5 and 3.3 +/- 0.5 cm (P < 0.05) and during straining 3.6 +/- 0.5 and 1.3 +/- 0.2 cm (P < 0.001), respectively. The change in peritoneal-anal distance was 2 +/- 0.5 cm in the enterocele group and 0.3 +/- 0.4 cm in the control group (P < 0.001). Two patients with enteroceles had complete rectal prolapse. Four patients with enteroceles underwent surgery. Postsurgical endoluminal endosonography showed closure of the pouch of Douglas. CONCLUSIONS: Enteroceles may be diagnosed by dynamic anorectal endosonography. Compared with defecography dynamic anorectal endosonography is easier to perform, less cumbersome for the patient, and bears no radiation exposure. Therefore, this new diagnostic means may be useful in first-line search for enteroceles, but further studies are needed to prove its sensitivity for screening of this disorder.

Aged↗
PubMed2000

Rectal compliance as a routine measurement: extreme volumes have direct clinical impact and normal volumes exclude rectum as a problem.

PURPOSE: The clinical impact of rectal compliance and sensitivity measurement is not clear. The aim of this study was to measure the rectal compliance in different patient groups compared with controls and to establish the clinical effect of rectal compliance. METHODS: Anorectal function tests were performed in 974 consecutive patients (284 men). Normal values were obtained from 24 controls. Rectal compliance measurement was performed by filling a latex rectal balloon with water at a rate of 60 ml per minute. Volume and intraballoon pressure were measured. Volume and pressure at three sensitivity thresholds were recorded for analysis: first sensation, urge, and maximal toleration. At maximal toleration, the rectal compliance (volume/pressure) was calculated. Proctoscopy, anal manometry, anal mucosal sensitivity, and anal endosonography were also performed as part of our anorectal function tests. RESULTS: No effect of age or gender was observed in either controls or patients. Patients with fecal incontinence had a higher volume at first sensation and a higher pressure at maximal toleration (P = 0.03), the presence of a sphincter defect or low or normal anal pressures made no difference. Patients with constipation had a larger volume at first sensation and urge (P < 0.0001 and P < 0.01). Patients with a rectocele had a larger volume at first sensation (P = 0.004). Patients with rectal prolapse did not differ from controls; after rectopexy, rectal compliance decreased (P < 0.0003). Patients with inflammatory bowel disease had a lower rectal compliance, most pronounced in active proctitis (P = 0.003). Patients with ileoanal pouches also had a lower compliance (P < 0.0001). In the 17 patients where a maximal toleration volume < 60 ml was found, 11 had complaints of fecal incontinence, and 6 had a stoma. In 31 patients a maximal toleration volume between 60 and 100 ml was found; 12 patients had complaints of fecal incontinence, and 6 had a stoma. Proctitis or pouchitis was the main cause for a small compliance. All 29 patients who had a maximal toleration volume > 500 ml had complaints of constipation. No correlation between rectal and anal mucosal sensitivity was found. CONCLUSION: Rectal compliance measurement with a latex balloon is easily feasible. In this series of 974 patients, some patient groups showed an abnormal rectal visceral sensitivity and compliance, but there was an overlap with controls. Rectal compliance measurement gave a good clinical impression about the contribution of the rectum to the anorectal problem. Patients with proctitis and pouchitis had the smallest rectal compliance. A maximal toleration volume < 60 ml always led to fecal incontinence, and stomas should be considered for such patients. A maximal toleration volume > 500 ml was only seen in constipated patients, and therapy should be given to prevent further damage to the pelvic floor. Values close to or within the normal range rule out the rectum as an important factor in the anorectal problem of the patient.

Adolescent↗
PubMed1993

Cinedefecography and electromyography in the diagnosis of nonrelaxing puborectalis syndrome.

