Sexually transmitted infections of the anus and rectum

Sexually transmitted infections (STIs) represent a significant public health concern. Several STIs, once thought to be on the verge of extinction, have recently reemerged. This change is thought to be partially related to an increase in STIs of the anus and rectum. Importantly, the global human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS) epidemic has contributed to the emergence of particular anorectal lesions that require specialized approaches. In this report, we review common anorectal STIs that are frequently referred to colorectal surgeons in the United States. Epidemiology, clinical presentation, and management are summarized, including the latest treatment recommendations. The particularity of anorectal diseases in HIV/AIDS is addressed, along with recent trends in anal cytology and human papillomavirus vaccination.     

Abdominal and anorectal surgery and the acquired immune deficiency syndrome in heterosexual intravenous drug users

Over a period of seven years, 474 patients with acquired immune deficiency syndrome (AIDS) or AIDS-related complex were admitted on 782 occasions to the St. Francis Medical Center, Trenton, New Jersey. Abdominal surgery was performed on 16 (3.4 percent) patients, 14 (88 percent) of whom were heterosexual intravenous drug users. Anorectal surgery was performed on 20 (4.2 percent), 14 (70 percent) of whom were intravenous drug users. Intravenous drug users undergoing abdominal surgery had the same types of surgical abdominal conditions that occur in the general population. None required surgery for complications secondary to cytomegalovirus, visceral lymphoma, or visceral Kaposi's sarcoma. The postoperative morbidity rate was 72 percent. The postoperative mortality rate (30 day) was 0 percent. No intravenous drug users who underwent anorectal surgery had associated anorectal malignancies or infectious diseases. Five of six homosexual patients had either an anorectal malignancy or an associated anorectal infectious disease. Anorectal wounds did not heal within one month in one third of the intravenous drug users. The rate of wound healing was inversely related to the white blood cell count. One third of the intravenous drug users undergoing anorectal surgery were dead within six months.Read at the meeting of the American Society of Colon and Rectal Surgeons, Toronto, Canada, June 11 to 16, 1989.     

Squamous cell carcinoma of the anus and HIV infection

We retrospectively reviewed six patients with squamous cell carcinoma of the anus (SCCA) and human immunodeficiency virus (HIV) infection treated between 1985 and 1988. All six patients were homosexual men. Five patients had AIDS and one was HIV-positive. The most common symptoms and signs were pain (n=5), mass (n =5), and bleeding (n=5). The average tumor size was 3.2 cm with a range of 1–10 cm. Five tumors were located in the anal canal and one at the anodermal junction. One patient was treated with biopsy alone, one with local excision, one with wide local excision and radiation therapy, and two with diverting colostomy. The average follow-up was 8 months. Of the five AIDS patients, two died, one was transferred to a hospice facility, one was lost to follow-up, and one remains alive 1 year following treatment. The HIV-positive patient died secondary to metastatic SCCA. This group of patients raises the question of a possible association between HIV and SCCA.     

