Rectal Stricture Research Articles

Can fecal continence be predicted in patients born with anorectal malformations?

PurposeThe purpose of this study was to identify factors associated with attaining fecal continence in children with anorectal malformations (ARM). MethodsWe performed a multi-institutional cohort study of children born with ARM in 2007–2011 who had spinal and sacral imaging. Questions from the Baylor Social Continence Scale were used to assess fecal continence at the age of ≥4 years. Factors present at birth that predicted continence were identified using multivariable logistic regression. ResultsAmong 144 ARM patients with a median age of 7 years (IQR 6–8), 58 (40%) were continent. The rate of fecal continence varied by ARM subtype (p = 0.002) with the highest rate of continence in patients with perineal fistula (60%). Spinal anomalies and the lateral sacral ratio were not associated with continence. On multivariable analysis, patients with less severe ARM subtypes (perineal fistula, recto-bulbar fistula, recto-vestibular fistula, no fistula, rectal stenosis) were more likely to be continent (OR = 7.4, p = 0.001). ConclusionType of ARM was the only factor that predicted fecal continence in children with ARM. The high degree of incontinence, even in the least severe subtypes, highlights that predicting fecal continence is difficult at birth and supports the need for long-term follow-up and bowel management programs for children with ARM. Type of StudyProspective Cohort Study. Level of EvidenceII.

A Case of Barium Enema–Induced Anal Fistula in a Long-term Care Resident: An Imperative to Avoid Barium Enema as a Screening and Diagnostic Tool in the Elderly

The use of barium enema study has decreased as lower GI endoscopy becomes more prevalent. However, it is still used in several clinical settings given benefits of sedation avoidance, less invasiveness and low cost. Even though barium enema is a relatively safe study, complications may result in rare cases. Colonic perforation is the most frequent serious complication, occurring in 0.02 to 0.04% of patients. Extra peritoneal perforation is usually less catastrophic than intra peritoneal perforation, but may result in pain, abscess, rectal stricture or fistula. The risk factors for complication are a recent colonoscopy especially with biopsy, impaired tensile strength of the bowel wall due to age, overinflation of the balloon and trauma from the enema.

Blocked by a Ring: A Case of Gastric Linitis Plastica Presenting as Large Bowel Obstruction Secondary to Rectal Stenosis.

Metastatic gut lesions from primary gastric carcinoma occur via hematogenous, lymphatic, or peritoneal seeding. We report an unusual case of large bowel obstruction secondary to rectal stenosis due to metastatic signet ring cell gastric cancer. A 61-year-old woman with a history of 8 weeks' duration of alternation in bowel movements presented with symptoms of bowel obstruction. Computed tomography revealed rectal wall thickening, and sigmoidoscopy demonstrated edematous and fibrotic rectal mucosa. Superficial biopsies were negative for malignant disease. Because of worsening of obstructive symptoms, an emergent surgical diversion was performed. Surgical biopsies were consistent with poorly differentiated adenocarcinoma. Gastroscopy established diagnosis of gastric adenocarcinoma with signet ring type cells. Rectal stenosis on examination and demonstration of rectal wall thickening on imaging should raise suspicion for Schnitzler's metastasis, and an upper endoscopy should be performed.

Rectal resection for Schnitzler’s metastasis in a patient presenting with severe rectal stenosis: case report and review of the literature

Rectal metastasis resulting from the hematogenous spread of gastric cancer (Schnitzler’s disease) is rarely seen. We report a case of 53-year-old female with rectal metastasis from gastic cancer who presented with abdominal pain, tenesmus, and severe constipation. Digital rectal examination revealed a severe stenosis 5-6 cm from the dentate line. Sigmoidoscopy showed a narrowed lumen at 5 cm up from the dentate line. The evident radiologic finding was circumferential stenosis of the rectum located at the same level. Very low anterior resection and total mesorectal excision with coloanal anastomosis in addition to protective ileostomy were performed. Pathological examination revealed metastatic adenocarcinoma (Schnitzler’s metastasis). The patient was discharged on the 9th postoperative day with no adverse events. It should be kept in mind that rectal stenosis could be metastasis from gastric carcinoma if consistent with the patient’s history.

Currarino syndrome: repair of the dysraphic anomalies and resection of the presacral mass in a combined neurosurgical and general surgical approach.

