Predictive accuracy of Goodsall's rule for fistula-in-ano

Introduction: Successful treatment of fistula-in-ano is sometimes challenging due to difficulty in recognising the internal opening and the course of the fistula tract. Although Goodsall's rule was accepted in the past, as a method to determine the course of the fistula, recent data have shown conflicting results. Objectives: To study the predictive accuracy of Goodsall's rule. Methods: A sample of 212 patients with simple fistulae were studied. Hydrogen peroxide was injected through the external opening and the appearance of air bubbles in the anal canal indicated the location of the internal opening. The morphological parameters including the site and number of internal and external opening/s and the course of the tract were recorded. Results: The median age of the participants was 39 (range, 18-78) years. The majority (n=167, 78.8%) were males. Of the study group, 63 (29.7%) had inter-sphincteric fistulae, 114 (53.8%) transphincteric fistulae and 35 (16.5%) superficial fistulae. The overall predictive accuracy of Goodsall's rule in our patients was 78.3%. Predictive accuracy was significantly associated with type of fistulae with high predictive accuracy seen in superficial fistulae (97.1%) and inter-sphincteric fistulae (84.1%) compared to transphincteric fistulae (69.3%) (p=0.001). Predictive accuracy was significantly higher in those with an external opening in the midline (98.2%), (p<0.001). Conclusions: Although Goodsall's rule was not accurate in 22% of all fistulae, it can be used as a guide in locating the path of the tract and the internal opening in simple fistulae.

Three-Dimensional Anorectal Manometry Findings in Primigravida.

BACKGROUND: Vaginal delivery is an identified risk factor for anal sphincter injury. Therefore, to identify postpartum injury, an antepartum value or a normal range is required. However, at present, the normal values of 3D manometry are not available for primigravida or pregnant mothers. AIMS: Our study aims at describing normal values of 3D manometry in primigravida. METHODS: We analyzed 3DARM data of 101 consecutive primigravid mothers in the third trimester. 3DARM was performed using the Given Imaging(®) ManoScan system. RESULTS: The mean age was 24.7 (SD 5.1) years. All patients had a normal Cleveland Clinic Incontinence Score. The mean resting pressure (RP) was 87.02 (SD 18.43) mmHg and the maximum squeeze pressure (SP) was 179.21 (SD 52.96) mmHg. The mean length of the high-pressure zone (HPZ) was 3.67 (SD 0.52) cm. Mean volumes for initial rectal sensation, urge, and discomfort were 50.36 (± 25.57), 76.70 (± 35.17), and 143.40 (± 66.26) ml, respectively. The pressure asymmetry was highest in the lower anal sphincter and lowest in the mid-sphincter. There was a statistically significant relationship between the HPZ and RP (Pearson ρ -0.23, p = 0.01), height (Pearson ρ 0.22, p = 0.028), and weight (Pearson ρ 0.25, p = 0.012). There were no statistically significant correlations between age, height, or weight with RP, SP, or balloon fill volumes. The characteristic appearance of the normal RP and SP was clearly visualized in all patients. CONCLUSIONS: Normal 3DARM values for Sri Lankan primigravid mothers have been established. These may be used as reference values by other investigators.

Validating a script concordance test for assessing neurological localization and emergencies.

