Norman Sohn

Carcinoma arising in anorectal fistulas of Crohn's disease

PURPOSE: Anorectal fistulas are commonly associated with Crohns disease. Carcinoma arising in an anal fistula in the absence of Crohns disease occurs rarely. Carcinoma arising in an anorectal fistula of Crohns disease is likewise rare and is the subject of this article. METHODS: We have seen eight cases in seven patients. Four of these were squamous carcinoma and three were adenocarcinoma. Details of these seven patients are presented. RESULTS: Two deaths in the four patients with squamous carcinoma and one in the two patients with adenocarcinoma with adequate follow-up suggest a poorer prognosis in both types of malignancy than when these lesions occur without Crohns disease. CONCLUSION: Carcinoma does arise in the midst of the anorectal fistulas and abscesses of Crohns disease. Carcinoma arising in a Crohns disease fistula can be very difficult to diagnose. Examination may be limited by pain, stricture, or induration of the perianal and perineal tissues. Examination under anesthesia can also overlook the lesion. Diagnostic examination under anesthesia yields increases with biopsies or curettage of the fistulous tracts.

Generalized melanosis secondary to malignant melanoma. Report of a case with serum and tissue tyrosinase studies

A case of generalized melanosis secondary to malignant melanoma is described. The tyrosinase activity of serum and tissues from this patient has been measured. The first 2 steps of melanogenesis (tyrosine → dopa and dopa → dopachrome) have been separately assayed. Serum and homogenates from skin and spleen showed the highest activity in both steps. Weak activity was detected in vagina and lung, but no activity was detected in the adrenals, kidney, liver, and rectum. An endogenous compound which inhibits the enzymic activity as well as the auto‐oxidation of dopa is found to be present in almost all of the tissues analyzed. Tyrosinase activity was not found in serum samples from control patients without malignant melanoma nor from other patients with malignant melanoma without generalized melanosis. Inhibition of tyrosinase activity by endogenous substances, however, was present in all serum samples analyzed.

Anorectal Crohn’s Disease

In some patients with Crohn’s disease the anorectal complications are the major cause of symptoms and morbidity. Anorectal Crohn’s disease may be present in patients with intestinal Crohn’s disease, may be the initial manifestation of the disease, or rarely occurs without involvement of Crohn’s disease elsewhere in the intestinal tract. The pathogenesis of these anorectal complications remains to be clarified.The anorectal examination is very important in the assessment of patients with suspected or documented inflammatory bowel disease. Meticulous physical examination, examination under anaesthesia and radiological imaging modalities may be utilised to specifically identify the location of abscesses and fistulae.Treatment strategy should be directed toward symptomatic relief; the most important symptom is pain. In most patients this pain will be attributable to an incompletely drained rectal abscess. Simple incision and drainage procedures are often all that is required as initial treatment of anorectal abscesses.Treatment of the anorectal fistulae that occur secondary to Crohn’s disease requires combined medical and surgical therapy. Drug therapy is more often initiated for Crohn’s disease that involves other areas of the gastrointestinal tract. The anorectal manifestations often respond to these same medications. Lay-open procedures (fistulotomies) are often all that is required surgically for simple (low) anorectal fistulae.High (complex) fistulae that involve large portions of the anorectal muscular ring are more difficult to treat. Patients with these fistulae must be treated on an individual basis, usually local surgical therapy combined with a medical regimen. Many surgical procedures are performed and many classes of medications are utilised on patients with these complex anorectal fistulae. Choosing the appropriate surgical and medical interventions is often quite difficult. Although sulfasalazine, mesalazine and corticosteroids have no lasting or maintenance value for fistulae, the immunosuppressive agents mercaptopurine, azathioprine and cyclosporin, the antibacterial metronidazole and the anti-tumour necrosis factor-α monoclonal antibody infliximab have varying degrees of effect. The goal of the combined regimen is to cure the fistula, or at least make it minimally symptomatic, without altering the patient’s continence.

Acute anal fissure: treatment by lateral subcutaneous internal anal sphincterotomy.

Lateral subcutaneous internal anal sphincterotomy in the management of chronic anal fissures is well established. Its role in the management of the acute severely painful fissure is reported and the technic described.

Roentgenography of the thoracic duct in man by oral administration of contrast media.

Summary X-ray views of the thoracic duct by means of orally administered contrast media have been obtained for the first time by providing for adequate emulsification and dispersion of an iodinated fat prior to administration.