OBJECTIVEIt is well established that Currarino syndrome (CS) may be associated with spinal dysraphism. Here, the authors report on 10 CS patients with dysraphic anomalies who had undergone a combined neurosurgical and general surgical approach to repair the dysraphic anomalies and resect the presacral mass in a single operation. They discuss the spectrum of spinal dysraphism that may coexist in CS in the context of its developmental etiology.METHODSChildren with a confirmed CS diagnosis who had undergone the combined operative approach were identified from a departmental database. Presenting features were recorded and preoperative imaging was analyzed to record features of the presacral mass and the dysraphic anomalies. The histopathological nature of the resected presacral mass and the outcomes postoperatively and at the last follow-up were reviewed.RESULTSBetween 2008 and 2015, 10 patients presented with CS, 9 with constipation. Median age at the time of surgery was 1.3 years. Six of the 10 patients had anorectal malformation consisting of anal stenosis, rectal stenosis, or imperforate anus. Spinal anomalies included anterior meningocele (5 cases), low-lying conus (8), terminal syrinx (4), fatty filum (5), caudal lipoma (3), and intraspinal cyst (1). In all cases, the lumbosacral spinal canal was accessed via a midline approach with laminoplasty, allowing spinal cord untethering and repair of the dysraphic anomalies. Following dural closure, the incision was extended inferiorly to incorporate a posterior sagittal approach to resect the presacral mass. The histopathological nature of the mass was mature teratoma (8 cases), complex hamartomatous malformation (1), or neurenteric cyst (1). There were no new instances of neurological deterioration, with most instances of persisting morbidity related to constipation (6 cases) or neurogenic bladder dysfunction (8). There were no infective complications, no instances of cerebrospinal fluid fistula, no recurrences of the presacral mass, and no cases of retethering of the spinal cord.CONCLUSIONSAlthough not part of the original triad, spinal dysraphic anomalies are common in CS and in keeping with a disorder of secondary neurulation. Lumbosacral MRI is an essential investigation when CS is suspected. Children are at risk of sphincter impairment due to the anorectal malformation; however, both spinal cord tethering and compression from the presacral mass may further compromise long-term continence. A combined operative approach to repair the dysraphic anomalies and resect the presacral mass is described with good postoperative and long-term outcomes.

Use of Self-Expandable Prosthesis for the Treatment of Colon and Rectal Benign Stenosis. Systematic Review

he main reason for the use of self-expandable prosthesis (SEP) is for the treatment of malignant colonic obstructions. The objective of this study is to determine the understanding with regard to results of applying SEP in benign stenosis of colon and rectum, measured in terms of numbers, etiology, and results. Systematic review. A search on MEDLINE, Cochrane Library CENTRAL, DARE, HTA, NHSEED, EMBASE and CINAHL and TRIP database was conducted. We considered all studies published since 1990 for this report. Search strategies were applied to each database using MesH terms, truncated, free words and Booleans. The results and level of evidence of the studies were summarized in tables summarizing efficacy, safety and complications. We obtained 19 related articles. All of these were case series and case reports (evidence level 4), totaling less than 150 cases treated with SEP. The observed results were adequate in terms of symptom reduction, however, a considerable percentage of complications were observed (intestinal perforation, migration, re-obstruction and pain). Published experience concerning the results of the installation of SEP in benign strictures of colon and rectum is scarce and evidence is limited. Therefore, further studies and articles with improved methodological qualities are required.

Refractory Anastomotic Rectal Stricture After Lower Anterior Resection and Radiation Exposure

