SHM Converge Scientific Abstract ePoster Gallery-Pain in the Butt: Anal Ulcer Complicated by Atypical Anal Fissure and Fistula

Pdf Summary

This case describes a 27-year-old immunocompromised man with ESRD and kidney transplant history who presented with diarrhea, rectal pain, and hematochezia. Initial CT suggested proctitis without abscess, and he was treated empirically with ciprofloxacin and metronidazole, but symptoms worsened. On repeat rectal exam, a large anal fissure was found. Flexible sigmoidoscopy revealed a large 8 x 7 cm ulcer adjacent to the anal canal with otherwise normal rectum, sigmoid, and descending colon. Examination under anesthesia demonstrated a fistula connecting the ulcer and fissure, and treatment included ulcer debridement, fistulotomy, and Botox injection.<br /><br />The infectious and inflammatory workup was largely negative, though stool AFB culture was positive while the ulcer swab was negative. He was ultimately diagnosed with an infected perianal ulcer complicated by atypical anal fissure and fistula, and he was discharged on doxycycline and amoxicillin-clavulanate for cellulitis, possibly due to Mycoplasma genitalium or Staphylococcus aureus.<br /><br />The discussion highlights that anal ulcers are open sores with tissue necrosis that can be slow to heal and often require biopsy, cultures, and antimicrobials. Anal fissures are clefts in the anal canal that commonly cause pain and bleeding, usually resulting from constipation, diarrhea, vaginal delivery, or trauma. Most fissures are posterior midline; fissures that are off-midline are atypical and should prompt further evaluation for causes such as Crohn’s disease, infections (HSV, CMV, syphilis, TB), HIV, malignancy, or other granulomatous disease.<br /><br />Key takeaway: clinicians should maintain a high suspicion for anal ulcer and atypical fissure, especially in immunocompromised patients, because these lesions may reflect serious infectious or inflammatory disease and require specialized evaluation.

Asset Subtitle

Jessica L. Guidici

Meta Tag

Author List Jessica L. Guidici, John P. Haydek, Nelly Bellamy

Category Clinical Vignettes

Concept Anal Ulcer

Concept Anal Fissure

Concept Pathophysiology

Concept Etiology

Concept Fistula

Distinguished Non-Finalist

Presenter Organization University of North Carolina Hospitals

Presenting Author Jessica L. Guidici

Track Adult

Keywords

immunocompromised

kidney transplant

end-stage renal disease

anal ulcer

atypical anal fissure

fistula

proctitis

hematochezia

flexible sigmoidoscopy

infectious workup

Anal Ulcer

Anal Fissure

Pathophysiology

Etiology

Fistula