Painless Rectal Bleeding Research Articles

Knowledge, awareness, and attitudes toward hemorrhoids and related surgical treatments among the general population in the Western region, Saudi Arabia: a cross-sectional study

Background: Hemorrhoids, or swollen veins in the anal canal, can result from factors such as chronic straining during bowel movements. While categorized as internal or external, they typically manifest as painless rectal bleeding, swelling, or a lump. Despite their significant global prevalence and impact, research on hemorrhoids in Saudi Arabia remains limited. This cross-sectional study aimed to evaluate public knowledge and attitudes toward hemorrhoids, anticipating prevalent misconceptions. Methods: It is a cross-sectional study conducted in the Western region of Saudi Arabia. Self-administered questionnaires will assess demographic data and perceptions about hemorrhoids. Data is analyzed by IBM SPSS 29. Results: Our study indicated that 97.7% were aware of hemorrhoids, with 18.9% citing pushing during excretion and 16.4% mentioning prolonged sitting as the leading cause. 30.1% perceived surgery as the primary treatment, and 85.9% agreed on hemorrhoids' negative impact on quality of life. Significant predictors of better knowledge included (OR=1.726) for the 21-40 age group, (OR=2.024) for Taif residents, (OR=3.393) for Ph. D. holders, (OR=1.567) for an income of 5000-10000 SAR, and (OR=8.542) for participants with prior knowledge of hemorrhoids. Conclusions: Our study sheds light on the knowledge, attitudes, and perceptions about hemorrhoids among the general population in the Western region of Saudi Arabia. There is good awareness but inadequate knowledge regarding hemorrhoids and their surgical treatment in the Western region of Saudi Arabia. The findings underscore the need for targeted educational interventions.

Meckel’s diverticulum mimicking acute appendicitis in children: a retrospective cohort study

BackgroundThe aims of this study were to summarize the clinical presentation and histological results of 20 cases of complicated Meckel diverticulum (MD) who were presumed to have acute appendicitis before surgery, as well as to improve the diagnosis and treatment of complicated MD in children.Materials and methodsWe retrospectively reviewed the records of 20 complicated MD admitted to our institution who were preoperatively diagnosed with acute appendicitis from January 2012 to January 2019. Patients were divided into the perforated MD group and the Meckel’s diverticulitis group. Patient demographics, clinical manifestations, laboratory data, auxiliary examinations, surgical methods, and the result of heterotopic tissue were recorded.ResultsA total of 20 cases of complicated MD (perforated or diverticulitis) were identified. Children were aged from 3 to 13 years, with a mean age of 7.75 years (median 7.75; range, 1–13 years). Perforated Meckel’s diverticulum occurred in 5 of 20 (25%) cases. For perforated MD versus diverticulitis, no significant differences were found between age, time to intervention, length of hospital stay, and distance from the ileo-cecal valve. Heterotopic tissue was confirmed on histopathology in 75% of all patients, including 10 cases of gastric mucosa, 3 cases of coexistent gastric mucosa and pancreatic tissue, and 2 cases of pancreatic tissue. All patients underwent diverticulectomy or partial ileal resection under laparoscopy or laparotomy; two cases combined with appendectomy owing to slight inflammation of the appendix.ConclusionsThe most common presentation of symptomatic MD is painless rectal bleeding; however, it can present symptoms of acute abdomen mimicking acute appendicitis. The key point of diverticulectomy is to remove the ectopic mucosa completely.

