Longitudinal evaluation of the cutaneous and rectal microbiota of German shepherd dogs with perianal fistulas undergoing therapy with ciclosporin and ketoconazole.

BACKGROUND: Perianal fistulas are painful ulcers or sinus tracts that disproportionately affect German shepherd dogs and are proposed as a spontaneous animal model of fistulising Crohn's disease. OBJECTIVES: To characterise the rectal and cutaneous microbiota in German shepherd dogs with perianal fistulas and to investigate longitudinal shifts with lesion resolution during immunomodulatory therapy. ANIMALS: Eleven German shepherd dogs with perianal fistulas and 15 healthy German shepherd dogs. MATERIALS AND METHODS: Affected dogs were evaluated and swabbed at three visits, 30 days apart, while undergoing treatment with ciclosporin and ketoconazole. Healthy German shepherd dogs were contemporaneously sampled. Sites included the rectum, perianal skin and axilla. The microbiome was evaluated following sequencing of the V4 hypervariable region of the 16S ribosomal RNA (rRNA) gene. RESULTS: Alpha diversity was not significantly different between healthy and affected dogs at each of the three body sites (p > 0.5), yet rectal and perianal beta diversities from affected dogs differed significantly from those of healthy dogs at Day 0 (p = 0.004). Rectal and perianal relative abundance of Prevotella spp. increased and perianal Staphylococcus spp. relative abundance decreased in affected dogs over time, coincident with lesion resolution. CONCLUSIONS AND CLINICAL RELEVANCE: Changes in lesional cutaneous and rectal microbiota occur in German shepherd dogs with perianal fistulas and shift over time with lesion resolution during immunomodulatory therapy. Further investigations of the role of cutaneous and enteric microbiota in the pathogenesis of perianal fistulas, and whether manipulation of microbial populations may ameliorate disease, are needed.

Urethrorectal fistula ligation and transection in a dog with a history of unilateral abdominal cryptorchidism and misdiagnosed anal gland disease.

A 10-month-old unilaterally cryptorchid male labradoodle dog was presented to a specialty surgery referral center with a reported history of persistent anal sac leakage that was unresponsive to conservative management. The dog underwent castration and left anal sacculectomy but was witnessed urinating from the anus postoperatively. A contrast urethrogram was performed, and a urethrorectal fistula located between the distal portion of the pelvic urethra and the caudal aspect of the rectum was diagnosed. One week later, the dog underwent ligation and transection of the fistula. Surgery was successful and the dog recovered unremarkably with complete resolution of clinical signs. A contrast urethrogram 1 mo after surgery confirmed the successful ligation and transection of the fistula. Key clinical message: To the authors' knowledge, this is the first clinical report of urethrorectal fistula ligation and transection in a dog with unilateral abdominal cryptorchidism and misdiagnosed anal sac disease. Our findings underscore the importance of a thorough physical examination, history taking, and clinical workup for appropriate diagnosis and treatment of multiple congenital abnormalities.

Ligature et transection de la fistule urétrorectale chez un chien ayant des antécédents de cryptorchidie abdominale unilatérale et de maladie des glandes anales mal diagnostiquée. Un chien Labradoodle mâle unilatéralement cryptorchide âgé de 10 mois a été présenté à un centre de référence en chirurgie spécialisée avec des antécédents signalés de fuite persistante du sac anal qui ne répondait pas à une prise en charge conservatrice. Le chien a subi une castration et une sacculectomie anale gauche, mais a été vu en train d'uriner par l'anus après l'opération. Un urétrogramme de contraste a été réalisé et une fistule urétrorectale située entre la partie distale de l'urètre pelvien et la face caudale du rectum a été diagnostiquée. Une semaine plus tard, le chien a subi une ligature et une section de la fistule. La chirurgie a été un succès et le chien s'est rétabli sans particularité avec une résolution complète des signes cliniques. Un urétrogramme de contraste 1 mois après la chirurgie a confirmé la réussite de la ligature et de la section de la fistule.Message clinique clé :À la connaissance des auteurs, il s'agit du premier rapport clinique de ligature et de transection de fistule urétrorectale chez un chien atteint de cryptorchidie abdominale unilatérale et d'une maladie du sac anal mal diagnostiquée. Nos résultats soulignent l'importance d'un examen physique approfondi, d'une anamnèse et d'un bilan clinique pour un diagnostic et un traitement appropriés des anomalies congénitales multiples.(Traduit par Dr Serge Messier).