We present a patient with history of neoadjuvant radiation and chemotherapy, with lower anterior resection, complicated with rectal anastomotic stricture refractory to endoscopic intervention. In the past, colorectal surgery had been the preferred method of treatment of rectal strictures, but endoscopic techniques, such as balloon dilation, have become the preferred modality. However, there is a high stricture recurrence rate of up to 18-20%, with increased risk of perforation due to uncontrolled stretching reported after balloon dilatation. A 68 year old female who migrated from West Africa with medical history of hypertension, Stage IIIB rectal cancer with low anterior resection and neoadjuvant chemo-radiation one year ago, presented to our gastrointestinal clinic for colon cancer surveillance. She denied melena, hematochezia, abdominal pain, diarrhea, nausea and vomiting, however noted a decrease in frequency of bowel movements. Colonoscopy performed revealed a very tight fibrotic stricture ˜8 cm from anal verge. With the use of a Through the scope (TTS ) balloon (6-7-8mm) dilation was performed. Minimal self limited mucosal oozing was noted. A subsequent flexible sigmoidoscopy was performed 2 weeks later with TTS using a larger sized balloon (8-9-10mm), which was inserted and dilation repeated. During a repeat colonoscopy performed 3 weeks later a very tight stricture was observed again in the rectum. Given recurrent stricturing / fibrosis - dilation was not attempted and was referred to colorectal surgery for surgical correction of stricture. Anastomotic stricture is a relatively common complication of low anterior resection especially in patients who had preoperative radiation. Endoscopic balloon dilatation is the most effective method to correct strictures, although repeated dilation over time is often required. There is some evidence in literature that dilating for the third or subsequent times may be futile. Even though balloon dilatation is a safe treatment, additional treatment modalities described in literature include; the use of neodymium: yttrium-aluminum-garnet laser treatment, electro-incision, electrocautery, and use of sphincterotomes. Colorectal Surgery should be considered in patients with recurrent strictures refractory to endoscopic therapy.2940 Figure 1. A very tight stricture ˜8 cm from anal verge seen. A TTS CRE ballon was inserted (6-7-8 cm) and dilation was performed. Minimal self limited oozing noted.

A Rare Cause of Colonic Obstruction: Metastatic Breast Cancer to the Rectum

Introduction Breast cancer (BC) is the most prevalent cancer in women and among the leading cause of death in these patients. While BC is known to spread to the bones, lungs, liver, brain, and soft tissues, gastrointestinal (GI) metastasis is rare. Furthermore, metastatic spread specifically to the rectum is exceedingly rare. We present a rare case of a woman with history of breast cancer presenting with rectal metastasis four years after mastectomy. Case Report A 53-year-old woman presented for a colonoscopy following a surveillance abdominal CT scan that showed an incidental thickening of her rectum. There was no history of rectal bleeding. Her past history was significant for grade 2 invasive ductal carcinoma (IDC) of the left breast diagnosed 4 years ago. Immunohistochemical staining was positive for estrogen receptor (ER), progesterone receptor (PR) and negative for human epidermal growth factor receptor 2 (HER2-neu). She was treated with left partial mastectomy, radiation, chemotherapy with Taxotere and cyclophosphamide, and hormonal therapy. She was in remission for approximately 3 years and then found to have recurrence to the bladder when she developed hematuria. At the time of presentation to the colonoscopy, her cancer antigen (CA) 15.3 was 721, CA 125 was 110, and CEA was 23.3. Colonoscopy revealed narrowing at the rectosigmoid with thickened mucosa without a clear obstructive lesion. Even a smaller diameter (11.6 mm) colonoscope could not be passed through the narrow rectosigmoid colon (Image 1). Multiple biopsies showed metastatic carcinoma of primary breast origin (Images 2-3). For her metastatic breast cancer, she was started on various chemotherapy agents including Faslodex and palbociclib and then AZD5363 and olaparib with variable response. Currently she is on Xeloda and has been tolerating it well and does not have any significant obstructive rectal symptoms. Discussion GI metastasis from invasive breast cancer is very rare ( 0.2% for ductal carcinoma and even rarer for lobular carcinoma). Rectal metastasis is even less frequent and only noted in several case reports. This can present masquerading as primary rectal mass, stricture or bleeding, years following the initial diagnosis of breast cancer. As such, physicians should have a heightened suspicion in caring for patients with new anorectal symptoms.1643_A Figure 1 No Caption available.1643_B Figure 2 No Caption available.1643_C Figure 3 No Caption available.

A Case of Rectal Stenosis Successfully Treated by Transanal Cicatrectomy

A Case of Rectal Stenosis Successfully Treated by Transanal Cicatrectomy

Conservative surgery versus colorectal resection in deep endometriosis infiltrating the rectum: a randomized trial.

