Complicaciones perianales causadas por agentes modeladores inyectados en glúteos / Perianal complications caused by gluteal injection of modeling agents

En este reporte presentamos tres pacientes en quienes ocurrieron condiciones inflamatorias perianales tardías, luego de la administración de sustancias modeladoras no identificadas en los glúteos. El diagnóstico inicial y supuesto no fue correcto, ya que no se investigó durante la evaluación preliminar el antecedente de la administración de elementos modeladores. Recomendamos que los pacientes con patologías inflamatorias del ano, sobre todo aquellos cuyo curso es extraño, se les pregunte acerca de la administración de agentes modeladores en los glúteos. Esta práctica puede contribuir a la eficacia del diagnóstico de manifestaciones perianales caracterizadas por flogosis, que se presentan de forma inusual. (AU)

In this report we present three patients in which late perianal inflammatory conditions occurred after administration of unidentified modeling agents to the buttocks. The initial diagnosis was not correct because of the administration of modeling agents was not investigated during the initial eval-uation. We recommend inquiring patients with inflammatory pathologies of the anus, especially those whose course is unusual, about the adminis-tration of modeling agents to the buttocks. This approach can contribute to the efficiency of the diagnosis of perianal complaints characterized by inflammation, but rare in its appearance. (AU)

Identification and reporting of anal pathology during routine colonoscopies

The gold-standard procedure for anal canal examination is anoscopy. Nonetheless, patients are referred for a colonoscopy for many reasons, and a routine exam might provide an opportunity to diagnose anal pathologies, such as hemorrhoids, anal fissures, anal polyps, condylomas, and anal squamous cell carcinoma. It is important to know the main features of these conditions and relevant information to report in order to help guide patient treatment and follow-up.

Anal mycobacterial infections / Infecções micobacterianas do ânus

Abstract Background Mycobacterial infections are a serious public health problem worldwide. Involvement of the anal canal and perineum is very rare, but constitute an important differential diagnosis with other equally serious pathologies that may affect the region, such as malignant neoplasms and Crohn's disease. Objectives To conduct a literature review on mycobacterial infections of the perianal region considering the most recent information for diagnostic and therapeutic guidance of this disease. Methods Research was performed on the PUBMED and LILACS databases with the expressions Mycobacterium, Anal, Infection and Tuberculosis. We reviewed articles referring to series of treated cases, clinical reports and literature review published since 2005. Results Information was compiled on the epidemiology of mycobacterial infections; the clinical behavior of affected individuals; diagnostic options and their validity in clinical practice; and, finally, therapeutic options. Conclusions Mycobacterial infections of the anus and perineum are rare. The most common clinical presentations are the presence of ulceration and fistulization. The diagnosis involves more than one procedure for identifying the bacilli and should consider the presence of manifestations in more than one organ. The treatment is based on pharmacological intervention. Surgery is recommended for acute complications or chronic sequelae of the disease.

Resumo Introdução Infecções micobacterianas constituem um grave problema de saúde pública a nível mundial. As manifestações anoperineais são raras, mas constituem um importante diagnóstico diferencial com outras patologias igualmente graves que podem acometer a região, como as neoplasias malignas e a doença de Crohn. Objetivos Realizar um levantamento da literatura sobre infecções micobacterianas da região anoperineal, considerando as informações mais atuais para orientação diagnóstica e terapêutica dessa enfermidade. Métodos Foi realizada pesquisa nos bancos de dados PUBMED e LILACS com as expressões Mycobacterium, Anal, Infection e Tuberculosis. Foram revisados artigos referentes a séries de casos tratados, relatos clínicos e revisão da literatura publicada a partir de 2005. Resultados Foram compiladas informações sobre a epidemiologia das infecções micobacterianas; o comportamento clínico dos indivíduos afetados; opções diagnósticas e sua validade na prática clínica; e, por fim, opções terapêuticas. Conclusões Infecções micobacterianas da região anoperineal são raras. As apresentações clínicas mais comuns são a formação de ulceras e a fistulização. O diagnóstico envolve mais de um procedimento para identificação dos bacilos, e deve considerar a presença de manifestações em mais de um órgão. O tratamento é principalmente medicamentoso, sendo a cirurgia recomendada nas complicações agudas ou sequelas crônicas da doença.

