Gastrointestinal: Beware of the painful rectum

An 85 year-old man underwent flexible sigmoidoscopy for removal of a rectosigmoid polyp. He also described recent onset constipation with passage of hard stool and a 3 weeks history of rectal pain. On digital rectal examination, there was a palpable “pea-sized” nodule, which was exquisitely tender. The colonoscope was introduced into the anal canal, confirming a single linear fissure (Figure 1). Retroflexion views of the rectum and dentate line were not obtained due to patient discomfort and small rectal vault however forward views appeared normal. The identified polyp within the rectosigmoid was then resected successfully. The patient was prescribed topical therapy and advised to maintain a soft stool. Initial flexible sigmoidoscopy revealed a single linear fissure without significant mass. The areas was exquisitely tender to palpation. The patient returned 3 months later. He had initial relief from his rectal discomfort however following discontinuation of therapy his symptoms recurred. Repeat flexible sigmoidoscopy now showed significant progression of the anal fissure with a clearly associated mass lesion (Figure 2). Biopsies were taken confirming a squamous cell cancer of the anal canal. Antegrade rectal view 3 months after initial flexible sigmoidoscopy now shows a clear ulcerated mass arising from the anal canal. Benign anorectal disease is common, however anal cancer is an uncommon disease in the heterosexual population, with an incidence of 1 per 100,000. In 1863, Rudolf Virchow first described a possible connection between inflammation and cancer which has since been validated with several cancers including ulcerative colitis and colorectal cancer, and Helicobacter pylori infection and gastric cancer. The possible association of benign anal lesions including fissures, with anal cancer has been long debated however this association is limited to small case control studies and cohort studies with conflicting results. The largest cohort study by Nordenvall and colleagues assessed this association in 45,186 patients hospitalised for inflammatory anal lesions. They found a strong association with anal cancer in patients with benign inflammatory anal lesions within the first 3 years of follow-up, and this was most marked within the first year with a standardised incidence ratio of 24 (95% CI 9-52). The authors postulate a direct causal role between the effects of chronic inflammation and eventual progression to cancer however also highlight the possibility of misdiagnosis, especially in those patients within the first year of diagnosis. This case report serves to highlight the high possibility of misdiagnosis of anal cancer in those patients presenting with suspected benign inflammatory anal lesions not responding to medical therapy and we would suggest early follow-up with re-evaluation under anaesthesia in those patients who fail to respond to initial medical therapies. Contributed by

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