Search

Haemorrhoid is one of the most common anorectal complaints1,2 reported in anorectal clinics with estimated prevalence of 4.4% in United States and 13–36% in the United Kingdom.3 It is one of the oldest ills known to mankind with accounts available in oldest literature like Atharwaveda (1500 BCE)4 from India and Egyptian Papyrus (1700BCE)5 from the west. Haemorrhoids are actually the vascular cushions that provide a physiological hermetic seal in the closure mechanism of anal canal and helps in maintenance of continence.6 Faulty dietary and toilet habits may cause the pathological enlargement of these cushions which create misery to the patient by producing bleeding, discomfort, prolapse and sometimes pain in the anorectal region. A modification in diet, lifestyle and defecation habits can alleviate the symptoms in many patients. For the rest, various surgical methods like haemorrhoidectomy, stapled haemorrhoidopexy etc. and the office procedures like rubber band ligation, sclerotherapy, photocoagulation, cryosurgery etc. are available with each having its own merits and limitations compared to other. Though haemorrhoidectomy is still considered as the ‘gold standard’ treatment for haemorrhoids,7 office treatments for symptomatic haemorrhoids are increasing8 over the last few decades. Rubber Band Ligation (RBL), as advocated by Barron,9 is one of the safe, simple, cost-effective and the most widely used office procedure by the surgeons which eliminate the pile mass by ischemic necrosis and promote submucosal fibrosis with subsequent fixation of anal epithelium to the underlying sphincter.10 In traditional Indian medicine i.e. Ayurveda, the term arsha is used to describe an abnormal fleshy growth originating in the anal region due to improper diet, lifestyle and defecation habits.11 By definition, the term arsha may broadly include sentinel tags, hypertrophied papillae, polyps and external as well as internal piles; however, to be very specific, haemorrhoidal disease may be corresponded with raktarsha (rakta means ‘blood’ and arsha means ‘fleshy mass’), a variety of arsha described in ancient texts. The management strategies for haemorrhoids include four modalities of treatments viz. medicinal treatment, chemical cauterization, thermal cauterization and surgical excision.12 While medical management is primarily advocated for uncomplicated haemorrhoids and focusses upon improvement of digestion, easy evacuation and correction of bowel habits; large and complicated piles are advised to be treated with thermal cauterization or excised surgically. Chemical cauterization is a form of parasurgical measure which is employed by local application of a caustic material, pratisaraneeya kshara (PK; pratisaraneeya means ‘to be applied locally’, kshara means ‘alkaline caustics’) in internal haemorrhoids. It is prepared from the ashes of medicinal plants by a special technique of preparation with addition of marine shells13 and, on application, brings about necrosis in the pile mass resulting into an ulcer which heals by fibrosis.14 Local application of PK, also known as kshara-karma, is one of the most widely practiced outpatient treatments for internal haemorrhoids by the Ayurveda surgeons in India. Thus, both RBL and local application of PK have a similar mode of action and are the office procedures of choice for internal haemorrhoids among the modern and Ayurveda surgeons respectively. So, the present study was designed to compare the efficacy of these two techniques in a prospective randomized trial.

Anal sphincter spasm contributes to the delay in surgical wound healing after hemorrhoidectomy. A prospective, experimental, randomized, double-blind trial was conducted on two groups of patients that underwent closed hemorrhoidectomy. There were 26 patients in each group. Group A received topical diltiazem in the anal region three times a day. Group B received a placebo. Cicatrization time was documented for 6 weeks through digital photography. Mean healing time for the group treated with diltiazem was 3.19 weeks (22.33 ± 0.884 days) and 3.92 weeks (27.44 ± 1.130 days) for the control group (p = 0.012 95% CI). At week three, the wounds in 73.07% of the patients in the diltiazem group had healed, compared with 46.15% of the patients in the control group. Resumen: El espasmo del esfínter anal contribuye al retardo en la cicatrización de las heridas quirúrgicas después de una hemorroidectomía. Se realizó un estudio aleatorizado, prospectivo, experimental, doble ciego, de dos grupos de pacientes en los que se efectuó hemorroidectomía con técnica cerrada. Cada grupo incluyó 26 pacientes; el grupo A recibió diltiazem tópico en la región anal 3 veces al día, y el grupo B recibió un placebo. Se documentó el tiempo de cicatrización, mediante fotografía digital, durante 6 semanas. El promedio del tiempo de cicatrización para el grupo tratado con diltiazem fue de 3.19 semanas (22.33 ± 0.884 días); en tanto que en el grupo control fue de 3.92 semanas (27.44 ± 1.130 días) (p = 0.012 IC 95%). A la tercera semana, el 73.07% de los pacientes del grupo tratado con diltiazem habían cicatrizado, en comparación con el 46.15% de los pacientes del grupo control. Keywords: Diltiazem, Cicatrization, Post-hemorrhoidectomy cicatrization, Palabras clave: Diltiazem, Cicatrización, Cicatrización posthemorroidectomía

