Neurolytic Caudal Epidural Block for Rectal Tenesmus: A Case Report

Rectal tenesmus is a very uncomfortable symptom. Though antiarrhythmic drugs and nerve blocks have been proposed as a treatment for rectal tenesmus, none is well-established. We report a 68-year-old female who undertook surgery for uterine cervical cancer and underwent chemotherapy. She got a bilateral nephrostomy and bowel obstruction during the chemotherapy because of recurrence. She decided to stop chemotherapy and to receive palliative care. She had a symptom of rectal tenesmus, which was refractory to medications. The clinical sign was severe and uncomfortable, making her very nervous. We planned to treat the rectal tenesmus with a nerve block. A ganglion impar block was insufficient to remove the symptom, and the saddle block failed due to epidural lipomatosis. We finally succeeded in alleviating the sign with a neurolytic caudal epidural block. Relief of tenesmus made her hope to spend her final period at home. She could stay at home with her family for seven days before death without recurrence of the symptom. Though there is no report about the effectiveness of neurolytic caudal epidural block for rectal tenesmus, we consider the block appropriate for the symptom.

Lipoma isquiorrectal gigante como causa de dolor anal, incontinencia fecal y dispareunia. Una asociación excepcional / Giant ischiorectal lipoma as a cause of anal pain, fecal incontinence and dyspareunia. An exceptional association

RESUMEN Los lipomas suponen el 50% de los tumores de partes blandas. Podrían comprimir estructuras adyacen tes. Presentamos el caso de una mujer de 49 años con dolor anal intenso asociado a urgencia defecatoria, tenesmo, incontinencia y dispareunia. Presentaba tumoración blanda a nivel del glúteo derecho compa tible con lipoma. La resonancia magnética identificó una masa de 15,7 × 9 × 6 cm, de apariencia encap sulada, que se extendía por la fosa isquioanal e isquiorrectal con impronta sobre el músculo elevador del ano, desplazando el recto. Se efectuó exéresis en bloque, con alta en 48 horas sin complicaciones. El informe de Anatomía Patológica definitivo fue lipoma. Valoramos la asociación de lipoma e incontinencia fecal con una búsqueda en PubMed. Se obtuvieron 87 artículos de los cuales ninguno respondía al objeto del estudio. Esta sintomatología es un fenómeno excepcional en la literatura, que se diagnostica funda mentalmente mediante RM y ecoendoscopia. Gran resultado funcional tras la exéresis.

ABSTRACT Lipomas account for 50% of soft-tissue tumors and may compress adjacent structures. We report the case of a 49-year-old female patient with intense anal pain associated with defecation urgency, tenesmus, incontinence and dyspareunia. A soft tumor was present in the right buttock suggestive of lipoma. On magnetic resonance imaging an apparently encapsulated mass with a size of 15.7 × 9 × 6 cm was identified extending through the ischioanal fossa and ischiorectal fossa, displacing the levator ani muscle and rectum. The lesion was excised en bloc and the patient was discharged 48 hours later without complications. The pathology report concluded that the lesion corresponded to a lipoma. We performed a bibliographic search in PubMed to assess the association between lipoma and fecal incontinence; Of the 87 articles retrieved, none of them responded to the subject of the study. These symptoms are exceptional in the literature. The diagnosis is made mainly with magnetic resonance imaging and endoscopic ultrasound. An excellent functional outcome was achieved with surgical excision.

Meckel’s diverticulum: Clinical manifestations and complications

Background: Meckel’s diverticulum (MD), a congenital anomaly of the gastrointestinal tract due to failed vitelline duct obliteration, affects 2% of population. It is a true diverticulum located along the antimesenteric border of distal ileum within 100 cm of the ileocecal valve. It contains heterotropic mucosa, 60% of which is gastric mucosa followed by pancreatic acini, colonic mucosa, etc. The key surgical principle is to completely remove symptomatic ectopic tissue. Objectives: The objectives of the study were to investigate clinical features and common complications of MD in different ages and genders that serve as a reminder to clinicians evaluating potential cases and help them giving proper management. Materials and Methods: A combined prospective and retrospective study of 30 patients operated for MD found incidentally on operative table or planned electively was done. Results: In our study, there was a clear male predominance with 21 cases (70%). It was more common in young and middle age (11–40 years) with 26 cases (86%). Common symptomatic presentations were obstruction (30%), perforation (13%), and diverticulitis (10%). The cases were surgically managed according to the size of base and length of the diverticulum. Post-operative complications were commonly seen in older age and symptomatic patients. Conclusion: MD is having low incidence, overlapping signs and symptoms of other conditions and higher post-operative complications. Hence, it is quite important to include it in differential diagnosis, diagnose it early and apply prompt surgical management.

