E.Stein Anorectal and Colon Diseases Springer Berlin Heidelberg NewYork Hong Kong London Milan Paris Tokyo E. Stein Anorectal and Colon Diseases Textbook and Color Atlas of Proctology
With 368 Figures in 878 Separate Illustrations, Mostly in Color and 54 Tables
Springer Dr. med. Ernst Stein Arzt fur Dermatologie - Allergologie Schwetzinger Str. 35,67117 Limburgerhof, Germany
Translator: Walter H. C.Burgdorf, M. D.
Title of the original German Edition: Proktologie, 4.Auflage © Springer-Verlag Berlin Heidelberg 1986, 1990, 1998,2003 ISBN 3-540-43033-4
ISBN 3-540-43039-3 Springer-Verlag Berlin Heidelberg NewYork
Cip data applied for Die Deutsche Bibliothek - CIP-Einheitsaufnahme Stein, Ernst: Anorectal and colon diseases : textbook and color atlas of proctology; with 54 tables I E.Stein. [Trans!.: Walter H. C.Burgdorf) . - Berlin ; Heidelberg; New York; Hong Kong; London ; Milan; Paris; Tokyo: Springer, 2003 Einheitssacht.: Proktologie
I am particularly pleased that my long desire to have my Ger• man textbook and color atlas of proctology appear in English has finally been fulfilled. Simultaneously with the writing of the 4th German edition, I worked together with W. H. C. Burgdorf to produce an English translation. I hope Anorectal and Colon Diseases will enable a greater number of readers around the world to acquaint themselves with this important multidiscipli• nary specialty.
Limburgerhof, August 2002 Ernst Stein Preface to the 4th German Edition
Since the 3rd edition of my book Proktologie was well received and soon became unavailable,I seized the opportunity to pre• pare this 4th completely revised edition. I want to thank many readers for their helpful suggestions and hope that I will receive additional ideas and comments from those who use this edition. In order to avoid producing a dinosaur of a book, I have once again tried to concentrate on relevant concepts and to present complex issues in a highly structured, easily understandable format. Because of this philosophy, I have been able to keep the book roughly the same size despite adding many new topics, pictures and references. I have devoted special attention to practice-oriented recom• mendations for diagnosis and therapy, relying heavily on the available evidence-based guidelines of various German specialty groups. In addition, the index has been expanded and I have attempted to make the cross-referencing within the text even more extensive. Finally, pertinent new references are included to make it easier for readers to obtain additional information on the topics of their choice. The book is designed for internists, family physicians, surgeons, urologists, dermatologists, gynecologists, pathologists, radiolo• gists and parasitologists, and especially for medical students, for whom it will hopefully serve as an early introduction to an often overlooked part of their education.
Lirnburgerhof, August 2002 Ernst Stein Preface to the 1st German Edition
The rapid advances in all facets of medicine, as well as our in• creased appreciation for the multidisciplinary aspects of many diseases, have unavoidably led to an expansion of the field of proctology. Proctology cannot be considered as the domain of any single medical specialty, especially since so many proctologic diseases require the efforts of multiple specialists for proper diagnosis and management. Instead, proctology should be viewed as a specialty in its own right, encompassing skills and knowledge from gastrointestinal or endoscopic surgery, internal medicine, dermatology, allergy, urology, microbiology, mycology, parasi• tology, and histopathology. Many diseases which were formerly considered non-treatable can today be cured or well controlled, thanks to the develop• ment of highly effective medications, new operative techniques, and other therapeutic approaches. In order to take advantage of these advances, the diseases must be diagnosed precisely and as early as possible. When one considers the consequences of long• term symptomatic therapy of perianal skin diseases such as ex• tramammary Paget disease which can so easily mimic a derma• titis, or the deadly error of delayed diagnosis of a carcinoma of the rectum while hemorrhoidal ointments or suppositories are prescribed, then