Proctitis: Whatʼs the Bottom Line?

ANORECTAL DISORDERS

To the Editor: A 20-year-old male student first presented to the surgical outpatient department of a tertiary hospital at the age of 16 in 2003, when he complained of constipation, pain on defecation and flatulence, which he said had started when he was 12 years old. Findings on examination were normal and he was treated with stool softeners, reassured and discharged. From 2003 to 2006, he presented to the surgical department on numerous occasions. The working diagnoses included haemorrhoids, fissure in ano, constipation and incontinence of gas, but his anus was always found to be normal. Treatment included analgesics, stool softeners, antiseptics, antibiotics, dietary advice and reassurance. Despite his demands, no surgical procedures were performed.

Transcutaneous needle-free injection of botulinum toxin: a novel treatment of childhood constipation and anal fissure

HomeRadioGraphicsVol. 43, No. 3 PreviousNext Cases from the Cooky JarFree AccessMpox (Monkeypox) ProctitisCiléin Kearns , Michael Orsi, Carlos J. Sanchez, Francisco CalleCiléin Kearns , Michael Orsi, Carlos J. Sanchez, Francisco CalleAuthor AffiliationsFrom the Department of Radiology, Wellington Regional Hospital, Te Whatu Ora (Health New Zealand), Riddiford St, Wellington 6021, New Zealand, and Artibiotics, Wellington, New Zealand (C.K.); South Texas Radiology Group, San Antonio, Tex (M.O.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (C.J.S.); and Department of Radiology, Hospital Militar Central, Universidad Militar Nueva Granada, Bogotá, Colombia (F.C.).Address correspondence to C.K. (email: [email protected]).Ciléin Kearns Michael OrsiCarlos J. SanchezFrancisco CallePublished Online:Feb 16 2023https://doi.org/10.1148/rg.220198MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In Monkeypox virus is an Orthopoxvirus first identified in primates (1), although the natural reservoir is likely rodents (2). Mpox disease (formerly monkeypox disease [3]) is less contagious and milder than smallpox, with a 3%–6% mortality rate (2). The May 2022 mpox outbreak has been driven by sexual transmission in most cases, but infection may also occur by contact with lesions, respiratory fluids, contaminated fabric, and infected meat (4,5).The disease lasts 2–3 weeks and manifests with characteristic mucosal lesions (Fig 1) that may be preceded by systemic symptoms such as fever (5,6). The lesions primarily affect the anogenital area, trunk, limbs or face, and 14%–36% of patients present with proctitis (5,7). Imaging can show proctitis (Fig 2), and complications include perianal abscess or rectal perforation (7). Rare severe complications include myocarditis, epiglottitis, pneumonia, sepsis, encephalitis, and vision loss (4–6).Figure 1. Mpox characteristic rash or lesion progression, symptoms, and complications. In the current outbreak, the majority of patients have had lesions in the anogenital region, and over half have lesions on the trunk or limbs, although lesions may also be concentrated on the palms, soles, and face (5). Other symptoms may include fever, lymphadenopathy, pharyngitis, headache, lethargy, myalgia, proctitis or anorectal pain, and low mood (5). The rash or lesions last 2–3 weeks, beginning as macules that progress to papules, vesicles, and then pustules that crust, fall off, and can leave scars. (Reprinted, with permission, from Ciléin Kearns, Artibiotics, Copyright © 2023.)Figure 1.Download as PowerPointOpen in Image Viewer Figure 2. Mpox proctitis in a 61-year-old man who underwent a kidney transplant and presented with rectal bleeding and pain. A nearly circumferential ulcerated mass was found in the lower rectum on clinical examination. Biopsy results were negative for malignancy but showed inflammation. Axial (A, B) and coronal (C, D) portal venous phase CT images show circumferential thickening of the low to mid rectum with mesorectal fat stranding and lymphadenopathy (arrow in A and C), findings very similar in appearance to those of rectal cancer with metastatic adenopathy. A repeat biopsy with larger samples and fulguration was performed, and the results also were negative for malignancy, showing only inflammation, ulceration, and abscess formation. Skin lesions developed 2–3 days after the second rectal biopsy. Monkeypox Orthopoxvirus DNA was detected by real-time polymerase chain reaction on lesion swab.Figure 2.Download as PowerPointOpen in Image Viewer Viral polymerase chain reaction results from lesions are diagnostic (5,6). Treatment is supportive, but the antiviral tecovirimat (TPOXX) and vaccinia immune globulin are used in those at risk for severe disease (1,4). The JYNNEOS mpox vaccination is approved by the U.S. Food and Drug Administration, and smallpox vaccination also provides protection (1,2).Disclosures of conflicts of interest.—C.K. Editorial board member of RadioGraphics.C.K. has provided disclosures (see end of article); all other authors have disclosed no relevant relationships.