BACKGROUND AND PURPOSE: Clinical judgment is the ability to weigh clinical information and make decisions under conditions of uncertainty. Although neurological localization (NL) and neurological emergencies (NE) present such uncertainties, no validated method is reported to assess these decision-making skills. A script concordance test (SCT) was designed and validated to assess clinical judgment in NL and NE. METHODS: Our SCT comprised 14 clinical scenarios (53 questions). Candidates picked the response they considered the best for the questions in each scenario. Undergraduates and internal medicine residents completed the SCT; their responses were scored against the scoring key derived from an expert panel of accredited neurologists. Scores were expressed as a percentage of the maximum score. RESULTS: Mean total scores for undergraduates (n = 52), residents (n = 37) and experts (n = 15) were 61.0 ± 0.9, 68.3 ± 1.1 and 76.6 ± 1.1 (mean ± standard error of the mean, P < 0.001). Mean scores for undergraduates, residents and experts were 59.3 ± 1.1, 66.4 ± 1.4 and 76.1 ± 1.8 (P < 0.001) for NL, and 62.9 ± 1.3, 70.4 ± 1.3 and 77.2 ± 1.6 (P < 0.001) for NE. Senior residents scored higher than junior residents (postgraduate years 2-5 versus postgraduate year 1, 69.7 ± 1.4 vs. 65.3 ± 1.1, P = 0.035). The higher scores with increasing clinical experience supports the construct validity of the SCT. The SCT showed acceptable reliability (G coefficient 0.74 ± 0.05). CONCLUSIONS: Our SCT is validated to reliably assess NL and NE in undergraduate and postgraduate learners; it is generalizable and feasible. It has potential as a valuable adjunct assessment tool for clinical judgment. Future plans to design SCTs to evaluate other topics in clinical neurology, as a multi-center study, are under way.

A comparison of endoanal ultrasound and computed tomography in staging rectal cancer and in clinical decision making - a preliminary study.

INTRODUCTION: The treatment options and the prognosis of rectal cancer (RC) depend mainly on the stage. Computed tomography (CT) has been the main staging tool in RC but endoanal ultrasound (EAUS) is thought to be more accurate. METHODS: Patients with histologically proven rectal cancer presenting for the first time were staged using CT and EAUS. TNM staging was used to stage the rectal cancer. RESULTS: 24 patients (M:F 1:1) with a mean age of 57.3 (range = 23-80, SD = 15.3) years were included. The majority had a tumour of stage IIA/T3N0M0 (CT = 10, EAUS = 12). The staging of the tumour was the same in both investigations in 11 patients, while in 8 patients, EAUS staging was higher. The agreement for the T and N stages were kappa 0.24 and 0.5 respectively. There was a moderate and fair agreement between the overall TNM staging (weighted kappa 0.435) and the treatment strategies (weighted kappa 0.226) respectively, based on each imaging method. Of the 13 patients whose staging was different, the management changed in 6 (25%) patients (p = 0.016). CT identified distal metastases in 2 patients. CONCLUSIONS: EAUS and CT have only a fair to moderate agreement for staging and deciding treatment. However,EAUS has a significant influence when deciding treatment protocols.

The value of routine histopathological analysis in patients with fistula in-ano.

OBJECTIVE: To determine the positive yield of routine histopathology in patients undergoing surgery for fistula in-ano. METHOD: Histopathology reports of all the patients who underwent surgery for fistulae-in-ano over a period of 36 months were reviewed. RESULTS: Analysis included 84 patients of which 73 (87%) were male subjects. The mean age was 39.4 years (range 11-68). Forty-one (49%) had recurrent fistulae. Granulomatous diseases such as Crohn's disease and tuberculosis (TB) were suspected in six patients. However, of the six patients, confirmation of the disease status was obtained only in three patients: stains for acid-fast bacilli confirmed TB in two (2.4%) patients and colonoscopy and biopsy confirmed Crohn's disease in one (1.2%) patient. All three patients had recurrent fistulae. CONCLUSION: As the positive yield of routine histopathology is minimal, we do not recommend routine histopathology for fistula in-ano, except for those presenting with recurrent fistulae and those with clinical suspicion of an underlying disease such as TB, HIV or Crohn's disease.

Developing clinical competency in crisis event management: an integrated simulation problem-based learning activity.

This study aimed to evaluate the integration of a simulation based learning activity on nursing students' clinical crisis management performance in a problem-based learning (PBL) curriculum. It was hypothesized that the clinical performance of first year nursing students who participated in a simulated learning activity during the PBL session would be superior to those who completed the conventional problem-based session. The students were allocated into either simulation with problem-based discussion (SPBD) or problem-based discussion (PBD) for scenarios on respiratory and cardiac distress. Following completion of each scenario, students from both groups were invited to sit an optional individual test involving a systematic assessment and immediate management of a simulated patient facing a crisis event. A total of thirty students participated in the first post test related to a respiratory scenario and thirty-three participated in the second post test related to a cardiac scenario. Their clinical performances were scored using a checklist. Mean test scores for students completing the SPBD were significantly higher than those who completing the PBD for both the first post test (SPBD 20.08, PBD 18.19) and second post test (SPBD 27.56, PBD 23.07). Incorporation of simulation learning activities into problem-based discussion appeared to be an effective educational strategy for teaching nursing students to assess and manage crisis events.

