Inflammatory cloacogenic polyps: a rare cause of rectal bleeding

Inflammatory cloacogenic polyps are infrequent lesions that usually arise in the anorectal zone. The most common clinical presentation is rectal bleeding. Two cases of rectal bleeding related to cloacogenic polyps with different endoscopic appearance are reported. Endoscopists should be familiar with this entity, which should be considered in the differential diagnosis with other polypoid lesions observed in colonoscopy.     

Cloacogenic cancer of the anorectal junction

Summary and Conclusions Highly malignant and distinctive transitional cell tumors of the anorectal area can arise from inconstant and persisting embryologic entodermal cloacal vestiges situated just above the dentate line. These nonkeratinizing lesions are quite similar histologically to the transitional cell tumors found in the cloacogenic portion of the lower genitourinary tract. Microscopic features of these junctional tumors vary somewhat, depending on the site of origin from the complex cloacogenic zone and the mixed epithelial components involved. The cellular patterns of the transitional cell anorectal tumors differ distinctly from the more common rectal adenocarcinoma, the keratinizing squamous cell tumor of the anal canal and the very rare basal cell perianal skin lesion. Most of the cloacogenic upper anal canal and lower rectal junctional lesions occur in women. Many of the reported transitional cell anorectal lesions have metastasized rapidly. The prognosis appears to be graver than that of more common rectal adenocarcinoma and the keratinizing squamous cell anal lesion. Early diagnosis and prompt radical surgical removal seem to offer the best hope for survival. Read at the meeting of the American Proctologic Society. Miami Beach, Florida, April 30 to May 3, 1962.     

Well-differentiated adenoma at the anorectal junction

Summary Twenty-six cases of patients having adenomatous polyps at the anorectal junction are presented. Most polyps in this region were well-differentiated, and atypical polyps were infrequently seen. Well-differentiated adenomatous polyps in the anorectal junction were larger in average size than ordinary colorectal polyps having the same grade of epithelial pseudostratification. The reason adenomatous polyps at the anorectal junction grow to large sizes with only a relatively rare occurrence of malignant degeneration is discussed in relation to their specific location. Some well-differentiated adenomas were considered to develop secondarily in the bases of hemorrhoids or in pre-existing fibrous polyp that were the end result of hemorrhoids.     

Inflammatory fibroid polyps of the colon

Inflammatory fibroid polyp is an uncommon lesion involving the stomach, the small bowel and occasionally the colon. Inflammatory fibroid polyp is a large polypoid lesion arising from the submucosa. It has no malignant potential although extensive infiltration may occur. The main histological characteristics are diffuse inflammatory infiltrate with eosinophils and highly vascularized fibrocytic stroma. Immunohistochemistry is always positive for vimentine and negative for S 100 and desmin. We report four cases of inflammatory fibroid polyps, 3 of which mimicked carcinoma of the colon. Exploratory laparotomy and histopathological examination of the resected specimen were necessary to confirm definitive diagnosis. In the last case, diagnosis was established by histological examination of an endoscopically-removed colonic polyp.     

Cloacogenic carcinoma of the anorectum in homosexual men: An observation of four cases

Summary Cloacogenic carcinoma of the anorectum is an uncommon neoplasm which arises from the transitional zone (cloacogenic) epithelium. The transitional zone epithelium is derived from the embryonic cloacogenic membrane as is the epithelium of the vagina and uterine cervix in the female. Four cases of cloacogenic carcinoma in male homosexuals who have engaged in longstanding receptive anal intercourse have been observed. This observation, along with the realization that the anorectal transitional zone shares a common embryologic origin with the uterine cervix, a site of cancer long known to be associated with factors related to sexual intercouse, leads to the serious question of the etiologic potential of receptive anal intercourse in the development of cloacogenic carcinoma.     

