Demartines, N.

Fried, M.

Gubler, C.

Hetzer, F.H.

Wildi, S.M.

Serveur académique lausannois

91Original article S W I S S  M E D  W K LY 2 0 0 5 ; 1 3 5 : 9 2 ·  w w w. s m w. c hLetter to the editorAnal lesions and suspected sexual abuse in a 17-year-old girlChristoph Gubler, Stephan M. Wildi, Franc H. Hetzer, Nicolas Demartines, Michael FriedAbteilung für Gastroenterologie und Hepatologie, Departement für Innere Medizin, Universitätsspital Zürich, SwitzerlandA 17-year-old school girl presented tothe emergency room accompanied by hermother. Over the previous 2 weeks she had ex-perienced anal paraesthesia and most recentlysuffered strong anal pain which made sittingalmost impossible. She had no history of perianal pain, nor any abdominal pain. Stoolfrequency and consistency had been normal.She had neither lost weight nor experiencedfever.The clinical examination showed ateenage girl in good health. Inspection of theperineum showed beside skin tags severaldeep anal fissures. The perianal soft tissues in-cluding the anal fold pattern were normal. Anincreased sphincter tonus together with se-vere pain made the digital rectal examinationimpossible. Rectoscopy under general anaes-thesia showed three long (>4 cm) anal fissurestogether with multiple mucosal lesions(figure). Since there was no indication in the his-tory of inflammatory bowel disease or any dis-order with perinal involvement, anal traumawas suspected. A meeting with the girl’s par-ents and a paediatrician from the child pro-tection service did not provide clear evidenceof sexual abuse. However, for the first time inher life the patient and her younger sister hadbeen alone at home with their father for 2weeks while their mother was on vacation.Thus further legal proceedings were debated.We performed a colonoscopy a few days laterwhich showed severe isolated ulcerative ileitisterminalis. Histology confirmed the suspi-cion of active Crohn’s disease. The patientrecovered within 8 weeks and remained inremission at 1-year follow-up following ini-tial treatment with metronidazole per os andimmunosuppressive therapy with azathio-prine.Anal mucosa lesions and ulcerationswithout other abdominal symptoms can becaused not only by sexual abuse, infectiousdiseases or Lichen sclerosus et atrophicans,but also by Crohn’s disease. Anal findings inCrohn’s disease may be present in up to onethird of patients [1]. Isolated perianal Crohn’sdisease occurs in approximately 10 percent[2]. Perianal involvement comprises a hetero-geneous and complex group of lesions con-sisting of skin tags, fissures, fistulas and ab-scesses. These findings are often mistaken forsexually transmitted diseases or sexual abuse.Perianal involvement can even precede anyclinical symptomatic primary manifestationof intestinal disease [3], as was the case in ourpatient.Conversely, the majority (>84%) of sex-ually assaulted children and teenagers exhibitno physical signs of abuse [4]. Most com-monly detected are hymenal lesions, followedby clinical findings relating to infections suchas herpes blisters and abnormal vaginal dis-charge which lead to the suspicion of sexualabuse (unlike anal fissures which are notspecific for abuse) [5].Crohn’s disease presenting as suspectedsexual abuse is often misdiagnosed, althoughthere are to our knowledge only five cases[6–8] reported in the literature. However, incontrast to all these cases our patient did notreport any abdominal symptoms while show-ing severe inflammation of the terminalileum. Pathological findings on perianal exami-nation, in particular anal lesions may heightensuspicion of sexual abuse. An assumption ofsexual abuse, even if subsequently disproved,leads to emotional trauma in the patient andhis or her family. Therefore Crohn’s diseaseshould always be included in the initial differ-ential diagnosis of perianal disease and thethreshold to perform endoscopy should below.References1 Lapidus A, Bernell O, Hellers G, Lofberg R. Clin-ical course of colorectal Crohn’s disease: a 