Hypertrophied Anal Papillae Research Articles

A case of partial prolapsed hypertropied multiple anal papillae

A 45-year-old male patient came to our patient department (OPD) with complaints of bleeding per rectum on and off, burning sensation at anal region and feeling of mass at anal region for 6 months. Prolapsed hypertrophied anal papillae as shown in the figure and mild tenderness in the anal region. Presently patient also having chronic fissure in ano and indigestion with irregular bowel habits on and off. In past history patient was having fistula in ano 2 years ago. The treatment advised was fissurectomy with electrodessication and curettage of anal papillae under spinal anesthesia. Patient was advised for IV fluids, Inj. Cefixime 200Â mg twice a day, Inj. Pantoprazole 40Â mg once day with Inj. Tramadol 50Â mg/1ml was given for 2 days. The patient was advised for Anometro gel ointment for local application and oral medication after 2 days. The patient was advised to take sitz bath daily. The patient came for follow-up on 10th day, after per rectal digital examination and anoscopy, it was revealed that there was no present mass at anal region, a healing wound, no spasm, no tenderness and no active bleeding. Patient was advised to continue oral medications and ointment for a week. The final diagnosis was partial prolapsed hypertrophied multiple anal papillae with chronic fissure in ano while the differentials included anal sentinel tags, piles, condylomata acuminata, cryptitis.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anal Fissures.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anal Fissures.

STUDY TO EVALUATE THE EFFECT OF AABZAN OF WARM WATER IN CASES OF INSHEQAQ MAQADHAAD (ACUTE ANAL FISSURE)

Insheqaq Maqadhaad (Acute Anal fissure) is an ulcer in the longitudinal axis of the lower anal canal. Clinical presentation of patients includes Common in middle aged w omen, not in elderly. Constipation, bleeding discharge and stools are hard pellet like and there is drop of blood or streaks of fresh blood. Chronic fissures are characterized by a hypertrophied anal papilla internally and a sentinel tag externally (both consequent upon attempts at healing and breakdown), between which lies the slightly indurated anal ulcer overlying the fibers of the internal sphincter. When chronic, patients may also complain of itching secondary to irritation from the sentinel tag, discharge from the ulcer or discharge from an associated intersphincteric fistula, which has arisen through infection penetrating via the fissure base. In Aabzan Therapy only hips are immersed in medicated water, level of water should not be above navel (umbilicus). This therapy is very common and is used to relieve pain and discomfort of lower and upper limbs. It is indicated in Anal fissure, hemorrhoids, rectal prolapsed, uterine prolapsed, oligomenorrhoea, hysteria, dysentery, diarrhoea, cystitis, uterine cramps, vaginitis, IBS and prostitis. Present study was conducted on 30 Lord's anal dilatation post operative patients of Insheqaq Maqadhaad (Acute Anal fissure) to evaluate the effect of Aabzan of warm water in cases of InsheqaqMaqadhaad(Acute Anal fissure). The significant reduction in various scores was found after the completion of the study.

Gastrointestinal: Obscuration of anorectal lesions in computed tomographic colonography due to balloon deflation.

An asymptomatic 58-year-old man underwent computed tomographic colonography (CTC) performed using a thin catheter (4.7-mm diameter) and automated carbon dioxide insufflation. The procedure was performed in the supine and prone positions with inflated and deflated balloons, respectively. An experienced physician detected a polyp in the supine images (Fig. 1a,b), but not in the prone position images(Fig. 1d,e). Colonoscopy revealed a fibroepithelial polyp (11 mm; hypertrophied anal papillae; Fig. 1c), which was concealed in the anal canal upon air aspiration (Fig. 1f). A 79-year-old woman who was diagnosed with lower rectal cancer by colonoscopy underwent a preoperative CTC evaluation (submucosal well-differentiated adenocarcinoma, Fig. 2a,b). The catheter and the dilatation method were the same as in the first case. Flat lesions were visible in the supine position with the inflated balloon (Fig. 2c,d), but not in the prone position with the deflated balloon (Fig. 2e,f). The catheter accidentally withdrew from the anus in this second case. A radiologist faces many pitfalls during CTC interpretations of anorectal lesions. One of these is that lesions are occasionally obscured by the inflated rectal balloon catheter. Hence, balloon deflation in the prone position is recommended while obtaining images. Despite this, the diagnosis of anorectal lesions is difficult. A combination of CTC and sigmoidoscopy is not recommended by any guidelines, as there are few additional lesions found. Although the rectum is more distended in the prone position, balloon deflation can reduce rectal distension. Consequently, the lesion can be concealed in the anal canal and obscured in the CTC image, as in the present cases. This could be due to gas leakage from the anal canal and the absence of physical expansion of the balloon. However, upon initial inspection, the dilatation appeared successful as the rectum did not entirely collapse. However, the fact that lesions can be obscured by balloon deflation has never been reported. We believe that this original report would be instructive to radiologists and physicians. Physicians interpreting CTCs should be aware that both inflated and deflated balloons can obscure lesions.

