Tailgut cyst - a case report

Retrorectal hamartoma, also called tailgut cyst, is a congenital lesion resulting from the non-regression of embryo remnants of the hindgut. We describe in this work the case report of a 68-year-old man, previously healthy, complaining of rectal bulging for 4 months, which was diagnosed by nuclear magnetic resonance imaging as a multi-loculated and mucinous lesion, suggestive of tailgut cyst. In view of the finding, the lesion was surgically resected, due to the potential for future complications, and, through the anatomopathological analysis, there were no findings of malignancy in the specimen. (AU)

Rectal ulcer due to Kayexalate deposition - an unusual case

SUMMARY Sodium polystyrene sulfonate (PSP) or Kayexalate is a cation-exchange resin, widely used in the management of hyperkalaemia due to renal disease. A rare, yet potentially dangerous, adverse event related to sodium polystyrene sulfonate use is intestinal mucosal injury, especially in the colon. The injury to the gastrointestinal mucosa can range from mild and superficial to wall necrosis and bowel perforation. The mechanism that leads to mucosal damage remains unclear. However, it is believed that sorbitol, commonly given to counteract PSP's tendency to cause constipation, may play an important role in the development of gastrointestinal injury. Other potential risk factors are uraemia or end-stage renal disease, hemodynamic instability, solid organ transplantation, postoperative status and concomitant opioid administration. The authors present a case of diarrhoea and haematochezia after the administration of PSP without sorbitol, in a patient with hyperkalaemia due to acute kidney injury, in the absence of other risk factors. A colonoscopy was performed and revealed a rectal ulcer which histological findings were suggestive of mucosal injury due to Kayexalate deposition. This case supports the concept that this widely used drug can itself, without sorbitol, cause injury to the gastrointestinal wall. Even though this is a rare adverse effect, the widespread use of this medication may put a large population at risk.

RESUMO O polistireno sulfonato de sódio (PSP) ou kayexalato é uma resina de troca iônica, amplamente usada no tratamento da hipercalemia associada à doença renal. Um efeito adverso raro, mas potencialmente grave, dessa terapêutica é a agressão à parede do trato gastrointestinal, principalmente ao nível do cólon, que pode ser ligeira e superficial ou culminar em necrose e perfuração intestinal. O mecanismo pelo qual o PSP lesa a mucosa intestinal não é totalmente conhecido. Contudo, pensa-se que o sorbitol, frequentemente administrado em simultâneo para contrabalançar o efeito obstipante do PSP, possa ter um papel preponderante no desenvolvimento de lesão gastrointestinal. Outros potenciais fatores de risco são a presença de uremia ou doença renal em estágio terminal, instabilidade hemodinâmica, pós-operatório, pós-transplante renal e a administração concomitante de opioides. Os autores descrevem um caso de diarreia e hematoquesias após a administração de PSP sem sorbitol, numa paciente com hipercalemia secundária a lesão renal aguda, sem outros fatores de risco para o desenvolvimento desse efeito adverso. A investigação etiológica com colonoscopia revelou a presença de uma úlcera retal, cujo estudo histológico foi compatível com lesão por deposição de cristais de kayexalato. Este relato incomum reforça o conceito de que este fármaco de uso frequente, mesmo na ausência de sorbitol, pode ser lesivo para a mucosa intestinal. Assim, e apesar de este ser um efeito adverso raro, a utilização difundida do PSP coloca uma vasta população em risco.

The importance of three-dimensional anorectal ultrasound in the study of patients with anal pain / A importância da ultra-sonografia anorretal tridimensional no estudo de pacientes portadores de dor anal

OBJECTIVES: Anal pain can be caused by various medical conditions; the exclusion of organic causes for proper treatment is important. Three-dimensional anorectal ultrasound can identify organic causes of anal pain. The objective of this study was to evaluate the importance of three-dimensional anorectal ultrasound in the detection of organic abnormalities in patients with anal pain. METHODS: Twenty-two patients (mean age: 49 years; 13 women) with chronic anal pain were enrolled to join a prospective study between June 2009 and June 2011. A complete proctology and colonoscopy examination was normal. Subsequently, the patients underwent three-dimensional anorectal ultrasound. RESULTS: Intersphincteric sepsis was found in 14 patients (63.6%). Two female patients (9.1%) had anal sphincter injury, one of them with the presence of a grade II rectocele. There was an increase in the thickness of the subepithelial tissue in three patients (13.6%). In one patient (4.6%), the presence of a hypoechoic circular retrorectal (presacral) cyst of the middle and lower rectum was observed. The three-dimensional anorectal ultrasound examination showed no abnormalities in two patients (9.1%). CONCLUSION: The three-dimensional anorectal ultrasound is a simple, economical, fast and useful test for the study of anorectal diseases and should be included in the examination of patients with anal pain, to exclude organic causes. (AU)

