Anal disorders in pregnant and postpartum women: epidemiological, diagnostic and therapeutic aspects in 10 maternities of Bamako in Mali.

Bowel transit disturbances favored by pregnancy and injuries during childbirth would be triggering or aggravating factors for anal pathologies. The objective of this work was to study the epidemiology, diagnosis, and treatment of anal pathologies during pregnancy and 6 weeks after delivery. We carried out a prospective, multi-centric, and analytical study in 10 obstetric units in Bamako from June 1st, 2019, to May 31st, 2020. After informed consent, we enrolled all first-trimester pregnant women admitted to the hospitals and who were followed up through the postpartum. We conducted a rectal examination in each participant and an anoscope in those with an anal symptom. Hemorrhoidal diseases were diagnosed in the case of external hemorrhoids (thrombosis or prolapse) or internal hemorrhoids. During the study period, we followed up 1,422 pregnant women and we found 38.4% (546) with anal pathologies (hemorrhoidal diseases in 13% (192), anal fissure in 10.5% (150) and anal incontinence in 8.6% (123). Risk factors for the hemorrhoidal disease were age of patient ≥30 years old aRR=5.77, 95% CI 4.57-7.34; p=0.000; a existence of chronic constipation aRR=2.61, 95% CI 1.98-3.44; p=0.000; newborn weight >3500 g aRR= 1.61, 95% CI 1.25-2.07; p=0.000 and fetal expulsion time >20 minutes aRR= 6.04, 95% CI 5.07-7.27; p=0.000. The clinical signs observed were constipation, anal pain, bleeding, and pruritus. The treatment was based on counseling on hygiene and diet, the use of laxatives, local topicals, and analgesics along perineal rehabilitation. Anal pathologies were common during pregnancy and 6 weeks after delivery. Pregnant women must be screened systematically for such pathologies. Early diagnostic and appropriate treatment would reduce serious complications.

Management of Hemorrhoids and Anal Fissures.

Hemorrhoids and anal fissures are two of the most common benign anorectal diseases. Despite their high prevalence, diagnostic accuracy of benign anorectal disease is suboptimal at 70% for surgeons, especially for hemorrhoidal diseases. Once the diagnosis is correctly made, numerous medical and surgical treatment options are available, each with different rates of success and complications. In this article, the authors review each step of patient management, with emphasis on evidence-based treatment options for hemorrhoids and anal fissures. The article discusses the pathophysiology, diagnosis, medical management, and procedures for hemorrhoids followed by a detailed overview on the management of anal fissures.

Anal fissures: An update on treatment options.

BACKGROUND: Anal fissure (AF) is the second most common anorectal complaint in healthcare settings. The presentation might be acute or chronic, characterised by severe pain with defaecation that persists for one to two hours. Non-surgical and surgical interventions are available based on the severity and persistence of the fissure. OBJECTIVE: The aim of this article is to review the pathophysiology, clinical presentation and management of AF under current guidelines. DISCUSSION: The aetiology of AF is unclear, although it is commonly associated with local trauma or associated chronic conditions. Acute AF is first treated with conservative therapy, including dietary fibre and sitz baths. Addition of topical nitrates, topical calcium channel blockers or botulinum toxin injection is indicated with failure of conservative treatment or at medical discretion. Surgical options are considered if AF persists despite treatment. Most present as hypertonic, but special consideration is needed for hypotonic or secondary presentations.

Rectal Bleeding in Infants: Diagnostic Work-up and Management.

Lower gastrointestinal bleeding is an alarming symptom in pediatrics, especially in infancy. However, it is commonly secondary to benign and self-limiting conditions, such as anal fissures, infections, and allergies; more rarely it is caused by more serious disorders, such as necrotizing enterocolitis, very early onset inflammatory bowel diseases, and vascular malformations. The present review aims at summarizing the different clinical conditions presenting with rectal bleeding in infancy and provides an evidence-based diagnostic work-up for the clinical management of patients with this occurrence.

The Italian Unitary Society of Colon-proctology (SIUCP: Società Italiana Unitaria di Colonproctologia) guidelines for the management of anal fissure.