S1615 Primary Rectal Lymphoma: A Rare Entity of Lower Gastrointestinal Bleeding

INTRODUCTION: Primary rectal lymphoma is an extremely rare gastrointestinal neoplasm. The diagnosis can be delayed with varied presentations depending on the site of the colonic involvement. We present a case of acute onset of hematochezia from primary diffuse large B-cell lymphoma at the rectum. CASE DESCRIPTION/METHODS: A 54-year-old Caucasian man who has sex with men presented with constipation for 3 weeks and rectal bleeding for one week. He reported rectal pain associated with having bowel movements and tenesmus. He denied fever, chills, night sweats, or weight loss. Physical examination was unremarkable. Laboratory showed WBC 11.1 K/MM3, Hb 14.6 g/dL, platelet count 325 K/MM3, and negative serum HIV screening. CT scan of the abdomen and pelvis revealed circumferential rectal wall thickening with mesorectal fat stranding and enlarged mesorectal lymph nodes (Figure 1). The patient underwent flexible sigmoidoscopy which demonstrated circumferential deep ulcerations, linear erosions, and loss of vascularity of mucosa from the anus to the recto-sigmoid colon up to 20 cm and hypertrophied anal papillae (Figure 2). Biopsy of the rectum up to 20 cm revealed diffused large B-cell lymphoma with germinal center origin. A whole-body PET-CT scan showed disease activity localized in the rectum. Bone marrow biopsy showed slightly hypocellular bone marrow but negative for lymphoma. He underwent R-CHOP chemotherapy and radiation with a good response. Repeat colonoscopy at 3 months after treatment did not show evidence of recurrence. Follow-up PET-CT and CT chest/abdomen/pelvis were without recurrence of the disease. He remains in remission for 15 months since the diagnosis. DISCUSSION: Gastrointestinal (GI) non-Hodgkin lymphoma accounts for 1-4% of primary GI neoplasms. The stomach is the most commonly involved site followed by the small intestine and colon. Primary colorectal lymphoma only accounts for 6-12% of GI non-Hodgkin lymphomas. Diffuse large B-cell lymphoma (DLBCL) is the most common histopathology. Symptoms are varied depending on the location of the disease. Rectal lymphoma can present with rectal bleeding and obstructive symptoms, for example, constipation, small stool caliber, or tenesmus, as in this case. DLBCL is sensitive to chemoradiation. The estimated median survival of patients with localized disease is approximately 23 months. A high index of suspicion is required to prevent delays in diagnosis.Figure 1.: CT scan of abdomen and pelvis showed circumferential wall thickening at the rectum (arrows).Figure 2.: Flexible sigmoidoscopy showed circumferential deep ulcerations, linear erosions, and loss of vascularity of mucosa at the rectum (A) and hypertrophied anal papillae in retroflection view (B).

