Anorectal symptoms during pregnancy and postpartum: a prospective cohort study.

AIM: The aim was to determine the prevalence and risk factors of anal symptoms prepartum and postpartum. METHOD: A prospective observational cohort study was carried out in Ghent University Hospital, Belgium. Ninety-four pregnant women between their 19th and 25th week of pregnancy were included. An anal symptom questionnaire was filled in at four different times: in the second and third trimester, immediately postpartum and 3 months postpartum. Descriptive data were obtained from patient files. A proctological diagnosis was presumed on the basis of combined symptoms (i.e. rectal bleeding, anal pain and swelling). Constipation was defined by the Rome III criteria. Risk factors were identified using multivariate analysis. RESULTS: Sixty-eight per cent of the patients developed anal symptoms. The most prevalent symptom was anal pain. Constipation was reported by 60.7% during the study period. Seven women (7.9%) suffered from faecal incontinence. The most prevalent diagnoses were haemorrhoidal thrombosis (immediately postpartum), haemorrhoidal prolapse (in the third trimester and immediately postpartum) and anal fissure (not episode related). The two independent risk factors for anal complaints were constipation, with a 6.3 odds ratio (95% CI 2.08-19.37), and a history of anal problems, with a 3.9 odds ratio (95% CI 1.2-13). The Bristol Stool Chart was shown to be a reliable indicator in pregnancy and postpartum as significant correlations were observed in all study periods. CONCLUSION: Two-thirds of pregnant women have anal symptoms during pregnancy and postpartum, especially haemorrhoidal complications and anal fissure. The most important risk factor is constipation. The prevention of constipation in pregnant women is therefore highly recommended.

Recurrent rejections after liver transplantation for hepatocellular carcinoma with stem cell features in an adult patient.

Patients with hepatoblastoma featuring carcinoma characteristics have better outcomes after liver transplantation, than after chemotherapy and resection. Possibly this should be extrapolated to aggressive subtypes of hepatocellular carcinomas in non-cirrhotic livers, where early liver transplantation might also be indicated. However, the risks associated with liver transplantation and immunosuppressive treatment after liver transplantation are once again demonstrated by this case of a 32-year-old women with a negative personal and familial history of liver diseases. She underwent transplantation (DBD) for a hepatocellular carcinoma with stem cell features (HCC-HS; an aggressive 'hepatoblast subtype' of hepatocellular carcinoma) after chemotherapeutical downstaging techniques failed to sufficiently downstage the tumor. Despite being on conventional immunosuppressive regimens (tacrolimus and mycophenolate mofetil with initial corticosteroids tapered), this patient still developed two severe rejection episodes, one of which necessitated retransplantation (DCD). Both episodes were preceded by alterations in tacrolimus trough levels, either intentionally, when tacrolimus was reduced within a nephroprotective regimen, or unintentionally, when rifampicin, a CYP3A4 inducer, significantly lowered the trough levels. Together, these episodes stress the importance of therapeutic drug monitoring of tacrolimus. Furthermore, the patient experienced an everolimus-linked drug-induced thrombotic microangiopathy, underwent multiple ERCPs for an anastomotic stricture and only one and a half year after the first liver transplantation she already suffers from long-term immunosuppressive-related side effects such as impaired glucose tolerance, hypertension and a potential cardiomyopathy. At present, she is still alive and experienced no recurrence of her primary tumor. Her case underscores the significant challenges in post-liver transplantation care.

Unexpected outcome of a sigmoid lesion believed to be malignant.

A 69-year-old male with a past medical history of an Olfactory nerve meningioma and left-sided Bell's palsy presented with 6 weeks of lower abdominal pain and weight loss of 4 kg in 6 months. His current medications included acetylsalicylic acid 80 mg once daily, Amlodipine 5 mg once daily and Allopurinol 300 mg once daily. Physical examination was benign without signs of acute abdomen. The abdomen was nondistended and soft but tender to palpation over the left lower quadrant. Laboratory studies showed no acute outliers. The patient was followed up by his pulmonologist because of thoracic lesions which required a PET-CT for further evaluation. This PET-CT revealed a focal zone of oedematous rectosigmoid colon with a strong suspicion of a semi-circular sigmoid neoplasia with continuation to the bladder (Figure 1a). A presumptive diagnosis of a primary colonic malignancy was made. Colonoscopy was performed and visualised a foreign linear object lodged in both walls of the diverticular sigmoid with surrounding inflammation, but otherwise normal mucosa (Figure 1b). No arguments could be made endoscopically to support the diagnosis of an underlying primary colonic malignancy.