INTRODUCTION: The aim of these evidence-based guidelines is to present a consensus position from members of the Italian Unitary Society of Colon-Proctology (SIUCP: Società Italiana Unitaria di Colon-Proctologia) on the diagnosis and management of anal fissure, with the purpose to guide every physician in the choice of the best treatment option, according with the available literature. METHODS: A panel of experts was designed and charged by the Board of the SIUCP to develop key-questions on the main topics covering the management of anal fissure and to performe an accurate search on each topic in different databanks, in order to provide evidence-based answers to the questions and to summarize them in statements. All the clinical questions were discussed by the expert panel in different rounds through the Delphi approach and, for each statement, a consensus among the experts was reached. The questions were created according to the PICO criteria, and the statements developed adopting the GRADE methodology. CONCLUSIONS: In patients with acute anal fissure the medical therapy with dietary and behavioral norms is indicated. In the chronic phase of disease, the conservative treatment with topical 0.3% nifedipine plus 1.5% lidocaine or nitrates may represent the first-line therapy, eventually associated with ointments with film-forming, anti-inflammatory and healing properties such as Propionibacterium extract gel. In case of first-line treatment failure, the surgical strategy (internal sphincterotomy or fissurectomy with flap), may be guided by the clinical findings, eventually supported by endoanal ultrasound and anal manometry.

Anorectal Emergencies.

Anorectal emergencies are rare presentations of common anorectal disorders, and surgeons are often called on to assist in their diagnosis and management. Although most patients presenting with anorectal emergencies can be managed nonoperatively or with a bedside procedure, surgeons must also be able to identify surgical anorectal emergencies, such as gangrenous rectal prolapse. This article provides a review of pertinent anatomy; examination techniques; and workup, diagnosis, and management of common anorectal emergencies including thrombosed hemorrhoids, incarcerated hemorrhoids, anal fissure, anorectal abscess, rectal prolapse, and pilonidal abscess and unique situations including rectal foreign body and anorectal sexually transmitted infections.

Caracterización del tratamiento con plasma rico en plaquetas y leucocitos en la fisura anal secundaria / Characterization of the Treatment with Platelet-Rich Plasma and Leukocytes against Secondary Anal Fissure

Introducción: Las enfermedades benignas de recto son muy frecuentes en la práctica médica habitual en todos los niveles de atención de salud. Dentro de estos procesos se reconoce que la fisura anal es uno de los más comunes. Objetivo: Caracterizar a los pacientes tratados con plasma rico en plaquetas y leucocitos por fisura anal secundaria en la provincia Camagüey en el período comprendido entre septiembre del 2020 y septiembre del 2022. Métodos: Se realizó un estudio cuasiexperimental, cuyo universo lo conformaron los pacientes con el diagnóstico de fisura anal secundaria que asistieron a la consulta de Coloproctología del Hospital Provincial Docente Oncológico María Curie. Se estableció una muestra no probabilística a criterio de los autores conformada por 132 pacientes adultos, quienes recibieron tratamiento con plasma rico en plaquetas y leucocitos por fisura anal secundaria en la provincia Camagüey. Resultados: Con respecto al sexo y a la edad, se observó una mayor frecuencia del grupo de 40 a 49 años y predominó el sexo femenino. El síntoma de mayor frecuencia fue el dolor, mientras que en la etiología prevaleció la proctitis facticia. En la mayoría de los casos estudiados la fisura anal cicatrizó en menos de 15 días y en cuanto a la evaluación final del tratamiento solo la minoría empeoró. Conclusiones: La caracterización de la muestra en estudio permite afirmar que el tratamiento con plasma rico en plaquetas y leucocitos tiene beneficios para los pacientes con fistulas perianales y su calidad de vida(AU)

Introduction: Benign rectal diseases are very frequent in routine medical practice at all levels of health care. Among these processes, anal fissure is recognized as one of the most common. Objective: To characterize patients treated with platelet-rich plasma and leukocytes for secondary anal fissure in Camagüey Province between September 2020 and September 2022. Methods: A quasiexperimental study was carried out, whose universe was made up of patients with the diagnosis of secondary anal fissure who attended the coloproctology office at Hospital Provincial Docente Oncológico María Curie. A nonprobabilistic sample was established according to the authors' criterions, made up of 132 adult patients who received treatment with platelet-rich plasma and leukocytes for secondary anal fissure in Camagüey Province. Results: Regarding sex and age, a higher frequency was observed in the group 40 to 49 years old and the female sex was predominant. The most frequent symptom was pain, while the prevailing etiology was factitious proctitis. In most of the cases under study, the anal fissure healed in less than 15 days and, regarding the final assessment of the treatment, only the minority worsened. Conclusions: The characterization of the sample under study allows to affirm that treatment with platelet-rich plasma and leukocytes has benefits for patients with perianal fistulas and their quality of life(AU)

[Management of anal fissure]. / Prise en charge de la fissure anale.