Laser Hemorrhoidoplasty for Treatment of the Hemorrhoids in Eastern Nepal

Background: Millions worldwide are affected by hemorrhoids (prevalence 2.9%-27.9%), causing symptoms in over 4% of individuals. These anorectal disorders result from enlarged anal hemorrhoidal cushions, often due to constipation. Internal or external, they're graded by prolapse severity, with common symptoms including painless rectal bleeding. Treatment options range from conservative to surgical, with the gold standard, Milligan-Morgan hemorrhoidectomy, associated with postoperative pain. Laser hemorrhoidoplasty, a minimally invasive diode laser approach, shows promise, offering less postoperative pain, shorter hospital stays, and fewer complications than traditional surgical methods.
 Materials and Methods: A prospective observational study of 40 adults undergoing laser hemorrhoidectomy for symptomatic Goligher’s grade II and III hemorrhoids at Nobel Medical College Teaching Hospital, Biratnagar, Nepal, from June 2022 to June 2023. Outcomes included pain scores, bleeding, operative time, postoperative complications, hospital stay length, return-to-work time, and patient satisfaction measured by QOL SF36 scoring.
 Results: Among 40 patients, 16 were male and 24 females, averaging 42.32 ± 12.26 years. Grade III hemorrhoids were found in 31 patients, Grade II in 9. Operative time averaged 17.22 ± 2.14 minutes, with one case of managed intraoperative bleeding. Postoperative symptoms included pain, skin tags, and wound infection, but no reactive bleeding, urinary, or stool/flatus incontinence. Two cases experienced recurrence. Patient satisfaction in general health evaluation scored 65.11 ± 10.35.
 Conclusion: Laser hemorrhoidoplasty is associated with less complications, quicker operative time, quick recovery and similar patient satisfaction when compared to surgical methods of hemorrhoidectomy.

Rectal Bleeding in a Child Revealing a Cavernous Hemangioma of the Sigmoid

Hemangiomas are the most common benign vascular tumors in the pediatric age group. They originate from embryonic remnants of unipotent angioblastic cells. Although hemangiomas may occur anywhere within the abdomen, including the solid organs, hollow viscera, ligaments, and abdominal wall, the liver is the most common site. Cavernous hemangiomas of the sigmoid colon are uncommon vascular malformations usually found in young adults with a long history of episodic and painless rectal bleeding. Imaging plays an essential role in diagnosis and post-therapeutic follow- up. The diagnosis of certainty remains histological and the treatment is essentially surgical. We report a case of cavernous hemangioma of the sigmoid diagnosed in a 5-year-old boy admitted to our hospital for investigation of repeated episodes of rectal bleeding. The diagnosis was confirmed after a histological examination.

S1906 A Rare Cause of Delayed Life-Threatening Hemorrhage in a Patient With Pancreas Transplant

Introduction: Complications of vascular anastomosis usually occur early after pancreas transplant (PTx) and carry a substantial risk of graft loss and mortality. Hemorrhage may result from arterial anastomosis failure, but more commonly from superior mesenteric or splenic vessel ligation. We present a challenging case of GI hemorrhage from a pseudoaneurysm (PA) in the implanted vascular Y graft 7 years after PTx. Case Description/Methods: A 45-year-old male 7 years post simultaneous pancreas-kidney transplant presented with painless rectal bleeding. EGD and Colonoscopy showed blood throughout the duodenum and colon, but the source could not be localized. Push enteroscopy showed blood extending into the proximal jejunum, and no active bleeding source could be identified. CT angiogram showed active extravasation into a small bowel loop near the PTx. Mesenteric angiography with IR revealed active extravasation into jejunum from a PA which had developed off the SMA Y graft anastomosis, eroding into the adjacent duodenal stump. Successful coil embolization was performed. 2 days later, he developed rectal bleeding requiring massive transfusion. Tagged RBC scan and CT angiography could not localize the bleeding source. Emergent mesenteric angiography showed contrast leakage into the anastomotic stump beyond the previously placed coil (Figure A). A covered stent was placed into the right external iliac artery arresting the bleeding into the SMA anastomotic stump (Figure B). Bleeding and shock resolved, and he was discharged with transplant surgery follow-up. Discussion: Pseudoaneurysms, AV fistulae, arterial dissection and stenosis represent rare vascular complications of PTx. PAs, if early, may be the result of surgical technique, infection, severe pancreatitis, or allograft biopsy. Arterial anastomotic PAs can be asymptomatic or present with symptoms signaling impending rupture such as abdominal pain, pulsatile mass, or endocrine failure. Endoscopic localization and management of bleeding from Y graft PAs are challenging due to altered anatomy and brisk bleeding. Multidisciplinary management is essential and often involves endovascular hemostasis with IR, possibly with surgical exploration. Stent placement is usually preferred over embolization due to the ability to deploy with precision while maintaining end-organ perfusion. Although guidelines are lacking, it would be reasonable to consider periodic Doppler US to screen for post-operative PAs for early detection and preventative endovascular treatment.Figure 1.: A. Pre-stent mesenteric angiogram with contrast leaking through coil into SMA anastomotic stump; B. Post stent mesenteric angiogram with no contrast leaking into the SMA anastomotic stump.