STUDY QUESTIONIs there a difference in functional outcome between conservative versus radical rectal surgery in patients with large deep endometriosis infiltrating the rectum 2 years postoperatively?SUMMARY ANSWERNo evidence was found that functional outcomes differed when conservative surgery was compared to radical rectal surgery for deeply invasive endometriosis involving the bowel.WHAT IS KNOWN ALREADYAdopting a conservative approach to the surgical management of deep endometriosis infiltrating the rectum, by employing shaving or disc excision, appears to yield improved digestive functional outcomes. However, previous comparative studies were not randomized, introducing a possible bias regarding the presumed superiority of conservative techniques due to the inclusion of patients with more severe deep endometriosis who underwent colorectal resection.STUDY DESIGN SIZE, DURATIONFrom March 2011 to August 2013, we performed a 2-arm randomized trial, enroling 60 patients with deep endometriosis infiltrating the rectum up to 15 cm from the anus, measuring more than 20 mm in length, involving at least the muscular layer in depth and up to 50% of rectal circumference. No women were lost to follow-up.PARTICIPANTS/MATERIALS, SETTING, METHODSPatients were enroled in three French university hospitals and had either conservative surgery, by shaving or disc excision, or radical rectal surgery, by segmental resection. Randomization was performed preoperatively using sequentially numbered, opaque, sealed envelopes, and patients were informed of the results of randomization. The primary endpoint was the proportion of patients experiencing one of the following symptoms: constipation (1 stool/>5 consecutive days), frequent bowel movements (≥3 stools/day), defecation pain, anal incontinence, dysuria or bladder atony requiring self-catheterization 24 months postoperatively. Secondary endpoints were the values of the Visual Analog Scale (VAS), Knowles–Eccersley–Scott-Symptom Questionnaire (KESS), the Gastrointestinal Quality of Life Index (GIQLI), the Wexner scale, the Urinary Symptom Profile (USP) and the Short Form 36 Health Survey (SF36).MAIN RESULTS AND THE ROLE OF CHANCEA total of 60 patients were enroled. Among the 27 patients in the conservative surgery arm, two were converted to segmental resection (7.4%). In each group, 13 presented with at least one functional problem at 24 months after surgery (48.1 versus 39.4%, OR = 0.70, 95% CI 0.22–2.21). The intention-to-treat comparison of the overall scores on KESS, GIQLI, Wexner, USP and SF36 did not reveal significant differences between the two arms. Segmental resection was associated with a significant risk of bowel stenosis.LIMITATIONS REASONS FOR CAUTIONThe inclusion of only large infiltrations of the rectum does not allow the extrapolation of conclusions to small nodules of <20 mm in length. The presumption of a 40% difference favourable to conservative surgery in terms of postoperative functional outcomes resulted in a lack of power to demonstrate a difference for the primary endpoint.WIDER IMPLICATIONS OF THE FINDINGSConservative surgery is feasible in patients managed for large deep rectal endometriosis. The trial does not show a statistically significant superiority of conservative surgery for mid-term functional digestive and urinary outcomes in this specific population of women with large involvement of the rectum. There is a higher risk of rectal stenosis after segmental resection, requiring additional endoscopic or surgical procedures.STUDY FUNDING/COMPETING INTEREST(S)This work was supported by a grant from the clinical research programme for hospitals (PHRC) in France. The authors declare no competing interests related to this study.TRIAL REGISTRATION NUMBERThis study is registered with ClinicalTrials.gov, number NCT 01291576.TRIAL REGISTRATION DATE31 January 2011.DATE OF FIRST PATIENT’S ENROLMENT7 March 2011.

Endoscopic Dilation Combined With Intramuscular Injection of Mitomycin C for Treatment of Congenital Rectal Stenosis: A First Case Report

Endoscopic Dilation Combined With Intramuscular Injection of Mitomycin C for Treatment of Congenital Rectal Stenosis: A First Case Report

Maternal Medicaid Recipient Status and Congenital Malformations among New York State Live Births in 2010.