A prospective study was undertaken to assess the correlation between electromyography (EMG) and cinedefecography (CD) for the diagnosis of nonrelaxing puborectalis syndrome (NRPR). Clinical criteria for NRPR included straining, incomplete evacuation, tenesmus, and the need for enemas, suppositories, or digitation. EMG criteria included failure to achieve a significant decrease in electrical activity of the puborectalis (PR) during attempted evacuation. CD criteria included either paradoxical contraction or failure of relaxation of the PR along with incomplete evacuation. In addition, other etiologies for incomplete evacuation, such as rectoanal intussusception or nonemptying rectocele, were excluded by proctoscopy and defecography in all cases. One hundred twelve patients with constipation, 81 females and 31 males, with a mean age of 59 (range, 12-83) years were studied by routine office evaluation, CD, and EMG. Forty-two patients (37 percent) had evidence of NRPR on CD (rectal emptying: none, 24; incomplete, 18). Twenty-eight of these patients (67 percent) also had evidence of NRPR on EMG. EMG findings of NRPR were present in 12 of 70 patients (17 percent) with normal rectal emptying. Conversely, 14 of 72 patients (19 percent) with normal PR relaxation on EMG had an NRPR pattern on CD. The sensitivity and specificity for the EMG diagnosis of NRPR were 67 percent and 83 percent, and the positive and negative predictive values were 70 percent and 80 percent, respectively. Conversely, if EMG is considered as the ideal test for the diagnosis of NRPR, CD had a sensitivity of 70 percent, a specificity of 80 percent, and positive and negative predictive values of 66 percent and 82 percent, respectively. In summary, sensitivity, specificity, and predictive values of EMG and CD are suboptimal. Therefore, a combination of these two tests is suggested for the diagnosis of NRPR.

Action Potentials↗
PubMed1994

Patterns of residual disease after preoperative chemoradiation in ultrasound T3 rectal carcinoma.

BACKGROUND: Rectal carcinoma tends to recur locally, with invasion of adjacent organs and significant pelvic pain. Both radiation therapy alone and combined chemoradiation have been used in an attempt to decrease the local recurrence rate and thereby improve survival. Although preoperative chemoradiation can clinically downstage rectal tumors, the pathologic extent of the residual disease has not been studied. METHODS: Thirty-seven patients with T3 rectal cancer diagnosed by transrectal ultrasonography (uT3) received 45 Gy with continuous infusion 5-fluorouracil (300 mg/m2/day). Proctoscopy with mucosal/submucosal biopsy was performed in patients (16 of 37) posttreatment and before definitive surgery. RESULTS: Microscopic evaluation of the 37 resected specimens showed a 30% (11 patients) pathologic complete remission rate. The pattern of residual disease in the remaining 26 patients showed that nine (25%) had microscopic residual tumor without evidence of mucosal involvement. Of the 14 patients with a negative proctoscopic evaluation and biopsy only, five (36%) had no residual tumor on final pathology. CONCLUSIONS: After chemoradiation, the pathologic presentation of rectal cancer may be altered, making endoscopic procedures and mucosal/submucosal biopsies unreliable in detection of residual disease. Despite the relatively good pathologic complete remission rate noted in this study, all patients undergoing chemoradiation for uT3 rectal carcinomas need definitive surgical resection to confirm a complete clinical remission.

Adenocarcinoma↗
PubMedDate not supplied

Hemorrhoidal bleeding following transrectal prostatic biopsy. Etiology and management.

Three cases of rectal bleeding within a series of 120 transrectal prostatic biopsies are reported. The precipitating factor was the presence of hemorrhoids which were unsuspected prior to prostatic biopsy. Rectal bleeding in these patients was arrested by ballon tamponade with a 24 French Foley catheter. In situ monitoring of the rectal Foley catheter was discontinued when no further rectal bleeding was ascertained. There were no complications due to this simple, safe, and effective technique. When hemorrhoids are suspected, preliminary proctoscopy aids and alerts surgeons to choose alternative routes to the prostatic bed.

Aged↗
PubMed1989

Perforation of the rectum and sigmoid colon during barium-enema examination. Management and prevention.

Perforation of the rectum or sigmoid colon complicated 5 of 2200 barium-enema examinations performed during a 4-year period. Three patients with rectal perforations manifested by air extravasation were successfully treated with intravenous antibiotics and complete bowel rest. Two patients with barium extravasation were treated with immediate operation and colostomy. All five patients recovered. Perforation was found to be associated with a rectal stricture due to ulcerative colitis, a rectal cancer, an incarcerated inguinal hernia, fulminant ulcerative colitis, and a normal colon in an elderly patient. To determine the pressure in the rectum that could potentially be generated during a barium-enema examination, the pressures created by a standard barium delivery set were measured, using 1-meter columns of water, 25 percent diatrizoate sodium (Hypaque), 20 percent barium, and 80 percent barium. The columns generated pressures of 70, 85, 95, and 120 mm Hg respectively. Squeezing the delivery bag increased the pressure 21 to 79 percent or a maximum of 55 mm Hg. Colorectal perforation during barium-enema examination that was not accompanied by barium extravasation could be successfully treated nonoperatively. The associated pathology and our studies of pressures generated during a barium-enema examination allow us to suggest that the incidence of colorectal perforation during barium-enema radiography can be reduced by 1) performing proctoscopy prior to barium enema, 2) avoiding the use of the rectal balloon in patients with known rectal lesions, 3) avoiding barium studies in patients with active colitis, 4) avoiding generation of pressure greater than that created by a column of barium suspension of one meter, and 5) using a lower concentration of barium when possible.