S2024 Elderly Patient, Youthful Pathology: Solitary Colonic Juvenile Polyp Found in a 75-Year-Old Male

Introduction: Colonic juvenile polyps are generally found in the pediatric population. Classically, juvenile polyps (JP) are the most common polyp subtype seen in pediatric gastroenterology, accounting for approximately 80-90% of polyps in children. Generally, JP are diagnosed within the first decade of life and most common presentation is painless rectal bleeding. Other terminology used are juvenile hamartomatous polyp or retention polyps. There is no malignant potential for solitary JP and they tend to not recur. Case Description/Methods: We present a 75-year-old male with past medical history of hypertension, diabetes and hyperlipidemia referred to gastroenterology for surveillance colonoscopy due to a history of tubular adenomas. At the pre-procedure visit, the patient was well without GI complaints such as overt bleeding, change in bowel habits or unintentional weight loss. No family history of colon cancer or polyps was reported. Physical exam and vitals were normal at the time of procedure. Colonoscopy revealed a 40mm pedunculated sigmoid colon polyp which was excised using an endoloop at the stalk base followed by hot snare polypectomy ((Figure A). Three other sub-centimeter sessile polyps in the rectosigmoid area were removed by cold snare polypectomy. Histopathological examination of the large pedunculated polyp was consistent with a JP(Figure B). Other polyps were tubular adenomas. Discussion: Our current patient is the oldest reported case of isolated colonic JP. These polyps tend to have a common phenotypical appearance measuring around 10-30mm and roughly 90% of them are considered pedunculated. JP are ultimately defined by their distinctive histopathological features such as edematous lamina propria with inflammatory cells, cystically dilated glands that are bordered by cuboidal or columnar epithelium with reactive changes, and mucus filled glands. Fortunately for our patient, the presence of only a solitary colonic JP generally carries no known malignant potential. Juvenile polyposis syndrome (JPS) on the other hand is a hereditary condition characterized by the presence of hamartomatous polyps in the digestive tract and is known to have an increased risk of digestive tract malignancies. JPS is suspected when a patient has 5 or more juvenile polyps in the gastrointestinal tract or a juvenile polyp and a family history of juvenile polyps. A DNA test to check SMAD4 or BMPR1A gene is helpful.Figure 1.: (a) A 40mm polyp (Paris 0-Ip) located in the in the sigmoid colon. (b) Hamartomatous polyp has ulcerated surface with benign dilated glands.