The distribution of the anal glands and the variable regional occurrence of fistula-in-ano: is there a relationship?

BACKGROUND: Fistula in ano is a rather common condition, but the disease process is not yet fully understood. The aim of our study was to determine how the distribution of anal glands contributes to the variable occurrence of fistula-in-ano in the perineum. METHODS: we conducted a blinded two-phase prospective study. In the first phase, the perineum of the patients with primary fistulae was anatomically divided into right upper and lower and left upper and lower quadrants in the lithotomy position. The fistulae were classified according to what quadrant the external and internal openings and the tract pathway were in. In the second phase, using 10 human cadaver specimens, full thickness tissue samples were taken from each quadrant of the anus. Samples were histologically evaluated for the volume fractions of the anal glands in each quadrant. RESULTS: The new classification system we propose revealed that the largest number of fistulae 43% (17/39) were in the right lower quadrant, and 22% (9/39), 12% (5/39) and 8% (3/39) were in the left lower, right upper and left upper quadrants, respectively. It was also observed that 14% (5/39) of fistulae were in more than one quadrant. The volume fractions of each quadrant showed that the largest volume fraction of the anal glands was in the right lower quadrant (right lower quadrant: 0.64, left lower quadrant: 0.35, right upper quadrant: 0.26 and left upper quadrant: 0.22, P = 0.001). CONCLUSIONS: To the best of our knowledge, this is the first study that has objectively shown that the distribution of the anal glands is variable, and the highest density of anal glands is in the right lower quadrant of the anus. This variable distribution may be associated with the variable occurrence in fistula in ano.

Hiradenitis suppurativa presenting as a polypoidal lesion at the anal verge.

Hidradenitis suppurativa is a chronic disease characterized by painful recurrent abscesses, fistulas and scarring lesions in axilla, groin, perineum and rarely mass lesions at the affected site. Here we present a case of hidradenitis suppurativa that presented as a polypoidal growth at the anal verge.

Risk factors for anal sphincter disruption during child birth.

BACKGROUND AND AIMS: The objective of our study was to analyse the risk factors in a cohort of women who suffered anal sphincter disruption (third-degree tear) and compare the results with a similar cohort of women who underwent an uncomplicated vaginal delivery (without a clinically detectable laceration) during the same period. MATERIALS AND METHODS: A retrospective analysis was carried out on 54 women (group 1) who suffered a third-degree tear and 71 women who had undergone uncomplicated vaginal delivery during the same period (group 2). The risk factors considered were forceps delivery, parity, second stage of labour longer than 1 h, episiotomy, birth weight over 4 kg, gestational age and maternal age at delivery. The Cleveland Incontinence Score was completed. RESULTS: Multiple logistic regression analysis of obstetric risk factors for third-degree perineal tear indicated forceps delivery (p = 0.0001), primiparity (p = 0.004), foetal birth weight over 4 kg (p = 0.030) and delay in the second stage of labour (p = 0.031) to be significant risk factors for a third-degree tear. Mediolateral episiotomy was shown to be a significant protective factor (p = 0.0001). Gestational age and the maternal age at delivery (p = 0.340) were not shown to be significant risk factors (p = 0.336). CONCLUSION: Primary prevention and identification of women with risk factors is recommended. In some cases, counselling regarding the potential risks and benefits of both vaginal and caesarean delivery may be appropriate.

Rectal tuberculosis: a rare cause of recurrent rectal suppuration.

