Massive gastrointestinal haemorrhage from a duodenal diverticulum: a case report

Bleeding duodenal diverticulum is a rare cause of gastrointestinal bleeding, which sometimes can be massive and life threatening. We report one such case and the management, with a successful outcome. Different diagnostic techniques and management options available are also discussed

The establishment of an anorectal physiology service and its impact on the management of women with pelvic floor dysfunction and obstetric anal sphincter injury

EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Characteristics and post-operative outcomes of surgery for fistula-in-ano managed at a tertiary care hospital in Sri Lanka: a retrospective study

Objectives Management of fistula-in-ano is associated with recurrence and, occasionally, with anal incontinence. We investigated the clinical characteristics and outcomes of fistula-in-ano. Methods We included patients with fistula-in-ano managed at a tertiary care center (2016–2021). We collected clinical characteristics and 1-year outcomes using questionnaires. The chi-square test was used in statistical analysis. Results In total, 284 patients (231 men, 81.3%; median age 39.5 [range: 7–73] years) were included. Most patients had simple fistulae (n = 191, 67.3%). Transphincteric (n = 110, 38.7%) fistulae were the most common type, followed by intersphinteric fistulae (n = 103, 36.6%). Fistulotomy (n = 157, 55.3%) was the most common procedure. Follow-up details were traceable in 157 (55.3%) patients. At 1 year, the overall healing rate was 88.5% (n = 136). There was no association between type of surgical procedure and incontinence. The mean Vaizey score, used to assess anal incontinence, was 0.84 (range: 0–14). Incontinence was observed in 32 patients (20.9%), and flatus incontinence was the most common type (n = 17, 53.1%). Complex fistulae were associated with higher recurrence rates than simple fistulae (32.6% vs. 2.8%). Conclusion The healing rate in surgical treatment of fistula-in-ano was 88.5%, with acceptable complication rates. There was no association between surgical procedure type and incontinence

Anal incontinence and quality of life following operative treatment of simple cryptoglandular fistula-in-ano: a prospective study

Abstract Background Anal incontinence is a known complication following operative treatment of fistula-in-ano which can significantly impact the quality of life. This study was aimed to objectively assess the impact of operative treatment of simple fistula-in-ano on quality of life related to anal incontinence. Therefore, a prospective study was conducted in 34 patients who underwent surgery for fistula-in-ano over a period of 24 months. Quality of life and incontinence were assessed using fecal incontinence quality of life (FIQL) scale and Cleveland clinic incontinence score (CCIS) preoperatively and after a minimum of 12 months follow up (mean-27 months, range 12–40 months). The difference in FIQL and CCIS was analysed using Wilcoxon Rank test and Mann–Whitney U test. Results The median age of the participants was 42.5 years (range 22–63, males = 30). The majority had a trans-sphincteric tract (n = 22, 65%). Superficial tracts and inter-sphincteric tracts were found in 8 (24%) and 4 patients (12%). The overall preoperative and postoperative rates of incontinence were 18 and 38% respectively, but the severity was low. The mean overall FIQL was 16.0 (SD ± 0.4) preoperatively and 16.1 (SD ± 0.4) postoperatively. Considerable difference was seen in the scale measuring “depression/self-perception” (p = 0.012). Only 1 patient (3%) had reduction in scale “lifestyle” which measures the impact of incontinence on day-to-day activities. Conclusions Analysis of a cohort of simple cryptoglandular fistula-in-ano with low pre-operative incontinence showed no worsening in the FIQL following successful treatment despite minor worsening of incontinence. Since greater improvement was noted in scale measuring depression/self-perception, psychological interventions may be helpful before surgery to improve quality of life

Duration taken for the anal sphincter pressures to stabilize prior to anorectal manometry

Abstract Objectives Anorectal manometry (ARM) is an integral part of evaluating the anal sphincter function. The current recommendation of waiting for 5 min (lead-in-time) prior to beginning the recording has no evidence. A prolonged procedure may reduce patient compliance. Results We analyzed data from 100 consecutive patients who underwent 3-dimensional ARM at a single center. Their pressure studies were analyzed in consecutive 10-s segments, beginning from the time of insertion of the probe into the anal canal. We defined stabilization of the pressure as the absence of a pressure difference among two consecutive 10-s segments. The study population had 31 males. Their mean age was 33.0 years (SD-14.4). The mean time for the pressure to stabilize was 84.2 s (SD-29.5), range 17.2–203.7 s, 95th percentile 136.2 s. Eleven and one participant(s) took longer than 120 and 150 s for the pressure to stabilize, respectively. There was no correlation of sex (Mann–Whitney U test, p = 0.89) and the time to pressure stabilization. Age and the time to stabilize (Spearman rho − 0.246, p = 0.017) showed a weak negative correlation. A lead-in-time of 5 min, as recommended by present guidelines may be unnecessary. Waiting for 150 s/2½ min may be sufficient and will minimize the procedure duration

Efficacy of irrigation tubes in the management of para rectal cavities associated with complex fistula-in-ano