Parikartika is one of the ano-rectal diseases. Its references available in Bruhatrayees. The word Guda Vidar means Parikartanavat vedana around guda Pradesh. It is also having the symptoms like burning sensation, cutting type of pain, itching, something time swelling, bleeding from anus. In modern science it can be correlated to fissure in ano. Here a case Report of 28 years-Male Patient having of Parikartika (fissure in ano) from last 15 days. He was suffering from Guda Pradesh parikartanavatvedana(Excruciating pain), Guda Pradesh shoth (swelling at anal region), Guda Pradesh Daha (burning sensation at anal region), Malavashtmbha (constipation), Sarakta-malapravrutti (stools streaked with blood), since last 10 days. Generally, he got relief from modern medicines, but this time medicines not give relief. He was treated with Ayurvedic medicine, which gives effective result within 3 days with Ayurvedic treatment.

The aim of the study described here was to examine the potential of tomography ultrasonography imaging (TUI) in evaluation of the fetal anal sphincter. In this prospective cross-sectional study of the fetal anal sphincter with TUI, 326 singleton pregnancies (mean age = 28 y, range: 22–38 y) were scanned at 19–40 wk of gestation. The fetal anal region and ischium were revealed in 320 of 326 patients (98.2%). The normal fetal anal sphincter diameter and ischial space reached maximums of 15 and 39 mm, respectively. The normal fetal anal sphincter diameter and the ischial space were plotted as a function of gestational age (GA) on a linear curve, and the regression equations for normal fetal anal sphincter diameter and ischial space as a function of GA in weeks were obtained. A scatterplot was also created that revealed a significant positive relationship between normal fetal anal sphincter diameter and ischial space. On the basis of these criteria, imperforate anus was diagnosed in one fetus. Ultrasonographic assessment of the fetal anal sphincter and the ischium with TUI is feasible. The reference values reported in this article may be useful in prenatal diagnosis of fetal anal sphincter abnormalities.

Background Betapapillomaviruses (β-PV) are etiologically associated with epidermodysplasia verruciformis and a proportion of skin precancerous lesions and cancer, mainly in immunocompromised individuals. Objectives The prevalence and persistence of anal β-PV infection and β-PV type distribution were determined in a cohort of men who have sex with men (MSM). A correlation with HIV-1 infection status and selected demographic and behavioral risk factors were additionally established. Study design A total of 181 anal swabs (135 initial and 46 follow-up swabs) obtained from 135 Slovenian MSMs (17.0% HIV-1 positive) were tested for the presence of 25 different β-PV types using Diassay RHA Kit Skin (beta) HPV assay and, if negative, with an in-house nested Ma/Ha PCR. Results β-PVs were detected in 88/135 (65.2%) initial anal swabs. Infection with multiple β-PV types was found in 26 samples; the number of β-PVs ranged from 2 to 9. A total of 29 distinct β-PVs were detected: HPV-36 and HPV-38 were the most prevalent, followed by HPV-23, HPV-24, and HPV-93. HIV-1 positive status, promiscuity and use of alkyl nitrites were significantly associated with a higher prevalence of anal β-PV infection. Three partial DNA sequences suggesting putative new HPV types were identified. Conclusion To the best of our knowledge, this is the first study to investigate and characterize β-PV infections in the anal region. We showed that anal β-PV infection is highly prevalent in the MSM population and that β-PVs can establish persistent infection in the anal region for up to 4.8 years.