the reasons for my plea for exact, early diag• nosis become more clear. Prompt and appropriate diagnosis and treatment of proctologic diseases is not achievable today without extensive cooperation between various specialists. Specialty pride and turf battles have no place in modern care. Each colleague should strive to pro• vide only those services which he or she can deliver expertly. Otherwise we face the danger of losing one of the most impor• tant features of our profession, the trust of our patients. The rapid, sometimes explosive advances in medicine mean that all medical publications age rapidly. The number of journal ar• ticles makes it more and more difficult to follow even a single specialty, keeping up with important diagnostic and therapeutic advances. Thus single-author authoritative textbooks appear today to be almost an anachronism, as most new textbooks have multiple editors and even more authors. I never had the illusion I could completely cover a subject as complex as proctology in a single book. Instead, my goal is to outline the possibilities and limitations of the modern evolving specialty of proctology. I have tried to present the essentials of X Preface to the 1st German Edition those diseases which traditionally belong to proctology as well as of the many disorders in which a proctologist may be called upon to help with the management. In each instance I have tried to present practice-relevant aspects of the etiology, clinical fea• tures, diagnosis, and therapy. This book is designed to be didactically sound and practice• oriented without detailed theoretical discussions. New or un• proved theories of pathogenesis, as well as untried or poorly tested therapeutic options, have been omitted. In addition, I have not attempted to describe any surgical pro• cedures in detail. The reader is referred to the numerous excel• lent textbooks and atlases of gastrointestinal and rectal surgery for more detailed information. Each section is uniformly struc• tured and followed by literature references which will help the reader further explore the topic. Proctology is a highly visual specialty; one must learn how to see and interpret not only direct visual findings but also endo• scopic images. For this reason, I have devoted special attention to providing numerous color pictures. In this way, the many different facets of a given disease can be shown, in order to make the characteristic features clearer and enable the exami• ning physician to make the correct diagnosis with greater fa• cility. My hope is that this book makes a contribution to the recogni• tion of proctology as an increasingly independent medical dis• cipline, while at the same time emphasizing that the approach to diagnosis and treatment of proctologic disorders must remain multidisciplinary. If these goals are achieved, then although this book may have only fleeting utility, my efforts will not have been in vain.
Ludwigshafen/Rhine, March 1986 Ernst Stein Acknowledgments
Many colleagues from various specialties helped me with the preparation of the 4th edition of this book. I would like to ex• press my thanks to all them for their efforts in reviewing var• ious sections of my text: Dr. W.H. C.Burgdorf (Tutzing, Germany), dermatologic disor• ders; Prof. Dr. J. F. Riemann (Ludwigshafen/Rhine, Germany) , colitides; Prof. Dr. H.Mehlhorn (Diisseldorf, Germany), parasitic diseases; Prof. Dr. W.lost (Wiesbaden, Germany), the techniques of defecography, biofeedback, manometry and electromyogra• phy; Prof. Dr.Dr. G.Schmidt (Heidelberg, Germany), forensic aspects of injuries in the colon, rectum, and sphincter regions. Furthermore, I would like to thank Prof. Dr. E.Schopf (Freiburg/ Br., Germany), Dr. H. Mlitz (Saarbriicken, Germany) and Dr. D.Bohringer (Karlsruhe, Germany) for many helpful suggestions. I am very grateful to Mr. J.Engelbrecht and Mrs. 1. Oppelt of Springer-Verlag for their encouragement and support in manag• ing the technical aspects of this publishing venture. Numerous pictures were given to me for use in this book by colleagues in many specialties from around the world. I would like to thank them all in the following list. If I have forgotten anyone, it was surely unintentional and I apologize profusely.