Neuroendocrine cancers of the colon and rectum

PURPOSE: Our goal was to define the incidence of neuroendocrine carcinomas of the colon and rectum, the patterns of neuroendocrine expression, and the cellular subtype within neuroendocrine tumors. We attempted to determine whether differences in neuroendocrine expression or specific cell type influenced survival. METHODS: Over a ten-year period, 988 patients had resections for colorectal cancer. Using immunohistochemical staining methods specific for neuroendocrine markers, 39 (3.9 percent) neuroendocrine cancers were identified retrospectively. Tumors were also stained with monoclonal antibody A-80 which is specific for exocrine differentiation. In this way we were able to determine the extent of neuroendocrine differentiation such as pure neuroendocrine, predominant neuroendocrine, and equal neuroendocrine-exocrine expression. RESULTS: Average patient age was 65.5 (range, 28–89) years; there were 25 males and 14 females. Nineteen tumors were located in the right colon, 11 in the left, and 9 were in the rectum. Three histopathologic patterns were identified: pure neuroendocrine (n=11), predominantly neuroendocrine (n=17), and cancers with equal exocrine and neuroendocrine differentiation (n=7). Three cellular subtypes were seen: small-cell (n=15), intermediate-cell (n=15), and well-differentiated neuroendocrine cancers (n=5). There was one Dukes A cancer, 7 Dukes B, 16 Dukes C, and 15 patients had metastases to distant sites at the time of diagnosis. As a group, neuroendocrine tumors have a poor prognosis: six-month survival was 58 percent, three-year survival was 15 percent, and five-year survival was 6 percent. Survival statistically correlated with tumor stage (P=0.01) but not with age, sex, tumor location, histopathologic pattern, or neuroendocrine subtypes. Median survival for pure neuroendocrine carcinomas was seven months and for predominantly neuroendocrine carcinomas was five months. Tumors with equal neuroendocrine and exocrine differentiation had a median survival of 22 months (P=0.3). Small-cell neuroendocrine carcinomas had a median survival of five months, intermediate-cell had 11 months, and well-differentiated had a median survival of 22 months (P=0.1). CONCLUSIONS: Neuroendocrine differentiation is found in at least 3.9 percent of colon and rectal cancers. Many of these tumors were initially diagnosed as carcinoids, the diagnosis was changed to neuroendocrine carcinoma after immunohistochemical staining. Overall survival is poor especially for small-cell and pure neuroendocrine carcinomas.Supported by the Bowman Research Fund, Chicago, Illinois.Read at the meeting of The American Society of Colon and Rectal Surgeons, San Francisco, California, June 7 to 12, 1992.     

Adenosquamous carcinoma of the colon and rectum

PURPOSE: Adenosquamous carcinomas of the colon and rectum are rare tumors. These tumors have malignant glandular and squamous components capable of metastasizing. We report seven patients with adenosquamous carcinoma of the colon and rectum and their clinical outcomes. METHODS: Retrospective review was undertaken of seven patients who were identified by the tumor registry at Roswell Park Cancer Institute between 1971 and 1994. RESULTS: These represent a 0.18 percent incidence of adenocarcinomas in our institution. There were five tumors located in the rectum and two in the colon. All patients were Stage III or IV on presentation. Median overall survival was 23 months. In three patients, the tumor was associated with ulcerative colitis; in one of these patients, hypercalcemia was present. All patients died of their disease or with the disease. CONCLUSIONS: Previously reported aggressive behavior of this cancer is confirmed in our series.     

Primary signet-ring cell carcinoma of the colon and rectum

PURPOSE: Colorectal signet-ring cell carcinoma (SRCC) is uncommon; discordant data have been previously reported about clinicopathologic features. Thirty-four cases of primary colorectal SRCC were retrospectively reviewed to clarify controversies. METHODS: Primary colorectal SRCC was diagnosed when the following criteria were satisfied: 1) the tumor was primary; 2) histologic material was adequate; 3) signet-ring cell represented more than 50 percent of the cancer. RESULTS: We identified 34 cases (1.1 percent) of 2,995 consecutive large bowel cancers collected at the Institute of Anatomic Pathology of Florence between 1985 and 1993. Patients ranged in age from 31 to 89 (mean, 63.5; median, 65) years; 19 were male, and 15 were female (male:female=1.31). Fifteen tumors were located in the proximal colon, 11 in the rectum, and 8 in the distal colon. The gross shape was infiltrative in 24 cases and exophytic in 10; only 6 cases (17.6 percent) showed features of linitis plastica. Most cancers (61.8 percent) were Stage C, 29.4 percent were Stage B, and distant metastases were present in only three cases (8.8 percent). No Stage A case was found. Prognosis was extremely poor, and overall five-year survival rate was 9.1 percent. Survival was influenced significantly by tumor stage (P <0.01). CONCLUSIONS: Comparison of our data with the literature showed many differences that could be related to different applied diagnostic criteria. We underlined the importance of histology as reproducible criterion for diagnosis of primary colorectal SRCC.     