35-yearfollow-up study of 507 patients. Gastroenterology1998;114:1151–60.2 Williams NS, Macfie J, Celestin LR. AnorectalCrohns disease. Br J Surg 1979;66:743–8.3 Palder SB, Shandling B, Bilick R. Perianal compli-cations of pediatric Crohn’s disease. J Pediatr Surg1991;26:513–5.4 Adams JA, Harper K, Knudson S, Revilla J. Exam-ination findings in legally confirmed child sexualabuse: it’s normal to be normal. Pediatrics 1994;94:310–7.5 Kellogg N, Parra J, Menard S. Children withanogenital symptoms and signs referred for sexualabuse evaluations. Arch Pediatr Adolesc Med 1998;152:634–41.6 Hey F, Buchan PC, Littlewood, Hall R. Differen-tial diagnosis in child sexual abuse. Lancet 1987;1:283.7 Stratakis C, Graham W, DiPalma J, Leibowitz I.Misdiagnosis of perianal manifestations of Crohn’sdisease. Clinical Pediatrics 1994;33:631–3.8 Sellman, Hupertz V, Reece R. Crohn’s disease pre-senting as suspected abuse. Pediatrics 1996;97:272–4.Correspondence:Prof. M. FriedAbteilung für Gastroenterologie und HepatologieDepartement für Innere MedizinUniversitätsspital ZürichRämistrasse 100CH-8091 ZürichSwitzerlandE-Mail: michael.fried@usz.chFigure 1Perianal examination with fissures.S W I S S  M E D  W K LY 2 0 0 5 ; 1 3 5 : 8 7 – 0Peer reviewed articleWhat Swiss Medical Weekly has to offer:• SMW’s impact factor has been steadily rising, to the current 1.537• Open access to the publication viathe Internet, therefore wide audience and impact• Rapid listing in Medline• LinkOut-button from PubMed with link to the full text website http://www.smw.ch (direct linkfrom each SMW record in PubMed)• No-nonsense submission – you submit a single copy of your manuscript by e-mail attachment • Peer review based on a broad spectrum of international academic referees• Assistance of our professional statisticianfor every article with statistical analyses• Fast peer review, by e-mail exchange withthe referees • Prompt decisions based on weekly confer-ences of the Editorial Board• Prompt notification on the status of yourmanuscript by e-mail• Professional English copy editing• No page charges and attractive colour offprints at no extra costEditorial BoardProf. Jean-Michel Dayer, GenevaProf. Peter Gehr, BerneProf. André P. Perruchoud, BaselProf. Andreas Schaffner, Zurich (Editor in chief)Prof. Werner Straub, BerneProf. Ludwig von Segesser, LausanneInternational Advisory CommitteeProf. K. E. Juhani Airaksinen, Turku, FinlandProf. Anthony Bayes de Luna, Barcelona, SpainProf. Hubert E. Blum, Freiburg, GermanyProf. Walter E. Haefeli, Heidelberg, GermanyProf. Nino Kuenzli, Los Angeles, USAProf. René Lutter, Amsterdam, The NetherlandsProf. Claude Martin, Marseille, FranceProf. Josef Patsch, Innsbruck, AustriaProf. Luigi Tavazzi, Pavia, ItalyWe evaluate manuscripts of broad clinicalinterest from all specialities, including experi-mental medicine and clinical investigation.We look forward to receiving your paper!Guidelines for authors:http://www.smw.ch/set_authors.htmlAll manuscripts should be sent in electronic form, to:EMH Swiss Medical Publishers Ltd.SMW Editorial SecretariatFarnsburgerstrasse 8CH-4132 MuttenzManuscripts: submission@smw.chLetters to the editor: letters@smw.chEditorial Board: red@smw.chInternet: http://www.smw.chSwiss Medical Weekly: Call for papersSwiss Medical WeeklyThe many reasons why you should choose SMW to publish your research Official journal ofthe Swiss Society of Infectious diseasethe Swiss Society of Internal Medicinethe Swiss Respiratory SocietyImpact factor Swiss Medical Weekly 0 . 7 7 01 . 5 3 71 . 1 6 200.20.40.60.811.21.41.61.82199519961997199819992000200220032004Schweiz Med Wochenschr (1871–2000)Swiss Med Wkly (continues Schweiz Med Wochenschr from 2001) Editores Medicorum Helveticorum

Anal lesions and suspected sexual abuse in a 17-year-old girl.

https://serval.unil.ch/resource/serval:BIB_E17A68B5DA9E.P001/REF.pdf

Anal lesions and suspected sexual abuse in a 17-year-old girl.

Abstract

Similar works

Full text

Available Versions

Serveur académique lausannois