An unusual cause of small bowel obstruction due to an ingested mango seed: a case report.

BACKGROUND: Intestinal obstruction can occur due to multiple aetiologies. Intestinal obstruction due to phytobezoar have been reported. However, intestinal obstruction due to a mango seed has not been reported. Therefore, accidental ingestion of a mango seed is rare, and for an ingested mango seed to cause intestinal obstruction is rarer. CASE PRESENTATION: This case report is of a male who accidentally ingested a mango seed and presented with intestinal obstruction. The obstruction was at the terminal ileum. It required laparotomy for retrieval. CONCLUSION: It is extremely rare for a mango seed to cause intestinal obstruction. Hence, diagnosis requires a high degree of clinical suspicion. Instead of laparotomy, studies have demonstrated the use of laparoscopy for removal of ingested seeds.

Predictive accuracy of Goodsall's rule for fistula-in-ano

Introduction: Successful treatment of fistula-in-ano is sometimes challenging due to difficulty in recognising the internal opening and the course of the fistula tract. Although Goodsall's rule was accepted in the past, as a method to determine the course of the fistula, recent data have shown conflicting results. Objectives: To study the predictive accuracy of Goodsall's rule. Methods: A sample of 212 patients with simple fistulae were studied. Hydrogen peroxide was injected through the external opening and the appearance of air bubbles in the anal canal indicated the location of the internal opening. The morphological parameters including the site and number of internal and external opening/s and the course of the tract were recorded. Results: The median age of the participants was 39 (range, 18-78) years. The majority (n=167, 78.8%) were males. Of the study group, 63 (29.7%) had inter-sphincteric fistulae, 114 (53.8%) transphincteric fistulae and 35 (16.5%) superficial fistulae. The overall predictive accuracy of Goodsall's rule in our patients was 78.3%. Predictive accuracy was significantly associated with type of fistulae with high predictive accuracy seen in superficial fistulae (97.1%) and inter-sphincteric fistulae (84.1%) compared to transphincteric fistulae (69.3%) (p=0.001). Predictive accuracy was significantly higher in those with an external opening in the midline (98.2%), (p<0.001). Conclusions: Although Goodsall's rule was not accurate in 22% of all fistulae, it can be used as a guide in locating the path of the tract and the internal opening in simple fistulae.

Three-Dimensional Anorectal Manometry Findings in Primigravida.

BACKGROUND: Vaginal delivery is an identified risk factor for anal sphincter injury. Therefore, to identify postpartum injury, an antepartum value or a normal range is required. However, at present, the normal values of 3D manometry are not available for primigravida or pregnant mothers. AIMS: Our study aims at describing normal values of 3D manometry in primigravida. METHODS: We analyzed 3DARM data of 101 consecutive primigravid mothers in the third trimester. 3DARM was performed using the Given Imaging(®) ManoScan system. RESULTS: The mean age was 24.7 (SD 5.1) years. All patients had a normal Cleveland Clinic Incontinence Score. The mean resting pressure (RP) was 87.02 (SD 18.43) mmHg and the maximum squeeze pressure (SP) was 179.21 (SD 52.96) mmHg. The mean length of the high-pressure zone (HPZ) was 3.67 (SD 0.52) cm. Mean volumes for initial rectal sensation, urge, and discomfort were 50.36 (± 25.57), 76.70 (± 35.17), and 143.40 (± 66.26) ml, respectively. The pressure asymmetry was highest in the lower anal sphincter and lowest in the mid-sphincter. There was a statistically significant relationship between the HPZ and RP (Pearson ρ -0.23, p = 0.01), height (Pearson ρ 0.22, p = 0.028), and weight (Pearson ρ 0.25, p = 0.012). There were no statistically significant correlations between age, height, or weight with RP, SP, or balloon fill volumes. The characteristic appearance of the normal RP and SP was clearly visualized in all patients. CONCLUSIONS: Normal 3DARM values for Sri Lankan primigravid mothers have been established. These may be used as reference values by other investigators.