Afecciones perianales no infecciosas, no neoplásicas, del adulto / Noninfectious, non-neoplasic adult perianal affections

Las enfermedades perianales del adulto, de carácter no infeccioso y no neoplásico, son un motivo de consulta poco frecuente. Se caracterizan por la variedad de su etiología y de su sintomatología clínica, y plantean dificultad en el diagnóstico y en la terapéutica. El objetivo del presente trabajo es abordar una patología que plantea la necesidad de una intervención interdisciplinaria. Se incluyen consideraciones anatomopatológicas, clínicas y terapéuticas. (AU)

Noninfectious, non- neoplasic perianal affections are uncommon diseases. They are characterized by the variety of the etiology and clinical symptomatology, posing difficulty in diagnosis and therapeutics. The objective of this paper is to address a pathology that raises the need for interdisciplinary intervention anatomopathological, clinical and therapeutic considerations are included. (AU)

Tuberculosis anal como diagnóstico diferencial de lesión ulcerada anal / Anal tuberculosis as a differential diagnosis of ulcerated anal lesion

La tuberculosis (TBC) es una enfermedad infecciosa crónica, granulomatosa, transmisible, producida por el microorganismo Mycobacterium tuberculosis o bacilo de Koch. Puede presentarse como enfermedad pulmonar, extrapulmonar o ambas. La presentación extrapulmonar, es rara, representando aproximadamente el 11% de todos los casos. El objetivo del presente trabajo es comunicar un caso clínico de tuberculosis de localización extrapulmonarr infrecuente: la región perianal. (AU)

Tuberculosis (TB) is a chronic infectious, granulomatous, transmissible disease produced by the Mycobacterium tuberculosis microorganism or Koch's bacillus.It can present as lung disease, extrapulmonary disease or both.Extrapulmonary presentation is rare, representing approximately 11% of all cases. The objective of the present work is to report a clinical case of tuberculosis of uncommon extrapulmonary location: the perianal region. (AU)

Anogenital warts in pediatric population

Abstract: The approach to children with anogenital warts in the context of sexual abuse is a challenge in clinical practice. This study aims to review the current knowledge of anogenital warts in children, the forms of transmission, and the association with sexual abuse and to propose a cross-sectional approach involving all medical specialties. A systematic review of the literature was conducted in Portuguese and English from January 2000 to June 2016 using the ISI Web of Knowledge and PubMed databases. Children aged 12 years or younger were included. The ethical and legal aspects were consulted in the Declaration and Convention on the Rights of Children and in the World Health Organization. Non-sexual and sexual transmission events of human papillomavirus in children have been well documented. The possibility of sexual transmission appears to be greater in children older than 4 years. In the case of anogenital warts in children younger than 4 years of age, the possibility of non-sexual transmission should be strongly considered in the absence of another sexually transmitted infection, clinical indicators, or history of sexual abuse. The importance of human papillomavirus genotyping in the evaluation of sexual abuse is controversial. A detailed medical history and physical examination of both the child and caregivers are critical during the course of the investigation. The likelihood of an association between human papillomavirus infection and sexual abuse increases directly with age. A multidisciplinary clinical approach improves the ability to identify sexual abuse in children with anogenital warts.

Detección temprana de la displasia anal con citología (PAP) y anoscopía de alta resolución (AAR) en la población de riesgo: experiencia inicial / Early detection of anal dysplasia with cytology (PAP) and high resolution anoscopy (AAR) in the population at risk: initial experience

Antecedentes: La incidencia del carcinoma de células escamosas anal (CCE) aumentó drásticamente, es de 35/100.000 habitantes en los hombres que tienen sexo con hombres (HSH), similar a la del cáncer del cuello uterino antes del Papanicolaou (PAP). En forma análoga a la pesquisa del cáncer cervical, el PAP anal y la anoscopía de alta resolución (AAR), se utilizan para la detección temprana de las lesiones precursoras del CCE. Objetivo: Evaluar los hallazgos de la citología anal y la AAR en una población de alto riesgo para desarrollar displasia y CCE. Diseño: Observacional, descriptivo, transversal, prospectivo. Población: Pacientes de alto riesgo (individuos HIV positivos, hombres que tienen sexo con hombres (HSH), mujeres con antecedentes de cáncer o displasia del tracto genital inferior, individuos con antecedentes de HPV anal o genital) que concurrieron al Consultorio de Detección Temprana de la Displasia Anal, entre 1 abril y 30 junio 2012. Método: Tacto rectal, anoscopía convencional, PAP anal y AAR, con biopsia dirigida de lesiones sospechosas. Comparación de la citología con la histología...

Background: The incidence of anal squamous cell carcinoma (SCC) has increased dramatically, with an incidence of 35/100.000 inhabitants in men who have sex with men (MSM), similar to that of cervical cancer before the Papanicolaou (PAP). In analogy form to screening of cervical cancer, anal PAP and high resolution anoscopy (HRA) are used for early detection of SSC precursor lesions. Objective: To assess the findings of anal cytology and HRA in a high risk population for developing dysplasia and SCC. Design: Cross-sectional, descriptive, prospective, study. Population: High-risk patients (HIV- positive individuals, men who have sex with men, women with previous cancer or dysplasia of the lower genital tract, individuals with previous anal or genital condylomata) who attended the Anal Dysplasia Early Detection Clinic between April 1-June 30, 2012, were included. Methods: Digital rectal examination, conventional anoscopy, anal PAP and HRA, with biopsies of suspected areas was performed...