Successful treatment of perianal fistulas in two dogs with oclacitinib.

Perianal fistula (PAF) formation in dogs is a frustrating and painful disease, occurring primarily in German shepherd dogs. Ciclosporin has become the recommended treatment of choice yet may be associated with numerous adverse effects. This case report describes the successful treatment of two cases of PAF with oclacitinib.

L'apparition de fistules périanales (PAF) chez les chiens est une affection frustrante et douloureuse, survenant principalement chez les bergers allemands. La ciclosporine constitue le traitement de choix recommandé mais peut être associée à de nombreux effets indésirables. Le cas présenté décrit le succès thérapeutique de deux cas de PAF avec l'oclacitinib.

A fístula perianal (FPA) em cães é uma doença frustrante e dolorosa que ocorre primariamente em pastores alemães. A ciclosporina se tornou o tratamento de eleição recomendado, apesar de estar a associado a numerosos efeitos colaterais. Este relato de caso descreve o tratamento bem-sucedido de dois casos de FPA com oclacitinib.

La formación de fístulas perianales (PAF) en perros es una enfermedad frustrante y dolorosa, que ocurre principalmente en perros pastores alemanes. La ciclosporina se ha convertido en el tratamiento de elección recomendado, pero puede estar asociada con numerosos efectos adversos. Este artículo describe el tratamiento exitoso de dos casos de PAF con oclacitinib.

Traumatic Rectovesicular Fistula in a Dog.

A 7 mo old intact male Australian cattle dog presented for evaluation of a suspected urethrorectal fistula after being examined by the primary veterinarian for leaking of urine from the rectum at rest and when posturing to urinate. Advanced imaging identified a caudally retroflexed urinary bladder, several healing pelvic fractures, and a rectovesicular fistula. Primary surgical repair of the fistula was performed. The dog recovered well from surgery and was urinating and defecating normally as of 5 mo after the operation. This is the first report of a traumatic rectovesicular fistula in the veterinary literature.

Local treatment for canine anal sacculitis: A retrospective study of 33 dogs.

BACKGROUND: Little information has been published regarding treatment of canine anal sacculitis (AS). OBJECTIVES: Primary objective: determine the outcomes of AS local treatment at the referral dermatology service of the authors' institution. SECONDARY OBJECTIVE: determine signalment, body condition score (BCS), stool quality and comorbidities associated with AS. ANIMALS: Thirty-three dogs with AS presented to the referral dermatology service between 1 January 2010 and 31 March 2021. MATERIALS AND METHODS: An electronic medical record search was conducted. Information regarding sex, breed, age at disease onset, weight, BCS, stool quality, comorbidities, treatment and treatment outcome were collected. Treatment outcome was categorised as "resolved clinically", "clinical signs resolved per owner", "did not complete treatment" or "failed". Dogs were excluded if seen by another service, not treated for AS, or if perianal sinuses (fistulae), anal sac masses, or anal sac abscesses were identified. RESULTS: Nineteen dogs were male and 14 female. Twenty-four breeds were included. Average age at disease onset was 4.4 years. Average BCS was 5.8 of 9. Stool quality was "poor" in seven of 33 and normal in 23 of 33 cases. Atopic dermatitis was the most common comorbidity (12 of 33). Treatment typically consisted of anal sac flushing with saline followed by infusion using a commercially available steroid/antibiotic/antifungal ointment. Treatment was repeated on average 2.9 times. Resolution of AS was obtained in 24 of 33 cases, clinical signs resolved per owner in four of 33, five of 33 cases did not complete treatment, and no cases failed treatment. CONCLUSIONS AND CLINICAL RELEVANCE: Local treatment with flushing and infusion is effective for treating AS in dogs.