A comparison of endoanal ultrasound and computed tomography in staging rectal cancer and in clinical decision making - a preliminary study.

INTRODUCTION: The treatment options and the prognosis of rectal cancer (RC) depend mainly on the stage. Computed tomography (CT) has been the main staging tool in RC but endoanal ultrasound (EAUS) is thought to be more accurate. METHODS: Patients with histologically proven rectal cancer presenting for the first time were staged using CT and EAUS. TNM staging was used to stage the rectal cancer. RESULTS: 24 patients (M:F 1:1) with a mean age of 57.3 (range = 23-80, SD = 15.3) years were included. The majority had a tumour of stage IIA/T3N0M0 (CT = 10, EAUS = 12). The staging of the tumour was the same in both investigations in 11 patients, while in 8 patients, EAUS staging was higher. The agreement for the T and N stages were kappa 0.24 and 0.5 respectively. There was a moderate and fair agreement between the overall TNM staging (weighted kappa 0.435) and the treatment strategies (weighted kappa 0.226) respectively, based on each imaging method. Of the 13 patients whose staging was different, the management changed in 6 (25%) patients (p = 0.016). CT identified distal metastases in 2 patients. CONCLUSIONS: EAUS and CT have only a fair to moderate agreement for staging and deciding treatment. However,EAUS has a significant influence when deciding treatment protocols.

The distribution of the anal glands and the variable regional occurrence of fistula-in-ano: is there a relationship?

BACKGROUND: Fistula in ano is a rather common condition, but the disease process is not yet fully understood. The aim of our study was to determine how the distribution of anal glands contributes to the variable occurrence of fistula-in-ano in the perineum. METHODS: we conducted a blinded two-phase prospective study. In the first phase, the perineum of the patients with primary fistulae was anatomically divided into right upper and lower and left upper and lower quadrants in the lithotomy position. The fistulae were classified according to what quadrant the external and internal openings and the tract pathway were in. In the second phase, using 10 human cadaver specimens, full thickness tissue samples were taken from each quadrant of the anus. Samples were histologically evaluated for the volume fractions of the anal glands in each quadrant. RESULTS: The new classification system we propose revealed that the largest number of fistulae 43% (17/39) were in the right lower quadrant, and 22% (9/39), 12% (5/39) and 8% (3/39) were in the left lower, right upper and left upper quadrants, respectively. It was also observed that 14% (5/39) of fistulae were in more than one quadrant. The volume fractions of each quadrant showed that the largest volume fraction of the anal glands was in the right lower quadrant (right lower quadrant: 0.64, left lower quadrant: 0.35, right upper quadrant: 0.26 and left upper quadrant: 0.22, P = 0.001). CONCLUSIONS: To the best of our knowledge, this is the first study that has objectively shown that the distribution of the anal glands is variable, and the highest density of anal glands is in the right lower quadrant of the anus. This variable distribution may be associated with the variable occurrence in fistula in ano.

Disease-related knowledge in inflammatory bowel disease: experience of a tertiary care centre in a developing country in South Asia.

INTRODUCTION: Disease-related knowledge plays a critical role in facilitating patients' acceptance of their diagnosis and compliance with active participation in the treatment of inflammatory bowel disease (IBD). The aim of this study was to analyse the deficits in knowledge for future health education programmes. METHODS: A validated questionnaire was used to assess and analyse disease-related knowledge among patients with ulcerative colitis (UC) and Crohn's disease who attended outpatient gastroenterology clinics of a tertiary care hospital in Sri Lanka. RESULTS: There were 184 patients (83 males) with a mean age of 44.5 (range 20-78) years. 83.2 percent of the patients had UC. The mean duration of IBD was 8.17 (range 1-28) years, and 33.7 percent of the patients had IBD for over ten years. The mean Crohn's and Colitis Knowledge questionnaire score was 6.86. The majority (68.5 percent) of the patients were aware that sulfasalazine can be used to reduce exacerbations. There was no statistical difference in disease-related knowledge between genders, but the level of education showed a significant difference. Only 14.1 percent of patients were aware that prolonged IBD is a risk factor for colorectal cancer and that screening for colorectal cancer is important. 9.2 percent of the study population was aware of restorative proctocolectomy. CONCLUSION: There is a lack of knowledge regarding colorectal cancer risk and surgical interventions. There was no significant difference in the knowledge scores between genders but there was a significant association with the educational level.