Endometriosis anal. A propósito de dos casos / Anal endometriosis. About two cases

Introducción: la endometriosis se define como la presencia de tejido endometrial fuera de la cavidad uterina. Pacientes y método: dos pacientes de entre 30 y 40 años que consultan por tumoracion perianal de aparicion ciclica asociada a dolor en dicha zona. Como método de estudio se realizó, en ambos casos, ecografía endorrectal de 360º, evidenciando imagen hipoecoica en región anterolateral derecha en contacto con el esfínter anal externo. Se realizó la resección completa de la masa, de la cicatriz de la episiotomía y de haces del esfinter anal externo, con plicatura simultánea del mismo. La anatomía patológica confirmó el diagnóstico. Se realizó seguimiento de las pacientes por el plazo de 15 y 84 meses. No se evidenciaron complicaciones postoperatorias o recidiva de la tumoración en ninguno de los casos. Discusión: la localización perianal es altamente infrecuente (0,3%) y mas aún el compromiso esfinteriano (0.18%). Suelen aparecer luego de la episiotomi´a o laceracio´n durante el parto. La ecografía 360º permite evaluar la extensión de la lesión y el compromiso de los esfínteres. La resección amplia del endometrioma con márgenes de tejido normal (entre 0,5 – 1 cm) es la mejor opción para la curación de la enfermedad, aunque puede causar incontinencia por resección del esfinter afectado, pudiendo necesitar la realización de una esfinteroplastía. Conclusión: la endometriosis de localización perianal es un padecimiento poco frencuente y de dificil diagnóstico. El tratamiento de elección es el quirúrgico. Incluyendo la masa completa con márgenes libres y la cicatriz de la episiotomía.

Background: endometriosis is defined as the presence of endometrial tissue outside of the uterine cavity. Patients and method: two patients between 30 and 40 years old consulting for perianal lump of cyclic emergence associated with pain in that area. The study method for both cases was a 360º transrectal ultrasound, showing an hypoecogenic image in then anterolateral region, in contact with the external anal sphincter. A complete resection of the mass, the episiotomy scar and beams of the external anal sphincter was performed, with simultaneous plication. Anatomopathological examination confirmed the diagnosis. The follow-up periods were 15 and 84 months. There were no apparent postop complications or recurrence of the tumor in any of the cases. Discussion: the perianal localization is highly uncommon (0.3%) and even more, the sphincter involvement (0.18%). They usually appear after episiotomy or laceration during delivery. 360 ultrasound allows to evaluate the extent of the injury and the commitment of the sphincters. Wide resection of the endometrioma with normal tissue margins (between 0.5 - 1 cm) is the best choice for the cure of the disease, although it can cause incontinence by resection of the affected sphincter and may need a sphincteroplasty. Conclusion: perianal location endometriosis is a non-frequent condition with a difficult diagnosis. The treatment of choice is surgery. Including the full mass, with free margins and episiotomy scar.

Rectal hyposensitivity and functional anorectal outlet obstruction are common entities in patients with functional constipation but are not significantly associated

BACKGROUND/AIMS: The causes of functional anorectal outlet obstruction (outlet obstruction) include functional defecation disorder (FDD), rectocele, and rectal intussusception (RI). It is unclear whether outlet obstruction is associated with rectal hyposensitivity (RH) in patients with functional constipation (FC). The aim of this study was to determine the association between RH and outlet obstruction in patients with FC. METHODS: This was a retrospective study using a prospectively collected constipation database, and the population comprised 107 patients with FC (100 females; median age, 49 years). We performed anorectal manometry, defecography, rectal barostat, and at least two tests (balloon expulsion test, electromyography, or colon transit time study). RH was defined as one or more sensory threshold pressures raised beyond the normal range on rectal barostat. We investigated the association between the presence of RH and an outlet obstruction such as large rectocele (> 2 cm in size), RI, or FDD. RESULTS: Forty patients (37.4%) had RH. No significant difference was observed in RH between patients with small and large rectoceles (22 [44.9%] vs. 18 [31%], respectively; p = 0.140). No significant difference was observed in RH between the non-RI and RI groups (36 [36.7%] vs. 4 [30.8%], respectively; p = 0.599). Furthermore, no significant difference in RH was observed between the non-FDD and FDD groups (19 [35.8%] vs. 21 [38.9%], respectively; p = 0.745). CONCLUSIONS: RH and outlet obstruction are common entities but appear not to be significantly associated.

