Focal lymphoid hyperplasia of the terminal ileum mimicking Crohn's disease.

Focal lymphoid hyperplasia of the terminal ileum is a rare cause of terminal ileitis. We describe the case of a 13-year-old boy with a stricture of the terminal ileum that was diagnosed as Crohn's disease on barium meal and follow through. This failed to resolve on steroid therapy and the boy eventually required resection of his terminal ileum. Pathology of the terminal ileum showed focal lymphoid hyperplasia and not Crohn's disease.

Comparison between Eusol and Silastic foam dressing in the postoperative management of pilonidal sinus.

Seventy-five consecutive patients with pilonidal sinus disease were randomized to receive either Eusol dressings or Silastic foam dressings. Patients were divided into those with pilonidal sinus and pilonidal abscess. There was no significant difference between time to hospital discharge or time to full healing in either group. The cost benefits and simplicity of Silastic foam dressing are discussed.

Varicose veins: optimum compression after surgery and sclerotherapy.

Graduated compression stockings are used in both surgical and non-surgical treatment of varicose veins. In a trial of high versus low compression stockings (40 mmHg vs 15 mmHg at ankle) after varicose vein surgery, both were equally effective in controlling bruising and thrombophlebitis, but low compression stockings proved to be more comfortable. In a further trial after sclerotherapy, high compression stockings alone produced comparable results to Elastocrepe bandages with stockings. It is concluded that after varicose vein surgery low compression stockings provide adequate support for the leg and that after sclerotherapy, bandaging is not required if a high compression stocking is used.

Fistula-in-ano is usually simple to manage surgically.

Our experience in the surgical management of 115 patients with fistula-in-ano treated over 14 years was reviewed retrospectively. The incidence of previous anorectal infection was 69%. After treatment eight patients (7%) developed a recurrence of the fistula and five (4%) experienced some complication directly resulting from surgical treatment. One patient died of pulmonary embolism following an operation for recurrence. Most of the patients (75%) had a successful outcome of a minor surgical procedure.

Changes in colorectal function in severe idiopathic chronic constipation.

Physiologic studies of colorectal and anal function were performed in 25 adult patients with severe idiopathic long-standing constipation compared with 22 age- and sex-matched normal subjects. Only patients with primary severe idiopathic constipation with no known underlying primary etiology have been studied. No significant changes were observed in the resting or squeeze anal canal pressures. There was indirect evidence that rectal sensation was grossly impaired in 17 of the constipated patients: mean values for constant sensation compared with controls being 269 +/- 21 ml and 136 +/- 10.3 ml, respectively (p less than 0.01). The mean anorectal angles during attempted defecation were significantly less in constipated patients compared with controls (p less than 0.001), and 10 patients were unable to evacuate from the rectum a balloon containing 150 ml of a weak barium suspension. Electromyography of the pelvic floor showed increased puborectalis activity on attempted defecation in 9 subjects. Although there was no significant difference in the basal sigmoid motility index between constipated patients and controls, response to intrarectal bisacodyl (5 mg) was impaired in the constipated group, being 479 +/- 22.1 and 735 +/- 24.7, respectively (p less than 0.01). Transit time was significantly delayed in the constipated patients; the percentage of markers passed by constipated patients after 5 days was 39.0 +/- 6.9 compared with 73.9 +/- 2.8 passed by controls (p less than 0.02). These results imply that there is often a motor abnormality of the pelvic floor and the colon in patients with long-standing chronic constipation.

Crohn's disease in the elderly.

The natural history of Crohn's disease in 47 patients, 60 years of age or older at the time of diagnosis has been defined, and their clinical management and long term prognosis reviewed. Distal colonic involvement is common in this group while extensive colonic and diffuse small bowel disease is rare. Distal colonic involvement usually carries a good prognosis except for those few patients who present with perforation which accounts for most of the disease related mortality. The pattern of distal ileal disease is similar to that observed in the younger patients except for the acute nature of symptoms at first presentation, and the low recurrence rates after initial surgical resection.

Abnormalities of colonic function in patients with rectal prolapse and faecal incontinence.

We have investigated changes in colonic motility and anorectal function in 6 continent patients with a rectal prolapse; in 10 incontinent patients with rectal prolapse and in 16 patients with idiopathic faecal incontinence compared with 26 age and sex match controls. A history of incontinence, irrespective of a prolapse, was associated with significantly lower anal squeeze pressures (P less than 0.05), a deficient anorectal angle (P less than 0.05), failure to retain a balloon containing more than 250 cm3 of air in the rectum (P less than 0.01) and increased sigmoid motility (P less than 0.02) compared with controls. By contrast patients with rectal prolapse and no incontinence had normal anal pressures, a normal anorectal angle and normal sigmoid motility, but transit was delayed. These results indicate that abnormal sigmoid motility is commonly associated with faecal incontinence and that slow transit constipation is frequent in patients with rectal prolapse who are continent.

Clinical and manometric features of the solitary rectal ulcer syndrome.

We report 33 patients with the solitary rectal ulcer syndrome seen between 1975 and 1982. Twenty-four were women and the median age was 32 years. The principal symptoms were bleeding (89 per cent), chronic constipation (64 per cent), rectal pain (42 per cent), tenesmus (42 per cent), and mucous discharge (45 per cent). Twenty-eight patients gave a history of straining (85 per cent). A full-thickness rectal prolapse was present in six patients, an anterior rectal prolapse was observed in 11, and 12 patients had clinical evidence of perineal descent. Defecation was only possible by digital evaluation in six women, and three male patients were passive homosexuals. Manometric studies were performed on 16 patients; eight patients were unable to tolerate rectal distention with 200 cc of air and impaired rectal sensation was present in two. Rectal distention was associated with bursts of involuntary external sphincter activity in three patients, and the distention reflex was absent in six, despite normal ganglia on rectal biopsy. In only four patients was there electromyographic evidence of contraction of the puborectalis during attempted defecation. Fourteen patients were treated by rectopexy; healing of the ulcer occurred in five of six with a full-thickness prolapse compared with only two of eight without a complete prolapse.

Outlet syndrome: is there a surgical option?

Of 46 patients investigated for constipation, 21 were found to have some other primary abnormality, leaving 25 patients for study: 6 had evidence of the outlet syndrome alone, 5 had slow transit constipation, 8 had both abnormalities and 6 had no apparent physiological disorder in the colon or rectum. Although colectomy and ileorectal anastomosis gave good results for slow transit constipation, partial pelvic floor division provided satisfactory long-term improvement in only one of the 7 patients with the outlet syndrome.