OBJETIVOS: A dor anal pode resultar várias condições clínicas e se faz necessário excluir causas orgânicas para o tratamento adequado. A ultra-sonografia anorretal tridimensional (3D-US) pode identificar causas orgânicas de dor anal. O objetivo deste estudo foi avaliar a importância da 3D-US para detectar anomalias orgânicas em pacientes com dor anal. MÉTODOS: Vinte e dois pacientes (média de idade: 49 anos; treze mulheres) com dor anal crônica foram incluídos em um estudo prospectivo entre junho de 2009 e junho de 2011. O exame proctológico completo e colonoscopia foram normais. Posteriormente, os pacientes foram submetidos à 3D-US. RESULTADOS: Sepse interesfincteriana foi evidenciada em quatorze pacientes (63,6%). Duas pacientes (9.1%) apresentaram lesão do esfíncter anal, sendo uma com presença de retocele grau II. O aumento da espessura do tecido subepitelial apresentou-se em três pacientes (13,6%). Em um paciente (4,6%), foi evidenciada a presença de cisto retrorretal circular hipoecoico no reto médio e inferior. O exame de US-3D não evidenciou anormalidades em dois indivíduos (9.1%). CONCLUSÃO: A ultra-sonografia anorretal tridimensional é um exame simples, econômico, rápido e útil no estudo de doenças anorretais e deve ser incluído no estudo dos pacientes com dor anal para descartar causas orgânicas. (AU)

Utilidad de la ecografía endo anal mediante el uso de videoecoendoscopio con transductor rotatorio de 360 / Usefulness of endo-anal ultrasound through the use of videoechoendoscope with 360 rotary transducer

Introducción: La aparición de la ecografía endoanal 360º significó un cambio importante en la Coloproctología de los últimos 20 años.1 Ha ganado popularidad por ser mínimamente invasivo, indoloro y costo/efectivo si se compara con otros estudios por imágenes. Además, es habitualmente realizada por un Coloproctólogo y puede formar parte del examen en la consulta. Objetivo: Comunicar la experiencia de nuestro grupo en el diagnóstico de diferentes patologías anorrectales mediante la utilización del método. Población y métodos: Entre noviembre de 2010 y abril de 2014 realizamos 978 ecografías endoanales de 360º. Las variables analizadas fueron: estudios realizados según diagnósticos de sospecha; variación en la cantidad de estudios solicitados y realizados durante el periodo establecido; especialidad del médico que solicita el estudio. Resultados: En cuanto al diagnóstico sospechado por el médico derivante, de los 978 estudios, 422 (43,1%) correspondieron a fístulas perianales, 311 (31,79%) ecografías fueron realizadas por diagnóstico de incontinencia anal, 93 (9,5%) como evaluación esfinteriana preoperatoria, 48 (4,9%) por proctalgia crónica, 7 (0,71%) fístulas ano-recto-vaginales, y 20 (2,04%) por otras sospechas diagnósticas (disinergias del piso pelviano, control postoperatorio, etc.). En cuanto a la variación de la cantidad de estudios en el tiempo, se realizaron 8 procedimientos en 2010, 146 durante 2011, 254 en 2012, 402 ecografías en 2013 y 168 durante los primeros meses de 2014. En cuanto a la especialidad acreditada por los médicos que prescribieron el estudio, el 84,1% (823) correspondía a cirujanos colorrectales, el 6,64% (65) a cirujanos generales, el 3,6% (36) a gastroenterólogos, el 2,4% (24) a ginecólogos y el 2,04% (20) a otros. Fueron excluidas del presente trabajo las ecografías realizadas para estadificar o reestadificar los tumores del recto inferior y el ano (22 estudios)...

