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© Borgis - Nowa Medycyna 1/2016, s. 14-21 | DOI: 10.5604/17312485.1203777
*Piotr Masiulaniec1, Krzysztof Jacyna2, Danuta Shafie3, Jadwiga Snarska1, 2
Melanoma associated with anal fissure – a literature review and case report
1Department of General Surgery, Faculty of Medical Sciences, University of Warmia and Mazury in Olsztyn
Head of Department: Jadwiga Snarska, MD, PhD, prof. of UWM
2Independent Public Healthcare Centre of the Ministry of the Interior with Warmia and Mazury Cancer Centre in Olsztyn
Head of Department: Marian Stempniak, Eng.
3Department of Anatomical Pathology, Provincial Specialist Hospital in Olsztyn
Head of Department: Błażej Szóstak, MD
Summary
Anal fissure is a common health problem in medical practice. This disease is characterised by a tear in the anal mucosa below the pectinate line. The incidence of this disease depends on the sex and age of the patients. The etiology of anal fissures remains unclear. The purpose of our work is to present a case of melanoma associated with anal fissure.
We present the case of a 32-year-old woman who was admitted to the Department of General Surgery for surgical treatment of anal fissure. On admission she was in a good general condition. She reported itching, burning and pain in the anus after defecation. Rectal examination in the jack-knife position revealed enlarged anoderm at 12 o’clock, covering a 1-millimetre hole with a medium-depth longitudinal area of tissue loss about 6-7 mm in length with thickened ridges, covered with granulation tissue and containing a hypertrophied papilla at the proximal pole. The skin of this region was reddened. There was no purulence on the surface or on the top of this skin lesion. A decision was made to introduce surgical treatment. The anal fissure was excised. Despite the fact that there were no macroscopic characteristics suggestive of malignancy, the collected material was sent for histopathological examination. The result: Melanoma epithelioides. The patient was referred to an oncology centre where she underwent abdominoperineal resection of the rectum. In the post-operative period parastomal hernia occurred. No decision has been made concerning further treatment using chemotherapy.
Our case report shows the need to maintain cancer vigilance during surgery and send the excised lesions for microscopic examination. It also showed that with a long duration of inflammation and the lack of appropriate therapeutic effect of conservative treatment surgical treatment should be introduced. The image of malignant melanoma can mimic various diseases, including anal fissure.
Introduction
Anal fissure (AF) is a common problem in clinical practice found in every age group (1). This disease involves the presence of a tear in the anal mucosa (anoderm) below the pectinate line (2). Ulceration of this site may also occur (3). Linear anoderm tear may be diagnosed in the lower half of the anal canal. In approximately 90% of cases in men and women posterior AF occur, which are located on the posterior wall of the anal canal along the midline of the body. Anterior AF occur in approximately 10% of patients and are more prevalent in women. In fewer than 1% of patients AF occurs in different sites than the midline of the body or multiple fissures occur, which may be associated with Crohn’s disease, anal cancer, tuberculosis or sexually transmitted infections (HIV, herpes virus, syphilis) (4). The first anatomical description of AF was compiled by Louis Lemmonier in 1869. The first description of a sphincterotomy procedure was published in “Traitè des maladies chirurgicales et des opèrations qui leur conviennent” by Alexis Boyer between 1818 and 1826 (5). The prevalence of AF depends on the age and sex of the patients. In the United States of America 342,000 new cases of AF are diagnosed every year, which is comparable to the number of appendectomy procedures performed in this country every year. The prevalence of AF in the U.S. is 1.1 per 100,000 persons per year. The mean risk of AF is 7.8% (6). The prevalence of AF is higher in women (1.14 per 100,000 persons per year) than in men (1.04 per 100,000 persons per year) (6). The peak incidence of the condition among women is during puberty and early adulthood. Men usually suffer from AF at middle age. It is suspected that the prevalence of AF depending on sex and age is associated with the different prevalence of constipation in given groups (7) and with other risk factors. The first observations concerning the association between constipation and AF were made by the aforementioned Boyer (5). Despite numerous studies the aetiology of AF remains unclear. The oldest theory is inflammation (cryptogenic) theory assuming that the cause of the disease is infection of the anal glands (8). Three other factors are also put forward as the causes of AF: mechanical trauma, ischaemia and increased pressure in the anal canal (9). Perfusion in the anal canal mucosa along the posterior midline of the body is 50% smaller than in other sites of the anal canal, which contributes to a decreased therapeutic effect (10). In addition, it was demonstrated that blood flow on the AF side is smaller than on the side of the anterior midline of the anal canal in a group of patients in comparison with a control group (11). Keck et al. find that as a result of AF elevated pressure is usually observed in the anal canal, which is probably due to the increased resting tension of the internal anal sphincter muscle (m. sphincter ani internus), as well as contraction of muscle tissue below the anoderm tear (12). The risk factors for AF may be pregnancy and postpartum period – the prevalence of the condition after the first delivery is 9% (8), the use of opioid analgesics, frequent constipation, large and hard stool masses, old age, comorbidities (especially the large intestine being affected with Crohn’s disease, which is manifested with AF in 50-80% of cases). Anal fissures may be divided into acute ones which heal after topical treatment within a few weeks and chronic ones which are present for 6 or more weeks and require intensified treatment (13). Acute AF are manifested by a sharp pain and strong contraction of the anal area. Patients describe this sharp pain occurring during defecation as “masses passing through broken glass” or “passing of sharp instruments”. Anal pain may be sharp and burning and occur for a few hours (from 1 to 2 hours) after defecation (4, 14). A typical symptom is bleeding during defecation or shortly after. The bleeding is usually very small, however, stool with a trace of blood may also appear. Diagnosis of AF involves taking the patient’s medical history (obtaining detailed information on the presence of risk factors), clinical physical examination consisting of inspection of the anal area, rectal examination and, additionally, anoscopy. The treatment of acute AF should be conservative in nature and involve increasing the amount of dietary fibre and fluids, taking warm sitz and regular baths and using topical analgesic ointments or ointments with calcium channel blockers or nitroglycerin. If symptomatic treatment fails, botulinum toxin injections into the internal anal sphincter muscle may be applied. These treatment methods are characterised by minimal side effects and a good prognosis (15). Warm bath treatment and increased dietary fibre intake leads to recovery in nearly half of acute AF cases (16). Warm sitz baths combined with regular baths cause the rectoanal reflex to occur, which leads to relaxation of the internal anal sphincter (17). Ointments containing nitrates cause the internal anal sphincter to relax by releasing nitrogen oxide (NO), which acts as an inhibitory neurotransmitter in this muscle (18). Efficacy of such treatment has been demonstrated (19). Ointments containing calcium channel blockers cause the internal anal sphincter to relax by blocking the influx of calcium ions to smooth muscle cells (20). Botulinum toxin is produced by Clostridium botulinum and acts as a neurotransmitter that inhibits the release of acetylcholine from the presynaptic terminals. Studies have demonstrated that it causes relaxation of both the internal and external anal sphincter muscles for up to 3 months (20, 21). According to various authors the treatment of AF in patients with Crohn’s disease may be successfully pursued using ointments with metronidazol, prednisone or sulfasalazine (15).