Congenital malformations are a leading cause of infant mortality in the United States, and risk for some congenital malformations varies by socioeconomic status (SES). Medicaid provides health insurance for people with low income, and covers approximately half of all live births in the United States. Income level is one aspect of SES. Studies have shown relationships between SES and some congenital malformations. This retrospective cohort study examined associations between maternal Medicaid recipient status and 46 congenital malformations in New York State for birth year 2010. The impact of Medicaid continuous enrollment (CE) status was evaluated in a sub-analysis of Medicaid recipients. Logistic regression was used to calculate adjusted odds ratios and 95% confidence intervals. The study cohort included 240,721 live births, 3778 infants with one or more congenital malformation of interest, and 118,631 maternal Medicaid recipients at the time of the infant's birth. Odds ratios for cleft lip with or without cleft palate and rectal atresia or stenosis were increased for Medicaid recipients compared with non-Medicaid recipients. However, odds ratios for cleft lip with or without cleft palate and rectal atresia or stenosis were decreased for CE compared with non-CE Medicaid recipients. Maternal Medicaid recipient status was associated with few of the 46 congenital malformations evaluated. However, some associations found were modified by CE in Medicaid. Birth Defects Research 109:1460-1470, 2017.© 2017 Wiley Periodicals, Inc.

Varied facets of rectal atresia and rectal stenosis.

Rectal atresia (RA) and rectal stenosis (RS) are rare anomalies with varied treatment options. A thorough literature review was done on reported cases/series of RA and RS. Based on evidence from cases managed over last 15years, new insights into embryology were hypothesized. A comprehensive review was compiled with updated knowledge on diagnosis and management. RA is classified into five types I: II: III: IV: V as RS: RA with septal defect: RA with a fibrous cord between two atretic ends: RA with a gap: Multiple RA and/or RS. Current definitive surgical repair of these anomalies preserves the anal canal, dentate line, and sphincter complex. Most neonates with RA undergo sigmoid colostomy except few with RS who can rarely decompress adequately. Membranous RS and septal RA may seldom respond to dilatation or be amenable to transanal repair. Posterior sagittal anorectoplasty with an end-to-end/side repair is recommended for RA and most intramural RS. RS may be associated with a presacral mass and colonic/rectal motility disorders. The expected postoperative outcome is good if the normally developed anal sphincter complex is retained undamaged. Early recognition of the type of anomaly is necessary for appropriate management.

Para-aortic node involvement is not an independent predictor of survival after resection for pancreatic cancer

Deep infiltrating endometriosis (DIE) is a complex disease that impairs the quality of life and the fertility of women. Colorectal DIE accounts for 70% to 93% of all the intestinal endometriotic sites and frequently needs a surgical approach. However, the indications for the surgical management of this condition are still controversial. From March 2010 to June 2014, we scheduled 33 consecutive patients presenting with retrocervical-rectal DIE of any diameter not involving the mucosa nor producing rectal stenosis >50% for laparoscopic robotic-assisted nerve-sparing rectal nodulectomy (LRN). All patients were examined preoperatively, at 3 months and 6 months postoperatively, and yearly thereafter. Dysmenorrhea, dyschezia, dyspareunia, and dysuria were evaluated on a 10-point visual analog scale. Among the 33 enrolled patients, 31 (93.9%) fulfilled the selection criteria and were submitted to LRN. In 1 out of 31 available patients (3.2%), a segmental bowel resection was considered necessary for prudential purpose at the end of the nodulectomy procedure. No laparotomic conversion was performed in any case. A wide variety of associated surgical procedures were performed in 25 of 30 patients (83.3%). No intraoperative complications were observed. One grade 3b and 2 grade 1 postoperative complications were recorded. The mean larger axis of the excised nodules measured on the formalin-fixed specimen was 26.4 mm. We found significant improvements in patient symptoms at a 3-month follow-up which persisted over the time. We observed 2 (6.7%) recurrences of intestinal endometriosis and 1 (3.3%) recurrence of chronic pelvic pain without clinical and/or radiologic evidence of endometriotic lesions. The mean follow-up time was 27.6 months. We believe that LRN is feasible and safe and shows promising results in terms of radicality, anatomic recurrence rate, and pain recurrence rate for treating isolated retrocervical-rectal DIE not involving the mucosa, without limiting this procedure to nodules smaller than 3 cm.