S1709 Nintedanib-Associated Colitis

INTRODUCTION: Nintedanib slows disease progression in patients with idiopathic pulmonary fibrosis (IPF). The most frequent adverse effects of nintedanib are nausea and diarrhea which are reversible following dose reduction, drug discontinuation, or symptomatic therapy. This is a case of a 60-year-old female with IPF on nintedanib found to have colitis on a screening colonoscopy. CASE DESCRIPTION/METHODS: A 60-year-old Japanese female with IPF and breast carcinoma status post mastectomy was referred for surveillance colonoscopy. Colonoscopy showed evidence of inflammation characterized by altered vascularity, congestion, erythema, and granularity in the entire colon. Other findings included small non-bleeding external hemorrhoids, hypertrophied anal papillae, and localized inflammation of the terminal ileum. Histopathology showed focal active colitis with no dysplasia or malignancy. Biopsies of the terminal ileum and rectum showed no abnormality or evidence of atypical epithelial elements. Stool studies were normal. Gram stain and cultures were negative. On further chart review, she was noted to have been started on nintedanib three years prior for management of her IPF. She was initially on pirfenidone, but had a significant dermatologic reaction, so was switched to nintedanib 150 mg twice daily. Only after starting nintedanib did she develop diarrhea and abdominal discomfort with up to 20 small volume, watery, non-bloody bowel movements daily. She denied nausea, vomiting, melena, or hematochezia. Her symptoms were noted to improve after dose-reduction or discontinuation of nintedanib, but reoccurred once restarting nintedanib at the original dose. Unfortunately, discontinuation of nintedanib may worsen her underlying pulmonary disease, so it was continued. Her symptoms have since improved with use of Bifidobacterium infantis and loperamide. DISCUSSION: Nintedanib slows disease progression in patients with IPF and is usually well-tolerated by most patients. However, as demonstrated in this case, diarrhea is a common and potentially distressing adverse effect. The mechanism of the development of nintedanib-induced diarrhea is still unknown but may include inhibition of intestinal epithelium receptors and direct mucosal damage, as evidenced by the histopathological findings demonstrated in this case. Diarrhea can be reversed by dose reduction, drug discontinuation, or use of anti-diarrheal agents. Addition of prednisolone to nintedanib therapy may also decrease the risk of diarrhea.Figure 1.: Erythematous and granular mucosa showing focal active colitis on colonoscopy.Figure 2.: Focal active colitis as seen on ×40 magnification.Figure 3.: Note the predominant lung fibrosis with traction bronchiectasis and bronchiolectasis with groundglass and reticular opacities with honeycomb cysts.

Differential diagnosis of hemorrhoidal disease

Hemorrhoidal disease is one of the most common illnesses in industrialized nations. Up to 70% of adults suffer from the disease once in their lifetime. This underlines the necessity and importance of knowing about the differential diagnosis of hemorrhoids. One can differentiate between differential diagnoses of symptoms (bleeding, pain, itching, tumor) and differential diagnoses of the phenotype findings (anal prolapse, mucosal prolapse and rectal prolapse, skin tags, hypertrophied anal papillae, condylomata acuminata, anal fissure, perianal venous thrombosis, anal cancer).

English

Anal fissure is one of the most common anorectal problems. Anal fissure is largely associated with high anal sphincter pressures and most treatment options are based on reducing anal pressures. There are many options to treat chronic fissures in ano. Some of them are non-surgical while the others are surgical. The efficacy claimed by each of the prevalent method is very high but the inconsistencies and contraindications are equally strong. To date, lateral sphincterotomy has been favoured by most of the proctologists, because it is the least extensive surgical procedure and is offering a long lasting relief in sphincter spasm. Various management technique are reviewed in this article along with Advancement flap for anterior fissure and a new method combining the age-old technique of Lord's manual dilatation followed by radio surgery is also highlighted along with their complications. The addition of radio surgery is found useful for refreshing the edges of the fissure and to tackle pathologies namely sentinel pile, small internal piles or hypertrophied anal papillae often found associated with chronic fissures. Revisiting the trends of treatment of chronic anal fissures, the most preferred options are the manual dilatation with radio surgery and the subcutaneous lateral anal sphincterotomy. Both methods are easy to perform, have negligible complications and no special setup is needed, except the radio surgical unit, in case of the first procedure.

MicroRNA let-7b-regulated epidermal stem cell proliferation in hypertrophied anal papillae.

