GRACE S.ROZYCKIMD, MBA
A 43-year-old African American woman with no significant medical history presented with 10 years of rectal pain. Initially, the pain was intermittent, mainly associated with her menstrual period, but recently it had become chronic and debilitating. No bleeding or discharge was observed. A perianal examination showed no fistula, abscess, or hemorrhoids. There was no tenderness on palpation. Colonoscopy revealed a diverticulum of the left anorectal wall with a 5-mm opening, which everted on suctioning. Radial endoscopic ultrasonography revealed a tubular anechoic area in the perirectal space along the left anorectal wall.
The patient was referred for surgery. Examination under anesthesia revealed a diverticular opening immediately above the dentate line (Figure 1). The surrounding mucosa was slightly erythematous but not ulcerated. Intraoperative fluoroscopy demonstrated a 3-cm diverticulum that extended laterally and superiorly, terminating in a blind pouch. The diverticulum was excised in total and the defect was closed primarily.
Intraoperative photograph revealing the rectal diverticulum opening just above the dentate line.
A. Transsphincteric fistula-in-ano
B. Chronic anal fissure-in-ano
C. Heterotopic gastric mucosa
D. Rectal neoplasm
Mareno J, Takabe K, Bakhtar O, Ramamoorthy S. Image of the Month—Quiz Case. Arch Surg. 2008;143(5):513. doi:10.1001/archsurg.143.5.513