Painless Rectal Bleeding in a Patient With Prostate Cancer

Painless Rectal Bleeding in a Patient With Prostate Cancer

A119 ACUTE DIVERTICULITIS & CONCURRENT DIVERTICULAR BLEED: A RARE CLINICAL ENTITY

AimsColonic diverticula are mostly asymptomatic incidental findings on cross sectional imaging or colonoscopy. In the setting of known diverticulosis, complications like diverticulitis and diverticular bleeding occur in only 4% and 1% of patients respectively. It is unusual to see both complications expressed in the same patient and moreover, rare to see them expressed concurrently. We report a case of concurrent diverticulitis with diverticular bleed and expand on the clinical course.MethodsCase reportResultsA 73-year old was diagnosed with sigmoid diverticulitis based on her clinical presentation and an abdominal CT scan. She was discharged home on oral antibiotics but presented a week later with painless rectal bleeding. In view of the ongoing diverticulitis, a colonoscopy was not pursued although it is the typical procedure of choice to manage active gastrointestinal bleeding. A CT scan was recommended as the alternate initial investigation, which revealed active colonic bleeding in the region of the hepatic flexure immediately adjacent to a diverticulum. A subsequent CT angiogram identified the middle colic artery to be the responsible blood supply to the region and embolization coils were deployed within this vessel in an attempt to achieve hemostasis.Despite vascular intervention the patient continued to bleed and resuscitation with blood products was insufficient. A repeat CT scan ruled out any areas of colonic ischemia as well as any further active areas of extravasation. A decision was made to proceed with a total colectomy to provide definitive treatment of the diverticular disease and manage the bleeding. An urgent intraoperative colonoscopy was attempted but quickly abandoned due to suboptimal preparation and ongoing bleeding obscuring the view. The patient underwent a total colectomy with ileorectal anastomosis. On pathology there was extensive diverticulosis of the ascending and the sigmoid colon with diverticulitis and diverticular abscess cavities within the sigmoid colon.ConclusionsDiverticulitis and diverticular bleed are thought to be unrelated complications of diverticulosis involving distinct physiologic pathways (Figure 1). Although diverticular bleed may occur in patients with a history of prior diverticulitis, concurrent presentation of these two entities is extremely rare. In addition, diverticular bleed is mostly self-limiting. While endoscopic and vascular embolization are established treatment options, colectomy is rare for the management of diverticular bleeding.We report a rare case of concurrent diverticulitis and lower GI bleeding. The presence of the sigmoid diverticulitis made interventional radiology a relatively safer option over endoscopy, which is the typical first line diagnostic and interventional procedure. Ongoing bleeding led to total colectomy and provided the patient with a definitive cure for her diverticular disease. Funding AgenciesNone

Meckel's Diverticulum - Clinical Presentation and Pitfalls in Diagnosis in the Pediatric Age Group in Singapore.

ABSTRACTPurpose:The purpose of this study was to study the presentation of patients who underwent Meckel's diverticulectomy (MD) and utility of pertechnetate Meckel's scan in the diagnosis of MD.Methods:The clinical presentation of a retrospective cohort of patients who underwent MD from January 2007 to December 2019 was studied. The modes of presentation, treatment, and the diagnostic utility of pertechnetate Meckel's scans were evaluated. False-positive and false-negative scans were reviewed. The presence of gastric mucosa on histology of Meckel's was correlated with presentation as gastrointestinal bleeding and positive scan results.Results:Ninety-nine patients underwent MD. Thirty-five out of 263 (13.3%) Meckel's scans done were positive. There was a male preponderance (86.9%). The peak age of presentation was 0–4 years (rectal bleeding or intestinal obstruction). Only a third of the patients with Meckel's diverticulum Meckel's had a preoperative diagnosis of Meckel's. The sensitivity/specificity of Meckel's scan was higher in patients presenting with painless rectal bleeding. Seven patients were false positive (weak tracer uptake or ectopic uptake) and five were false negative. Two patients with false-negative Meckel's scan, having gastrointestinal bleeding had gastric mucosa on histology of Meckel's.Conclusion:Meckel's diverticulum has a male predominance. Meckel's scan has a high sensitivity in the children presenting with fresh painless rectal bleeding but is of limited use in the diagnosis of Meckel's diverticulum in other forms of presentations. False-positive scans can be anticipated in the presence of weak or ectopic uptake. False-negative scans can occur even in the presence of bleeding and in spite of the presence of gastric mucosa in the Meckel's diverticulum. Laparoscopy is a useful tool in diagnosis and treatment.