Delay in the diagnosis of esophageal carcinoma: experience of a single unit from a developing country.

OBJECTIVES: Main objective was to analyze the time delay between the onset of symptoms and the histological diagnosis of esophageal cancer. The subsidiary objective was to analyze the relationship between the time delay and stage of the disease at the time of definitive treatment. STUDY DESIGN, SETTING, AND METHODS: A prospective analysis of patients with esophageal cancer presenting to a single unit over a period of 24 months was performed. Interval from the onset of symptoms to the histological diagnosis and stage at presentation was analyzed. RESULTS: There were 48 patients (male = 26) with a median age of 59.5 (range 43 - 84) years. First symptom was progressive dysphagia in all patients. Subsidiary symptoms were, weight loss in 83.3% (n = 40), abdominal / chest pain in 10 (20.8%), regurgitation in 14 (29.2%), odynophagia in three (6.2%), abdominal discomfort in two (3%), and dyspepsia in two (3%). The mean delay from the appearance of the first symptoms to the end point was 14.9 weeks (range 3 - 37 weeks). Total delay was due to patient delay in 82%, endoscopy delay in 7%, and delay in histological diagnosis in 11%. CONCLUSIONS: As the majority (82%) in our study showed patient delay, a community education program may help in their early presentation to the hospital. However, there is also a notable delay in endoscopy and histology (15%) services, mainly due to a shortage of endoscopy units and qualified histopathologists in the state sector.

The value of routine histopathological analysis in patients with fistula in-ano.

OBJECTIVE: To determine the positive yield of routine histopathology in patients undergoing surgery for fistula in-ano. METHOD: Histopathology reports of all the patients who underwent surgery for fistulae-in-ano over a period of 36 months were reviewed. RESULTS: Analysis included 84 patients of which 73 (87%) were male subjects. The mean age was 39.4 years (range 11-68). Forty-one (49%) had recurrent fistulae. Granulomatous diseases such as Crohn's disease and tuberculosis (TB) were suspected in six patients. However, of the six patients, confirmation of the disease status was obtained only in three patients: stains for acid-fast bacilli confirmed TB in two (2.4%) patients and colonoscopy and biopsy confirmed Crohn's disease in one (1.2%) patient. All three patients had recurrent fistulae. CONCLUSION: As the positive yield of routine histopathology is minimal, we do not recommend routine histopathology for fistula in-ano, except for those presenting with recurrent fistulae and those with clinical suspicion of an underlying disease such as TB, HIV or Crohn's disease.

Risk factors for anal sphincter disruption during child birth.

BACKGROUND AND AIMS: The objective of our study was to analyse the risk factors in a cohort of women who suffered anal sphincter disruption (third-degree tear) and compare the results with a similar cohort of women who underwent an uncomplicated vaginal delivery (without a clinically detectable laceration) during the same period. MATERIALS AND METHODS: A retrospective analysis was carried out on 54 women (group 1) who suffered a third-degree tear and 71 women who had undergone uncomplicated vaginal delivery during the same period (group 2). The risk factors considered were forceps delivery, parity, second stage of labour longer than 1 h, episiotomy, birth weight over 4 kg, gestational age and maternal age at delivery. The Cleveland Incontinence Score was completed. RESULTS: Multiple logistic regression analysis of obstetric risk factors for third-degree perineal tear indicated forceps delivery (p = 0.0001), primiparity (p = 0.004), foetal birth weight over 4 kg (p = 0.030) and delay in the second stage of labour (p = 0.031) to be significant risk factors for a third-degree tear. Mediolateral episiotomy was shown to be a significant protective factor (p = 0.0001). Gestational age and the maternal age at delivery (p = 0.340) were not shown to be significant risk factors (p = 0.336). CONCLUSION: Primary prevention and identification of women with risk factors is recommended. In some cases, counselling regarding the potential risks and benefits of both vaginal and caesarean delivery may be appropriate.