The present study investigated the role of epidermal stem cell-expressed microRNA let-7b in the pathogenesis of hypertrophied anal papillae. Hypertrophied anal papillae were examined for the presence of epidermal stem cells. Epidermal stem cells were identified using flow cytometry and immunofluorescent staining for the cell surface markers, integrin α6 and integrin β1 subunits. Expression levels of microRNA let-7b in α6+/β1+and α6-/β1-cells were compared using reverse transcription-quantitative polymerase chain reaction and northern blotting. Lentivirus-mediated expression of microRNA let-7b in epidermal stem cells was utilized in order to study the effects of this microRNA on the cell cycle proteins, cyclin D1 (CCND1) and cyclin-dependent kinase 4 (CDK4). MicroRNA let-7b-overexpressing cells were examined using flow cytometry, in order to determine the effects of the microRNA on cell cycle progression. α6+/β1+epidermal stem cells were identified in hypertrophic anal papillae. Following isolation and enrichment of the α6+/β1+population, these cells were found to have a rapid rate of proliferation in vitro. The expression of cell cycle-related proteins was elevated in this population, compared with that in α6-/β1-cells. The expression of microRNA let-7b in α6+/β1+epidermal stem cells was significantly lower than that in α6-/β1-cells. Two microRNA let-7b target genes, CCND1 and CDK4, were found to be upregulated in α6+/β1+cells. When the exogenous precursor, microRNA let-7, was overexpressed in α6+/β1+ epidermal stem cells, the cell proliferation rate was significantly lower than that in cells expressing microRNA let-7 containing a mutated seed sequence. The addition of exogenous microRNA let-7 resulted in an increased expression level of mature microRNA let-7b, while the expression of CCND1 and CDK4 was reduced. Epidermal stem cells transfected with microRNA let-7b were arrested in the G2/M phase and the percentage of cells in S-phase was significantly reduced. In conclusion, let-7b expression results in upregulation of the cell cycle-related proteins, CCND1 and CDK4, resulting in the excessive proliferation that leads to the formation of hypertrophic anal papillae.

A Symptomatic Anorectal Polyp

A Symptomatic Anorectal Polyp

Internal sphincterotomy versus topical nitroglycerin ointment for chronic anal fissure

Anal fissure is a common benign condition. An anorectal problem is defined as a split in the anal canal mucosa that extends from the dentate line to the anal verge. Chronic anal fissure is defined by a history of symptoms present for more than 2 months' duration and with a triad of external skin tags, namely, a hypertrophied anal papilla, an ulcer with rolled edges, and a base exposing the internal sphincter. Because complications such as incontinence are associated with surgical treatment, chemical sphincterotomy is currently favored. The objective of this study is to compare the difference in outcome between open partial lateral anal sphincterotomy and application of topical 0.2% nitroglycerin ointment for the treatment of chronic anal fissure. This was a quasi-experimental study carried out between January 16, 2007 and January 15, 2008 in the Surgical Department of Jinnah Hospital, Lahore, Pakistan. Sixty consecutive cases with a clinical diagnosis of chronic anal fissure were recruited in the study. All recruited patients met the study inclusion criteria and were randomly assigned to one of the two groups. Group A was managed conservatively using topical 0.2% nitroglycerin ointment, whereas Group B underwent open partial lateral anal sphincterotomy. Both groups were followed up at 1 week, 2 weeks, 4 weeks, and 6 weeks after the treatment. All the patients complained of pain. A total of 43 (71.7%) patients had pain with constipation, whereas 31 (51.7%) patients had bleeding per rectum. Upon clinically examining the anal area, tenderness was elicited in all 60 (100%) patients. Group A included 30 (11 females and 19 males) cases treated with topical 0.2% nitroglycerin ointment and Group B included 30 (11 females and 19 males) cases who underwent open partial lateral anal sphincterotomy. In Group A, only 15 patients with fissures were successfully treated (50%). By contrast, 28 (93%) patients with fissures in Group B were successfully treated, and only two (7%) remained uncured. These two patients (6.6%) in Group B suffered from incontinence due to flatus and feces as a complication of the procedure. This quasi-experimental study demonstrates that open partial lateral internal sphincterotomy is superior to topical 0.2% nitroglycerin application in the treatment of chronic anal fissure, with good symptomatic relief, high rate of healing, fewer side effects, and a very low rate of early continence disturbances.

Effect of Chronic Anal Fissure Components on Isosorbide Dinitrate Treatment

Chronic anal fissure is diagnosed in the presence of persistent symptoms: The classic triad includes a linear mucosal tear exposing the internal sphincter fibers, hypertrophied anal papilla, and a sentinel skin tag. Thus, chronic anal fissure can be divided into three components: the fissure itself; hypertrophied anal papilla; the sentinel skin tag. Not every chronic anal fissure has all three components; some have two components, and others present with only a persistent fissure. The success rate of medical treatment for chronic anal fissure is reported as 42-86 %. In this study, we intended to observe the effect of said components on healing with isosorbide dinitrate treatment. A total of 105 patients with chronic anal fissures were admitted and were divided into three groups. Patients in group I had a single component (only the fissure with a linear mucosal tear exposing the internal sphincter fibers); group II had two components (skin tag or hypertrophied papilla in addition to the fissure); group III had all three components (fissure, skin tag, hypertrophied papilla). Isosorbide dinitrate 0.25 % was applied three times a day. The success rates in the study groups were 93, 74, and 64 %, respectively. The success rate was significantly higher for group I than for groups II and III. Chronic anal fissure components should be considered when evaluating the success rates of studies reporting the results of various medical treatments. The number of components seems to be an important factor that affects the results of isosorbide dinitrate treatment.

