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Differential Diagnosis

In the differential diagnosis of rectal stricture, many inflammatory diseases of the colon must be considered, including idiopathic chronic ulcerative colitis, and especially granulomatous diseases such as Crohn's disease, tuberculosis, schistosomiasis, amebiasis, and actinomycosis since they may produce roentgenographic findings similar to those of lymphogranuloma venereum. In many of these diseases, rectal biopsies may show granulomas similar to those seen in LGV.

Actinomycosis, although rare, can produce fistulous tracts. Amebiasis and tuberculosis can cause proctocolitis, rectal narrowing, and perianal fistulas. All can occasionally simulate LGV. Schistosomiasis may cause diffuse irregular narrowing and ulceration of the rectosigmoid colon, often with a pelvic abscess. However, fistulous tracts, which are so common in LGV, are not a feature of schistosomiasis. Conversely, colonic granulomatous polyps may be seen in schistosomiasis, especially in Africa and Arabia, but do not occur in LGV.

Post-traumatic strictures caused by foreign bodies, or by sclerosing agents used in hemorrhoid treatment, may produce smooth rectal strictures which radiographically may resemble those of LGV; they seldom cause fistulas or ulceration. Colitis cystica profunda may cause nodular rectal lesions, but the rectal narrowing does not extend into the sigmoid colon. The appearance on sigmoidoscopy is different from that of LGV; the nodular lesions are covered with mucosa and, on rectal biopsy, the two diseases are easily differentiated. Perirectal abscess or tumor may cause rectal narrowing but, in these lesions, the mucosa overlying the narrow rectal wall does not show multiple ulcers. A rare case of gonorrhea involving the rectum, simulating LGV, is illustrated in (Fig. 20.13).

Fig. 20.13 Gonorrhea involving the rectum in a man who admitted to anal sex. There is diffuse ulceration, marked irregularity of contour, and moderate narrowing of the entire rectum and distal sigmoid colon. A short wide sinus extends from the left lateral wall of the rectum, and a pelvic soft tissue abscess is suggested. This is a rare case, and must be distinguished from LGV, which it resembles. (Courtesy of Dr. John Evans, New York City).

An infiltrating scirrhous carcinoma can also cause a long rectal stricture, but usually the mucosa is not ulcerated as it so often is in LGV. Adenocarcinoma of the rectum is of shorter length and duration than LGV, usually begins in the rectal pouch rather than in the anorectal area, causes a localized irregular lobular mass protruding into the lumen with mucosal destruction, and shows a shelf-like rather than tapering margin. Sinus tracts and fistulas are infrequent in cancer, whereas they are common in lymphogranuloma venereum.

Sigmoidoscopy and rectal biopsy, as well as clinical findings and symptoms, may be necessary in the differentiation of the above entities.

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