Contexte - Peu d'informations ont été publiées concernant le traitement de la sacculite anale canine (SA). Objectifs - Objectif principal : déterminer les résultats du traitement local de la SA au service de dermatologie des auteurs. Objectif secondaire : déterminer le signalement, le score d'état corporel (BCS), la qualité des selles et les comorbidités associées à la SA. Animaux - Trente-trois chiens SA présentés au service de dermatologie entre le 1er janvier 2010 et le 31 mars 2021. Matériels et méthodes - Une recherche dans le dossier médical électronique a été effectuée. Des informations concernant le sexe, la race, l'âge au début de la maladie, le poids, le BCS, la qualité des selles, les comorbidités, le traitement et les résultats du traitement ont été recueillies. Le résultat du traitement a été classé comme « résolu cliniquement ¼, « signes cliniques résolus par le propriétaire ¼, « n'a pas terminé le traitement ¼ ou « échec ¼. Les chiens ont été exclus s'ils étaient vus par un autre service, non traités pour la SA, ou si des sinus périanaux (fistules), des masses du sac anal ou des abcès du sac anal étaient identifiés. Résultats - Dix-neuf chiens étaient des mâles et 14 des femelles. Vingt-quatre races ont été incluses. L'âge moyen au début de la maladie était de 4,4 ans. Le BCS moyen était de 5,8 sur 9. La qualité des selles était « mauvaise ¼ dans sept cas sur 33 et normale dans 23 cas sur 33. La dermatite atopique était la comorbidité la plus fréquente (12 sur 33). Le traitement consistait généralement en un rinçage du sac anal avec une solution saline suivi d'une perfusion à l'aide d'une pommade stéroïde/antibiotique/antifongique disponible dans le commerce. Le traitement a été répété en moyenne 2,9 fois. La résolution de la SA a été obtenue dans 24 des 33 cas, les signes cliniques ont disparu dans quatre des 33 cas, cinq des 33 cas n'ont pas terminé le traitement et aucun cas n'a échoué au traitement. Conclusions et pertinence clinique - Le traitement local par rinçage et perfusion est efficace pour traiter la SA chez le chien.

Introducción- se ha publicado poca información sobre el tratamiento de la saculitis anal canina (AS). Objetivos - Objetivo primario: determinar los resultados del tratamiento local de la AS en el servicio de referencia dermatológica de la institución de los autores. Objetivo secundario: determinar la presentación clínica, la puntuación de la condición corporal (BCS), la calidad de las heces y las comorbilidades asociadas a la AS. Animales - Treinta y tres perros con AS presentados al servicio de dermatología de referencia entre el 1 de enero de 2010 y el 31 de marzo de 2021. Materiales y métodos - Se realizó una búsqueda en la historia clínica electrónica. Se recopiló información sobre sexo, raza, edad de inicio de la enfermedad, peso, BCS, calidad de las heces, comorbilidades, tratamiento y resultado del tratamiento. El resultado del tratamiento se clasificó como "resuelto clínicamente", "signos clínicos resueltos por propietario", "no completó el tratamiento" o "fracasó". Los perros fueron excluidos si fueron vistos por otro servicio, no tratados por AS, o si se identificaron senos perianales (fístulas), masas en los sacos anales o abscesos en los sacos anales. Resultados- diecinueve perros eran machos y 14 hembras. Se incluyeron veinticuatro razas. La edad promedio de inicio de la enfermedad fue de 4,4 años. BCS promedio fue 5.8 de 9. La calidad de las heces fue "mala" en siete de 33 y normal en 23 de 33 casos. La dermatitis atópica fue la comorbilidad más común (12 de 33). El tratamiento generalmente consistía en enjuagar el saco anal con solución salina seguido de una infusión usando un ungüento de esteroide/antibiótico/antifúngico disponible en el mercado. El tratamiento se repitió un promedio de 2,9 veces. La resolución de AS se obtuvo en 24 de 33 casos, los signos clínicos se resolvieron por propietario en cuatro de 33, cinco de 33 casos no completaron el tratamiento y ningún caso fracasó en el tratamiento. Conclusiones y relevancia clínica- el tratamiento local con lavado e infusión intrasacular es eficaz para tratar la AS en perros.

