Showa Univ J Med Sci 13(4), 315 319, December 2001

Case Report

Intractable Fissures in a Patient with Ulcerative

Naokuni YASUDA 1), Makoto WATANABE 1), H1rotaka TANAKA 1), Mlkl SHIBUSAWA2) and Mltsuo KUSANO 2)

Abstract : Anal fissures rarely occur in patients with . Here we report a 26-year-old man diagnosed with ulcerative colitis involving intractable anal fissures. The patient underwent restorative proctocolectomy for ulcerative colitis and sliding skin graft (SSG) for intractable anal fissures. Anal function was monitored by a manometric study. Generally, patients subjected to pouch surgery should retain fairly well-preserved anal sphincter muscle structure and function. A manometric study confirmed that SSG was an effective procedure for the preservation of the sphincter in patients receiving restorative proctocolectomy for ulcerative colitis and intractable fissures.

Key words : ulcerative colitis, intractable fissure, manometry

Introduction Anal fissures occur more rarely in ulcerative colitis than Crohn's disease. In this report, we present a patient subjected to sliding skin graft (SSG) for intractable anal fissures and restorative proctocolectomy for ulcerative colitis, with the monitoring of anal function by a manometric study.

Case Report

A 26-year-old Japanese man was admitted to hospital with severe anal bleeding. The patient was diagnosed with ulcerative colitis ( type) in July 1989. In 1993, the subject was prescribed prednisolone, 5-30 mg/day, and salazosulfapyridine, 3000 mg/day (or 5-ASA, 1500 mg/dav) by our medical department.

The patient was admitted to our hospital on August 15, 1997 due to bloody . At

the time of admission, height and weight measurements were 172 cm and 56 kg, respectively.

Medical examination revealed that the patient was very weak. Body temperature and pulse

rate were 36.8•Ž and 76 bpm, respectively. The blood pressure was 124/80 mmHg. Standard

laboratory tests were performed (Table 1). Three days after admission, severe bleeding was observed from the anus due to ulcerative colitis. Despite a consequent increase in prednisolone dosage to 60 mg, anal bleeding persisted. Thirteen days after admission, the patient went into shock due to amemia (hemoglobin count of 7.2 g/dl ), and was therefore given a blood transfusion at 6 units/day. Following transfusion, hemoglobin levels increased to 8.4 g/dl. Fifteen days after admission, the patient was referred to our department. He underwent an emergency operation of total colectomy with ileostomy and mucus fistula (Fig. 1). Two deep anal fissures were observed

1) Department of Surgery, Isesaki Municipal Hospital, 1180 Tsunatori-Town Isesaki, 372-0812, Japan, 2) Second Department of Surgery, Showa University 316 Naokuni YASUDA, et al

Table 1.

Fig. 1. Macroscopic appearance of resected . Inflamed mucosa and multiple ulcers are evident. at 0 and 6 o'clock respectively, during surgery (Fig. 2). On the second day after surgery, bleeding was noted from the mucus fistula. After treatment with enema kits containing 1.5 mg betamethasone (Steronema), bleeding ceased. The patient was discharged on the 60th day after surgery. Following improvement of the general condition of the subject, restorative proctectomy and SSG for persistent anal fissure were performed six months later (Fig. 3). Recovery was uneventful, and over the next several weeks, prednisolone dosage was rapidly reduced. The patient was discharged 18 days after the operation. Six months later, an examination was conducted under anesthesia because of persistent discharge from the anus. This revealed that the wound from SSG had not yet healed. After another six months, closure ileostomy was performed, following healing of the wound from the anal fissure. The patient was able to resume normal activities and return to work. Anal Fissures in Ulcerative Colitis 317

Fig. 2. Anal fissures are shown.

Fig. 3. SSG ; An elliptical incision is made around the fissure, dissecting the scarred internal sphincter. The rectal mucosa is sutured to the lower margin of the incision. Then, a semicircle incision is made around the suture line to slide the skin graft.

Manometry A manometric study was carried out using a three-channel catheter (G92-005/485, Synectics Medical, Stocholm, Sweden), a PC Polygraf HR (Medtronic Functional Diagnostics, Skovlunde, Denmark) and a personal computer with Polygram Software 318 Naokuni YASUDA, et al

Table 2.

(Medtronic Functional Diagnostics). The study was performed in the left lateral decubitus position. Bowel preparation was not necessary before the study. Maximum levels of basal pressure, squeeze pressure and tolerable volume were measured, using a station pull-through technique. Manometric study was performed prior to restorative proctectomy and SSG, six and twelve months after closure ileostomy, respectively. Results are shown in Table 2.

Discussion

Anal complications may develop in patients with Crohn's disease. Initially, these complications were considered uncommon in patients with ulcerative colitis1). However, a limited number of authors have reported on patients with ulcerative colitis and complicated fissures2). Notably, in Japan, cases of ulcerative colitis patients displaying anal fissures are much rarer. Restorative proctocolectomy with pouch surgery is the gold-standard surgical treatment for ulcerative colitis3-5). In our department, a two-stage procedure comprising proctocolectomy with ileostomy and closure ileostomy, is usually performed. A three-stage procedure was employed in the present case due to the added risk of complications upon high dosage of steroids and an emergent case. At the first stage of the operation, the fissure was not surgically treated. The fissure appeared to be curing naturally because of dysfunction due to ileostoma. Conditions of high resting pressure, such as of the , may cause anal fissures6). There are several traditional techniques for treatment, including dilatation or partial division of the internal sphincter7). However, these procedures are complicated by permanent incontinence8,9). Lateral sphincterotomy appears to be the current standard surgical treatment procedure for anal fissures6,10) It is dangerous to perform lateral sphincterotomy on patients receiving restorative proctectomy, due to possible permanent lower resting anal pressure. It is extremely important that the structure and function of the anal sphincter muscle is preserved in patients subjected to restorative proctocolectomy with pouch surgery11,12). Recent reports indicate that chemical sphincterotomy may be effective in these patients13-15). However, a number of studies suggest that severe headaches often develop as a side-effect following Anal Fissures in Ulcerative Colitis 319 chemical sphincterotomy16,17) We employed SSG in our analyses because of a large severe fissure, which persisted despite covering ileostomy. In the present case, the internal sphincter was preserved as much as possible, although it is usually cut substantially during SSG. In the manometric study, maximal tolerable volume was low before restorative proctectomy and SSG due to inflammation of the . After restorative proctectomy and SSG, the maximal levels of basal pressure, squeeze pressure and tolerable volume improved gradually. Moreover bowel movement was stable (5 times per day). No abnormalities in anal sphincter function were presented. In summary, SSG is an extremely effective procedure for the preservation of the sphincter in patients with intractable fissures who receive restorative proctocolectomy for ulcerative colitis.

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[Received September 3, 2001: Accepted November 29, 2001]