Other anorectal problems

Carcinoma of the rectum (32.27) is not uncommon in India, but is still unusual in Africa. Try to diagnose it and refer the patient. Here also are some other problems which you will meet occasionally.

OTHER ANORECTAL PROBLEMS LESIONS OF THE RECTUM If a patient has an ULCERATIVE or PROLIFERATIVE LESION OF HIS RECTUM, it might be an amoebic granuloma, which an unusual complication of amoebic colitis (31.10). This can obstruct his colon or his rectum, but is more common in his caecum. An amoebic granuloma of the rectum is softer, and lacks the craggy hardness and friability of a carcinoma. Look for amoebic trophozooites in his stools, and biopsy the lesion. Don't do a colostomy. Metronidazole will usually make the lesion melt away.

CAUTION ! If you think that any granulomatous mass in relation to the large gut might be an amoeboma, try metronidazole.

If he presents with CONSTIPATION, TENESMUS, and the passage of MUCUS, one possibility is a SOLITARY RECTAL ULCER (common in India in adults and older children). Sigmoidoscopy shows a solitary linear ulcer 8-10 cm from his anus. Digital evacuation is an important cause. Instead of asking ''Do you put your finger into your rectum?'', ask ''How often do you put your finger into your rectum to remove the faecal matter?''. Treat him with a hydrophilic colloid and the threat: ''Although there is as yet no evidence of cancer, persistence with digital evacuation might produce it''.

LESIONS AT THE ANUS If he has a FIRM FUNGATING MASS at his anus, perhaps with enlarged inguinal lymph nodes, it may be a CARCINOMA OF HIS ANAL CANAL. Take a biopsy and refer him.

If you cannot refer him, there is little you can do for advanced lesions, but, if the lesion is small and near his anal margin, infiltrate it with local anaesthetic solution containing adrenalin. Ask your assistant to hold a speculum in position, while you excise the tumour widely.

If he has WARTY CAULIFLOWER-LIKE LESIONS in his perianal area, he probably has CONDYLOMATA ACUMINATA. These are of viral origin, and may extend inwards as far as his pectinate line, and become infected and ulcerated. They move on the underlying tissue (unlike a carcinoma), and the skin between them is normal. If in doubt, take a biopsy.

Infiltrate his perianal skin with dilute lignocaine with adrenalin (A 5.4). Then carefully remove the growths with scissors. Treat the raw areas that are left with hypochlorite or saline dressings, like any other perianal granulating lesion.

If he has a STRICTURE OF HIS RECTUM, which may partly obstruct it and cause alternating constipation and diarrhoea, with faecal incontinence, it is probably due to: (1) Lymphogranuloma venereum (much the most likely cause, see below). (2) Carcinoma. (3) Fibrosis following a corrosive traditional enema (usually a long stricture). (6) Schistosomiasis. (7) Amoebiasis (8) Unskilful haemorrhoidectomy (22.6). A stricture due to lymphogranuloma venereum is usually a localized shelf-like lesion of hard fibrous tissue about 1 cm deep, 5 cm in from the anus, and lined by thin adherent anal skin. Sometimes there is a rectovaginal fistula below the stricture.

If you remove the stricture entirely, he may become more incontinent. Either: (1) Carefully dilate it with Hegar's dilators under general anaesthesia. Try not to tear it, or you will cause further inflammation and fibrosis. Or, (2) put the patient into the lithotomy position, and, preferably using diathermy, make four V-shaped incisions in the 12, 3, 6, and 9 o'clock positions to remove four triangular pieces of fibrous tissue. Or, (3) if obstruction is severe, consider referring him for an abdominoperineal resection and a permanent end colostomy.

If a woman has ULCERATIVE LESIONS ON HER GENITALIA, accompanied by acute inflammation and suppuration of her inguinal nodes, she probably has LYMPHOGRANULOMA VENEREUM. Most chronic cases are seen in women, in whom it causes thickened and oedematous perianal and vulval skin, with anorectal suppuration, fibrosis, fistulae, and a stricture (see above). Meanwhile, her perianal region discharges pus, blood, and mucus. Ultimately, her anus and lower rectum are destroyed, and replaced by a thick fibrotic tube. The demonstration with a probe of ''bridges of skin' virtually confirms the diagnosis. Amoebiasis is the important differential diagnosis. Early, tetracycline and chloramphenicol are effective. Later, they can do nothing, except control sepsis.