Surgical perspectives of symptomatic omphalomesenteric duct remnants: Differences between infancy and beyond

BACKGROUNDThe clinical manifestations of omphalomesenteric duct remnant (OMDR) can vary with the age at diagnosis, from asymptomatic incidental findings to symptoms related to gastrointestinal complications. The lifelong complication rates are reported as 4%-34%, and complications are more common in patients younger than 2 years of age. The authors attempted to identify different clinical features and management for the various pediatric age groups.AIMTo find surgical perspectives for the pediatric age-related variants of OMDR and make recommendations for optimal management.METHODSThe medical records of pediatric patients diagnosed with OMDR were reviewed retrospectively. Fifteen patients diagnosed based on incidental findings during other surgeries were excluded. The patients were divided into two groups based on age: < 12 mo (infants) and > 12 mo (beyond infancy). We analyzed the demographic characteristics, clinical manifestations, diagnostic tools, surgical procedures, and clinical outcomes of the patients and compared them for the age groups. Chi-squared and Fisher's exact tests were used for nominal scales and a Mann-Whitney test was used for ratio scales.RESULTSA total of 35 patients (7 infants, 28 children beyond infancy) were finally included. In both groups, Meckel's diverticulum (MD) was the most common type of OMDR, while umbilical lesions were more common in the infant group (P = 0.006). Hematochezia and abdominal pain were common in the beyond infancy group, while umbilical lesions were the most frequent symptoms in the infant group. Several diagnostic tools were used, but Meckel's scan was most useful in diagnosing OMDR in patients with painless rectal bleeding. Minimally invasive surgery was more commonly performed for children than for infants (P = 0.016). Single-incision laparoscopic surgery (SILS) was performed for fifteen patients who underwent laparoscopic surgery. There were only three cases of postoperative complications, and all patients survived in good condition.CONCLUSIONThe clinical type of OMDR varies with age, umbilical lesions in infants, and MD beyond infancy. SILS is effective for managing children with MD regardless of age.

Gastrointestinal Bleeds.

Gastrointestinal Bleeds.

Meckel's Masquerade: Penetrating the Disguise.

Children with abdominal pain are frequently seen in emergency departments. Physicians and parents worry about appendicitis; physicians are also concerned about intussusception and bowel obstruction in patients with previous surgical procedures. Sometimes the patient is ill, and the diagnosis is elusive. In a 6-month period at our pediatric emergency department with an annual census of 57,400 patients, we cared for 4 patients who presented with abdominal pain due to complications of Meckel's diverticulum. None presented with painless rectal bleeding, the complication of which physicians are most aware. We are reporting these patients to raise awareness of Meckel's diverticulum as a cause of acute abdomen in children. Meckel's diverticulum may masquerade as appendicitis, an abdominal mass, intussusception, or a complication of severe constipation.

Solitary Juvenile Polyp at a Rural Ugandan Hospital Presenting with Recurrent Rectal Bleeding

Juvenile polyps (JP) are rare but important causes of acute gastrointestinal symptoms in children. They are a recognized cause of painless rectal bleeding in preschool age children and also the most common intraluminal disorder of the colon in children They are often solitary, pedunculated and small in size but may occasionally grow to large sizes or occur in great numbers, as in juvenile polyposis syndrome. Histologically juvenile polyps are similar to inflammatory polyps with irregular dilated glands, lamina propria expansion and granulation tissue expansion. Sporadic juvenile polyps of the colon occur in up to 2 percent of children under the age of 10 years, are usually solitary, and are not associated with an increased cancer risk. The etiology, diagnosis, clinical presentation, and management of these intestinal polyps depend on the type of polyp or polyposis syndrome. A change in bowel habits, abdominal pain, rectal bleeding, rectal prolapse, and even intussusception may be the initial presentation in children. In addition to a careful history, including a detailed family history, a physical examination, contrast studies, and endoscopic examination are vital diagnostic tools. Juvenile polyps may also present with prolapse of the polyp from the anus, abdominal pain due to intussusception or may even be asymptomatic. All such polyps should be removed by colonoscopy or transanal resection

Anorectal polyp.