Verrugas anogenitales y sospecha de abuso sexual infantojuvenil / Anogenital warts and suspicion of child sexual abuse

El presente trabajo se refiere a las lesiones por verrugas anogenitales producidas por el virus de papiloma humano (HPV) en niños. Describe el diagnóstico, la epidemiología, los modos de transmisión, los diagnósticos diferenciales y su relación con el cáncer a largo plazo; también, la presencia de verrugas anogenitales como indicador de abuso sexual infantojuvenil. Finalmente, incluye sugerencias para el pediatra en el manejo de estos pacientes y sus familias.

This article deals with anogenital warts (AGW) injuries caused by human papiloma virus (HPV) in children. Diagnosis, epidemiology, modes of transmission, differential diagnosis, relationship between AGW and cancer are descript. Also, it remarks the presence of AGW as indicator of child sexual abuse. Finally, it includes suggestions for the management of patients and their families by the paediatrician.

Colostomía previa a escisión quirúrgica de un tumor de Buschke-Lõwenteim en la infancia / Temporary colostomy before surgery in Buschke-Lõwenteim tumour in children

Buschke-Lõwentein tumor is a verrucous lesion, with slow growth and locally infiltrating. Despite her benign histology, is an intermediate lesion between condiloma acuminatum and verrucous carcinoma. It has been linked to human papilloma virus (subtypes 6 and 11). Other factors implicated include poor hygiene, chronic irritation, promiscuity and cellular inmunocompromised states. It is exceptional in children. We report a case of a 6-year-old girl with HIV infection B3 and giant condyloma that affect genitoanal region and rectal mucosa. The temporary colostomy aimed good results of the surgical excision.

El tumor de Buschke-Lõwentein es una lesión verrucosa, con crecimiento lento, y localmente infiltrante. A pesar de su histología benigna, se trata de una lesión intermedia entre el condiloma acuminado y el carcinoma verrucoso. Su aparición está ligada con el virus del papiloma humano (subtipos 6 y 11). Otros factores que intervienen son la baja higiene, promiscuidad, irritación crónica y la inmunosupresión celular. Es excepcional su aparición en niños. La exéresis quirúrgica radical es el tratamiento de elección. La realización de una colostomía de descarga previa, permite el aislamiento, facilitando la cicatrización de la zona y evitando el contacto con material fecal que contribuye a la recidiva. Presentamos un caso de una niña de 6 años con VIH estadio B3 y condilomatosis gigante que afectaba a la región genitoanal y a la mucosa rectal adyacente. La colostomía temporal contribuyó al éxito tras la resección quirúrgica.

Urgencias proctológicas / Proctology emergencies

Las urgencias proctológicas son una causa frecuente de consulta en Servicios de Urgencia. Para los pacientes este tipo de problemas implican, además de los propios síntomas, en muchos casos pudor o vergüenza, lo cual puede redundar en una consulta tardía en relación al inicio del cuadro clínico. Para el médico de urgencia es un desafío poder determinar de forma clara el diagnóstico y el tratamiento adecuado, así como la necesidad de hospitalizar o indicar la consulta por un especialista. Es por esto que se hace necesario el poseer los conocimientos básicos para el diagnóstico y el manejo inicial de las patologías más frecuentes tales como el dolor anal, sangrado vía anal o aumento de volumen en la zona perianal. El objetivo de esta revisión es entregar las bases para un adecuado diagnóstico y manejo de las patologías proctológicas que más frecuentemente requieren una atención de urgencia.

Proctologic emergencies are a frequent cause of consultation in the emergency room. For these patients, such problems involve not only a physical discomfort or pain, but also shame in many cases, which can result in a late consultation in relation of the onset of symptoms. These problems are a chellenge, in order to perform an accurate diagnosis and appropriate treatment. Like wise it is necessary to determine the need for hospitalization or evaluation by a specialist. This is why it is necessary to have the basic knowledge and skills for diagnosis and initial management of most common diseases such as anal pain, rectal bleeding or increased volume in the perianal area. The aim of this review is to provide the basis for a proper diagnosis and management of proctologic pathologies most frequently evaluated in an emergency room.

The value of high-resolution anoscopy in the diagnosis of anal cancer precursor lesions in hiv-positive patients / Anuscopia de alta resolução: valor diagnóstico em lesões precursoras de câncer anal em pacientes soropositivos

