We wish to point out the relation ship between anal fissure and treatment with isotretinoin derived from vitamin A, which is used in dermatiological practice for the treatment of acne. We recently were made aware of a 15-year old female referred to the dermatology clinic with nodulocystic acne. Her laboratory work up was normal and she had no previous medical history. Treatment with isotretinoin was started 40 mg twice daily. After two months, the patient was referred to a general surgery outpatient clinic with rectal bleeding and anal pain. This article is protected by copyright. All rights reserved.

Many patients present to emergency departments with anorectal problems, such as haemorrhoids, anal fissure and pruritis ani. Often, patients with such problems are embarrassed about them or fearful about their potential diagnoses, so practitioners must approach history taking and examination sensitively. They should also have a good understanding of the anatomy of the anorectal area, and be able to recognise the signs and symptoms of relevant conditions. This article provides an overview of the anatomy and physiology of the anorectal area, explains how to undertake anorectal examinations, and describes the signs and symptoms of some common conditions.

Interpreting the significance of anal findings in child sexual abuse can be difficult. The aim of this study is to compare the frequency of anal features between children with and without anal penetration. This is a retrospective blinded review of consecutive charts of children seen for suspected sexual abuse at a regional referral center from January 1. 2005 to December 31. 2009 Based on predetermined criteria, children were classified into two groups: low or high probability of anal penetration. The charts of 1115 children were included, 84% girls and 16% boys with an age range from 0.17 to 18.83 years (mean 9.20 year). 198 children (17.8%) were classified as belonging to the anal penetration group. Bivariate analysis showed a significant positive association between the following features and anal penetration: Anal soiling (p=0.046), fissure (p=0.000), laceration (p=0.000) and total anal dilatation (p=0.000). Logistic regression analysis and stratification analysis confirmed a positive association of soiling, anal lacerations and anal fissures with anal penetration. Total anal dilation was significantly correlated with a history of anal penetration in girls, in children examined in the prone knee chest position and in children without anal symptoms. Several variables were found to be significantly associated with anal penetration, including the controversial finding of total anal dilatation. Due to limitations in the study design, this finding should still be interpreted with caution in the absence of a clear disclosure from the child.

The present article aimed to review some important aspects regarding the work and life of the legendary English surgeon William Ernest Miles. His masterwork began at the beginning of the 20th century, when he devised the first radical procedure that aimed to control rectal cancer, after analyzing the poor outcomes of perineal resections for the disease. The famous 1908 publication, focusing on the technique and early results of abdominoperineal excision influenced numerous surgeons for decades, at a time when most rectal tumors were managed through rectal amputation, regardless of their location. Miles was recognized as a brilliant, fast, and skilled surgeon, and his fame attracted many surgeons to watch him at work in London at that time. He was also recognized as a gentle and kind man who became a trusted leader in coloproctology. In this context, he also made various contributions in the field of anorectal diseases, such as hemorrhoids, anal fistula, anal fissure, and rectal procidentia. Thus, he deserves the honors as the pioneer in the elaboration and refinement of a surgical technique that allowed a significant decrease in tumor recurrence and mortality. Furthermore, the Miles operation shifted the perspectives of rectal cancer, and for that his name will always be regarded as one of the giants in the history of colorectal surgery.

Sphincterotomy is used to treat chronic anal fissure, but the length of the sphincterotomy is associated with incontinence.We used 3-dimensional anal ultrasonography to determine the proportion of the internal anal sphincter that may be divided during lateral internal sphincterotomy in women without predisposing them to a high risk of fecal incontinence.This was a prospective, observational cohort study conducted at a tertiary-care hospital.Women treated for chronic anal fissure with high anal resting pressure and no symptoms of fecal incontinence were selected. Asymptomatic women recruited from different departments of the same hospital served as controls to provide reference values for anal canal measurements.Patients underwent a standardized technique of lateral internal sphincterotomy.Three-dimensional ultrasonography was used to measure sphincter lengths. Continence was assessed with the Cleveland Clinic Florida (Wexner) score. The relationship between the extent of the surgically divided portion of the internal anal sphincter and the continence score was evaluated.Successful healing was achieved in all patients within 2 months. Follow-up continence scores were significantly correlated with the extent of sphincter division. The proportion of patients with a continence score of 0 was significantly greater in patients in whom sphincter division was less than 25% in comparison with patients with a division of 25% or more. Anal canal and sphincter lengths in patients after sphincterotomy did not significantly differ from those in asymptomatic women.The study is limited by its nonrandomized nature and the lack of preoperative ultrasound assessment.Based on data from this study, the safe extent of division is less than 25% of the total sphincter length, which in women corresponds to less than 1 cm.

INTRODUCTION:

Anal fissures can be resistant to treatment and some patients may undergo several trials of medical therapy before definitive surgery.. It would be useful to identify predictors of poor response to medical therapy.. This study assesses the role of anorectal physiological criteria to identify patients with anal fissure predicted to fail Botulinum toxin (BT) treatment

METHOD:

A retrospective analysis of anorectal physiological data collected for patients with resistant chronic anal fissures referred to one consultant surgeon between 2007-2011 was undertaken. These were correlated with treatment plans and healing rates.