Transitional cloacogenic carcinoma of the anus

Conclusions Transitional cloacogenic carcinomas are a distinct group of anal neoplasms, arising from the embryologic cloacogenic membrane. Many previously described anal tumors may be placed in this category. Abdominoperineal resection with posterior vaginectomy in the female is indicated for invasive lesions. Wide local exicision may be adequate in small, well-differentiated lesions. Groin dissection should be an interval procedure or deferred until clinical evidence of inguinal metastases is present. Careful pathologic examination of all tissue excised for benign anorectal disease should be performed, since unsuspected neoplasia may be found. Patients who have tumors of the anorectal area must be followed diligently, because of the potential development of a second primary neoplasm in the region.     

A large inflammatory fibroid polyp of the colon treated by endoclip-assisted endoscopic polypectomy: A case report

Inflammatory fibroid polyp is a rare benign polypoid lesion of the gastrointestinal tract. Histologically, inflammatory fibroid polyp is characterised by an admixture of numerous small vessels, fibroblasts and oedematous connective tissue, accompanied by marked inflammatory infiltration by eosinophils. A 40-year-old man visited our hospital for the purpose of colorectal screening due to a positive faecal occult blood test. A pedunculated and reddish polyp was found endoscopically in the ascending colon. The polyp was large but was resected endoscopically without any problems. Histologically, the abnormal tissue of the polyp was located in the submucosal and mucosal layer. Proliferation of spindle cells and infiltration of inflammatory cells, such as plasma cells and eosinophils, were observed. Immunohistochemically, the spindle cells were positive for CD34, which was localised in the cytoplasm. These cells were also positive for S100 protein but were negative for c-kit and muscle markers. These findings are compatible with the histological diagnosis of inflammatory fibroid polyp. The surgical margin of the polyp was free of the tumour. Inflammatory fibroid polyp is more commonly found in the stomach or small intestine, and rarely in the colon, and therefore our case is a rare example of large and pedunculated colonic inflammatory fibroid polyp, which was treated successfully by endoscopic polypectomy.     

Sphincter denervation in anorectal incontinence and rectal prolapse.

Biopsies of the external anal sphincter, puborectalis, and levator ani muscles have been examined in 24 women and one man with long-standing anorectal incontinence, 18 of whom also had rectal prolapse, and in two men with rectal prolapse alone. In 16 of the women anorectal incontinence was of unknown cause, but in eight there was a history of difficult labour. Similar biopsies were examined in six control subjects. In all the incontinent patients there was histological evidence of denervation, which was most prominent in the external anal sphincter muscle biopsies, and least prominent in the levator ani muscles. Myopathic features, which were thought to be secondary, were present in the more abnormal biopsies. There were severe histological abnormalities in small nerves supplying the external anal sphincter muscle in the three cases in which material was available for study. We suggest that idiopathic anorectal incontinence may be the result of denervation of the muscles of the anorectal sling, and of the anal sphincter mechanism. This could result from entrapment or stretch injury of the pudendal or perineal nerves occurring as a consequence of rectal descent induced during repeated defaecation straining, or from injuries to these nerves associated with childbirth.     

What is the clinicopathological characteristic of cloacogenic carcinoma outside the anorectal zone?

This study aimed to examine English-language publications on cloacogenic carcinoma which has developed outside the anorectal zone. Studies published in English literature on cloacogenic carcinoma developing in the colorectal area were accessed via Pubmed and Google scholar databases. Within these articles, studies in which there were developments in the other segments of the colon outside the anorectal zone were examined. We retrieved seven studies matching our selection criteria from the research. The studies were published between 1977 and 2009. Four of the patients were female and three were male; patient age ranged from 23 to 69 years. The anatomic tumors were in the sigmoid colon in four patients, and splenic flexure, descending colon and proximal rectum in one patient each. Four patients developed liver metastases. Basaloid carcinoma above the rectum is difficult to diagnose clinically. When suspected, the diagnosis can be made by immunohistochemical staining.     