CONTEXT: Anal cancer, although a still rare disease, is being observed in ascending rates among some population segments known to be at risk for the development of the disease. Human papillomavirus (HPV) infection, immunodepression and anal intercourse are some factors associated with the development of the malignancy. Its similarities to cervical cancer have led to many studies aiming to establish guidelines for detecting and treating precursor lesions of anal cancer, with the goal of prevention. High-resolution anoscopy is routinely used for the diagnosis of anal cancer precursor lesions in many centers but the medical literature is still deficient concerning the role of this diagnostic modality. OBJECTIVES: To evaluate diagnostic validation and precision measures of high-resolution anoscopy in comparison to histopathological results of anal biopsies performed in HIV-positive patients treated at the Tropical Medicine Foundation of Amazonas, AM, Brazil. To observe any possible association between some risk factors for the development of anal cancer and the presence of anal squamous intraepithelial lesions. METHODS: A hundred and twenty-eight HIV-positive patients were submitted to anal canal cytological sampling for the detection of HPV infection by a PCR based method. High-resolution anoscopy was then performed after topical application of acetic acid 3 percent in the anal canal for 2 minutes. Eventual acetowhite lesions that were detected were recorded in respect to location, and classified by their tinctorial pattern, distribution aspect, relief, surface and vascular pattern. Biopsies of acetowhite lesions were performed under local anesthesia and the specimens sent to histopathological analysis. The patients were interviewed for the presence of anal cancer risk factors. RESULTS: The prevalences of anal HPV infection and of anal squamous intraepithelial lesions in the studied population were, respectively, 79 percent and 39.1 percent. High-resolution anoscopy showed sensibility of 90 percent, specificity of 19.23 percent, positive predictive value of 41.67 percent, negative predictive value of 75 percent, and a kappa coefficient of 0.076. From the analyzed lesions, high-grade squamous intraepithelial lesions was more frequently observed in association to dense (68 percent), flat (61 percent), smooth (61 percent), non-papillary (83 percent) and normal vascular pattern (70 percent) acetowhite lesions, while low-grade squamous intraepithelial lesions tended to be associated to dense (66 percent), flat-raised or raised (68 percent), granular (59 percent), non-papillary (62 percent) and normal vascular pattern (53 percent) acetowhite lesions. No statistical significance was observed as to the association of epidemiological characteristics and of most of the investigated anal cancer risk factors and presence of acetowhite lesions or anal squamous intraepithelial lesions. However, anal receptive sex and anal HPV infection were significantly associated to anal squamous intraepithelial lesions (P = 0.0493 and P = 0.006, respectively). CONCLUSION: High-resolution anoscopy demonstrated to be a sensitive, but not specific test for the detection of anal squamous intraepithelial lesions. Risk factors anal receptive sex and anal HPV infection were significantly associated to the presence of anal squamous intraepithelial lesions. Based on high-resolution anoscopy image data, acetowhite lesions relief and surface pattern were prone to distinguish between low-grade squamous intraepithelial lesions and high-grade squamous intraepithelial lesions.

CONTEXTO: O câncer anal, muito embora ainda seja uma doença rara, vem sendo observado com frequência ascendente em alguns grupos populacionais considerados sob risco para o desenvolvimento da doença. Infecção pelo vírus do papiloma humano (HPV), imunossupressão e o sexo anoreceptivo são alguns dos fatores associados ao desenvolvimento da neoplasia. Suas semelhanças com o câncer do colo do útero levaram muitos estudos voltados para o estabelecimento de regras para a detecção e tratamento de lesões precursoras do câncer anal, tudo com o objetivo de prevenir a doença. A anuscopia com magnificação de imagem é rotineiramente utilizada para o diagnóstico de lesões precursoras do câncer anal em muitos centros, mas a literatura médica ainda é escassa a respeito do papel a ser desempenhado por essa modalidade diagnóstica. OBJETIVOS: Avaliar as medidas de validação e precisão diagnósticas da anuscopia com magnificação de imagem em comparação com resultados histopatológicos de biopsias anais realizadas em pacientes HIV-positivos tratados na Fundação de Medicina Tropical do Amazonas, Manaus, AM, Brasil. Observar qualquer possível associação entre alguns fatores de risco para o desenvolvimento do câncer anal e a presença de lesões intraepiteliais escamosas anais. MÉTODOS: Cento e vinte e oito pacientes HIV-positivos foram submetidos a coleta de material celular anal para a realização da detecção da presença de HPV pela reação em cadeia da polimerase. Anuscopias com magnificação de imagem foram realizadas após a aplicação tópica de ácido acético a 3 por cento no canal anal por 2 minutos. As lesões acetobrancas eventualmente observadas foram registradas com respeito a sua localização e classificadas quanto ao seu padrão tintorial, aspecto de distribuição, relevo, características de sua superfície e vascularidade. Foram realizadas biopsias das lesões acetobrancas sob anestesia local e os espécimes foram remetidos para estudo histopatológico. Os pacientes foram entrevistados em relação à presença de fatores de risco para o câncer anal. RESULTADOS: As prevalências de infecção anal pelo HPV e de lesões intraepiteliais escamosas anais na amostra populacional estudada foram de 79 por cento e 39,1 por cento, respectivamente. A sensibilidade e a especificidade da anuscopia com magnificação de imagem foram, respectivamente, de 90 por cento e 19,23 por cento, enquanto que o valor preditivo positivo foi de 41,67 por cento, o valor preditivo negativo foi de 75 por cento e o coeficiente kappa de 0,076. Com respeito às lesões analisadas de alto grau foram mais frequentemente observadas em associação com lesões acetobrancas densas (68 por cento), planas (61 por cento), lisas (61 por cento), não-papilíferas (83 por cento) e com padrão vascular normal (70 por cento), enquanto que lesões de baixo-grau tenderam a se associar a lesões aetobrancas densas (66 por cento), plano-elevadas ou elevadas (68 por cento), granulares (59 por cento), não-papilíferas (62 por cento) e de padrão vascular normal (53 por cento). Não se observou significância estatística na associação entre características epidemiológicas e a maioria dos fatores de risco para o câncer anal e a presença de lesão acetobrancas ou de lesões intraepiteliais escamosas anais. Entretanto, o sexo anorreceptivo e a detecção de infecção anal por HPV, segundo a técnica da reação da cadeia de polimerase, associaram-se significantemente com lesões intraepiteliais escamosas anais (P = 0,0493 e P =0,006, respectivamente). CONCLUSÕES: A anuscopia com magnificação de imagem demonstrou ser um método diagnostico sensível, mas inespecífico para a detecção de lesões intraepiteliais escamosas anais. Os fatores de risco sexo anorreceptivo e infecção anal pelo HPV associaram-se significantemente à presença de lesões intraepiteliais escamosas anais. Com base nos achados da anuscopia com magnificação de imagem, o relevo e o aspecto morfológico da distribuição das lesões acetobrancas na superfície do canal anal tenderam a permitir a distinção entre lesões de baixo e alto grau.