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Piśmiennictwo
1. Esfahani MN, Madani G, Madhkhan S: A novel method of anal fissure laser surgery: a pilot study. Lasers Med Sci 2015; 30: 1711-1717. 2. Kucharczyk A, Ciesielski P, Kolodziejczak M: Current views on etiopathogenesis and treatment of anal fissures. Nowa Med 2009; 3: 169-172. 3. Higuero T: Update on the management of anal fissure. J Visc Surg 2015; 152: 37-43. 4. Nelson RL: Anal fissure (chronic). BMJ Clin Evid 2014; 12: 407. 5. DeMoulin D: A fundamental affair – a short history of anal fissure. Arch Chir Neerl 1977; 3: 163-166. 6. Mapel DW, Schum M, von Worley A: The epidemiology and treatment of anal fissures in a population-based cohort. BMC Gastroenterol 2014; 4: 129. 7. Sanchez MI, Bercik P: Epidemiology and burden of chronic constipation. Can J Surg 2011; 25: 11-15. 8. Kolodziejczak M, Kucharczyk A, Obcowska A: Treatment specifity of anal fissures in pregnant women and peri-labour period. Nowa Med 2010; 1: 12-14. 9. Foxx-Orenstein AE, Umar SB, Crowell MD: Common Anorectal Disorders. Gastroenterol Hepatol (N Y) 2014; 10: 294-301. 10. Schouten WR, Briel JW, Auwerda JJ: Relationship between anal pressure and anodermal blood flow. The vascular pathogenesis of anal fissures. Dis Colon Rectum 1994; 37: 664-669. 11. Schouten WR, Briel JW, Auwerda JJ, De Graaf EJ: Ischaemic nature of anal fissure. Br J Surg 1996; 83: 63-65. 12. Keck JO, Staniunas RJ, Coller JA et al.: Computer-generated profiles of the anal canal in patients with anal fissure. Dis Colon Rectum 1995; 38: 72-79. 13. Shawki S, Costedio M: Anal fissure and stenosis. Drug Ther Bull 2013; 51: 102-104. 14. Nelson RL, Thomas K, Morgan J, Jones A: Non-surgical treatments for anal fissure in adults. Chirurg 2012; 83: 1033-1039. 15. Zaghiyan KN, Fleshner P: Anal Fissure. Clin Colon Rectal Surg 2011; 24: 22-30. 16. Shub HA, Salvati EP, Rubin RJ: Conservative treatment of anal fissure: an unselected, retrospective and continuous study. Dis Colon Rectum 1978; 21: 582-583. 17. Jiang JK, Chiu JH, Lin JK: Local thermal stimulation relaxes hypertonic anal sphincter: evidence of somatoanal re?ex. Dis Colon Rectum 1999; 42: 1152-1159. 18. Bailey HR, Beck DE, Billingham RP et al.: Fissure Study Group. A study to determine the nitroglycerin ointment dose and dosing interval that best promote the healing of chronic anal fissures. Dis Colon Rectum 2002; 45: 1192-1199. 19. Bielecki K, Kolodziejczak M: A prospective randomized trial of diltiazem and glyceryltrinitrate ointment in the treatment of chronic anal fissure. Colorectal Dis 2003; 5: 256-257. 20. Bhardwaj R, Vaizey CJ, Boulos PB, Hoyle CH: Neuromyogenic properties of the internal anal sphincter: therapeutic rationale for anal fissures. Gut 2000; 46: 861-868. 21. Jost WH: One hundred cases of anal fissure treated with botulin toxin: early and long-term results. Dis Colon Rectum 1997; 40: 1029-1032. 22. Arko FR: Anorectal disorders. Am Fam Physician 1980; 22: 121-126. 23. Moore R: Recurrent melanosis of the rectum, after previous removal fr
otrzymano: 2016-02-10
zaakceptowano do druku: 2016-03-03

Adres do korespondencji:
*Piotr Masiulaniec
Katedra Chirurgii Ogólnej Wydział Nauk Medycznych Uniwersytet Warmińsko-Mazurski w Olsztynie
tel. +48 (89) 539-85-51
e-mail: piotr.masiulaniec@gmail.com

Nowa Medycyna 1/2016
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