Abstract Background Surgical management of complex perianal fistula associated with pararectal cavities can be challenging. We hypothesised that healing of the pararectal cavities prior to healing of the fistula leads to a better outcome. We aimed to assess the efficacy of irrigation catheters in the healing of pararectal cavities associated with fistula-in-ano. Methods This study design was consistent with IDEAL stage 2a (development) and was conducted at the Professorial Surgical Unit, National Hospital of Sri Lanka, Colombo. Thirty-two patients with complex fistulae with a pararectal cavity (detected by 2D-Endoanal ultrasounography-EAUS) were included. All patients underwent examination under anaesthesia (EUA), during which insertion of an irrigation catheter to the pararectal cavity and tagging of the primary fistula tract with a drainage seton was done. Patients were advised to irrigate with antiseptic solution and were followed-up at three weekly intervals to assess cavity reduction. Results The majority were males (96.8%, n = 31). The primary fistula tract in 26 patients (81.2%) was trans-sphincteric and was inter-sphincteric in 6 patients (18.7%). Mean time of cavity contraction was 34.78 (range, 21–112) days. Complete healing was seen in 87.5% (n = 28), with 3 patients (9.37%) being lost to follow-up and 1 patient (3.12%) having a persistent perianal fistula after 6 months of follow-up. Those who had complete healing were followed up for a median duration of 6 (range, 3–20) months and there were no recurrences. Conclusions Irrigation in the management of pararectal cavities yielded satisfactory results. A case control trial with larger numbers and assessment of cavity size pre and post procedure by 3D-EAUS/MRI evaluation would be necessary for more objective evaluation of the efficacy of this novel intervention

Spontaneous rupture of a parastomal hernia with evisceration of small bowel: a case report

Abstract Background Long standing ostomy related complications such as parastomal hernia and stoma prolapse may be at a higher risk of developing spontaneous rupture and evisceration, especially in patients suffering from chronic cough. Such patients may need early refashioning of the stoma to prevent this serious complication. Parastomal evisceration is a very rare complication of stomas and to date, only few cases have been reported in the literature. Case presentation A 51 year old patient with chronic obstructive pulmonary disease (COPD) and extensive hidradenitis suppurativa of the perineum underwent a temporary defunctioning loop sigmoid colostomy and subsequent perineal skin excision and skin grafting. The ostomy was complicated by a parastomal hernia and stoma prolapse 6 weeks post operatively. Five months later he developed spontaneous rupture of parastomal hernia and evisceration of small bowel. Urgent surgery was done and reduction of small bowel loops and re-siting of the sigmoid colostomy was done. Discussion and conclusions Parastomal evisceration is an extremely rare life threatening stoma-related complication which requires urgent treatment

Crohn’s Disease in South Asia

Crohn’s disease (CD) is a highly complex disease of unknown aetiology. We analysed the epidemiology, clinical characteristics, diagnosis, treatment and pathogenesis of Crohn’s disease in South Asia compared to the rest of the world.The PubMed database and Google scholar were searched till March 2016 for articles on CD. Articles dealing with CD in South Asians were reviewed by the authors, critically analyzed and then summarized.There is a lower incidence of CD in South Asia compared to the West and disease characteristics differ. Although novel genetic factors associated with CD have been identified, significant gaps exist in relation to disease pathogenesis, molecular genetic mechanisms and the use of evidence based treatment modalities.Our review provides a comprehensive overview of existing knowledge on CD in South Asia and identifies gaps in knowledge for future research 

Epidemiology, Pathogenesis and Treatment of Ulcerative Colitis in South Asia

Ulcerative colitis (UC) is a chronic inflammatory disorder of the colon and rectum. Its prevalence is on the rise in many non-Western countries and several factors such as changes in lifestyle and improvements in hygiene may account for this. The cultural and ethnic background of South Asia is different from Western countries and other parts of Asia. We have reviewed the scientific literature on UC in South Asia and describe its epidemiology, clinical characteristics, molecular mechanisms, diagnosis and treatment.

Types and Patterns of Colonic Polyps Encountered at a Tertiary Care Center in a Developing Country in South Asia

Purpose. To identify the prevalence, types, and patterns of colonic polyps in a cohort of patients presenting to a tertiary care referral center in Sri Lanka. Methods. Endoscopy and pathology reports of a single unit from 2006 to 2013 were analyzed retrospectively. Spearman’s correlation coefficient and chi-square test were used to identify correlations. Results. There were a total of 158 patients (M : F, 10 : 57) who had polyps encountered on colonoscopy (n=1408) and flexible sigmoidoscopy (n=2402) with an incidence of 4.1%. Mean age was 56.5 years (SD 16.4) and the incidence of polyps increased with age. The majority (81.6%) had one polyp. A total of 188 polyps were assessed and most were seen in the rectum (33.5%) followed by sigmoid colon (22.9%). The commonest histological type was tubulovillous adenoma (33.5%) followed by tubular adenoma (24.5%). Most polyps were benign (91.5%). There was no statistically significant correlation with age or gender with malignancy, site, or histology. Discussion and Conclusion. The incidence of colorectal polyps was lower than the values reported in the west. More polyps were identified in males. There was no statistically significant association between age, gender, or multiplicity and malignant change in the polyps