Examen proctológico y tacto rectal en el diagnóstico clínico de síntomas anorrectales / Proctological examination and rectal exam in the clinical diagnosis of anorectal symtoms

Objetivo: evaluar la información proporcionada por el examen proctológico y en particular eltacto rectal en pacientes con síntomas anorrectales. Material y método: se incluyeron los pacientes remitidos a una policlínica de proctología desde enero de 2005 a diciembre de 2008. Se registraron datos demográficos, principalsíntoma de consulta y diagnóstico clínico. Se evaluó el rendimiento diagnóstico del examen anoperineal (EAP), tacto rectal (TR) y anoscopía (AS) frente a cada patología. Lainformación aportada por las diferentes maniobras se clasificó en tres categorías: 1) aportó información suficiente para establecer el diagnóstico clínico primario; 2) aportó informaciónpara el diagnóstico, pero no oncluyente, y 0) no aportó información para el diagnóstico. Resultados: se incluyeron 606 pacientes (319 mujeres, 52%), edad media 47 años, (rango 14 a93 años). El síntoma más frecuente fue dolor anal (33%), seguido de sangrado rectal (19%) y procidencia (18%). Se realizó un diagnóstico clínico primario en 94% de los pacientes; el EAP y la AS aportaron información suficiente para el diagnóstico en 54% y 51%,respectivamente, mientras que el TR lo aportó en 10% de los casos. Conclusión: el estudio mostró que un examen proctológico completo permite establecer un diagnóstico clínico primario en la mayoría de los pacientes que consultan por síntomasanorrectales. Más de la mitad de las condiciones patológicas pueden ser puestas en evidencia mediante una correcta inspección y palpación anoperineal. El tacto rectal fue la maniobra de menor rendimiento diagnóstico, permitiendo establecer el diagnóstico clínico primario en10% de las consultas.

Objective: to evaluate the information provided by the proctological examination, and in particular, the rectal exam in patients with anorectal symptoms. Method: patients referred to a proctology polyclinic from January 2005 through December 2008 were included in the study. We recorded demographic data, main symptomfor consultation and clinical diagnosis. We evaluated the diagnostic performance of perianal examination, rectal examination and anoscopy for each pathology. The informationobtained through the different maneuvers was classified into three categories: 1) it provided enough information to establish the primary clinical diagnosis; 2) it provided diagnostic information, although not conclusive; and 0) it failed to provide diagnostic information. Results: 606 patients were included (319 women, 52%), average age was 47 years old, (range 14 to 93 years old). The most frequent symptom was anal pain (33%), followed by rectal bleeding (19%) and procidentia (18%). We performed a primary clinical diagnosis in 94% of patients; perianal examination and anoscopy provided enough information for diagnosis in 54% and 51% of cases respectively, whereas the rectal examination did so in 10% ofcases. Conclusion: the study showed that a complete proctologicalexamination enables a primary clinical diagnosis in most patients who consulted for anorectal symptoms.Over half of the pathological conditions may be evidenced by means of a correct examination and perianal palpation.Rectal exam was the maneuver that obtained the least diagnosticperformance, only allowing for a primary clinical diagnosis in 10% of the consultations.