A 71-year-old female with hypertension presented with painless rectal bleeding and found to have a soft mass on rectal exam. The colonoscopy revealed a large pedunculated polyp with patchy discoloration arising from the dentate line (Fig. 1). Biopsies of the polyp were obtained.

A199 SEVERE COLITIS FOLLOWING PELVIC RADIOTHERAPY: CASE REPORT AND REVIEW OF THE LITERATURE

Abstract Background Mild-to-moderate proctocolitis is a well-known complication of pelvic radiation therapy, occurring in 43% and 6% of patients following external beam radiotherapy (EBRT) and brachytherapy (BT), respectively. This typically presents as recurrent painless rectal bleeding, diarrhea, urgency, and/or iron-deficiency anemia. Severe ulcerating proctocolitis is a less common complication of pelvic radiotherapy and is rare following BT. We report two cases of severe ulcerating proctocolitis mimicking inflammatory bowel disease (IBD) following pelvic radiotherapy in patients without known IBD, including an elderly male undergoing EBRT, and an elderly female undergoing vaginal vault BT. Aims To describe two cases of severe ulcerating proctocolitis, mimicking IBD, following pelvic radiotherapy. Methods Case descriptions and literature review. Results A 71-year-old male without antecedent gastrointestinal disease developed bloody diarrhea 3 months following EBRT for treatment of prostate cancer. Infectious work-up was negative. Blood work showed anemia and an elevated CRP. CT scan showed distal large bowel inflammation concerning for proctocolitis. Flexible sigmoidoscopy revealed severe proctosigmoiditis with circumferential thickening and nodularity of the mucosa and multiple ulcers. Biopsies showed ulcer tissue with fibrinopurulent exudate. He was treated with systemic corticosteroids and symptoms gradually resolved. Repeat colonoscopy 8 months later showed healed inflammation with scarring and residual radiation proctosigmoiditis. A 74-year-old female without antecedent gastrointestinal disease developed watery diarrhea 2 weeks after initiating low dose vaginal vault BT for treatment of endometrial cancer. Infectious work-up was negative. Blood work showed an elevated CRP and CT scan revealed proctocolitis extending to the descending colon. Flexible sigmoidoscopy revealed severe ulcerating proctosigmoiditis with tram tracks of denuded mucosa. Biopsies showed moderate diffuse chronic active colitis with crypt abscesses and apoptotic bodies. She was treated with systemic corticosteroids followed by infliximab and methotrexate, with mild symptomatic improvement. However, repeat endoscopy revealed persistent severe ulceration. Unfortunately, she developed a sigmoid perforation with pelvic abscess, leading to bacteremia and fungemia, and subsequently passed. Conclusions While rare, severe ulcerating proctocolitis mimicking IBD can occur following pelvic radiotherapy, including BT. The decision to manage these patients as IBD using immunosuppressive therapy should be weighed against the risks of these therapies, considering a patient’s age and underlying health, and in collaboration with a patient’s health care team. Careful assessment for risk factors and pathological findings from biopsy specimens may help in predicting the likelihood of IBD in such patients. Funding Agencies None

Conservative Treatment of Hemorrhoidal Disease.

Hemorrhoids are vascular cushions underlying the distal rectal mucosa and contributing to approximately 15-20% of the resting anal pressure with a complete closure of the anal canal. They can become pathological (hemorrhoidal disease, HD) being the most common cause of painless rectal bleeding during defecation with or without prolapsing anal tissue. The treatment of HD must be tailored to both the severity of disease and patient's expectation. A narrative review of all the most relevant papers present on the three major databases (PUBMED, EMBASE and WEB OF SCIENCE) regarding conservative treatment was conducted. Conservative treatment is effective in managing the majority of patients complaining of early stages of the disease. Dietary and lifestyle modifications are the first therapeutic step necessary to achieve a regular defecation with soft stool whereas oral phlebotonic drugs can help to control symptoms. The use of topical medications, particularly during the acute phase or in the post-operative period can also be beneficial for all patients complaining of HD. Despite a large number of available products in the market and the high incidence of HD, very few randomized controlled trials have been carried out and most of the studies are uncontrolled case series. Larger and better designed studies are necessary to establish the real benefit of all types of drugs for the treatment of early stages of HD.