Clinical significance of diminutive polyps of the rectum and sigmoid colon

A retrospective review of 637 consecutive colonoscopies with polypectomy in 526 patients was performed to determine the association of small polyps of the rectum and sigmoid colon with more proximal colonic neoplasms. All colonic polyps were proximal to the sigmoid colon in 117 procedures. Proximal neoplasms were found in 32 percent of patients with a single polyp in the rectum or sigmoid colon. The incidence increased to 83 percent for those with three or more polyps. The occurrence of proximal colonic neoplasms was not affected by the size or histologic type of the rectosigmoid polyps. These findings would suggest that total colonic evaluation be considered in all patients with a polyp in the rectum or sigmoid colon regardless of the size or histologic type of the polyp.     

Quantitative cultures of the mucosalassociated bacteria in the mechanically prepared colon and rectum

Little is known about the mucosal microflora of the colon and rectum at the time of elective surgery. Our objective was to determine the concentrations of anaerobic and aerobic bacteria associated with the mucosa of the mechanically prepared large bowel. Ten patients were studied after a standard polyethylene glycol-electrolyte lavage preparation. No patient had taken antibiotics in the preceding four weeks. Sterile wire brushes passed through the colonoscope during advancement were used to culture the rectal, transverse colon, and cecal mucosa. Total anaerobic, aerobic, Gram-positive, and enteric bacterial counts were determined along with specific cultures for Bacteroides fragilis, Clostridium difficile, Escherichia coli, Pseudomonas aeruginosa,enterococcus, and staphylococcus species. The results showed that there was a significant increase (P<0.01) in aerobes, anaerobes, enterics, Gram positives,B. fragilis,and E. coli mucosal counts with proximal progression. Aerobes showed a steady gradient, while anaerobes demonstrated an increase from the rectum to the transverse colon but no change between the transverse colon and cecum. We conclude that, in the prepared bowel, there is an increase in the mucosal bacterial counts in the more proximal portions of the bowel. The results may serve as a baseline for future studies on the mucosal-associated bacteria of the large intestine.This research was supported by the scientific division of Miles Pharmaceuticals.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, San Francisco, California, June 7 to 12, 1992.     

Endoscopic appearance of the colon and small intestine of a patient with hemorrhagic enteric graft-vs.-host disease

Endoscopic appearance of the gastrointestinal tract of a patient with severe hemorrhagic enteric graft-vs.-host disease (GVHD) is presented. A 29-year-old man with chronic myelogenous leukemia suffered from severe enteric GVHD after allogeneic bone marrow transplantation. Endoscopy showed hemorrhagic ulceration of the upper jejunum, terminal ileum, and colon at the onset of melena. Sections of biopsies were compatible with acute GVHD. Repeat endoscopy showed gradual healing of the lesions after steroid pulse and antilymphocyte globulin therapy, but the patient died of cytomegalovirus pneumonitis 14 months later. Autopsy revealed submucosal fibrosis of the small intestine and colon.     

Oral administration of cyclosporin does not prevent expansion of antigen-specific,gut-associated,and spleen lymphocyte populations duringChlamydia trachomatis proctitis in nonhuman primates

To study the effects of oral cyclosporin (CsA) administration on immune responses in the gastrointestinal tract, humoral and cellular immune responses were studied in CsA-treated nonhuman primates having Chlamydia trachomatis proctitis (lymphogranuloma venereum, LGV). There was no apparent effect of CsA treatment on the gross or microscopic appearance of LGV proctitis, but CsA-treated animals, with or without LGV infection, had lymphoid hyperplasia of spleen and mesenteric lymph nodes. CsA treatment inhibited the primary antibody response to LGV, inhibited peripheral blood lymphocyte mitogen-induced proliferation and IL-2 production, and inhibited LGV-specific proliferation of peripheral blood lymphocytes. In contrast, mitogen-stimulated proliferation of spleen, mesenteric lymph node, and lamina propria lymphocytes was not significantly inhibited in CsA-treated animals. In addition, LGV-specific proliferation of spleen and mesenteric lymph node lymphocytes was not inhibited. High mitogen-stimulated IL-2 production of lamina propria lymphocytes was only partially inhibited in CsA-treated animals. In vitroCsA treatment had the expected inhibitory effects on mitogen- and antigen-induced proliferation of spleen and mesenteric lymph node lymphocytes. Thus, although oral cyclosporin inhibits the antibody and proliferative responses of peripheral blood lymphocytes to antigens and mitogens in animals having Chlamydia trachomatis proctitis, it does not prevent the expansion of antigen-specific, gut-associated, and spleen lymphocyte populations.Part of this work has been published as a preliminary report in abstract form (Clinical Research 34:446A, 1986).     