Hiradenitis suppurativa presenting as a polypoidal lesion at the anal verge.

Hidradenitis suppurativa is a chronic disease characterized by painful recurrent abscesses, fistulas and scarring lesions in axilla, groin, perineum and rarely mass lesions at the affected site. Here we present a case of hidradenitis suppurativa that presented as a polypoidal growth at the anal verge.

Comparison of vector symmetry index and endoanal ultrasonography in the diagnosis of anal sphincter disruption.

BACKGROUND: Anal pressure vectography is an anorectal physiology study that evaluates the radial pressures in the anal canal from which a symmetry index that indicates the anatomical integrity of the anal sphincter can be calculated. However, there are conflicting opinions of its validity. Since endoanal ultrasonography (EAUS) has been recognized as the gold standard for detecting anal sphincter disruption, the aim of this pilot study was to observe whether a vector symmetry index (VSI) determined at the level of injury shown in EAUS has a better sensitivity than the overall VSI in detecting anal sphincter disruption. METHODS: A group of 11 women in whom EAUS had shown defects in both the internal and the external anal sphincters underwent anorectal manometry using a water-perfused vector manometry catheter, and the overall VSI and the VSI at the level of sphincter disruption (shown on EAUS) were calculated. RESULTS: Overall VSI at rest indicated internal sphincter injury in 7 women (64%) but the VSI at the level of disruption indicated internal sphincter injury in all 11 women (100%, p=0.0137). Similarly, the overall VSI at squeeze indicated external sphincter injury in 6 women (55%), but the VSI at the level of disruption indicated external sphincter injury in 10 women (91%, p=0.0049). CONCLUSIONS: Our pilot study showed that EAUS and VSI are equally sensitive in diagnosing a localized anal sphincter defect, provided a segment-for-segment comparison is carried out.

Long-term anal continence and quality of life following postpartum anal sphincter injury.

OBJECTIVE: Anal incontinence occurs as a result of damage to pelvic floor and the anal sphincter. In women, vaginal delivery has been recognized as the primary cause. To date, figures quoted for overt third degree anal sphincter tear vary between 0% and 26.9% of all vaginal deliveries and the prevalence of anal incontinence following primary repair vary between 15% and 61%. Our aim was to analyse the long-term (minimum 10 years post primary repair) anorectal function and quality of life in a cohort of women who suffered a third degree tear (Group 1) and compare the results with a cohort of women who underwent an uncomplicated vaginal delivery (Group 2) or an elective caesarean delivery (Group 3). METHOD: In all, 107 patients who suffered a third degree tear between 1981 and 1993 were contacted with a validated questionnaire. The two control groups comprised of 125 patients in each category. Those who responded to the questionnaire were invited for anorectal physiology studies and endoanal ultrasound. RESULTS: Of the total number contacted, 54, 71 and 54 women from the three groups returned the completed questionnaire. In the three groups, a total of 28 (53%), 13 (19%) and six (11%) complained of anal incontinence (P < 0.0001) respectively. Comparison of quality of life scores between the groups showed a poorer quality of life in those who suffered a tear (P < 0.0001). In addition, in spite of primary repair, 13 (59%) patients in group 1 showed a persistent sphincter defect compared to one (4%) occult defect in Group 2 and none in Group 3. CONCLUSION: Our study indicates that long-term results of primary repair are not encouraging. It therefore emphasizes the importance of primary prevention and preventing further sphincter damage in those who have already suffered an injury (during subsequent deliveries).

Rectal tuberculosis: a rare cause of recurrent rectal suppuration.

Tuberculosis affecting the rectum is a rare extra-pulmonary form of the disease that needs recognition, because it requires specific treatment and avoids multiple, unwarranted surgical interventions. The following discussion is centred on a case of rectal tuberculosis, a disease that rarely affects the anorectal region. The condition was diagnosed on histology and was successfully treated medically with complete resolution.