Transanal Endoscopic Microsurgery for the Treatment of Uncommon Rectal Lesions

IntroductionTransanal endoscopic microsurgery (TEM) was developed as a less aggressive alternative treatment for rectal lesions (mainly adenomas and adenocarcinomas). However, its use for other rectal lesions has become more frequent, trying to reduce the morbidity associated with more invasive techniques. The aim of this study is to describe our experience in the use of TEM in other rectal lesions. MethodsRetrospective and descriptive study including patients operated with TEM (from June 2008 to December 2016) for the treatment of rectal lesions different from adenomas or adenocarcinomas. ResultsAmong the 138 patients treated by TEM in our department, 10 patients were operated on for rectal lesions other than adenomas or adenocarcinomas. Rectal lesions were 3 neuroendocrine tumors, a neuroendocrine tumor metastasis, a rectal stenosis, a cloacogenic polyp, an endometrioma, a retrorrectal tumor, a presacral abscess and a lesion in the rectovaginal septum. Mean operative time was 72min and postoperative stay was 4.2 days. Only one patient needed a reoperation, due to rectal bleeding. ConclusionsTEM could be a useful tool for the treatment of rectal lesions different from adenomas or adenocarcinomas, potentially decreasing the morbidity associated with more aggressive surgical techniques.

Microcirugía endoscópica transanal en el tratamiento de lesiones rectales atípicas

IntroductionTransanal endoscopic microsurgery (TEM) was developed as a less aggressive alternative treatment for rectal lesions (mainly adenomas and adenocarcinomas). However, its use for other rectal lesions has become more frequent, trying to reduce the morbidity associated with more invasive techniques. The aim of this study is to describe our experience in the use of TEM in other rectal lesions. MethodsRetrospective and descriptive study including patients operated with TEM (from June 2008 to December 2016) for the treatment of rectal lesions different from adenomas or adenocarcinomas. ResultsAmong the 138 patients treated by TEM in our department, 10 patients were operated on for rectal lesions other than adenomas or adenocarcinomas. Rectal lesions were 3neuroendocrine tumours, a neuroendocrine tumour metastasis, a rectal stenosis, a cloacogenic polyp, an endometrioma, a retrorrectal tumour, a presacral abscess and a lesion in the rectovaginal septum. Mean operative time was 72min and postoperative stay was 4.2 days. Only one patient needed a reoperation, due to rectal bleeding. ConclusionsTEM could be a useful tool for the treatment of rectal lesions different from adenomas or adenocarcinomas, potentially decreasing the morbidity associated with more aggressive surgical techniques.

Robotic-Assisted Conservative Excision of Retrocervical-Rectal Deep Infiltrating Endometriosis: A Case Series

Deep infiltrating endometriosis (DIE) is a complex disease that impairs the quality of life and the fertility of women. Colorectal DIE accounts for 70% to 93% of all the intestinal endometriotic sites and frequently needs a surgical approach. However, the indications for the surgical management of this condition are still controversial. From March 2010 to June 2014, we scheduled 33 consecutive patients presenting with retrocervical-rectal DIE of any diameter not involving the mucosa nor producing rectal stenosis >50% for laparoscopic robotic-assisted nerve-sparing rectal nodulectomy (LRN). All patients were examined preoperatively, at 3 months and 6 months postoperatively, and yearly thereafter. Dysmenorrhea, dyschezia, dyspareunia, and dysuria were evaluated on a 10-point visual analog scale. Among the 33 enrolled patients, 31 (93.9%) fulfilled the selection criteria and were submitted to LRN. In 1 out of 31 available patients (3.2%), a segmental bowel resection was considered necessary for prudential purpose at the end of the nodulectomy procedure. No laparotomic conversion was performed in any case. A wide variety of associated surgical procedures were performed in 25 of 30 patients (83.3%). No intraoperative complications were observed. One grade 3b and 2 grade 1 postoperative complications were recorded. The mean larger axis of the excised nodules measured on the formalin-fixed specimen was 26.4 mm. We found significant improvements in patient symptoms at a 3-month follow-up which persisted over the time. We observed 2 (6.7%) recurrences of intestinal endometriosis and 1 (3.3%) recurrence of chronic pelvic pain without clinical and/or radiologic evidence of endometriotic lesions. The mean follow-up time was 27.6 months. We believe that LRN is feasible and safe and shows promising results in terms of radicality, anatomic recurrence rate, and pain recurrence rate for treating isolated retrocervical-rectal DIE not involving the mucosa, without limiting this procedure to nodules smaller than 3 cm.

Treatment of inflammatory rectal strictures by digital bougienage: a retrospective study of nine cases.