- Prof. Dr. F. A.Bahmer, Bremen, Germany Fig.3.19 a-c - Prof. Dr. V.Becker, Erlangen-Niirnberg, Germany Fig. 16.29 - Dr. R. S. Berardi, Des Moines, Iowa, USA Fig. 3.49 a-c - Prof. Dr. H. Birzle, Ludwigshafen/Rhine, Germany Figs. 24, 25, 3.7b, 4.2a, 14.13, 14.39, 14.40, 16.21 - Dr. D. Bohringer, Karlsruhe, Germany Fig. 17 b - Dr. W.H. C. Burgdorf, Tutzing, Germany Figs. 2.8, 2.23, 2.31 a, b, 2.43 a, b, 2.52 a, b, 2.65, 2.67, 2.76, 2.86a-c - Dr. H. B. Carstens, Louisville, Kentucky, USA Figs. 14.27, 14.29, - Dr. L.Corey, Seattle, Washington, USA Fig. 2.34 - Prof. Dr. A.E. Daccach, Guayaquil, Ecuador Figs. 2.30 e, 14.25 - Prof. Dr. T.C. B. Dehn, London, Great Britain Fig. 3.30 a, b - Dr. U. Detmar, Munich, Germany Fig. 15.22 XII Acknowledgments
- Dr. W.Dietze, Ludwigshafen/Rhine, Germany Figs. 17a, 20, 22, 23, 1.9c, e, 1.11a, 1.15a, 3.3g, k, 3.7 c-e, 3.15 d, f, 3.16a, 14.1k, I, 14.30b, c, e - Prof. Dr. F. Ehring, Miinster-Handorf, Germany Figs. 15.21 a-c, 15.19 - Prof. Ch. Ell, Wiesbaden, Germany Fig. 3.42a, b - Prof. Dr. K.Ewe, Mainz, Germany Fig. 3.5 a, - Dr. G.Di Febo, Bologna, Italy Fig.3.47b, c - Prof. Dr. G.Feifel, Homburg/Saar, Germany Fig. 28 - Dr. K. Fenn, Bruchsal, Germany Figs.8.2a, 15.9 b - Priv. Doz. Dr. H. S. FiieBl, Munich, Germany Fig. 3.3 m, n - Dr. F. Gabrielli, Trieste, Italy Fig. 14.41 e - Prof. Dr. H. R.Gelderblom, Berlin, Germany Fig. 15.37 - Dr. B.E. Genter, Jenkintown, Pennsylvania, USA Fig. 3.40 a-c - Prof. Dr. P.Gerhard, Munich, Germany Figs.3.7a, 8.4 a, b. 14.31, 14.37a, b - Prof. Dr. M. Gloor, Karlsruhe, Germany Fig. 3.41 a, b - Prof. Dr. K.-J.Goerg, Wuppertal, Germany Fig. 3.54 a, b - Dr. D.Goldmeier, London, Great Britain Fig. 2.33 a - Dr. A.van Gompel, Leuven, Belgium Figs. 3.38, 3.39 a, b, 3.45 a, b, 3.46, 3.47 a, 3.48 b - Dr. S.E.Goodell, Washington, USA Fig. 2.33 c - Prof. Dr. H. Graffner, Helsingborg, Sweden Fig. 5.3 - Prof. Dr. W. Grill, Starnberg, Germany Figs. 3.5 d, 3.8 a-c, 3.19 e - Prof. Dr. G.Gross, Rostock, Germany Fig. 2.39 - Prof. Dr. E.1.Grussendorf-Conen, Aachen, Germany Fig. 2.50 - Dr. G.D. Guest, Victoria, Australia Fig. 14.5 a, b - Prof. Dr. T.Giirgen, Istanbul, Turkey Fig. 3.27 c - Dr. J.Hadlich, Erfurt, Germany Fig. 2.62 b - Kl.Hain, Nehren, Germany Figs. 32, 33 a-d, 34 a, b, 35, 36a, b - Dr. B.Hammer, St. Gallen, Switzerland
Fig. 3.5e, e1 - Prof. Dr. K.Hasegawa, Tokyo, Japan Fig. 3.39 d, e Acknowledgments XIII