Clinical,demographic, and follow-up characteristics of patients with two primary metachronous tumors,one of them being in the colon

The clinical characteristics of 152 patients diagnosed with two primary metachronous tumors—one or both of them in the colon—were studied. Nineteen patients had both primary tumors in the colon (Group I), 59 had the first primary tumor in the colon and the second tumor elsewhere (Group II), and 74 had the second primary tumor in the colon and the first primary tumor elsewhere (Group III). The group in which the second primary tumor was in the colon included significantly more female patients than did the other two groups, with a younger median age at diagnosis of first tumor. The median time interval between the two primary tumors was 44, 57, and 62 months in Groups I, II, and III, respectively. The number of clinic visits during the year before diagnosis of the second primary was similar in all groups, but only 60 percent of the patients kept their follow-up appointment. In most instances, the diagnosis was made after the patients' symptoms, although only a small percentage of the second primary tumors (15–30 percent) were diagnosed during routine follow-up. The second primary tumor occurred in the field of radiotherapy of the first primary tumor in 27 of 35 patients who received radiotherapy. To increase the number of patients diagnosed in an earlier stage of disease, they should be urged to keep their follow-up appointment, and physicians following patients with single tumors should be aware of the increased likelihood of a second tumor. To increase the cure rate of those tumors, efforts toward early diagnosis are warranted. This includes physical examination and mammography to detect breast cancer in women, annual occult blood tests and rectal examination, and sigmoidoscopy or colonoscopy at three-year intervals to detect colon cancer early     

Intravenous Immunoglobulin for the Treatment of Severe, Refractory, and Recurrent Clostridium difficile Diarrhea

Purpose Clostridium difficile diarrhea is common in elderly patients and leads to prolonged hospitalization. Patients with severe or recurrent Clostridium difficile diarrhea have poor antitoxin antibody responses. Intravenous immunoglobulin has been advocated in these patients. This study was designed to assess the response of patients with refractory, recurrent, or severe Clostridium difficile diarrhea to intravenous immunoglobulin. Methods Retrospective review (November 2003–January 2005) of 14 patients with severe, refractory, recurrent Clostridium difficile diarrhea treated with intravenous immunoglobulin (Flebogamma^?, 150–400 mg/kg) from 264 Clostridium difficile toxin-positive patients. Results Median age was 79 (range, 54–91) years. Median length of symptoms before intravenous immunoglobulin was 29 (range, 3–90) days. Patients received a median of three (range, 1–5) courses of vancomycin or metronidazole before intravenous immunoglobulin. All had hypoalbuminemia (median, 22 g/l; range, 18–33) and raised C-reactive protein (median, 47 mg/l; range, 25–255) at time of infusion. The median white cell count was 15.3 × 10⁹/liters (range, 4–24). Eight patients had evidence of pancolitis on abdominal imaging, suggesting severe Clostridium difficile diarrhea. All patients tolerated intravenous immunoglobulin without side effects. Nine (64 percent) responded with bowels normalizing in a median of ten (range, 2–26) days; one patient received two doses. One patient had a partial response from two doses but died two months later after a recurrence. The other four patients died of other causes within three weeks of infusion. Conclusions Intravenous immunoglobulin may be effective for severe, refractory, or recurrent Clostridium difficile diarrhea after failed conventional treatment. Presented at Digestive Diseases Week, Chicago, Illinois, May 14 to 19, 2005, and the meeting of the British Society of Gastroenterology, Birmingham, England, March 14 to 17, 2005. Reprints are not available.