Objetivo: avaliar a informação proporcionada pelo exame proctológico e em particular o toque retal em pacientes com sintomas anorretais.Material e método: foram incluídos os pacientes referidos a uma clínica de proctologia no período janeiro de2005 a dezembro de 2008. Foram registrados: dados demográficos,sintoma principal da consulta e diagnóstico clínico. Fez-se uma avaliação do rendimento diagnóstico doexame ano-perineal (EAP), toque retal (TR) e anoscopia (AS) em relação a cada patologia. A informação aportadapelas diferentes manobras foi classificada em três categorias: 1) gerou informação suficiente para estabelecer o diagnóstico clínico primário; 2) gerou informação para odiagnóstico, porém não conclusiva, e 0) não gerou informação para o diagnóstico.Resultados: foram incluídos 606 pacientes (319 mulheres, 52%), idade média 47 anos, (intervalo 14 a 93 anos). O sintoma mais freqüente foi dor anal (33%), seguido de sangramento retal (19%) e procidência (18%).Realizou-se um diagnóstico clínico primário em 94% dos pacientes; o EAP e a AS geraram informação suficientepara o diagnóstico em 54% e 51%, respectivamente, enquanto o TR somente em 10% dos casos. Conclusão: o estudo mostrou que um exame proctológico completo permite estabelecer um diagnóstico clínicoprimário na maioria dos pacientes que consultam por sintomas anorretais. Mais da metade das condições patológicaspodem ser mostradas por uma inspeção e palpação ano-perineal corretas. O toque retal foi a manobra queapresentou o menor rendimento diagnóstico, permitindo estabelecer el diagnóstico clínico primário em 10% dasconsultas.

Ulceración perianal: Dos casos de una rara manifestación de tuberculosis extrapulmonar / Perianal tuberculosis: Report of two cases

Perianal tuberculosis is an uncommon variant of extra pulmonary tuberculosis and mimics other common perianal conditions. We report two patients with perianal tuberculosis. An 82-year-old male presenting with purulent perianal discharge and weight loss. A pelvic magnetic resonance imaging showed a low trans sphincteric anorectal fistula with abscess formation. A fistulectomy was performed and the pathological study showed a granulomatous-tuberculous chronic inflammation. Mycobacteria were recovered from gastric contents. A 48-year-old male with the same symptoms. An ulcerated lesion in the anal region was biopsied, disclosing a granulomatous inflammatory process with Ziehl-Nielsen stainable organisms.

Infecciones graves del periné: unificación de conceptos / Perineal severe infections: concepts unification

Esta monografía se refiere a diferentes procesos que se caracterizan por una inflamación progresiva de la región perineal que llega a la necrosis de la piel, el tejido celular subcutáneo y ocasionalmente el músculo, generando una severa toxicidad sistémica. Es necesario agruparlos bajo la denominación de “infecciones graves del periné” teniendo en cuenta su forma similar de presentación, el diagnóstico precoz que merecen, y el tratamiento exhaustivo del que depende su curación. Existen factores predisponentes, como la diabetes mellitus, y otros desencadenantes, como los procedimientos invasivos locorregionales, que favorecen la aparición de esta afección. Las causas más frecuentes son infecciones anorrectales, genitourinarias y lesiones traumáticas. Casi todos los casos se caracterizan por presentar flora bacteriana mixta y sinérgica. En los cultivos se identifican organismos anaerobios y aerobios facultativos. El diagnóstico se basa en los hallazgos clínicos. La utilidad de las imágenes se limita al diagnóstico precoz de lesiones que potencialmente pueden dar lugar al surgimiento de esta entidad, y a la búsqueda de colecciones que han pasado desapercibidas. La bacteriología provee las bases para ejercer un programa de tratamiento de rutina. El tratamiento debe ser instaurado inmediatamente. La buena evolución de esta grave patología se basa en las medidas urgentes y generales de reanimación, compensación y sostén, antibióticoterapia adecuada, y con una cirugía que siempre debe ser precoz y agresiva. El impacto de la terapia coadyuvante con oxígeno hiperbárico en cuanto a mejoras en los resultados permanece en controversia. Con respecto a la cirugía reparadora, debe tenerse en cuenta que el realizar un debridamiento agresivo, conlleva acarrear con malos resultados estéticos y dificultad en la cicatrización del lecho quirúrgico...