Optimal treatment duration of glyceryl trinitrate for chronic anal fissure: results of a prospective randomized multicenter trial

BackgroundChronic anal fissure (CAF) is a painful condition that is unlikely to resolve with conventional conservative management. Previous studies have reported that topical treatment of CAF with glyceryl trinitrate (GTN) reduces pain and promotes healing, but optimal treatment duration is unknown.MethodsTo assess the effect of different treatment durations on CAF, we designed a prospective randomized trial comparing 40 versus 80 days with twice daily topical 0.4% GTN treatment (Rectogesic®, Prostrakan Group). Chronicity was defined by the presence of both morphological (fibrosis, skin tag, exposed sphincter, hypertrophied anal papilla) and time criteria (symptoms present for more than 2 months or pain of less duration but similar episodes in the past). A gravity score (1 = no visible sphincter; 2 = visible sphincter; 3 = visible sphincter and fibrosis) was used at baseline. Fissure healing, the primary endpoint of the study, maximum pain at defecation measured with VAS and maximum anal resting pressure were assessed at baseline and at 14, 28, 40 and 80 days. Data was gathered at the end of the assigned treatment.ResultsOf 188 patients with chronic fissure, 96 were randomized to the 40-day group and 92 to the 80-day group. Patients were well matched for sex, age, VAS and fissure score. There were 34 (19%) patients who did not complete treatment, 18 (10%) because of side effects. Of 154 patients who completed treatment, 90 (58%) had their fissures healed and 105 (68%) were pain free. There was no difference in healing or symptoms between the 40- and the 80-day group. There was no predictor of fissure healing. A low fissure gravity score correlated with increased resolution of pain (P < 0.05) and improvement of VAS score (P < 0.05) on both univariate and multivariate analysis. A lower baseline resting pressure was associated with better pain resolution on univariate analysis (P < 0.01). VAS at defecation and fissure healing significantly improved until 40 days (P < 0.001), while the difference between 40 and 80 days was not significant.ConclusionWe found no benefits in treating CAF with topical GTN for 80 days compared to 40 days. Fissure healing and VAS improvement continue until 6 weeks of treatment but are unlikely thereafter.

Obstructive ileus due to a giant fibroepithelial polyp of the anus

Fibroepithelial polyps or hypertrophied anal papillae are essentially skin tags that project up from the dentate line and the junction between the skin and the epithelial lining of the anus. They are usually small in size, but sometimes they become enlarged, causing unexpected medical conditions. An extremely rare case of a giant hypertrophied anal papilla complicated by obstructive ileus is reported. Fibroepithelial anal polyp, despite its size, should be included in the differential diagnosis of a smooth mass located near the anal verge, especially in a patient with a history of chronic anal irritation or infection.

Hypertrophied anal papillae and fibrous anal polyps, should they be removed during anal fissure surgery?

Hypertrophied anal papillae and fibrous anal polyps are not given due importance in the proctology practice. They are mostly ignored being considered as normal structures. The present study was aimed to demonstrate that hypertrophied anal papillae and fibrous anal polyps could cause symptoms to the patients and that they should be removed in treatment of patients with chronic fissure in anus. Two groups of patients were studied. A hundred patients were studied in group A in which the associated fibrous polyp or papillae were removed by radio frequency surgical device after a lateral subcutaneous sphincterotomy for relieving the sphincter spasm. Another group of a hundred patients who also had papillae or fibrous polyps, were treated by lateral sphincterotomy alone. They were followed up for one year. Eighty-nine percent patients from group A expressed their satisfaction with the treatment in comparison to only 64% from group B who underwent sphincterotomy alone with the papillae or anal polyps left untreated. Group A patients showed a marked reduction with regard to pain and irritation during defecation (P = 0.0011), pricking or foreign body sensation in the anus (P = 0.0006) and pruritus or wetness around the anal verge (P = 0.0008). Hypertrophied anal papillae and fibrous anal polyps should be removed during treatment of chronic anal fissure. This would add to effectiveness and completeness of the procedure.