- Dr. N. Heger, Saarbriicken, Germany Figs. 3.3 0, 3.5a, 4.2d, 5.2, 8.2b, 14.11 h, 14.15b, 14.32, 14.36 a-c - Dr. A.Heidelberger, Niirnberg, Germany Fig. 2.28 - Prof. W.-P. Herrmann, Bremen, Germany Fig. 15.17 - Prof. Dr. C.J.Hobbs, Leeds, Great Britain Fig. 9 - Prof. Dr. O. P.Hornstein, Erlangen, Germany Fig. 2.83 - Dr.med. E.Hoting, Hamburg, Germany Fig. 2.85 a - Dr. J. Iongen, Kiel, Germany Fig.3.15 h - Prof. Dr. W.lost, Wiesbaden, Germany Figs. 26, 31 - Prof. Dr. E.G.lung, Mannheim, Germany Fig.38, 2.30 d. , 2.57, 2.62 a, e, 2.70d, 2.74, 3.25 h., i, n, 15.28a, d, 15.29c, d, 15.30, 15.33 b - Priv. Doz. Dr. M. Kahle, Giessen, Germany Fig. 14,41 a - Dr. D.Kanto, Rio de Janeiro, Brazil Fig. 14.9 a - Dr.J.C. Kim, Seoul, Korea Fig. 15.8 a-f - Prof. Dr. Dr. H.-G. Knoch, Bad Salzuflen, Germany Figs. i .i a, d, f, ILl - Prof. Dr. J.Koo, Edmonton, Alberta, Canada Figs. 15.16, 15.23c, d, 15.24a, b - Prof. Dr. G. W.Korting, Mainz, Germany Figs. 2.68b, 2.82 b - Prof. Dr. E.Landes, Darmstadt, Germany Figs. 39, 2.54, 2.70b, 2.72 a, 2.75, 2.82 a - Prof. Dr. A.Landsberger and his son Anselm, Heidelberg, Germany Figs. 1, 2a, b, 3a, b, 4a, b, 5, 6, 7,10,13,14,19,1.17,1.19,12.1 - Dr. B.H. Lenhard, Heidelberg, Germany Figs. 3,44 a, b, 15.38b, 15,41 b - Prof. Dr. D. J. C.Levasseur, Reims, France Figs. 3.31 a, b, 3.32, 3.33 - Dr. R. Lorenz, Munich, Germany Fig. 3,4 b - Dr. Ph. van Maercke, Cologne, Germany Fig. 2.60 - Prof. Dr. B.C.Manegold, Mannheim, Germany Figs.Ll b, 1.9f, 2.35e, 2.68c, 2.84f, g, 3.3 k. , 3.5 d., 3.10, 3.15 fl> 3.16c, 3.29d, 3.36, 3.52a, b, 3.53a, b, 5,4, 9.1, 9,4,9.5,9.6, 14.8a, 14.21, 14.30a, d, 14.35, 14.38 - Prof. Dr. J.Maufl, Diisseldorf, Germany
Figs. i.i h, Ll1 c, Ll8 d, 2.5 0 1-04, q, 2,44 b, 2.50 b, 2.62f, 2.70 el' e2, 2.72b, 3.13b, 3.15a, b, 3.27 al' d, 15.27c, 16.17 - Prof. Dr. H. Mehlhorn, Diisseldorf, Germany Figs. 16.1, 16.3, 16,4 a-d, 16.6 a-c, 16.7a, b, 16.8a, b, 16.9a, b, 16.10a, 16.11a, b, 16.12a, b, 16.13 a-c, 16.14 a-e, 16.15 a-c, 16.16 a-c, 16.18a, b, 16.19c, d, 16.20, 16.22 a-c, 16.23, 16.24, 16.25, 16.26, 16.27, 16.28, 16.30a, b, 16.31, 16.32, 16.33a, b, 16.34, 16.35, 16.36a, b, 16.37b, XIV Acknowledgments
16.38a, 16.40, 16.41 a-c, 16.42a, b, 16.43a, b, 16.44a, b, 16.45a, b, 16.46 b-d, 16.47, 16.48, 16.49 a-c - Prof. Dr. W.N.Meigel, Hamburg, Germany Fig. 15.39 a - Prof. Dr. R. Mennigen, Steinfurt, Germany Figs. 29, 30 - Dr. M. Merlini, Lausanne, Switzerland Fig. 15.36 e - Dr. S.Meryn, Vienna, Austria Fig. 2.81 - Prof. Dr. R. Michalowski, Lublin, Poland Fig. 2.70 f - Dr. H. Mlitz, Saarbriicken, Germany Figs. 1.1 d ., 1.2 a, b, 1.13, 1.18c, 2.5 u, 2.46 c, 2.49, 2.51 a, b, 2.87 a, 3.7 k, 1,
3.13d, 3.15g, 3.16b, 3.1ge, 3.23, 3.29 cp 3.37a, 3.39 cp c2' 3.48 b p 3.51, 7.1 b., 8.1 a-d, 8.3, 9.2, 9.3,10.1,10.2,14.6,14.7, 14.15a, 14.22c, d, 15.1 b - Dr. 1. Nakada, Tokyo, Japan Fig. 3.28 a-e - Prof. Dr. Th. Nasemann, Hamburg, Germany Fig.3.13 a - Prof. Dr. F. Niedobitek, Berlin, Germany Fig. 14.3 - Dr. M.-E.Olszewsky, Furth, Germany Fig. 2.5 t - Prof. Dr. Dr. H. F. Otto, Heidelberg, Germany Figs. 3.1 a-i, 3.2 a-f, 3.5b, b. , c, 3.8d, 3.11 a, b, 3.12a, b. 3.18, 3.50, 3.55c, 5.1, 7.1e, 14.2, 14.10, 14.11g, 14.12a, b, 14.17, 14.23 a-c, 14.24, 14.28, 14.34, 15.2, 15.43 - Prim. Dr. W.Pachinger, Klagenfurt, Austria Fig. 2.64 f - Dr. K.-P. Peters, Erlangen, Germany