Inflammatory rectal strictures in dogs and cats have been rarely reported. The aim of this study was to describe nine cases and their treatment by digital bougienage. Medical records of dogs and cats referred for constipation, dyschezia or tenesmus and diagnosed with an inflammatory rectal stricture were obtained from the database of two referral centres between 2007 and 2014 and reviewed. Four dogs and five cats met the inclusion criteria. Four of the five cats were purebred kittens. Three cats and two dogs had a history of diarrhoea and two dogs had a history of bone ingestion. Digital rectal examination revealed rectal strictures in all cases. Histopathology revealed a lymphoplasmacytic infiltration in all four dogs and in two cats. All cases were treated by digital bougienage. A psyllium-enriched diet was prescribed in all cats and in two dogs. A complete resolution of clinical signs was reported in all eight cases for which follow-up information was available. Benign rectal strictures associated with gastrointestinal inflammation should be routinely included in the differential diagnosis of constipation, tenesmus and dyschezia, especially after an episode of acute or chronic diarrhoea. The treatment described here is simple, minimally invasive and effective in the long term.

便通異常を契機に見つかった腸骨動脈瘤による直腸狭窄と，進行S状結腸癌による腸重積をきたした1例

症例は80歳代男性．脳梗塞後遺症にて老健施設に入所中．ADLは床上，四肢も拘縮し，発語なく，全介助で経口摂取可能なPS4の状態で，下痢を主訴に当センターを受診した．内服薬で軽快しないため大腸内視鏡検査を施行した．直腸に粘膜下腫瘍様の白色調で比較的軟らかな巨大腫瘤を認め，直腸狭窄をきたしていた．CT検査を施行したところ，直腸腫瘤は径4cm大の内腸骨動脈瘤で破裂の危険があった．また，これとは別にS状結腸に全周性壁肥厚を認め，癌が強く疑われた．破裂の危険の高い動脈瘤に対してカテーテル治療を行い，その後，癌が腸重積を引き起こしたため，S状結腸切除を行った．術後18日目に軽快退院した．内腸骨動脈瘤による極めて稀な内視鏡像を報告する．

A Case of Diffuse Large B-cell Lymphoma of Colon in a Patient with Ulcerative Colitis

INTRODUCTION: Adalimumab is an anti-TNF agent approved for the treatment of severe active Ulcerative Colitis (UC). Use of anti-TNF agents along with thiopurines increases the risk of lymphoma compared to thiopurines alone. Limited data is available regarding the risk of lymphoma in UC patients treated with anti-TNF agents alone. CASE: A 66 y/o old male with Left sided UC maintained on azathioprine (5 years) and adalimumab (3 years), presented with increasing abdominal cramping and bloody diarrhea with mucus for 3 weeks. Hemodynamically stable and physical exam significant for diffuse abdominal tenderness. Labs: Hgb 12.2 g/dL, normal WBC, negative Stool studies and C. difficile toxin. CT Abdomen showed distal sigmoid and rectal wall thickening with pericolonic fat stranding consistent with active inflammation and lymphadenopathy. Flexible sigmoidoscopy showed near complete obstruction due to rectal stricture with inability to pass scope beyond 10 cm. Biopsy revealed Diffuse large B-cell lymphoma. Azathioprine and Adalimumab were stopped and the patient received chemotherapy (with R-CHOP), followed by radiation and subsequent colectomy. DISCUSSION: Patients with Inflammatory Bowel Disease (IBD) have a slightly increased risk of lymphoma compared to the general population. The absolute risk is nearly twice as high in Crohn's Disease (CD) compared to UC. Incidence of lymphoma is approximately 4 times higher in IBD patients treated with thiopurines compared to patients not on these drugs. Among patients treated with anti-TNF agents (with and without thiopurines), the SIRR was 5.5 for past use (95% CI: 4.5-6.6) and 4.4 for current use (95% CI: 3.4-5.4). However studying the association between lymphoma and anti-TNF drugs is complicated because most patients treated with anti-TNF agents have been previously treated with Thiopurines or are receiving both medications concurrently. Reactivation of latent EBV infection is the best-studied mechanism for development of lymphoma in IBD patients on immunosuppressant therapy. When the patient develops lymphoma, therapy should be discontinued until the lymphoma has been treated and is in remission. If the patient has UC, surgical therapy is a better option when there is concern for lymphoma. Anti-TNF agents are effective in the treatment of IBD and can significantly improve quality of life. Decision to start these agents should be made by considering the potential risk of lymphoma against benefits.Figure 1Figure 2Figure 3