In clinical practice and the literature, malignant melanoma usually appears in typical sites where melanocytes can be found: skin, eyes meninges and anal region. Malignant melanomas of the esophagus-gastrointestinal (EGI) tract are usually metastatic. Primary and diffuse EGI tract melanoma is rare and only a few descriptions of this presentation have been found in the literature. The prognosis of EGI tract melanoma is frightening because of late diagnosis and high malignancy potential. Treatment is based essentially on surgery. The objective of the present study is to specify the clinical and therapeutic aspects of primary digestive melanoma.

Microbacterium nematophilum is a gram positive bacterium that colonizes the Caenorhabditis elegans rectal region causing swelling and constipation. This interaction has been exploited as a model system to identify and study genes important in host–pathogen interactions and innate immunity. During attempts to inhibit the host–pathogen interaction, it became important to clarify the route of infection. Using bacteria labeled with the fluorescent dye Cy3, we show that infection is via the oral route only and that infection follows a clear pattern of ingestion, plug formation, and bump development that can be quantitatively tracked over time.

The distribution of sialic acids and antimicrobial products (lysozyme, β-defensin-1, lactoferrin, IgA) in the anal glands of miniature pig was studied by glycoconjugate histochemistry and immunohistochemistry. The glandular acini of these glands exhibited considerable amounts of sialoglycoconjugates that terminated in Siaα2-6Gal/GalNAc or Siaα2-3Gal1-4GlcNAc, including O-acetylated sialic acids. Additionally, all antimicrobial products examined could be demonstrated in the anal glands, especially in the serous cells. The results obtained are discussed with regard to the functional significance of the anal glands. Our observations corroborated the view that sialic acids closely interact with defense cells and antimicrobial substances in the innate immune response. Therefore, the anal glandular secretions may function as protective agents in order to preserve the integrity of the anal region.

Summary Invasive anal cancers are generally successfully treated by combined chemotherapy with radiation therapy (XRT). For those patients who locally fail this intervention many are salvaged by surgery which generally results in permanent colostomy. We examined the treatment and outcome of Photofrin ® based photodynamic therapy (PDT) in a cohort of patients with anal cancer who failed locally despite chemo-radiation ( N = 6) and two patients with positive margins of resection after excision of small T 1 squamous cell anal cancers who refused further surgery or chemo-radiation. PDT consisted of outpatient infusion of Photofrin ® at 1.2 mg/kg followed 48 h later by outpatient illumination. Red light (630 nm) illumination was delivered by a 5 cm diffusing fiber, treating transphincterally at 300 J/cm followed by microlens illumination at 200 J/cm 2 to the perianal tumor bed with 2 cm margin. All patients completed PDT without incident and all have maintained local control of disease in the anal region for the length of follow up (18–48 months). PDT may serve as a new means to salvage local failures and perhaps could be employed as a primary treatment modality in select patients with early stage of disease.

Purpose The purpose of this study is to demonstrate that digital photos and video images taken by a parent can provide a definite diagnosis and makes some diagnostic procedures (eg, air contrast enema, sigmoidoscopy) unnecessary for anal swelling and anal protrusions in children with normal physical examination. Methods In a 41-month period (September 2007-January 2011), 23 parents brought their children to the clinic, stating that they saw a swelling in the anal region and/or that something protruded from the anus while their children were defecating. If the visual inspection of the anal region and digital rectal examination of the patients were normal, parents were asked to take photos or record videos when the lesion occurred to make a diagnosis and avoid the need for air contrast enema and/or sigmoidoscopy. The parents were also asked either to send these images to the surgeon via e-mail or bring an image or the camera to the surgeon's office. The patients age, sex, symptoms, medical history, results of their first physical examination, photos and video records, and the diagnosis and treatment were recorded. All of these information were retrospectively reviewed. Results The photos provided by 20 parents and the video records from 3 parents were assessed, and the diagnoses of all patients were confirmed. Of these 23 patients, a definitive diagnosis of rectal prolapse in 8, hemorrhoids in 10, rectal polyps in 3, and sentinel skin tag in 2 was made. In addition, the photographic and video evidence gave the clinicians an idea of the degree of rectal prolapse in patients for whom this was a problem. Three patients diagnosed with a rectal polyp underwent polyp excision. One patient with rectal prolapse who was unresponsive to medical treatment underwent laparoscopic posterior rectopexy, and all other patients received medical treatment. Conclusion When a swelling or protruding anal lesion in a child is discovered by parents and visual inspection of the anal region and digital rectal examination is normal, parents should be encouraged to take photos or videos of the anal region before performing air contrast enema and/or sigmoidoscopy. These photos and videos can provide a definitive diagnosis and prevent unnecessary diagnostic procedures.