Dynamic transperineal ultrasound vs. defecography in patients with evacuatory difficulty: a pilot study

BACKGROUND AND AIMS: Defecating proctography has been traditionally used to assess patients with evacuatory dysfunction. More recently, dynamic transperineal ultrasound has been described, defining the interaction between the infralevator viscera and the pelvic floor at rest and during straining. This study compared qualitative diagnosis and quantitative measurement obtained by defecography and dynamic transperineal ultrasonography in patients with evacuatory difficulty. PATIENTS AND METHODS: Thirty-three women were examined using both techniques with both examiners blinded to the results of the other method. Quantitative measurement was made of rectocele depth, anorectal angle (at rest and during maximal straining) and anorectal junction position at rest and movement during straining. RESULTS: There was good agreement for the diagnoses of rectocele, rectoanal intususseption, and rectal prolapse. Dynamic transperineal ultrasound was more likely than defecography to make multiple diagnoses or to diagnose an enterocele when a rectocele was present. There was no difference noted between the two techniques for the measurement of anorectal angle at rest, anorectal junction position at rest, or anorectal junction movement during straining. The mean anorectal angle during straining was 123.3+/-4.3 degrees as measured by defecography and 116.4+/-3.3 degrees as measured by dynamic transperineal ultrasound, nearly reaching statistical significance. CONCLUSION: Dynamic transperineal ultrasound is a simple and accurate technique for assessment of the pelvic floor and soft-tissues in patients with evacuatory dysfunction.     

Observer variation in the radiological measurement of the anorectal angle

Determination of the anorectal angle (ARA) and the position of the pelvic floor is, theoretically, very important in understanding the mechanisms of anorectal continence and defaecation. The variability in the measurement of the ARA was analyzed. Nine experts drew the rectal axis either as a line along the posterior wall of the distal rectum or as the central axis of the rectal lumen on the outlines of 18 representative proctographic images. The standard deviations and ranges of the mean values of each ARA were comparable but large in both methods. On average, the S.D. was 8° and the range value about 23°. Inter-observer variation was not related to the magnitude of the ARA, but rather to the anorectal configuration. Drawing a line along the posterior distal rectal wall is difficult when it is irregular or when the puborectalis impression is indistinct. The central rectal axis is difficult to draw when the junction between the upper and lower rectum is ill defined or when the outlines of the distal rectum are asymmetric e.g by the presence of a rectocele. Thus, the variability of both methods was not strongly interrelated (r=0.68 for the median values). It is concluded that, in general, radiologic assessment of the ARA is not reliable enough for comparative investigation of the dynamics of the anorectum.     

Solitary Rectal Ulcer Syndrome—Clinical, Endoscopic, and Histological Spectrum

Nineteen patients with solitary rectal ulcer syndrome are presented. The diagnosis was established on sigmoidoscopic and histopathological grounds; the clinical, endoscopic, and histological states were assessed at presentation and on last follow-up. Most of the patients suffered from rectal bleeding, abdominal and anorectal pains, constipation, and straining at defecation. Thirteen patients had macroscopic ulcerations on presentation and six patients did not. These six patients did not develop ulcer during the follow-up period. Four patients entered clinical and endoscopic remission with no histological improvement. Three of them managed conservatively and one underwent suturing of the ulcer and internal anal sphincter dilatation. They remained in remission for a mean follow-up of 1 yr.     

Colorectal melanoma: review of two distinct forms of presentation

Malignant melanoma of the colon and rectum is an infrequent disease. Primary anorectal melanoma accounts for 0.1-4.6% of all malignant neoplasms of the anal canal. Melanoma metastatic to the colon is symptomatic only in 4.4% of patients with a primary melanoma at another site and most of these tumors are diagnosed postmortem. We report two cases of colorrectal malignant melanoma. The first case concerned a patient with rectal bleeding who was diagnosed with a rectal lesion compatible with melanoma. Abdominoperineal resection was performed due to positivity of the sentinel lymph node. We discuss the utility of sentinel lymph node detection in this kind of tumor. In the second case, we discovered a polyp compatible with metastatic melanoma in the transverse colon in a patient with a previous diagnosis of melanoma. In both surgical specimens, the diagnosis of melanoma was confirmed by positivity for protein S-100, Melan-A and HMB-45.     

