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Ulcerative colitis in children has not been reported previouslyin Bangladesh. This case report is of a 7 year old girl whopresented with frequent passage of slimy stool mixed with bloodfor 4 months. She also had fever, weight loss, abdominal painand urgency at defecation. Barium enema showed pancolitiswith multiple pseudopolyps and collar button appearance.Colonoscopy revealed a friable and granular mucosa withdiffuse ulceration and multiple pseudopolyps. There was bloodyexudate and the lumen was narrow. Histopathology findingsshowed necrosed tissue probably representing a base of ulcerand inflammatory cell infiltrate in the lamina propria. Thecrypt architecture was distorted with cryptitis and goblet celldepletion. There was no granuloma. She was diagnosed as acase of ulcerative colitis & treated with Sulfasalazine and oralcorticosteroid. Her response to treatment was very well andnow she is on regular follow up.DOI: 10.3329/jbcps.v28i2.5372J Bangladesh Coll Phys Surg 2010; 28: 117-120

Summary A group of 124 patients with ulcerative colitis, who had colon surgery, an autopsy, or both, was studied. Review of clinical data and of proctoscopic, roentgenologic, and histopathologic findings revealed frequent lack -of correlation between them. A segment of bowel, although normal grossly by inspection or x-ray examination, may reveal disease when examined microscopically. Ulceration and pseudopolyp formation were the most constant histologic features. Cryptitis could not account for the mechanism of the ulcerative process. Other features observed in a large proportion of cases were granuloma formation, giant cells, and tissue eosinophilia. Their possible relation to the presence of a hyperimmune mechanism in the bowel wall is discussed. Vascular thrombosis, lymphatic dilation, and perivascular infiltrates were present frequently. Similar features are associated with hypersensitive states in the experimental animal. Acute vasculitis was present in only 1 case; it does not seem to play a role in the mechanism of ulceration in ulcerative colitis. Endothelial desquamation, observed in 3 cases, could not account for either thrombosis or ulceration. No information was obtained concerning the role of changes of the homogenous ground substance or of the number and activity of mast cells—both requiring special techniques and special studies. No suggestion could be found in our material of defective cellular regeneration. Adenomas and carcinomas were present in 26 and 19 per cent of the cases, respectively.

A review of 100 cases of ischiorectal and pararectal abscess showed that 44 already had fistular formation upon entering the clinic and 23 had had one or more incomplete operations. The origin and pathology of pararectal inflammatory disease is traced from the relatively simple acute cryptitis to the complex picture of ischiorectal abscess and fistula. Three factors appear to complicate the picture; (1) delay on the part of the patient; (2) delay on the part of the doctor and (3) incomplete therapy. The principal sources of infection of the ischiorectal space other than that outlined, are tuberculosis, pilonidal cyst with abscess, perforated rectal diverticulitis, trauma and malignancy. The entire excision of the fistular tract with widely open drainage is advocated as the desired form of treatment. Bacteriophage therapy as an adjunct to surgery is suggested.

The basic principles of plastic surgery for sliding skin graft have been employed routinely in and about the anal canal. In 2,072 patients operated upon by the authors the infected fissure and crypt-bearing hemorrhoidal tissue was excised and the defect closed primarily with a broad-based sliding skin graft. Any associated disease—hemorrhoids, cryptitis, etc.—was also removed, employing the closed technic.

The large role in anal disease which is played by the crypts of Morgagni is generally recognized. According to Rankin, Bargen and Buie, 1 infection of these structures is the underlying factor not only of cryptitis, anal fissure, periproctitic abscess and anal fistula but also of hemorrhoids. Our own microscopic studies 2 of more than four hundred proctologic specimens demonstrated that the crypts of Morgagni were not by themselves responsible for the frequency of anal infection but that infection originated as a rule in preformed tubules which we called anal ducts. They were found to open into the crypts, affording a ready path for infective organisms from the intestinal lumen into the wall of the anal canal. While the pathogenic significance of the anal ducts was thus established, the question presented itself whether these structures have a definite function or whether they represent a vestigial organ. We hoped to obtain

In a study of 700 children with anorectal complaints, anal stenosis, redundant rectal mucosa, fissures, fistula in ano, cryptitis, colitis, and polyps were diagnosed in all but 20%. In this 20%, two thirds of whom were seen for constipation, no organic cause for the complaint could be found. An anorectal examination should be a part of every physical examination of the newborn, infant, and child. Careful examination of the distal bowel is indicated in all instances of gastrointestinal complaints. All too often, many of these infants and children are treated for intestinal colic, milk allergy, and emotional problems when definite pathological abnormality amenable to correct treatment was present.

To the Editor:— We were surprised and somewhat dismayed at "Non-operative Ligation Treatment of Internal Hemorrhoids" ( 204 :375, 1968). We have used Barron ligation technique since the ligator became commercially available. This is considerably longer than the 18 months mentioned in the article. In our practice of colon and rectal surgery, the patient who has only internal hemorrhoids as a cause of symptoms is a distinct rarity. Anal ulceration, fistula, hypertrophied papillae, and cryptitis frequently coexist with internal hemorrhoids in symptomatic individuals. Hemorrhoids which traverse the anal canal and are distal to the pectinate line are far more likely to cause symptoms than are pure internal hemorrhoids. The article states that hemorrhoidectomy is "extremely unpleasant" for the patient. However, it is our experience that nine out of ten patients undergoing anorectal surgery make some variation of the statement, "If I'd known that this was all there was to it, I

This well-organized volume, based on 450 consultations carried out by the author at the Hopital des Enfants-Malades in Paris, discusses the anorectal anatomy of the child, the technique and indications for endoscopy, and the relative frequency of anorectal disorders in children. Separate chapters cover vascular disorders (angiomas and hemorrhoids), ulcerations, cryptitis, venereal infections, fissures, rectal infections, mucous prolapse, encopresis, constipation, polyps, and malignant tumors. The illustrations are very good, and the therapy recommended is sensible. Each chapter is headed by a brief summary of its contents, and there is an excellent bibliography of the world literature. This book would be a valuable addition to the library of any physician doing endoscopy or anorectal surgery in children, and would be of interest to the general pediatrician.