Solitary rectal ulcer syndrome associated with constipation and abnormal defecation dynamics has been well described in adults, but not in children. The diagnosis and management of this entity remains a significant clinical challenge. We describe 8 patients (6 males and 2 females) at 3 centers recently diagnosed with SRU at a mean age of 11.3 years (range 1-16 years). Presenting symptoms included constipation passage of blood, mucus with in the stool and difficulty with defecation. In 2 subjects, the incorrect diagnosis of ulcerative proctitis was assigned prior to referral. Evaluation included normal CBC/ESR studies, normal stool cultures, normal barium enema, rectal manometry and suction biopsies for ganglion cells. Sigmoidoscopy findings varied from edematous rectal folds, localized proctitis, polypoid lesions and early to well defined rectal ulcers in all patients. Visual inspection or the use of anoscopy documented rectal prolapse in 3 patients. Defecography in an additional 3 patients was normal in 1 but revealed internal rectal prolapse and intussusception in 2 patients. Histology of the mucosa and polypoid lesions revealed edema, inflammation and infiltration of the lamina propria with fibrous tissue or smooth muscle. Treatment with stool softeners or fiber supplements resulted in clinical improvement in 4 patients, including one who had progression of ulcer size at sigmoidoscopy. 3 subjects required surgical correction of the distal intussusception for refractory symptoms with good to excellent results noted. In summary: (1) the diagnosis of SRU in children should be considered in all patients with constipation and/or rectal bleeding; (2) the final diagnosis is made by classical features on sigmoidoscopy and rectal biopsy; (3) medical therapy and management is challenging with some patients requiring surgical intervention; (4) SRU should be considered in the differential diagnosis of proctitis.

In the interval 1944-1983, 54 patients with leukemia and acute rectal pathology were seen at our institution, including: 25 patients with perirectal abscesses and/or fistulas (PF/F), 16 patients with acutely prolapsed or thrombosed hemorrhoids, 11 patients with anal fissures with or without hemorrhoids, and 2 patients with perianal excoriations. In the past, concerns have been raised about development of septicemia secondary to diagnostic or therapeutic instrumentation. In only 4 of 54 cases did the clinical course clearly suggest digital examination or instrumentation of the rectum may have caused bacteremia though 13 of 54 patients had positive blood cultures for gram negative organisms at some time during their course of which 7 were clearly coliform. Most (42/54) patients were treated initially by sitz baths, suppositories, and stool softeners and/or antibiotics. We observed five patients only and treated two by radiotherapy. Eleven patients required surgical intervention for thrombosed hemorrhoids and perirectal abscess and/or fistulas. Eight other patients with PA/F drained spontaneously. Poor healing after surgical or spontaneous drainage was documented in only one case. This study suggests that sitz baths, suppositories, antibiotics, and judicious surgical drainage (where needed) form the core of therapy for these patients.