Transanal repair of rectocele and full rectal mucosectomy with one circular stapler: a novel surgical technique

Abstract We present a new surgical stapling technique for treatment of rectocele when associated with internal mucosal prolapse or haemorrhoids using only one circular mechanical stapler. Eight female patients, mean age 53 years (range, 42–70), complaining of obstructed defecation with vaginal digitation because of rectocele associated with internal mucosal prolapse underwent transanal repair of rectocele and rectal mucosectomy using one circular stapler between April and July 2004. A running horizontal mattress suture was placed through the base of the rectocele including mucosa, submucosa and the muscle layer of the whole anterior anorectal junction wall. The prolapsed mucosa and the muscular layer were then excised with an electrical scapel. Acontinuous pursestring rectal mucosa suture was placed 0.5 cm before the previous anterior mucosa and muscle layers resected wound, including the anorectal junction wall which was kept separate from the posterior vaginal wall by a Babcock forceps. Posteriorly, the pursestring suture included only mucosal and submucosal layers. The stapled suture was positioned between normal anterior rectal wall and the anal canal, 0.5 cm above the pectinate line. The stapler was then closed, fired and withdrawn. One patient complained of a perianal hematoma on the seventh postoperative day, requiring surgical excision. Postoperative defecography showed correction of the rectocele and outlet obstruction disappeared in all patients. This novel combined manual-stapled technique for rectocele and rectal internal mucosal prolapse seems to be a safe procedure and the preliminary results are encouraging. Further investigations have to be performed to assess long-term outcome in a larger number of patients.     

Evacuation proctography: an investigation of rectal expulsion in 20 subjects without defecatory disturbance

Evacuation proctography is a dynamic investigation of rectal expulsion that records the voluntary evacuation of thick barium paste on videotape. Evacuation is a passive phenomenon in a defined zone of the rectum, associated with pelvic floor descent of 3 cm from a resting position of the anorectal junction less than 2 cm above the plane of the ischial tuberosities. The anal canal does not open immediately; it takes about 4.5 sec to open to a maximum diameter of 1.5 cm, with rectal emptying in 11 sec. Anterior rectoceles commonly invert over the anal canal as the rectum collapses in at the end of evacuation.     

A case of gastric hyperplastic polyp with malignant transformation

In this paper we report a case of hyperplastic polyp with malignant transformation. The patient was followed up by annual radiographic and endoscopic examination during 9 years. The first gastroscopy revealed a semi-pedunculated polyp beneath the esophageal-cardiac junction, 1.5cm in diameter and slightly reddish with smooth surface. Histological findings showed a hyperplastic polyp. There was slight change in size, but no change in histological examination of the lesion during the follow-up. In 1996, the biopsy specimen showed an atypical epithelium and the polyp was removed by snear polypectomy. A microscopic examination revealed a well-differentiated adenocarcinoma. Immunohistochemically, p53 and Ki-67 immunostaining showed positive in the carcinoma portion of the adenocarcinoma bearing a hyperplastic polyp in the stomach.     

A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation

A study, comprising dissection and microscopic examination of the pectinate area with special consideration to anal glands, was performed in 29 cadavers varying from fully mature neonatal deaths to 52 years of age. At the junction of the anal canal proper with the rectal neck, an “anorectal sinus” (a submucosal anal circumferential depression) was identified in 18 specimens; in 6 specimens, the anorectal sinus was replaced by a fibroepithelial band (“anorectal band”); in 5 specimens, the anorectal sinus was absent, and in 3 of the 5 specimens only scattered epithelial cells (“epithelial debris” of the anorectal sinus) were detected. These findings suggest that the anorectal sinus is an embryonic vestige which results from hindgut “invagination” by the proctodeum. Its persistence or partial obliteration would result in the formation of tubular structures which are considered by investigators as anal glands. The sinus may be completely obliterated or may leave behind a submucosal “anorectal band” or scattered “epithelial debris”. Evidence in favor of this new concept is put forward. The role of anorectal sinus, anorectal band, and epithelial debris in the genesis of some idiopathic anal lesions is discussed.     