RESULTS:

Twenty-five patients with idiopathic chronic anal fissures underwent anorectal physiology studies and were subsequently treated with BT injection. Eleven had a characteristic high-frequency low-amplitude 'saw tooth' waveform or Anal Sphincter Fibrillation (ASF) and higher anal sphincter pressures. Nine of these patients (82%) had resolution of their anal fissure symptoms following treatment with BT. Of 14 patients with no evidence of ASF and a greater range of anal sphincter pressures, only 1 (7%) had resolution following BT..

CONCLUSION:

ASF appears to be an anorectal physiological criterion that helps predict response of anal fissures to BT injection. This could help streamline fissure management. © 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland.

The principle to avoid surgery for haemorrhoids and/or anal fissure in Crohn's disease (CD) patients is still currently valid despite advances in medical and surgical treatments. In this study we report our prospectively recorded data on medical and surgical treatment of haemorrhoids and anal fissures in CD patients over a period of 8 years.Clinical data of patients affected by perianal disease were routinely and prospectively inserted in a database between October 2003 and October 2011 at the Department of Surgery, Tor Vergata University Hospital, Rome. We reviewed and divided in two groups records on CD patients treated either medically or surgically according to the diagnosis of haemorrhoids or anal fissures. Moreover, we compared in each group the outcome in patients with prior diagnosis of CD and in patients diagnosed with CD only after perianal main treatment.Eighty-six CD patients were included in the study; 45 were treated for haemorrhoids and 41 presented with anal fissure. Conservative approach was initially adopted for all patients; in case of medical treatment failure, the presence of stable intestinal disease made them eligible for surgery. Fifteen patients underwent haemorrhoidectomy (open 11; closed 3; stapled 1), and two rubber band ligation. Fourteen patients required surgery for anal fissure (Botox ± fissurectomy 8; LIS 6). In both groups we observed high complication rate, 41.2% for haemorrhoids and 57.1% for anal fissure. Patients who underwent haemorrhoidectomy without certain diagnosis of CD had significantly higher risk of complications.Conservative treatment of proctologic diseases in CD patients has been advocated given the high risk of complications and the evidence that spontaneous healing may also occur. From these preliminary results a role of surgery is conceivable in high selected patients, but definitve conclusions can't be made. Further randomized trials are needed to establish the efficacy of the surgical approach, giving therapeutic recommendations and guidelines.

To assess the physical and mental health of fissure patients before and after topical treatment with diltiazem.Consecutive patients were enrolled prospectively into the study. Quality of life was measured with the short-forum 36 health survey (SF-36) before and after 6-wk treatment with diltiazem. Patients scored symptoms of pain, bleeding, and irritation using numeral rating scales at the initial and follow-up visits. Fissure healing was assessed and side effects were noted.Fissures healed in 21 of 30 (70%) patients. There were significant reductions in the scores of pain, bleeding, and irritation after 1 wk of treatment, respectively. Four patients experienced perianal itching and one patient reported headache. When measured at baseline, pain and irritation showed a negative impact on two of the eight subscales on the SF-36, respectively (bodily pain and social functioning for pain; vitality and mental health for irritation). Repeating the SF-36 showed an improvement in bodily pain (P = 0.001). Patients whose fissures healed reported an improvement in bodily pain, health-perception, vitality, and mental health (P < 0.05).Successful treatment of chronic anal fissure with topical diltiazem leads to improvement in health-related quality of life.

BACKGROUND:

Previous laboratory studies have shown that angiotensin II is produced locally in the rat internal anal sphincter causing potent contraction. The aim of this first human study was to evaluate the safety and manometric effects of topical application of captopril (an ACE inhibitor) on the resting anal pressure in healthy adult volunteers.

METHODS:

Ten volunteers, mean age 32.5 years (range, 19-48 years), underwent anorectal manometric evaluation of the mean anal resting pressure (MRAP) and the length of the high-pressure zone (HPZ) before 20 and 60 min after topical application of captopril (0.28 %) cream. Cardiovascular variables (systolic blood pressure, diastolic blood pressure and pulse) were measured before and for up to 1 h after cream application. Side effects were recorded. Adverse events and patient comfort after the cream application were evaluated within a 24-h period by completing a questionnaire.

RESULTS:

There was no significant change overall in MRAP following captopril administration, although in half the patients, there were reductions in MRAP after treatment. Half the patients had a reduction in the mean resting HPZ length; however, there was no overall difference between pre- and post-treatment values. There was no effect on basic cardiovascular parameters and no correlation between manometric and cardiovascular variables.

CONCLUSIONS:

Topical application of captopril cream may result in a reduction in MRAP in volunteers without anorectal disease. Its use is associated with minimal side effects. It may be a new potential therapeutic option in the treatment of anal fissure. Further studies are required to determine the optimal concentration, dose and frequency of application.