A 9-year-old Cancer Patient with Rectal Irritative Symptoms Relieved by Yokukansan: A Case Report

Rectal irritative symptoms in cancer patients are often refractory to treat and exacerbate their quality of life. We experienced a peadiatric case of rectal irritative symptoms treated by Yokukansan. A 9 year-old boy developed rectal irritative symptoms as itching sensation in rectum caused by relapsed rhabdomyosarcoma in pelvis. Oral Yokukansan, which is common Japanese Kampo medicine for temper tantrum of children, was administered and relieved his symptoms. Yokukansan is known as adjuvant drug for neuropathic pain. It could be one of the adjuvant drugs for refractory symptoms in palliative care setting.

Efficacy and safety of a polyherbal formulation in hemorrhoids.

Background: The medical management of hemorrhoids should include an integrated approach. This integrated approach can be achieved by polyherbal formulations containing anti-inflammatory, styptics, analgesics, and laxative effect which reduce inflammation, pain, and bleeding, and increase gastro-intestinal motility and soften stools. One such polyherbal kit is “Arshkeyt™, a 7 day kit,” which consists of oral tablets and powder along with topical cream. Objective: Efficacy and safety of Arshkeyt™, a 7 day kit, a marketed polyherbal formulation was evaluated in comparison with conventional therapy practiced in surgery outpatient departments. Materials and Methods: Patients (n = 90) with hemorrhoids were randomly allocated to receive either Arshkeyt™ or standard therapy (combination of oral Isabgul powder and 2% lidocaine gel) for 14 days. Assessment on the basis of rectal symptoms and proctoscopic examination was done on day 0, 7, and 14 to derive a “composite score” which ranged from 0 to 25 by a blinded evaluator. The primary endpoint was number of patients achieving composite score 0 at the end of therapy (day 14). Inter-group analysis was done using Chi-square test. Results: On day 14, the composite score of 0 was achieved in 15 patients of Arshkeyt™ group versus 6 patients receiving standard therapy. The symptoms and signs which showed significant improvement in Arshkeyt™ group compared to standard treatment group were the tenesmus (visual analog score) score (P = 0.047), anal sphincter spasm (P = 0.0495) and a decrease in the grade of hemorrhoids (P = 0.0205) on day 14. Arshkeyt™ was also more beneficial in case of bleeding hemorrhoids as compared to nonbleeding hemorrhoids (P < 0.05). The incidence of adverse drug reactions in both groups was comparable and no patient required any treatment for the same. Conclusion: “Arshkeyt™, a 7 day kit,” was effective in the treatment of hemorrhoids and had a good safety profile.

Successful management of rectal tenesmus with oral amoxapine and infusional lidocaine in a terminally ill cancer patient：a case report and literature review

Background: Although rectal tenesmus in patients with advanced cancer can have marked negative impact on quality of life, effective treatment has not yet been established. Case: A 71 -year-old man with an inoperable rectal cancer developed tenesmus 11 months after a colostomy. Tenesmus worsened over the following 3 months, and the patient suffered from involuntary straining every 5-15 minutes. After unsuccessful symptom control with radiotherapy to the primary lesion, we started oral amoxapine 25 mg that alleviated symptoms related to tenesmus. As the general condition deteriorated, however, oral intake became difficult. After the discontinuation of amoxapine, the tenesmus recurred even though intravenous administration of clomipramine was initiated. We started continuous infusion of intravenous lidocaine 200 mg/day which successfully relieved tenesmus. The dose of lidocaine was subsequently increased to 290 mg/day for worsening symptoms, which continued to control his distress caused by tenesmus until he died. Consideration/Conclusion: This is the first report that demonstrates the efficacy of oral amoxapine for rectal tenesmus with malignant tumor. After the discontinuation of amoxapine due to the inability of taking medications orally, symptoms remained under adequate control with infusional lidocaine until the patient died. Further studies are warranted to confirm our findings and to propose optimal use of medications in the management of rectal tenesmus.