Topically applied 0.2% glyceryl trinitrate ointment to the anal region, incision and excision were compared in the treatment of perianal thrombosis, in order to establish which method is the best in terms of pain relief, number of recurrences and the appearance of anal skin tags.A total of 150 patients were randomly divided into three groups of 50, each group being treated by one of the above-mentioned methods. The results of the treatment were evaluated during the first 4 days, after one month and after one year.A statistically significant reduction of pain was achieved by excision if compared with incision or conservative treatment with glyceryl trinitrate (p0.001), and by conservative treatment with glyceryl trinitrate if compared with incision (p0.01 on the 4th day of follow-up. Comparison of patients treated by the three different methods did not reveal any significant difference between these methods after one month (p0.05). After one year the number of recurrences was significantly reduced after excision if compared with incision (p0.05) or conservative treatment with glyceryl trinitrate (p0.05). The number of patients without symptoms was significantly greater after excision if compared with incision or conservative treatment with glyceryl trinitrate (p0.001). The number of patients with anal skin tags was significantly reduced in patients treated by excision if compared with incision (p0.001) or glyceryl trinitrate treatment (p0.001).Excision is a significantly better method of treatment of perianal thrombosis than incision or topically applied 0.2% glyceryl trinitrate ointment.

Basal cell carcinoma of the anus is extremely rare, accounting for only 0.1% of anorectal malignancies. We report the reconstruction of the anus with a biaxial pedicled scrotal island myofasciocutaneous flap following excision of an anal basal cell carcinoma, and conclude that this technique may be valuable in the reconstruction of the anal region.

Summary Background Studies of the use of artificial urinary sphincters for faecal incontinence have led to refinement and adaptation of such sphincters to the anatomy of the anal region. We aimed to test this new device. Methods Six women, median age 53 (range 32–58) years, who were unsuitable for sphincter repair, had an artificial bowel sphincter implanted as a one-stage procedure without colostomy cover. Clinical assessment, physiological testing, and endosonography were done before and after the operation. Plain radiography, threedimensional endosonography, and magnetic-resonance imaging were done after the operation, to define its anatomical location. Results Median follow-up was 10 (range 5–13) months and the device was functional in five patients. In one patient, the device was removed after ulceration through the skin. Of the patients with intact devices, Wexner incontinence scores improved from a median of 19 (18–20) of 20 before the operation, to 3 (0–6) of 20 after the operation. Median anal pressure at rest significantly increased from 60 (range 30–80) cm H2O to 110 (100–120) cm H2O. Functional anal-canal length varied after the operation from 3·3 cm to 3·8 cm. There was no significant change in the maximum tolerated volume of the rectum (140 [80–230] vs 100 [75–250] mL), or rectal compliance (2·9 [2·8–6·0] cm H2O/mL vs 3·5 [2·3–7·3] cm H2O/mL). All the imaging techniques accurately located the implant relative to the anal canal and pelvic floor in each patient.

Summary Anal intra-epithelial neoplasia (AIN) is a pre-malignant condition, which over time may progress to invasive anal squamous cell carcinoma. There is no standard treatment for AIN, but one of the therapeutic options available is photodynamic therapy (PDT). There are very few published studies of the efficacy of PDT, but it has been shown to produce downgrading of high-grade dysplasia in the anal region. The aim of the study was to evaluate the role of PDT in the treatment of AIN. Fifteen patients who received anal PDT between 2004 and 2013 were identified; twelve of these had AIN, two had intra-epithelial adenocarcinoma and one had dysplasia with high-risk human papillomavirus. After a median follow-up of nineteen months, ten of these have had at least one follow-up with aceto-white staining. Six of these ten patients had a complete response to PDT, although three subsequently had some recurrence. Three further patients had a partial response to PDT. There were no major therapeutic complications. Our findings suggest that PDT is a safe and feasible treatment option for AIN, associated with reasonable response rates and relatively little morbidity. Further research into the efficacy of PDT for AIN is required.