Infantile juvenile polyposis syndrome: A rare cause of protein-losing enteropathy

Juvenile Polyposis Syndrome (JPS) is a rare autosomal dominant hereditary syndrome affecting 1:100000-160000 individuals. JPS most presents with rectal bleeding, anemia, abdominal pain, obstruction and rarely with rectal prolapsus of the polyp. In this case, we diagnosed Infantile Juvenile Polyposis Syndrome due to protein losing enteropathy, rectal bleeding and extraintestinal manifestations of the syndrome. A 2-year-old male infant was referred to the hospital due to complaints of painless rectal bleeding and rectal prolapsus of the polyp which occurred at 15 months of age. Pathological examination revealed that it was a juvenile polyp. After a short while, the patient was hospitalized due to rectal bleeding, paleness, swelling in both legs and periorbital edema. Physical examination of the patient revealed +3 pretibial, scrotal, periorbital edema, clubbing and pale appearance. The patient had macrocephaly, hypotonicity and neuromotor retardation. Laboratory test results revealed low immunoglobulin levels, hypoalbuminemia, anemia, and electrolyte imbalance. We diagnosed the case with JPS due to protein losing enteropathy with extraintestinal manifestations of the syndrome. Gastroscopic and colonoscopic examinations revealed multiple polyps through the antrum and colon. JPS diagnosis is based on the detection of polyps which are histopathologically defined as juvenile polyps. One of the most common causes of painless, rectal bleeding in children are colorectal polyps. We wanted to emphasize that the sporadic juvenile polyp diagnosis should be made by pathological examination of polypectomy material and clinical exclusion of JPS. In our patient, there were extraintestinal system manifestations such as macrocephaly, congenital heart disease and clubbing, accompanied with protein-losing enteropathy. Awareness of these clinical findings is necessary for the differential diagnosis of protein-losing enteropathy and polyposis syndrome. We would also like to draw attention to the importance of a multidisciplinary approach, early recognition of the syndrome and appropriate referral of the patient.

Prolapsed Hemorrhoids Treatment Options

Objectives: Hemorrhoids are among the most common complaints worldwide, ranging from painless rectal bleeding to prolapsed hemorrhoids. Hemorrhoids can be classified into external and internal types. External hemorrhoids do not need any specific treatment unless they are cause pain, bleed or become thrombosed.&#x0D; Methods: This study is a prospective study (case series study), approved by ethical committee, conducted on Fifty patients with prolapsed pile, 46 of whom were males and 4 were females and were collected in the span of 2 years from Sulaymaniyah Teaching hospital and Shar hospital. Topical application of mannitol included a gauze soaked with mannitol solution and applied to the prolapsed hemorrhoids.&#x0D; Results: All the patients presented with prolapsed hemorrhoids, 46 of them were males and 4 of them were females. Most of patients were heavy workers (46%), while students made up (18%), employee (22%), retired (8%) and free workers (6%). The most common clinical presentations were constipation (72%), anal pain (68%), bleeding (50%), itching (14%), discharge (4%) and prolapse only (6%).&#x0D; Conclusions: Prolapsed hemorrhoid can be managed conservatively by topical application of mannitol as it decreases edema, causing the hemorrhoidal tissue to retract to its position.

A novel group of HPV-related adenocarcinomas of the lower anogenital tract (vagina, vulva, and anorectum) in women and men resembling HPV-related endocervical adenocarcinomas.

