The management of rectal internal mucosal prolapse (RIMP) is not based on an accepted classification of the lesion which helps to choose the appropriate treatment. The aim of this prospective study was to report a new endoscopic grading of RIMP and to evaluate its clinical value. Thirty-two patients (7 men, 25 women; mean age 56 years, range 28-72) affected by symptomatic RIMP were prospectively classified as follows: RIMP was defined as first degree when detectable below the anorectal ring on straining, as second degree when it reached the dentate line, and as third degree when it reached the anal verge. Anal manometry was carried out in 26 patients, and anal ultrasound and defecography in 6 prior to surgery. A correlation was found between the occurrence and severity of symptoms and the degree of the prolapse as obstructed defecation, bleeding and fecal soiling affected mainly patients with third-degree RIMP. At manometry the maximal resting tone was 60+/-23 mm Hg and voluntary contraction 96+/-41 mm Hg (mean+/-SEM). At anal ultrasound the mean internal sphincter thickness was 2.1+/-0.2 mm, and external sphincter thickness was 7.0+/-0.8 mm. A significant rectocele and rectal intussusception (n = 2) and a nonrelaxing puborectalis muscle on straining (n = 2) were observed at defecography in cases with third-degree RIMP. The anorectal angle was 100+/-75 degrees at rest, 63+/-20 degrees on squeezing, and 115+/-9 degrees on straining. A conservative treatment with high-fiber diet and/or rubber band ligation was carried out in all cases of first and in most patients with second-degree RIMP (n = 26). Those who required surgery, i.e., stapled transanal excision of the prolapse (n = 6), had either severely symptomatic third-degree RIMP with solitary ulcer syndrome (n = 4) or second-degree RIMP (n = 2). A positive outcome was achieved in 71% of cases. The proposed classification evaluated by the present study may be of clinical value in managing rectal internal mucosal prolapse.

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We report a case of Campylobacter jejuni enterocolitis presenting as inflammatory bowel disease in a 19-year old woman. After a useless course of corticosteroids, ceftazidime and metronidazole, she was successfully treated with erythromicin. Campylobacter species represent an important cause of gastroenteritis in children and adults. The rate of Campylobacter isolation is 5-6 per 100,000 persons. This rate, however, grossly understimates the actual number of Campylobacter infections. In most cases, Campylobacter enteritis is a self-limiting disease, rarely associated with severe complications. Our case demonstrates the difficulty in distinguishing inflammatory bowel disease (Crohn's disease or ulcerative colitis) at onset from atypical infectious colitis. Unfortunately, corticosteroids (necessary for the treatment of inflammatory bowel disease) may exacerbate infectious etiologies. Campylobacter jejuni should be ruled out when assessing inflammatory bowel diseases at onset (as during flare-ups), especially if corticosteroids or immunosuppressive therapies are required.

Submucosal saline injection and triple pursestring are reported to prevent peritoneal stitching and mucosal pocketing, two intraoperative complications in patients who undergo a stapled transanal excision for internal mucosal prolapse causing obstructed defaecation.

Endoscopic mucosal resection is a potential alternative to surgery when submucosal invasion and lymph node involvement are excluded. We describe an en bloc resection of a large, focal, high-grade tubulovillous nonampullary adenoma of duodenal wall using hydroxypropyl methylcellulose as a lifting agent.