This work talks about different processes that characterize by a progressive inflammation of the perineal region which includes skin, hypodermis and occasionally the muscle necrosis, generating a severe general toxicity. It is necessary to group them under the denomination of “serious infections of perineum” considering its similar form of presentation, the precocious diagnosis needed, and the exhaustive treatment that depends its treatment. There are many helping factors, such as diabetes mellitus, and other leading ones, like regional invasive procedures, which help to promote this affection. The most frequent causes are anorectal and genitourinary infections, and traumatic injuries. Almost all cases are characterized by displaying mixed and sinergical bacterial flora. Anaerobic and facultative aerobic organisms are identified in tissue cultures. The diagnosis is based on the clinical findings. The utility of images is limited to the precocious diagnosis of injuries that can give rise to the sprouting of this illness, and the search of unnoticed collections. Bacteriology provides the bases to start a program of routine treatment. Treatment must be restored immediately. The favorable evolution of this serious pathology is based on urgent and general measures of resuscitation, suitable antibiotic therapy, and surgery, that always must be precocious and aggressive. The impact of helping hyperbaric oxygen therapy as far as improvements in results remains in controversy. As far as repairing surgery, it must be consider that making an aggressive surgery entails to carry with bad aesthetic results and difficulties in the cicatrization of the surgical wound. This fact does not have to be more important than the initial therapeutic success, which will save of the patient's life. Without a suitable handling, the perineum severe infections present a terrible prognosis, with high mortality rate and anatomic and functional sequels that causes invalidity.

Abordaje inicial del paciente con infecciones de transmisión sexual en proctología / Initial approach of patients with sexually transmitted infections in proctology

Introducción: Las Infecciones de Transmisión Sexual (ITS) han experimentado un incremento en su incidencia en los últimos años, especialmente en ano y recto. Por esto es importante que hoy en día el proctólogo se encuentre preparado para atender pacientes con ITS. El objetivo del presente trabajo, además de mostrar los datos recabados en el registro de ITS del Centro Privado de Coloproctología, es describir lo aprendido al interrogar nuestros pacientes y hacer hincapié en la importancia que tiene la primera consulta de un paciente que se presume padece una ITS. Diseño: Observacional, prospectivo. Pacientes y Métodos: Entre diciembre de 2006 y Febrero de 2009 registramos 100 pacientes con presunta ITS o antecedentes de riesgo; 87 hombres - 73 homosexuales, 14 heterosexuales -, con edad promedio de 33.4 años (20-70). 41 eran VIH+. En la primera entrevista completamos una ficha clínica especial, evaluamos el estado serológico y el esquema de vacunación del paciente. Realizamos un examen proctológico completo y dimos consejos acerca de prevención de ITS. Resultados: Diagnosticamos 66 lesiones por HPV, 13 úlceras y 1 condiloma asociado a sífilis. Diagnosticamos 3 VIH y 6 sífilis no sospechadas. 30 pacientes tenían serología negativa para hepatitis A y 46 para hepatitis B. 4 pacientes tenían Hepatitis B en actividad, 8 sífilis y 22 Herpes Simplex II. 36 pacientes negaron la utilización de preservativo, 49 lo utilizan sólo en relaciones sexuales ano-genitales y sólo 14 para el sexo oral. Discusión: La primera entrevista a un paciente con una presunta ITS debe ser considerada como única por lo que no debemos perder la oportunidad de realizar una anamnesis dirigida, un examen físico completo, solicitar un panel serológico y, además dar pautas de educación sexual...

Introduction: Incidence of Sexually Transmitted Infections (STIs) has increased in recent years, especially in the ano-rectum. Therefore it is important that proctologists be prepared to treat patients with STls. The purposes of this paper are to show the data collected in the register ofSTIs at the Centro Privado de Coloproctología and to describe what we learned interviewing our patients, emphasizing the importance of the first interview. Design: Observational, prospective. Patients and Methods: Between December 2006 and February 2009 we registered 100 patients with suspected STI; 87 were men -73 homosexual, 14 heterosexual, and 33.4 years old (20-70). 41 were HIV +. During the first interview we completed an especial clinical history, assessed patient's serological status and vaccination schedule. We made a complete proctological exam and gave advice about prevention of STls. Results: We diagnosed 66 HPV related lesions, 13 ulcers and 1 condyloma associated with syphilis. We also diagnosed 3 unsuspected HIV and 6 syphilis. 30 patients had negative serology for hepatitis A and 46 for hepatitis B. 4 patients had active hepatitis B, 8 syphilis and 22 Herpes Simplex TI. 36 patients refused the use of condoms, 49 use it only for ano-genital sex and only 14 for oral sex. Discussion: The first interview with a patient with a suspected STI should be considered unique so we can't lose the opportunity to perform a clinical history, a complete physical examination, request a serological panel and give an advice about prevention of STIs. Respect, sensitivity and lack of prejuice are essential to achieving the confidence of the patient, thus enabling correct diagnosis and treatment, in addition to providing adequate preventive advice.