Figs. 2.5 r, rp s, 14.30 e1 - Prof. Dr. D.Petzoldt, Heidelberg, Germany Figs. 15.26, 15.29 b - Ass. Dr. W.Pimpl, Salzburg, Austria Figs.I4.16a, b, 14.19 - Prof. Dr. M. Poll, Liibbecke/Westfalen, Germany Fig. 14.26 a-c - Dr. H. van Poppel, Leuven, Belgium Figs. 15.10, 15.11 - Dr. C. Povysil, Prague, Czech Republic Fig. 6.3 b - Prim. Doz. Dr. H. J.Prexl, Voitsberg, Austria Fig. 4.2 b - Dr. K. Rappersberger, Vienna, Austria Fig. 2.66 a-d - Prof. Dr. K.Remberger, Homburg/Saar, Germany Figs.2.87b, 3.37 b - Prof. Dr. J. F. Riemann, Ludwigshafen/Rhine, Germany Figs. 14.14, 14.20, 15.1 a - Dr. W.G.Robertson, Santa Barbara, California, USA Fig. 2.88 a, b - Dr. A.M. Rywlin, Miami Beach, Florida, USA Fig. 6.3 a - Prof. Dr. P.L. Samarasinghe, London, Great Britain Fig. 2.33 b Acknowledgments XV
- Prof. Dr. K. P. Schaal, Bonn, Germany Figs. 15.6, 15.12, 15.13, 15.14a, b - Pr iv.Doz. Dr. R. Schaller, Hamborn, Germany Figs. 6.1, 6.2a, b - Dr. H. Schmelzer, Munich, Germany Fig. 27 - Prof. Dr. Dr. U. W. Schnyder, Ziirich, Switzerland Figs. 37, 2.3 a, b, 2.6a, b, 2.10, 2.21, 2.25, 2.27a, 2.36, 2.38 a, b, 2.41 a, b, 2.44 a, 2.45, 2.48, 2.55, 2.61, 2.62d, 2.63, 2.68 a, 2.69, 2.71, 2.73, 2.78, 2.79 a-c, 2.80, 3.14a, b, 3.24 a, b, 3.43 a-c, 15.5a, b, 15.27a, 15.32, 15.33a, 15.34, 15.35a, 15.36 a, c - Priv. Doz. Dr. H. H. Schofer, Frankfurt, Germany Figs.2.47, 15.38a, 15.40, 15.41 a - Prof. Dr. E. Schopf, Freiburg/Breisgau, Germany Figs. 1.9a, 1.20 b, 2.2 b, 2.4 a, 2.5 p, 2.42 b, 2.46 a, 2.70 a, 2.72 d, 2.77b, c, e, 2.84a, 3.13c, 3.20b, 3.21 a, b, 3.22a, b, 14.4, 15.20a, b. 15.28 c, 15.36 b, 15.42 b - Prof. Dr. H. M. Seitz, Bonn, Germany Figs. 16.5 a, b, 16.19a, b, 16.30c, 16.33c, d, 16.37a, 16.39 a, b, 16.46 a - Dr. J. O.Sieck, Riyadh, Saudi Arabia Fig. 15.23 a, b - Dr. C. Sousa, Porto, Portugal Fig. 3.39 f - Dr. A. Stary, Dortmund, Germany Fig. 2.24 - Dr. D.Stenger, Dillingen, Germany Figs. 1.20 e, 2.5 c, ql' 2.46 b, 2.62 el' 2.84 e, 3.15 e - Prof. Dr. E. Strunk, Siegen, Germany Fig. 4.3 - Prof. Dr. G.Stiittgen, Berlin, Germany Fig. 15.36 d - Prof. Dr. R. H.Thorlakson, Winnipeg, Manitoba, Canada Fig. 3.34 a-c - Dr. J.J. Tjandra, Parkville, Australia Fig. 2.84 b-d, h - Dr. Y.Tomiki, Tokyo, Japan Fig.3.9 a- d - Prof. Dr. G.Triadafilopoulos, Palo Alto, California, USA Fig. 14.33 d - Dr. M. Varney, Diisseldorf, Germany Fig.4.2 c - Prof. Dr. 1. Weber, Ulm, Germany Figs. 15.5c, d, 15.9a, 15.15 - Prof. Dr. K.Wegener, Ludwigshafen/Rhine, Germany Figs. 2.26 a, b, d, 3.17, 3.25 b, 4.1 a, b, 7.2, 14.1 b, 14.8, 14.42, 15.4 - Prof. Dr. J. P.Weill, Strasbourg, France Fig. 3.55 a, b - Prof. Dr. V. Wienert, Aachen, Germany Figs. 1.11 b, 2.2c, 2.35d, 2.44c, 2.70c, 2.82c, 15.18, 15.28e, f - Prof. Dr. J. L. Williams, Sheffield, Great Britain Fig. 5.5 - Prof. Dr. R. K. Winkelmann, Rochester, Minnesota, USA Figs. 2.30 el' 2.85 b, 3.4 a, c-e - Dr. M. Winzer, Liibeck, Germany Fig. 15.39 b XVI Acknowledgments