MANAGEMENT OF ANAL FISSURE. The news in the management of the anal fissure are few but to know. The medical treatment must be well explained to the patient and optimized from the outset. Healthy bowel movements combining a sufficient fiber intake and soft laxatives must be continued for at least 6 months. Pain control is important. Topicals, specific (in case of sphincter hypertonia) or not, must be maintained for 6 to 8 weeks. Calcium channel blockers seem the most interesting with fewer side effects for similar effectiveness. Surgery is proposed (apart a no medically control of the pain or a fistula associated) in the event of failure of well-conducted medical treatment. It remains the most effective long-term treatment. Lateral internal sphincterotomy has its place in the absence of anal continence disorder, in which case fissurectomy and/or cutaneous anoplasty can be proposed.

PRISE EN CHARGE DE LA FISSURE ANALE. Les nouveautés dans la prise en charge de la fissure anale sont peu nombreuses mais à connaître. Le traitement médical doit être bien expliqué au patient et optimisé d'emblée. La régulation du transit associant un apport de fibres suffisant et des laxatifs doux doit être poursuivie au moins six mois. Le contrôle de la douleur est important. Les topiques, spécifiques (en cas d'hypertonie sphinctérienne) ou non, doivent être maintenus six à huit semaines. Les inhibiteurs calciques semblent les plus intéressants, avec moins d'effets indésirables pour une efficacité similaire. La chirurgie est proposée (sauf en cas de fistule associée ou de caractère hyperalgique non contrôlé médicalement) en cas d'échec d'un traitement médical bien conduit ; elle reste le traitement le plus efficace à long terme. La sphinctérotomie latérale interne a sa place en l'absence de trouble de la continence anale, auquel cas la fissurectomie et/ou les plasties anocutanées peuvent être proposées.

Identification and reporting of anal pathology during routine colonoscopies

The gold-standard procedure for anal canal examination is anoscopy. Nonetheless, patients are referred for a colonoscopy for many reasons, and a routine exam might provide an opportunity to diagnose anal pathologies, such as hemorrhoids, anal fissures, anal polyps, condylomas, and anal squamous cell carcinoma. It is important to know the main features of these conditions and relevant information to report in order to help guide patient treatment and follow-up.

Anal Cryptitis: A misdiagnosed condition.

Introduction: Crypts are small anatomical structures situated between the anal papillae, which do not cause any symptoms unless they become inflamed. Cryptitis is a localized infection of one or more of the anal crypts. Case presentation: A 42-year-old woman presented to our practice, complaining intermittently of anal pain and pruritus ani over a span of 1 year. She was referred multiple times to various surgeons, and she was treated conservatively for anal fissure without any evident improvement. The referred symptoms were increased often after defecation. Under general anesthesia, a hooked fistula probe was introduced into the inflamed anal crypt and the whole length of the crypt was layed open. Conclusion: Anal cryptitis is a misdiagnosed condition. The un-specific symptomatology of the disease can easily mislead. The clinical suspicion is fundamental for the diagnosis. Patient's history, digital ex-amination, and anoscopy are essential for the diagnosis of anal cryptitis.

[Proctology]. / Proktologie.

This article provides a practice-oriented overview of the most common proctological diseases: Anal eczema, hemorrhoidal disease, anal thrombosis, marisca, anal abscess and fistula, and anal fissure. Definitions and etiopathogenesis, clinic and diagnostics, and current therapy are presented.

Management of chronic anal fissure: results of a national survey among gastrointestinal surgeons in the Netherlands.

BACKGROUND: Chronic anal fissure (CAF) is a common, bothersome condition frequently accompanied by pelvic floor complaints. Despite current guidelines, optimal management is challenging. The aim of this study is to evaluate current management of CAF among gastrointestinal surgeons in the Netherlands. METHODS: Dutch gastrointestinal surgeons and residents were sent a survey invitation by email, which was available online between June 2021 and September 2021. The questionnaire consisted of 21 questions concerning work experience, physical examination, diagnostic and surgical techniques, and follow-up. RESULTS: Overall, 106 (33%) respondents completed the survey. Most respondents (59%) had at least 10 years of experience in treating CAF. Only 23% always addressed pelvic floor complaints. Fifty-one percent performed digital rectal examination and 22% always, or almost always, examined the pelvic floor muscles. Most respondents started treatment with fibers and/or laxatives and ointment (96%). Diltiazem was in 90% the preferred ointment. Twenty-two percent referred patients for pelvic floor physical therapy. Botulinum toxin was in 54% performed under general or spinal anesthesia or sedation. The surgical procedure of choice was fissurectomy (71%) followed by lateral internal sphincterotomy (27%). Fissurectomy was in 51% always combined with botulinum toxin. Fifty-seven percent of the respondents preferred a physical follow-up appointment. CONCLUSION: Guideline recommendations are largely followed in the Netherlands, starting with conservative measures followed by surgical procedures. Surgeons do not consistently assess pelvic floor complaints, nor do they routinely examine the pelvic floor muscles. Awareness of pelvic floor dysfunctions is important to refer patients for pelvic floor physical therapy.