Human papillomavirus (HPV) is an oncogenic virus associated with the development of several human cancers. Primary vaginal, vulvar, and anal adenocarcinomas are rare and, to date, have rarely been shown to be associated with HPV infection. We report a series of nine HPV-related adenocarcinomas of the lower anogenital tract distal to the cervix. The tumors involved the vagina (4), anorectum (3), and vulva (2). Two of the three anorectal cases involved men. Patients presented with a vulvar or vaginal mass/nodule, painless rectal bleeding, or during screening colonoscopy. Lesions ranged in size from 3.2 to 8.4 cm. The most salient morphologic characteristic was the presence of papillary or villiform/villoglandular architecture in all cases. Tumors displayed features similar to those of usual type high-risk HPV-related endocervical adenocarcinoma, namely, mucinous or mucin-poor (pseudoendometrioid) features or a hybrid of these, with columnar cells with crowded, cigar-shaped to ovoid irregular nuclei. Mitoses (mostly apical) and apoptotic bodies were easily identified. Adenosis was present in two vaginal cases. One anal tumor featured abundant intracytoplasmic mucin that was multivacuolated in some areas imparting a "clear cell"-like appearance. All tumors were diffusely and strongly positive for p16. Seven of seven tested cases were positive for high-risk HPV by in situ hybridization or polymerase chain reaction. Follow-up information, available in five patients, revealed two local recurrences but no tumor related deaths or distant metastases. We report the first well-documented series of HPV-associated primary adenocarcinomas of the vagina, vulva, and anorectum and broaden the spectrum of HPV-related neoplasia involving the lower anogenital tract in both women and men.

1941 Meckel’s Diverticulum in an Adult Presenting as Acute Gastrointestinal Bleeding

INTRODUCTION: Meckel’s diverticulum (MD) is the most common congenital anomaly of the gastrointestinal (GI) tract. MD develops as incomplete obliteration of the vitelline duct forms a true diverticulum in the small intestine. It often presents in children as painless rectal bleeding, while adults are often asymptomatic. We are presenting an unusual case of MD in an adult with acute, frank GI bleeding. CASE DESCRIPTION/METHODS: A 35-year-old male presented with one day of bright red blood per rectum (BRBPR), LLQ abdominal discomfort followed by a near syncopal episode. Vital signs were stable on arrival. Physical exam significant for pallor and bright red blood in the rectal vault. Initial hemoglobin was 11.6 g/dl and hematocrit 33.5%. Computed tomography angiogram (CTA) abdomen and pelvis was negative for active bleed. Initial colonoscopy showed gross blood throughout colon without an identifiable source of bleeding. Esophagogastroduodenoscopy was also negative. Patient continued to have episodes of BRBPR with progression to hemorrhagic shock. Hemoglobin and hematocrit the next day decreased to 6.1 g/dl and 17.9%, respectively. However, repeat CTA was negative for active bleeding. Repeat colonoscopy showed blood in the terminal ileum. Technetium 99m pertechnetate scintigraphy demonstrated a focal area of ectopic gastric mucosa in the distal ileum. Laparoscopic small bowel resection was performed with symptom resolution. DISCUSSION: While uncommon in adults, MD should be included on the differential diagnosis of adults with obscure GI bleeding. GI bleeding in MD develops as ileal mucosa is exposed to acid secretion from ectopic gastric mucosa resulting in ulceration in 11.8% of symptomatic adults. Adults often present with melena; hence it is unusual for an adult to present with frank BRBPR. Technetium 99m pertechnetate scintigraphy, also known as Meckel’s scan, is regarded as the modality of choice for diagnosis in the pediatric population, due to its sensitivity of 85%, specificity of 95%, and overall diagnostic accuracy of 90%. Meckel’s scan is less reliable in adults with a sensitivity of 62.5%, specificity of 9% and diagnostic accuracy of 46%. One study illustrated that balloon assisted enteroscopy provided the highest accuracy for diagnosis of bleeding MD in adults and should be considered the preferred modality for preoperative diagnosis. Despite its rarity, awareness and understanding of MD in adults as well as its complications is imperative and may improve patient outcomes.