This study was carried out in five full-term newborn babies and 11 patients with anorectal anomalies (five of whom had high deformity, five had intermediate, and one had low), using the modified Bielschowsky method. The following four kinds of sensory nerve ending were found: muscle spindle in the puborectalis and the external anal sphincter, Pacinian corpuscle in the plane between the internal anal sphincter and the external anal sphincter and in the presacral space, globular ending in the presacral space, and free nerve ending in the epithelium of the anal canal and in the perianal skin. It was found that there were significantly fewer muscle spindles in the puborectalis and many fewer Pacinian corpuscles and globular endings in the presacral space of high and intermediate deformities than normal. No spindle was found in the external sphincteric muscles of the deformities. On the other hand, the Pacinian corpuscles and the globular endings of high and intermediate deformities lagged behind normal in development. The densities of the nerve bundles in the subepidermis and the nerve fibers in the dermis of perineal region in high and intermediate deformities were much lower than normal, and the decrease in density corresponded to the levels of the rectal pouch. The observation showed that the agenesis of sensory nerve endings in the puborectalis and the anal region was one of the most significant pathological features in high and intermediate types of anorectal anomalies, and might be responsible for the abnormalities of the reflex of the anal sphincter and the anal sensation in such patients. The muscle spindles in the puborectalis may be only potential receptors for the reflex and sensation after surgery.

1. 1. Sixty-nine cases of epidermoid carcinoma of the anal region seen at Memorial Center between January, 1942, and December, 1952, have been reviewed. 2. 2. Forty of the sixty-nine patients did not present clinically recognizable groin metastases. Twenty-nine or 42 per cent did show metastases to this location. 3. 3. Sixteen of the twenty-nine patients had obvious groin metastases at the time of admission. Of the thirteen that appeared subsequently, eleven or 85 per cent appeared within the first two years of observation. 4. 4. The study of surgical specimens in this series tends to confirm two routes of spread from the anal region: (a) by the way of the perianal lymphatics or upper thigh directly to the superficial groin nodes, then to the iliac and obturator; (b) by way of the internal iliac or obturator nodes and then possibly to the superficial groin nodes. 5. 5. The route by which malignant celis are borne to the groins has little relation to the exact location of the primary lesion if the anal canal is involved, although the inferior route appeared more frequent in this group. 6. 6. Treatment of patients with groin metastases is not satisfactory as the three- and five-year survival rates are 16.0 and 12.5 per cent, respectively. However, it is not useless. 7. 7. Of seventeen patients in whom groin dissections were performed, nine died of their disease in less than three years, two died after five years, one died of other causes without evidence of disease and five are living free of disease two to six years. None of the patients having groin metastases present on admission is among those still alive. 8. 8. The presence of metastases to the deep pelvic nodes does not always mean a fatal outcome inasmuch as four of five patients who had obturator or iliac node metastases removed by radical groin dissection are living and free of evidence of their disease two to six years. 9. 9. If “prophylactic” groin dissections had been the practice in this series, fifty-three bilateral groin dissections would have been performed for the possible salvage of three patients who were not controlled by therapeutic groin dissection.

1.1. Bowen's disease of the anal region is a rare chronic and clinically varied type of intraepidermal tumor with infiltrating and metastatic potentia. Squamous cell cancer in situ is a more proper classification than precancerous dermatoses. 2.2. The diagnosis of a Bowen's epithelioma is made by histologic examination of the tissue. Serial section with careful examination of the entire tumor is required to eliminate the possibility of invasion. 3.3. Local excision offers a good prognosis because of the tendency of Bowen's epithelioma to remain intraepidermal for many years before penetrating the dermal layer.