Contexto - Poucas informações foram publicadas sobre o tratamento da saculite anal (SA) canina. Objetivos - Objetivo primário: determinar os desfechos do tratamento tópico localizado da SA em um serviço especializado de dermatologia veterinária da instituição do autor. Objetivo secundário: determinar as manifestações clínicas, escore de condição corporal (ECC), qualidade das fezes e comorbidades associadas à SA. Animais - Trinta e três cães com SA apresentados ao serviço de dermatologia entre 1° de janeiro de 2010 e 39 de março de 2021. Materiais e métodos - Realizou-se um levantamento de prontuários eletrônicos. Foram coletadas informações sobre sexo, raça, idade no surgimento da doença, peso, ECC, qualidade das fezes, comorbidades, tratamentos e desfecho do tratamento. O desfecho do tratamento foi categorizado como "resolvido clinicamente", "sinais clínicos resolvidos de acordo com o tutor", "não completou o tratamento" ou "falhou". Os cães foram excluídos do estudo se tivessem sido tratados em outro serviço, não tivessem sido tratados para SA, ou se fossem identificados abscessos, massas ou fístulas nos sacos anais. Resultados - Dezenove cães eram machos e 14 fêmeas. Vinte e quatro raças foram incluídas. A idade média no surgimento da doença foi de 4,4 anos. O ECC médio foi 5,8 em 9. A qualidade das fezes foi ruim em sete de 33 cães e normal em 22 de 33 casos. A dermatite atópica foi a comorbidade mais comum (12 de 33). O tratamento tipicamente consistiu de lavagem dos sacos anais com solução salina seguido de infusão de uma solução comercial contendo esteroide/antibiótico/antifúngico. O tratamento foi repetido em média 2,9 vezes. Resolução da SA foi alcançada em 24 de 33 casos, os sinais clínicos se resolveram de acordo com o tutor em quatro de 33 casos, cinco de 33 casos não completaram o tratamento e em nenhum caso houve falha terapêutica. Conclusões e relevância clínica - Tratamento tópico com lavagem e infusão é eficaz para tratar SA em cães.

Management of canine perianal fistula with fluorescence light energy: preliminary findings.

BACKGROUND: Canine perianal fistula (CPF) is a severe, painful, debilitating skin condition affecting the perianal skin. It often interferes with the quality of life of both dog and owner. Conventional medical treatment involves the use of immunosuppressive therapy; however, the successful resolution of lesions can be limited by poor owner compliance, adverse drug effects and dependence on costly therapies. HYPOTHESIS/OBJECTIVES: The present study aimed to assess the potential benefits of fluorescent light energy (FLE) on cases of CPF. ANIMALS: Four dogs with active perianal fistulas METHODS AND MATERIALS: FLE was applied as sole management therapy once a week with two consecutive applications in the same session for each dog until clinical signs had significantly improved, with weekly assessments for a six week period. Dogs were assessed by measuring the size of lesions at the start of the study and then weekly for six weeks, using planimetry software. Owners recorded vocalization and straining frequency scores during their pet's defaecation, and perianal licking frequency on a 0-5 point scale to assess the response to therapy. RESULTS: All dogs improved with FLE, achieving a significant reduction in vocalization, straining and licking after two weeks (P = 0.002). After five weeks of FLE therapy, lesional areas had significantly decreased (P = 0.04). Only one dog required more than seven applications. No adverse events were reported. CONCLUSION AND CLINICAL IMPORTANCE: FLE may be a promising alternative therapy for CPF.

Partial urorectal septum malformation sequence in a kitten with disorder of sexual development.

A 2-month-old kitten exhibited simultaneously an imperforate anus, hypospadias, rectourethral fistula and genital dysgenesis (penis restricted to the glans, absence of prepuce and bifid scrotum). Surgical correction consisted of separation of the urinary and digestive tracts, perineal urethrostomy and connection of the rectum to the newly made anal opening. Pathological examination of the testes, conventionally removed at 9 months of age, showed no mature spermatozoa and underdevelopment of germ and Leydig cells. In humans, the absence of an anal opening in association with abnormal sexual development defines the urorectal septum malformation sequence. Here, we describe the first case of this syndrome in a kitten with a normal male karyotype (38,XY) and a normal coding sequence for the SRY gene. Both the rectourethral fistula and observed genital abnormalities might have been induced by a disturbance in the hedgehog signalling pathway. However, although four polymorphic sites were identified by DHH gene sequencing, none cosegregated with the malformation.

[Atresa ani and rectocutaneous fistula in an adult guinea pig (Cavia porcellus)]. / Atresia ani und rektokutane Fistel bei einem adulten Meerschweinchen (Cavia porcellus).

