Mucosal cast: (a) protruding through the anus; (b) expelled slough
Amoebic strictures in the (a) midrectum and (b) anal canal
14.3.2 Tuberculous Stricture
Tuberculous infection is nearly always secondary to pulmonary tuberculosis (Williams 2004a). Bovine type of infection is very rare. The stricture usually involves all coats of the bowel wall as compared to amoebic stricture which remains restricted to the mucosa and submucosa (Joshi 2001). The diagnosis is made by taking endoscopic biopsy which will show caseation or presence of Langhans-type giant cells. The antituberculosis treatment should be started, and once the disease is under control, the operative treatment is undertaken which consists of either stricturoplasty or segmental resection (Figs. 14.4 and 14.5).
Tuberculosis stricture: (a) upper rectum (b) after stricturoplasty
14.3.3 Lymphogranuloma Venereum
This is a sexually transmitted disease. It involves the perirectal lymphatic which produces constriction of the rectal wall. These types of strictures are now very rare and are difficult to treat. Dilation does not suffice and the patient may require permanent colostomy.
This type of infections occurs usually after perforation of bowel. Perforative appendicitis, diverticular perforation, or perforation following fecal impaction may result in actinomycotic stricture formation. Endoscopic biopsy may help in arriving at diagnosis. The resected specimen shows sulfur sunray granules arranged in a sunray pattern which is diagnostic. Actinomycotic infection responds to penicillin group of drugs. The treatment consists of resection of the segment and proximal colostomy which may be closed later on Haj et al. (2000) (Fig. 14.6).
Actinomycotic stricture following perforation
14.3.5 Inflammatory Bowel Diseases
Benign strictures of the colon and rectum are more common in Crohn’s colitis (Keighley 2007; Linares et al. 1988). This disease has to be differentiated from tuberculous stricture. Evidence of pulmonary tuberculosis and typical findings of caseation in the resected specimen are diagnostic of tuberculosis infection. Surgical management is indicated for established stricture after the patient is stabilized on medical treatment. Strictures of Crohn’s disease are treated by stricturoplasty or segmental resection (Gumaste et al. 1992). Strictures of ulcerative colitis are usually malignant unless proved otherwise. The surgical treatment of ulcerative colitis is total proctocolectomy, and there is no scope for any conservative treatment of the stricture (Joshi 2001).
14.3.6 Ischemic Colitis
Individuals suffering from peripheral vascular disease are likely to suffer from ischemic colitis (Joshi 2001). After an attack of bloody diarrhea, they may develop one or multiple strictures of the colon and rectum. The presence of vascular disease should help in differentiating it from amoebic stricture. The stricture involves all coats of the bowel wall. The treatment includes that for basic disease and stricturoplasty or segmental resection for established stricture (Fig. 14.7).
Ischemic stricture (a) in a patient (b) with peripheral vascular disease
14.3.7 Stricture Following Bowel Anastomosis
Stricture can occur after bowel anastomosis if the site of anastomosis is narrower than the proximal segment or if the vascular supply to the anastomosing segment is jeopardized or following a leak after bowel anastomosis (Joshi 2001). This is more commonly seen in low anterior resection (Williams 2004a). Treatment consists of dilatations or redoing the anastomosis.
14.3.8 Stricture Following Anorectal Surgery
Anal stenosis occurs more frequently after classical Milligan-Morgan hemorrhoidectomy (Liberman and Thorson 2000; Williams 2004b) (Fig. 14.8). It can occur even after stapled anopexy. It complicates radical amputative hemorrhoidectomy in 5–10 % of cases. Ninety percent of anal stenosis is caused by overzealous hemorrhoidectomy. Narrowing of the anus results as considerable amount of anoderm is sacrificed without leaving normal skin in between, and the healing of the wound occurs by secondary intension. Stricture can occur after fistula surgery due to cross adhesions while wound healing takes place. Anorectal strictures occur after sclerotherapy and Kshar Sutra treatment of piles and fistula (Williams 2004a, b) (Fig. 14.9). Application of sclerosants by quacks for the treatment of anorectal diseases also produces strictures.
Anal stenosis following hemorrhoidectomy