Tuberculosis affecting the rectum is a rare extra-pulmonary form of the disease that needs recognition, because it requires specific treatment and avoids multiple, unwarranted surgical interventions. The following discussion is centred on a case of rectal tuberculosis, a disease that rarely affects the anorectal region. The condition was diagnosed on histology and was successfully treated medically with complete resolution.

Long-term anal continence and quality of life following postpartum anal sphincter injury.

OBJECTIVE: Anal incontinence occurs as a result of damage to pelvic floor and the anal sphincter. In women, vaginal delivery has been recognized as the primary cause. To date, figures quoted for overt third degree anal sphincter tear vary between 0% and 26.9% of all vaginal deliveries and the prevalence of anal incontinence following primary repair vary between 15% and 61%. Our aim was to analyse the long-term (minimum 10 years post primary repair) anorectal function and quality of life in a cohort of women who suffered a third degree tear (Group 1) and compare the results with a cohort of women who underwent an uncomplicated vaginal delivery (Group 2) or an elective caesarean delivery (Group 3). METHOD: In all, 107 patients who suffered a third degree tear between 1981 and 1993 were contacted with a validated questionnaire. The two control groups comprised of 125 patients in each category. Those who responded to the questionnaire were invited for anorectal physiology studies and endoanal ultrasound. RESULTS: Of the total number contacted, 54, 71 and 54 women from the three groups returned the completed questionnaire. In the three groups, a total of 28 (53%), 13 (19%) and six (11%) complained of anal incontinence (P < 0.0001) respectively. Comparison of quality of life scores between the groups showed a poorer quality of life in those who suffered a tear (P < 0.0001). In addition, in spite of primary repair, 13 (59%) patients in group 1 showed a persistent sphincter defect compared to one (4%) occult defect in Group 2 and none in Group 3. CONCLUSION: Our study indicates that long-term results of primary repair are not encouraging. It therefore emphasizes the importance of primary prevention and preventing further sphincter damage in those who have already suffered an injury (during subsequent deliveries).

An unusual cause of small bowel obstruction due to an ingested mango seed: a case report.

BACKGROUND: Intestinal obstruction can occur due to multiple aetiologies. Intestinal obstruction due to phytobezoar have been reported. However, intestinal obstruction due to a mango seed has not been reported. Therefore, accidental ingestion of a mango seed is rare, and for an ingested mango seed to cause intestinal obstruction is rarer. CASE PRESENTATION: This case report is of a male who accidentally ingested a mango seed and presented with intestinal obstruction. The obstruction was at the terminal ileum. It required laparotomy for retrieval. CONCLUSION: It is extremely rare for a mango seed to cause intestinal obstruction. Hence, diagnosis requires a high degree of clinical suspicion. Instead of laparotomy, studies have demonstrated the use of laparoscopy for removal of ingested seeds.

Students' perception of problem-based learning in the medical curriculum of the Faculty of Medicine, University of Colombo.

INTRODUCTION: Problem-based learning (PBL) is used as an instructional method in the system-based modules of the new innovative curriculum of the Colombo Medical Faculty in Sri Lanka. This study was undertaken to assess whether objectives of having PBL to facilitate acquisition of desirable learning skills and generic skills had been achieved. The perceived advantages and disadvantages of PBL were also studied. MATERIALS AND METHODS: The study population comprised third year medical students who had completed 12 PBL sessions. A self-administered questionnaire, which measured learning outcomes and acquisition of generic skills on a 5-point Likert rating scale, was used. RESULTS: The response rate was 87.2% (n = 188). Eighty per cent of students were aware of the rationale for having PBL and of learning from recommended material. Seventy-five per cent knew the competencies that could be acquired from PBL and two-thirds knew about the importance of small group discussions. PBL had helped to improve communication skills in 57% and problem solving skills in 52%. The main disadvantage was that it was time-consuming. Only 46.6% were satisfied with the participation of colleagues in the group. Seventy-six per cent felt that PBL could be better conducted. CONCLUSION: Awareness of concepts of PBL, reasons for its inclusion in the curriculum and educational advantage was high. The main disadvantage perceived was that it was time-consuming. There is a need to improve the conduct of PBL and, provide guidance and awareness programme for students.