Background: The appeareance of the 360º endoanal ultrasonography as a diagnostic method an improvement for coloproctology in the last 20 years.(1) It has been gaining popularity in virtue of being minimally invasive, painless and cost/effective, especially when compared to other methods. Furthermore, it is mainly realized by coloproctologists, making it almost part of the physical exam at the consult. Objective: To communicate our experience at the diagnostic of different anorectal pathologies. Population and methods: Between November 2010 and April 2014, we performed 978 studies with the 360º endoanal ultrasound. All of the studies were done with the same equipment and by the same operator. We analyzed the followings variables: Studies performed according to different initials diagnostics; variation in the number of studies requested and performed during the 4 years period; specialty of the primary physician who requested the study. Results: From 978 studies performed, 422 (43,1%) correspond to fistula in ano, 311 (31,79%) to anal incontinence, 93 (9,5%) were done for preoperative evaluation of the anal sphincter, 48 (4,9%) for chronic anal pain, 7 (0,71%) for recto vaginal fistula, and 20 (2,04%) for other presumed diagnostics (pelvic floor dyssynergia, post operatory control). As regards to the variation of the number of studies requested during this 4 years period we found that during 2010 we performed 8 procedures, 146 during 2011, 254 in 2012, 402 in 2013 and 168 during the firsts months of 2014. In relation to the specialty of the primary physician who requested the study, 84,1% (823) were solicited by coloproctologists, 6,64% (65) by general surgeons, 3,6% (36) by gastroenterologists, 2,4% (24) by gynecologists, and 2,04% (20) by other specialists. Studies performed for rectal and anal tumors staging (22 studies...

Subcutaneous Emphysema Mimicking Gas Gangrene Following Perforation of the Rectum: A Case Report

We report a case of extensive subcutaneous emphysema of the lower extremity mimicking gas gangrene following perforation of the rectum in a 38-yr-old man. Subcutaneous emphysema of the leg may rarely occur secondary to perforation of the gastrointestinal tract and has often created serious diagnostic problems and high mortality rates. Therefore, prompt diagnosis and aggressive treatment is imperative.

The Efficacy of Metallic Stent Placement in the Treatment of Colorectal Obstruction

DBJECTIVE: To evaluate the efficacy of newly designed covered and non-covered coated colorectal stents for colonic decompression. MATERIALS AND METHODS: Twenty-six patients, (15 palliative cases and 11 preoperative) underwent treatment for the relief of colorectal obstruction using metallic stents positioned under fluoroscopic guidance. In 24 of the 26, primary colorectal carcinoma was diagnosed, and in the remaining two, recurrent colorectal carcinoma. Twenty-one patients were randomly selected to receive either a type A or type B stent; for the remaining five, type C was used. Type A, an uncovered nitinol wire stent, was lightly coated to ensure structural integrity. Type B (flare type) and C (shoulder type) stents were polyurethane covered and their diameter was 24 and 26mm, respectively. The rates of technical success, clinical success, and complications were analyzed using the chi-square test, and to analyse the mean period of patency, the Kaplan-Meier method was used. RESULTS: Thirty of 31 attempted placements in 26 patients were successful, with a technical success rate of 96.8% (30/31) and a clinical success rate of 80.0% (24/30). After clinically successful stent placement, bowel decompression occurred within 1-4 (mean, 1.58+/-0.9) days. Five of six clinical failures involved stent migration and one stent did not expand after successful placement. In the preoperative group, 11 stents, one of which migrated, were placed in ten patients, in all of whom bowel preparation was successful. In the palliative group, 19 stents were placed in 15 patients. The mean period of patency was 96.25+/-105.12 days: 146.25+/-112.93 for type-A, 78.82+/-112.26 for type-B, and 94.25+/-84.21 for type-C. Complications associated with this procedure were migration (n=6, 20%), pain (n=4, 13.3%), minor bleeding (n=5, 16.7%), incomplete expansion (n=1, 3.3%), and tumor ingrowth (n=1, 3.3%). The migration rate was significantly higher in the type-B group than in other groups (p=0.038). CONCLUSION: Newly designed covered and non-covered metallic stents of a larger diameter are effective for the treatment of colorectal obstruction. The migration rate of covered stents with flaring is higher than that of other types. For evaluation of the ideal stent configuration for the relief of colorectal obstruction, a clinical study involving a larger patient group is warranted.