A 4-year-old, male guinea pig in a good general condition was presented for a routine castration. Since its birth, the animal had been kept outdoors with a male sibling. At the initial examination the perineal sac was smaller compared to other intact male guinea pigs. At the caudal end of the perineal sac a small dimple was noted, that ended blindly after 3mm. The following examination under anaesthesia revealed a fistula opening 1cm caudodorsally to the anus. The skin around the opening was bulging but without any signs of inflammation. Slightly protruding and reddened mucosa was visible inside the opening. After instillation of a contrast agent into the fistula a radiograph showed a contrast-filled caudal region of the large intestine. The intestine appeared to be normal and no other abnormalities were present. The excretion of normal faeces through the fistula was visible and atresia ani with a rectocutaneous fistula was diagnosed. The examination of the male sibling showed a normally developed anus. As the guinea pig had no clinical signs or associated malformations apart from the smaller perineal sac and the passage of normal faeces was possible through the fistula opening, no therapy was scheduled. To the authors' knowledge, this is the second report of this congenital abnormality in a guinea pig. The characteristics of this case include the high age of the animal at diagnosis of the atresia ani, the gender and the formation of a single rectocutaneous fistula.

Creation of a urethral conduit from a preputial indirect flap in a dog with perineal hypospadias.

OBJECTIVE: To report a surgical technique for creation of a urethral conduit using a preputial indirect flap. STUDY DESIGN: Case report. ANIMALS: Male Doberman Pinscher (6 weeks old). METHODS: A urethral conduit was constructed using a multistage preputial indirect flap in a dog with severe perineal hypospadias. RESULTS: Successful transfer of a perineal located urethral meatus to a more anatomically normal inguinal location was achieved with a preputial flap. The procedure was performed to aid control of recurrent urinary tract infections after anal and urethral separation in a dog with imperforate anus, urethrorectal fistula, and proximal perineal hypospadias. CONCLUSIONS: Creation of a urethral conduit from a tubed bipedicle flap using redundant preputial tissue eliminated fecal contamination of the urethral meatus, aiding control of urinary tract infection. A good functional and cosmetic outcome was achieved. CLINICAL RELEVANCE: This technique should be considered in aiding control and prevention of urinary tract infections in dogs with proximal perineal hypospadias where a preputial remnant exists.

Long-term prospective evaluation of topically applied 0.1% tacrolimus ointment for treatment of perianal sinuses in dogs.

OBJECTIVE: To evaluate effectiveness of a combination of topically applied tacrolimus, orally administered prednisone, and a novel-protein diet for treatment of perianal sinuses in dogs and to monitor clinical progress and owner management of the condition for 2 years. DESIGN: Noncontrolled clinical trial. Animals-19 dogs with perianal sinuses. Procedures-Perianal sinuses were diagnosed during physical examination, and dogs were placed on a 16-week treatment protocol consisting of topically applied 0.1% tacrolimus ointment, orally administered prednisone (tapering dose), and a novel-protein diet. Metronidazole was orally administered for the first 2 weeks. Anal sacculectomy was recommended whenever anal sacs were involved. Dogs were evaluated every month for the first 4 months and then every 6 to 12 weeks for 2 years. RESULTS: Perianal sinuses resolved completely in 15 of 19 dogs during the 16 weeks. In the remaining 4 dogs, the lesions markedly improved but failed to completely resolve. Three of these had anal sac involvement, and the owner of 1 dog had complied poorly with treatment instructions. During the 2 years following treatment, all dogs were maintained on intermittently applied tacrolimus ointment, 4 dogs also received prednisone every other day, and 11 dogs remained on the novel-protein diet. At the conclusion of the study, 13 of the 15 dogs that survived to that point were free of perianal disease. CONCLUSIONS AND CLINICAL RELEVANCE: The described protocol was effective and economical for resolving perianal sinuses. Dogs maintained on intermittent medications were unlikely to redevelop lesions. When the anal sacs were involved, anal sacculectomy appeared to improve the outcome.

Use of a temporary incontinent end-on colostomy in a cat for the management of rectocutaneous fistulas associated with atresia ani.

A 2 1/2-month-old cat was evaluated for the presence of multiple draining tracts ventral to the tail of 8 days duration. Clinical and radiographic examination revealed that the cat had rectocutaneous fistulas and type II atresia ani. The cat underwent a temporary end-on colostomy for faecal diversion. Sixty days after surgery and after the fistulas resolved the animal underwent a second surgery for colostomy closure and anal reconstruction. Two years after surgery the cat was reported to be in good health with no faecal incontinence.