Incidence and Characterization of Rectal Complications From Fecal Management Systems.

BACKGROUND: Fecal management systems have become ubiquitous in hospitalized patients with fecal incontinence or severe diarrhea, especially in the setting of perianal wounds. Although fecal management system use has been shown to be safe and effective in initial series, case reports of rectal ulceration and severe bleeding have been reported, with a relative paucity of clinical safety data in the literature. OBJECTIVE: The purpose of this study was to determine the rate of rectal complications attributable to fecal management systems, as well as to characterize possible risk factors and appropriate management strategies for such complications. DESIGN: This was a retrospective cohort study. SETTINGS: The study was conducted at a large academic medical center. PATIENTS: All medical and surgical patients who underwent fecal management system placement from December 2014 to March 2017 were included. MAIN OUTCOME MEASURES: We measured any rectal complication associated with fecal management system use, defined as any rectal injury identified after fecal management system use confirmed by lower endoscopy. RESULTS: A total of 629 patients were captured, with a median duration of fecal management system use of 4 days. Overall, 8 patients (1.3%) experienced a rectal injury associated with fecal management system use. All of the patients who experienced a rectal complication had severe underlying comorbidities, including 2 patients on dialysis, 1 patient with cirrhosis, and 3 patients with a recent history of emergent cardiac surgery. In 3 patients the bleeding resolved spontaneously, whereas the remaining 5 patients required intervention: transanal suture ligation (n = 2), endoscopic clip placement (n = 1), rectal packing (n = 1), and proctectomy in 1 patient with a history of pelvic radiotherapy. LIMITATIONS: The study was limited by its retrospective design and single institution. CONCLUSIONS: This is the largest study to date evaluating rectal complications from fecal management system use. Although rectal injury rates are low, they can lead to serious morbidity. Advanced age, severe comorbidities, pelvic radiotherapy, and anticoagulation status or coagulopathy are important factors to consider before fecal management system placement. See Video Abstract at http://links.lww.com/DCR/B698. INCIDENCIA Y CARACTERIZACIN DE LAS COMPLICACIONES RECTALES DE LOS SISTEMAS DE MANEJO FECAL: ANTECEDENTES:Los sistemas de manejo fecal se han vuelto omnipresentes en pacientes hospitalizados con incontinencia fecal o diarrea severa, especialmente en el contexto de heridas perianales. Aunque se ha demostrado que el uso del sistema de tratamiento fecal es seguro y eficaz en la serie inicial, se han notificado casos de ulceración rectal y hemorragia grave, con una relativa escasez de datos de seguridad clínica en la literatura.OBJETIVO:Determinar la tasa de complicaciones rectales atribuibles a los sistemas de manejo fecal. Caracterizar los posibles factores de riesgo y las estrategias de manejo adecuadas para tales complicaciones.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO CLINICO:Centro médico académico de mayor volumen.PACIENTES:Todos los pacientes médicos y quirúrgicos que se sometieron a la colocación del sistema de manejo fecal desde diciembre de 2014 hasta marzo de 2017.PRINCIPALES MEDIDAS DE VALORACION:Cualquier complicación rectal asociada con el uso del sistema de manejo fecal, definida como cualquier lesión rectal identificada después del uso del sistema de manejo fecal confirmada por endoscopia baja.RESULTADOS:Se identificaron un total de 629 pacientes, con una duración media del uso del sistema de manejo fecal de 4,0 días. En general, 8 (1,3%) pacientes desarrollaron una lesión rectal asociada con el uso del sistema de manejo fecal. Todos los pacientes que mostraron una complicación rectal tenían comorbilidades subyacentes graves, incluidos dos pacientes en diálisis, un paciente con cirrosis y tres pacientes con antecedentes recientes de cirugía cardíaca emergente. En tres pacientes el sangrado se resolvió espontáneamente, mientras que los cinco pacientes restantes requirieron intervención: ligadura de sutura transanal (2), colocación de clip endoscópico (1), taponamiento rectal (1) y proctectomía en un paciente con antecedentes de radioterapia pélvica.LIMITACIONES:Diseño retrospectivo, institución única.CONCLUSIONES:Este es el estudio más grande hasta la fecha que evalúa las complicaciones rectales del uso del sistema de manejo fecal. Si bien las tasas de lesión rectal son bajas, pueden provocar una morbilidad grave. La edad avanzada, las comorbilidades graves, la radioterapia pélvica y el estado de anticoagulación o coagulopatía son factores importantes a considerar antes de la colocación del sistema de manejo fecal. Consulte Video Resumen en http://links.lww.com/DCR/B698.