Aged↗
PubMed1980

Pseudo-obstruction of the colon (Ogilvie's syndrome).

Pseudo-obstruction of the colon is an acute abdominal problem that can occur from a variety of causes and multiple organ failures. It is characterized by massive colonic dilatation and a clinical picture suggestive of mechanical large-intestinal obstruction, without any organic obstruction. Decompression should be cautiously attempted with proctoscopy and, possibly, colonoscopy; if these fail, then surgical decompression, usually be a cecostomy, is indicated.

Aged↗
PubMed1994

Fournier's gangrene of the scrotum following anorectal disorders.

Five cases of Fournier's gangrene of the scrotum following anorectal disorders were encountered in a period of 2 years. Perirectal abscess was the most common associated underlying condition occurring in three patients. E. coli was the predominant organism cultured in all cases. A chronic debilitating condition was encountered in 3 patients. The mortality rate was 20%, but serious life threatening complications occurred in 4 of our patients. Error in diagnosis and delay in initiating medical treatment were the main causes of the high mortality rate associated with the disease. We advocate thorough rectal examination including proctoscopy in all cases of Fournier's gangrene, especially when no obvious source is apparent.

Abscess↗
PubMed2004

[Condylomata acuminata gigantea. Surgical and combined immunomodulatory therapy].

A 50-year-old female developed extensive condylomata acuminata in the genitoanal region over a period of 12 years. She presented with multiple, verrucous lesions involving the whole genitoanal area plus the adjacent perineum and gluteal region which made it impossible to identify the anatomical structures. Proctoscopy was normal. Serology for infectious diseases was negative. Several biopsies showed no signs of malignant transformation. Tumor excision under general anaesthesia was incomplete. Therefore, adjunctive therapy with immunomodulatory agents was administered, utilizing local application of imiquimod cream (3 x weekly) for 3 months and subcutaneous injections of interferon-alpha-2a (3 million IU 3 x weekly) for 5 months. This treatment regimen resulted in complete remission of all skin lesions with only discrete superficial scarring but no significant loss of anatomical structures or functions. During a 1-year follow-up the patient showed no sign of relapse.

Adjuvants, Immunologic↗
PubMed2000

[Coloproctological diseases of the pelvic floor].

PURPOSE: The aim of this review is to describe the most frequent and important coloproctologic pelvic floor disorders. Relevant diagnostic procedures of the pelvic floor will be presented. MATERIAL AND METHODS: A host of diagnoses and symptoms such as the descending perineum syndrome, rectocele, cystocele, enterocele, uterine and vaginal descensus, anal and rectal prolapse, outlet obstruction, anismus, inertia recti and intussusception are included under the heading "pelvic floor disorders". Although symptoms are often varied, problems concerning urinary and/or faecal continence commonly lead to primary consultation of a physician. RESULTS: Quite often, apparently divergent symptoms such as constipation and incontinence are simultaneously mentioned. A clear gender disposition is observed with female patients inflicted nine-fold in comparison to male patients. The primary consultant may belong to a variety of specialities such as urology, proctology, gynaecology or dermatology, depending upon the predominant symptom. A feeling of trust is essential for the treatment of a disorder involving highly intimate regions of the body. DISCUSSION: An exact medical history and standardized proctologic evaluation consisting of inspection, palpation, rectoscopy and proctoscopy may be augmented by investigations such as anorectal manometry or endosonography. Conventional defecography has been replaced more and more by dynamic MRI of the pelvic floor in specialized institutions, enabling additional gynaecologic and urologic investigations avoiding ionizing radiation.

Colonic Diseases↗