Rectocutaneous fistulas.

This article reviews the etiology, diagnosis, and treatment of rectal perforation and rectocutaneous fistula in small animals. In addition, the literature regarding use of enterostomy in small animals is reviewed and comparative aspects of this procedure in humans and horses are presented. A case report of rectal perforation leading to rectocutaneous fistula formation and the use of colostomy in the management of the case is presented.

Evaluation of azathioprine on lesion severity and lymphocyte blastogenesis in dogs with perianal fistulas.

Fourteen dogs with perianal fistulas were entered into a prospective clinical study to investigate the effects of long-term azathioprine on clinical outcome and to determine if the clinical results correlated with lymphocyte blastogenesis tests. Complete remission of perianal fistulas was seen in eight (57%) of 14 dogs; partial remission occurred in one (7%) dog; and no response was detected in five (36%) dogs. The results of lymphocyte blastogenesis assays did not correlate with therapeutic response.

Evaluation of the effect of two dose rates of cyclosporine on the severity of perianal fistulae lesions and associated clinical signs in dogs.

OBJECTIVE: To investigate the effect of cyclosporine (2 or 5 mg/kg every 24 hours) on perianal fistulae (PAF) lesions. STUDY DESIGN: Blinded randomized, prospective trial. ANIMALS: Dogs (n = 20) with perianal fistulae. METHODS: Dogs were randomly assigned to administration of either 2 mg/kg (n = 10) or 5 mg/kg (n=10) of cyclosporine orally every 24 hours for 8 weeks. Lesion surface area was measured, lesion severity was graded using a visual analog scale, and the presence and severity of clinical signs recorded every 2 weeks. RESULTS: Lesion variables were significantly reduced in both groups after 8 weeks and owners also reported a reduction in clinical sign severity. The 5 mg/kg dose rate significantly accelerated lesion resolution compared with 2 mg/kg. In the 2 mg/kg group, 20% of dogs had complete resolution of clinical signs and 10% had resolution of lesions. In the 5 mg/kg group, 40% of dogs had complete resolution of clinical signs and 60% had resolution of lesions. CONCLUSIONS: A dose rate of 5 mg/kg every 24 hours was more effective at reducing the surface area and severity of PAF lesions than 2 mg/kg every 24 hours but less effective at resolving PAF lesions than previous studies using dose rates > or =5 mg/kg every 12 hours. CLINICAL RELEVANCE: Cyclosporine at 5 mg/kg every 24 hours may be useful for the palliation of PAF lesions.

A urethrorectal fistula due to prostatic abscess associated with urolithiasis in a dog.

An 8-year-old, entire male crossbreed dog had a 2-day history of abdominal pain and straining to urinate and defecate. A diagnosis of urolithiasis with urinary retention, and probable prostatitis was made. The dog was treated with fluids and enrofloxacin. Five days later, ultrasonography of the prostate showed two hypoechoic areas compatible with abscesses. Twelve hours later, the patient started to urinate from the rectum during micturition and urethrorectal fistula was diagnosed. The omentalization of the prostatic abscesses and castration were performed and calculi were removed. The urethrorectal fistula was treated conservatively with an indwelling urinary catheter, a low residue diet and antibiotics. The dog recovered uneventfully without recurrence of the fistula.

Use of laparoscopic-assisted jejunostomy for fecal diversion in the management of a rectocutaneous fistula in a dog.

A 2-year-old female Siberian Husky was referred for evaluation of a rectocutaneous fistula of unknown etiology. On evaluation, a rectal tear and an associated perivulvar abscess and draining tract were identified. Several attempts were made to repair the rectocutaneous fistula and associated rectal tear. Primary repair and fascia lata graft repair failed. Successful management was achieved via a laparoscopic-assisted end-on jejunostomy for fecal diversion, and the wound healed readily by second intention. During the period of hospitalization, the dog lost a considerable amount of weight. Particular care should be taken regarding fluid therapy, administration of antimicrobials, and adequate nutrition in patients with rectocutaneous fistulas. Overall, the use of laparoscopic-assisted end-on jejunostomy for fecal diversion in the management of rectocutaneous fistulas in dogs appears to be feasible; end-on or loop jejunostomy may also be an option for the treatment of other diseases of the distal portion of the gastrointestinal tract.