- Prof. Dr. H. H. Wolff, Lubeck, Germany Figs. 2.53, 2.56 a, b - Dr. R.Wotzka, Munich, Germany Fig. 3.42 c - Dr. Th. K.Wu, New York, New York, USA Fig. 3.48c, d - Dr. E.Zillessen, Bad Neuenahr, Germany Figs. 1.1c, e, 1.7d, 2.29 a, b, 3.3 a-f, h-j, 1, 3.7 f-j, 3.29 a-c, 3.35, 3.48a, 7.1 a-d, 14.1 c-j, 14.9b, 14.11 a-f, 14.18 b-e, 14.22a, b, 14.33 a-c, 14.41 b-d, 15.3, 15.7, 15.9c, 15.44, 16.38b, c - Prof. Dr. A.Zissiadis, Thessaloniki, Greece Fig. 1.10 Table of Contents
Introduction
Anatomy of the Anorectal Region 3 Anal Canal 3 Rectum 3 Musculature of the Pelvic Floor 6 Pelvic Connective Tissue 6 Anorectal Veins 9 Anorectal Arteries 9 Anorectal Nerves 9 Anorectal Lymphatics 11
Physiology and Pathophysiology of Anorectal Function 13 Continence 13 Incontinence 15
The Proctologic Examination 19 Examination Positions 19 Disinfection and Sterilization 20 Methods of Evaluation 27 History 27 Physical Examination 28 Digital Examination 29 Speculum Examination 30 Proctoscopy and Anoscopy 31 Rigid Rectosigmoidoscopy 33 Flexible Rectosigmoidoscopy 37 Colonoscopy 38 Imaging Studies 41 Sonography 46 Anorectal Manometry and Electromyography 47 Mycological and Bacteriological Evaluation 50 Allergological Testing Methods 59 Cancer Prevention 64 XVIII Table of Contents
Anorectal and Colon Diseases
1 Hemorrhoidal Symptom Complex 71 1.1 Hemorrhoids 71 1.2 Anal Tags 79 1.3 Perianal Thrombosis 80 1.4 Anal Prolapse 82 1.5 Rectal Prolapse 84 1.6 Cryptitis and Papillitis 87 1.7 Hypertrophic Anal Papillae 88 1.8 Anal Rhagades and Erosions 90 1.9 Anal Fissure ...... 91 1.10 Anorectal Abscess ...... 97 1.11 Fistulas 101
2 Perianal Skin Diseases 107 2.1 Pruritus Ani 107 2.2 Side Effects of Topical Corticosteroids 109 2.3 Perianal Contact Dermatitis 112 2.4 Pigmentary Disorders 121 2.4.1 Perianal Hyperpigmentation 122 2.4.2 Perianal Depigmentation 124 2.5 Perianal Hematoma 128 2.6 Acne Tetrad 128 2.7 Pilonidal Sinus 133 2.8 Bacterial Diseases 135 2.8.1 Pyodermas 135 2.8.2 Perianal Streptococcal Dermatitis 135 2.8.3 Erythrasma 137 2.9 Tinea Inguinalis 138 2.10 Herpes Simplex 141 2.11 Herpes Zoster 147 2.12 Mollusca Contagiosa 151 2.13 Infections with Human Papilloma Virus ...... 154 2.13.1 Verrucae Vulgares ...... 155 2.13.2 Condylomata Acuminata 158 2.13.3 Bowenoid Papulosis 162 2.13.4 Bowen Disease 165 2.13.5 Verrucous Carcinoma 169 2.14 Epizoonoses 171 2.14.1 Scabies 172 2.14.2 Pediculosis Pubis ...... 176 2.15 Lichen Planus ...... 177 2.16 Lichen Sclerosus et Atrophicus 181 2.17 Acrodermatitis Enteropathica 184 2.18 Glucagonoma Syndrome 188 2.19 Acanthosis Nigricans 191 2.20 Darier Disease ...... 194 2.21 Hailey-Hailey Disease ...... 197 Table of Contents XIX