Le mélanome anorectal: étude microscopique à propos de deux cas

Anorectal melanoma is a rare malignant tumor. It represents less than 2% of melanomas and less than 4% of malignant anorectal tumors. It is an adult pathology of poor prognosis. The purpose of our study is to assess the contribution of the microscopic examination in the positive diagnosis of these tumors. We report to observations of the department of pathology of the Ibn-Sina hospital Rabat, in Morocco. The first patient was 47 years old and presented rectal bleeding and perineal pain. Rectosigmoidoscopy revealed a brownish ulcerated and budding tumor at 1 cm of the anal margin. Computed tomography of the pelvis showed deep lymph nodes and bilateral ureteral compression. Pathologic examination concluded to the diagnosis of anorectal melanoma. The second patient was 50 years old and presented rectal bleeding with an anal tumor that rises to 10 cm in the rectum at the rectosigmoidoscopy. Microscopic study revealed an anorectal melanoma. Anorectal melanoma is a rare tumor. The absence of early clinical manifestations and the lack of clinical suspicion due to its infrequency contribute to delayed diagnosis. The confirmation of the diagnosis is based principally on the histological study coupled with immunohistochemistry. Surgery is the main treatment when it is technically feasible associated to adjuvant therapeutics such as chemotherapy and irradiation. The prognosis remains poor because of synchronous metastasis when the tumor is diagnosed.     

Diagnostic yield of a positive fecal occult blood test found on digital rectal examination. Does the finger count?

The value of a positive fecal occult blood test (FOBT) found at the time of digital rectal examination is disputed. To determine the significance of a positive FOBT obtained in this manner, the records of 270 patients who underwent colonoscopy for any positive FOBT were retrospectively reviewed. Occult blood was found in 144 patients at the time of digital rectal examination and in 126 individuals after they submitted three spontaneously passed stool specimens. Of the patients with a positive FOBT on rectal examination, 77% were hospitalized at the time compared with only 17% of those with positive FOBTs from spontaneously passed stools. The frequency of colonic abnormalities was similar with both stool collection methods in inpatients and outpatients. No statistically significant differences in neoplastic polyp or colon cancer detection rates, nor in the finding of hemorrhoids or other anorectal abnormalities, were apparent. Therefore, the belief that a positive FOBT found at the time of digital examination can or should be discounted as a false positive (because of the presence of hemorrhoids or other lesions prone to trauma at the time of digital examination) was not substantiated by this study.     

A Novel Technique to Identify Patients with Megarectum

Purpose Traditional methods of identifying patients with persistent dilation of the rectum, or megarectum, are associated with inherent methodologic limitations. The purpose of this study was to use a barostat to establish criteria for the diagnosis of megarectum and to assess rectal diameter during isobaric (barostat) and volumetric (barium contrast) distention protocols in constipated patients with megarectum on anorectal manometry. Methods During fluoroscopic screening, rectal diameter was measured at minimum distending pressure of the rectum, achieved using a barostat. It was also measured during evacuation proctography (volumetric distention). Having established a normal range in 25 healthy volunteers, 30 constipated patients with evidence of megarectum on anorectal manometry (elevated maximum tolerable volume on latex balloon distention) were studied. A further 10 constipated patients without evidence of megarectum were studied (normal rectum). Results Megarectum was diagnosed when the rectal diameter was greater than 6.3 cm at minimum distending pressure. Rectal diameter at minimum distending pressure was increased in 20 patients (67 percent) with megarectum on anorectal manometry, but was normal in the remaining 10 patients (33 percent) and all patients with a normal rectum on anorectal manometry. Rectal diameter was increased at evacuation proctography in only 15 patients (50 percent) with evidence of megarectum on anorectal manometry. Conclusions The prevalence of megarectum is overestimated and underestimated when rectal diameter is assessed using anorectal manometry and contrast studies, respectively. Controlled (pressure-based) distention combined with fluoroscopic imaging allowed accurate identification of patients with megarectum on the basis of a rectal diameter greater than 6.3 cm at the minimum distention pressure. Measurement of rectal diameter at minimum distention pressure may be useful in those patients with an elevated maximum tolerable volume on anorectal manometry when surgery is being contemplated. Presented at the meeting of the Association of Coloproctologists of Great Britain and Ireland, Birmingham, United Kingdom, July 2004. Published in abstract form in Colorectal Dis 2004;6(Suppl 1):72. Marc A. Gladman is supported by the Frances and Augustus Newman Foundation Research Fellowship of the Royal College of Surgeons of England.