AGA technical review on the diagnosis and care of patients with anal fissure

Anal fissure is a disruption of the skin at the distal anal canal. Most anal fissures are located in the posterior midline, with 10% to 15% occurring anteriorly. “Off the midline” fissures must be viewed with suspicion for underlying pathology such as Crohn's disease, HIV/AIDS, tuberculosis, syphilis, or anal carcinoma. Early fissures have the appearance of a simple tear in the anoderm. With the passage of time, chronic fissures develop thickened skin margins, and fibers of the internal anal sphincter (IAS) become visible at the fissure's base. Many patients with chronic fissures develop a sentinel skin tag at the distal fissure margin and a hypertrophied anal papilla just proximal to the fissure within the anal canal.GASTROENTEROLOGY 2003;124:235-245

A new method of evaluating hemorrhoids with the retroflexed fiberoptic colonoscope

Background: The conventional classification of the degree of hemorrhoids does not consider the severity of hemorrhage. The purpose of this study was to establish a new objective method for evaluating hemorrhoids in close relation to the main symptoms, hemorrhage and prolapse, as observed through a retroflexed colonoscope in the rectum. Methods: The subjects were 531 consecutive patients who complained of symptoms related to the rectum or the anus. The degree of mucosal elevation of the rectal columns, changes in color (the existence and degree of red color sign, dilated vein, and white area), and the existence and size of hypertrophied anal papillae were evaluated by colonoscopy. Results: Red color sign was the finding closely related to hemorrhage ( p < 0.0001). Dilated vein, white area, and a large hypertrophied anal papilla were related to prolapse ( p < 0.0001). The degree of mucosal elevation of the rectal columns was related to both hemorrhage and prolapse ( p < 0.0005, p < 0.05). Conclusion: Retroflexing the colonoscope intrarectally facilitated identification of findings in the anal canal related to hemorrhage and prolapse, which are the clinical manifestations of hemorrhoids. (Gastrointest Endosc 1998;48:272-5.)

4. The New Classification of Anal Fissure and the Treatment

Anal fissure treatment must be decided by objective macroscopic finding than subjective symptom that is serious or not.Anal fissure group into three classes according to the progress.First degree anal fissure ; it is a new simple fissure of anal canal.Second degree anal fissure ; it is ulceration, surface of the ulcer change the fiberous in the lateral edges where undermine.Third degree anal fissure ; it combined with big sentinel tag, hypertrophied anal papilla, haemorrhoids and fistula in ano, etc.On the other hand, the treatment classification three big classes.1) Concervative treatment : Avoidance of constipation. It use an internal medicine ointment and suppository.2) Intermediate treatment : Lapis cautery. Use of an anal dilatator and streching of the anal sphincter, and lockal anaesthetics.3) Operative treatment : L. S. I. S. (Lateral subcutaneous anal internal sphincterotomy).S. S. G. (Excision with sliding skin grafts).Excision and sphincterotomy.Cryosurgical fissurectomy.These three groups are fit for three treatments, and I've been tried to treatment.During the past two years, 1 treated 326 patents, and get the satisfying answer.This method help to simplify a treatment, and can use an example for biginners. 1 believe this method is very useful.

MEDIASTINAL EMPHYSEMA AFTER RECTAL BIOPSY.

IN THE day-to-day practice of medicine, routine or frequently utilized procedures are often regarded as being devoid of danger to the patient. The following case history illustrates the occurrence of an unusual and potentially serious complication after the performance of a presumably innocuous procedure. Report of a Case A 34-year-old Caucasian man was admitted to the Rancocas Valley Hospital in Willingboro, NJ because of a three-week history of rectal bleeding during bowel movements. He was otherwise asymptomatic. The past medical history was unremarkable. Physical examination, including a digital rectal examination was normal. The hemoglobin, hematocrit, urinalysis, and fasting blood sugar values were normal. On the second hospital day, an upper gastrointestinal x-ray series was performed. A deformed duodenal bulb, attributed to scarring from previous ulceration was noted. No other abnormalities were seen. On the same day, a sigmoidoscopic examination was performed after a cleansing enema. A hypertrophied anal papilla was