2.22 Porokeratosis of Mibelli 200 2.23 Inverse Psoriasis 202 2.24 Pemphigus Vegetans 207 2.25 Behcet Disease 210 2.26 Extramammary Paget Disease 214 2.27 Langerhans Cell Histiocytosis 218 2.28 Syringocystadenoma Papilliferum 220
3 Tumors and Tumor-like Lesions of the Colon, Rectum, Anus and Perianal Region 223 3.1 Epithelial Tumors 223 3.1.1 Colorectal Polyps ...... 223 3.1.2 Carcinomas 236 3.1.2.1 Colorectal Carcinoma 236 3.1.2.2 Anal Carcinoma 246 3.1.3 Neuroendocrine Tumors (Carcinoid Tumors) 254 3.2 Malignant Melanoma 257 3.3 Mesenchymal Tumors and Tumor-like Lesions ...... 265 3.3.1 Tumors of Fatty Tissue 266 3.3.2 Tumors of Muscle 272 3.3.3 Tumors of Blood Vessels 275 3.3.4 Tumors of Lymphatic Vessels 288 3.4 Lymphoma 288 3.4.1 Malignant Lymphoma 288 3.4.2 Pseudolymphoma 293
4 Endometriosis 295 5 Pneumatosis Coli 299 6 Malacoplakia 303 7 Melanosis Coli 307 8 Stenoses and Atresias 311 9 Injuries to the Colon, Rectum and Anal Sphincter 317 10 Descending Perineum Syndrome 325 11 Pectenosis 329 12 Coccydynia 331 13 Proctalgia Fugax 333 14 Inflammatory Diseases of the Colon, Rectum, Anus and Perianal Region 335 14.1 Crohn Disease 335 14.2 Ulcerative Colitis 351 14.3 Ischemic Colitis 363 xx Table of Contents
14.4 Collagenous Colitis 368 14.5 Pseudomembranous Colitis 371 14.6 Irritable Bowel Syndrome 376 14.7 Colitis Cystica Profunda 380 14.8 Solitary Rectal Ulcer 383 14.9 Diverticulosis and Diverticulitis 386 14.10 Radiation Proctitis 394
15 Infectious Diseases 399 15.1 Traveler's Diarrhea 399 15.2 Shigellosis 402 15.3 Yersiniosis 404 15.4 Campylobacteriosis 409 15.5 Actinomycosis 412 15.6 Tuberculosis 418 15.7 Gonorrhea 424 15.8 Syphilis 428 15.9 Chancroid 437 15.10 Granuloma Inguinale 440 15.11 Lymphogranuloma Venereum 442 15.12 HIV Infection/AIDS 445 15.13 Candidiasis 454
16 Intestinal Parasites 459 16.1 Laboratory Diagnosis of Intestinal Parasites 460 16.1.1 Stool Examination for Ova 460 16.1.2 Stool Examination for Protozoa 462 16.1.3 Serological Methods 463 16.1.4 Blood Eosinophil Count 463 16.1.5 IgE Measurements 464 16.2 Worms (Helminthes) 464 16.2.1 Flatworms (Platyhelminthes) 464 16.2.1.1 Flukes (Trematoda) 464 16.2.1.2 Tapeworms (Cestoda) 471 16.2.2 Roundworms (Nematoda) 480 16.3 Protozoa 495 16.3.1 Amebiasis 496 16.3.2 Giardiasis 500 16.3.3 Leishmaniasis 502 16.3.4 Balantidiasis 504 16.3.5 Sarcocystosis 505 16.3.6 Isosporiasis 507 16.3.7 Cryptosporidiosis 507 16.3.8 Microsporidiosis 509 16.3.9 Cyclosporiasis 510 16.3.10 Blastocystosis 510
Subject Index 513