82 - Anorectum

Anal fissure (AF) is an illness of anal canal and is characterized by cracks appearing in stratified squamous epithelium of distal anal canal. The tear, being present in the squamous part of the epithelium, causes considerable pain, fresh bleeding while defecation. The current study is planned to compare the Botulinum toxin Injection and botulinum toxin Injection with Glyceryl trinitate for the treatment of chronic anal fissure in terms of healing. Materials and Methods: Patients will be sent home after one hour with stool softener .while patients in group B will be will receive treatment with 0.2 ml (20 units) Botulinum toxin injection plus 1 gram 0.2% topical glyceryl trinitate cream 8 hourly with dose of 1 gram on middle fingers tip and apply it 1 cm2 in anal canal circumferentially. In both groups, patients will be assessed at follow up after 2 , 4 and 8 weeks post treatment. At follow up, patients will be examined for healing (yes or no) and any other side effect will be documented. Results: In Botulinum toxin injection group, 26(78.8%) had wound healing after 2 months and 30(90.9%) in Botulinum toxin injection with glyceryl trinitrate group with a p-value = 0.170. Conclusion: Botulinum toxin injection with glycerylyl trinitrate is a better technique for treatment of chronic anal fissure healing in comparison with Botulinum toxin injection alone. Keywords: Chronic Anal Fissure, Treatment, Botulinum Injection, Botilinum Injection with Glyceyl Trintrate, Comparison

Carcinoma and Epithelial Dysplasia Complicating Ulcerative Colitis

INTRODUCTION: Intestinal spirochetosis is a rare infectious diarrheal illness. Here we present a case of colonic spirochetosis initially diagnosed and treated as ulcerative proctitis. CASE DESCRIPTION/METHODS: A 57-year-old male presented to the office with 2 months of diarrhea occurring over 10 times per day with urgency and bleeding. The patient had an unremarkable past medical and family history. On social history, he practiced high risk sexual behavior with unprotected anal intercourse. Initial work-up showed mild elevation of ESR/CRP and an elevated calprotectin. Colonoscopy revealed ulcerative proctitis extending to 15 cm with normal colonic mucosa proximally. Rectal biopsies showed moderately active chronic colitis, remaining biopsies of colon were normal. He was started on mesalamine with improvement and subsequent sigmoidoscopy showed remission. Eight weeks later the patient presented to the ED with blurry vision. He was seen by ophthalmology who identified left optic nerve edema. An RPR was sent and resulted with a titer of 1:1024. He was referred to Infectious Disease with high suspicion for ocular syphilis and completed 14 days of IV penicillin G. Lumbar puncture showed no neurologic involvement. His RPR titers downtrended and visual changes improved. One month later, the patient developed large volume loose stools. Again stool studies were negative. Pathology was contacted to conduct repeat histochemical stains on earlier specimens, which showed spirochetes in the colonic mucosa. He was given metronidazole for 14 days for intestinal spirochetosis with improvement. With suspicion that proctitis may have originally been infectious the mesalamine therapy was weaned. DISCUSSION: Clinical manifestations of colonic spirochetosis can vary from asymptomatic to watery diarrhea. Rectal ulcerations are an uncommon presentation of primary syphilitic infection when compared to other mucosal sites. A literature review revealed a range of endoscopic findings from normal mucosa to erythema, friability, and polypoid lesions. To our knowledge the development of multiple ulcers has not been reported. It is necessary to maintain a high clinical suspicion because the diagnosis can be missed on a histologic level without appropriate additional staining. Given the increasing prevalence of syphilis, this case highlights the importance of collecting a thorough sexual history as to not delay the diagnosis and prevent the progression of disease, especially since early disease can frequently be asymptomatic.

Common anorectal problems can often be treated in the office setting. Hemorrhoids are usually relieved with use of bulk laxatives or stool softeners; if this fails, coagulation or rubber band ligation may be effective. Surgical therapy is still preferred for third- and fourth-degree hemorrhoids. Perirectal and perianal abscesses are treated by drainage, but in up to 30% of cases a fistula occurs following treatment. Surgical evaluation is appropriate when a fistula is suspected. Acute anal fissures often heal with conservative management; sphincterotomy may be needed for chronic fissures. Anal warts tend to recur and require several treatment sessions with use of ablative techniques.

Twenty-three children, aged between 8 and 168 months, underwent lateral subcutaneous sphincterotomy. All fissures healed by 8 weeks after operation. Two children had recurrent proctalgia and defaecating difficulties after surgery despite a healed fissure. Requirement for stool softener was reduced or abolished in 17 children. The parent-child satisfaction score after operation was more than 70 per cent in 19 of 23 cases. Lateral subcutaneous sphincterotomy is an effective procedure in children.