Objectives: Pediatric lower gastrointestinal bleeding encompasses a broad and age-dependent spectrum of conditions, ranging from benign anorectal disorders to inflammatory bowel disease, colorectal polyps, and less common structural or vascular lesions. Despite advances in diagnostic evaluation, contemporary pediatric data on the distribution of underlying diagnoses, particularly according to age and sex, remain limited. This study aimed to evaluate the endoscopic and histopathologic spectrum of pediatric lower gastrointestinal bleeding and to examine age- and sex-related diagnostic patterns. Methods: This retrospective single-center study included children aged 0-18 years who presented with overt lower gastrointestinal bleeding and underwent colonoscopic evaluation at a tertiary pediatric gastroenterology center between May 2010 and May 2026. Demographic data, colonoscopic and histopathologic findings, final diagnoses, inflammatory bowel disease subtypes, and polyp histopathology were reviewed. Patients were categorized into four age groups: 0-3, 4-6, 7-12, and 13-18 years. Results: A total of 268 children were included. The mean age was 11.4 ± 4.9 years, and 130 patients were female (48.5%). The most common diagnosis was inflammatory bowel disease, identified in 79 patients (29.5%), including 62 with ulcerative colitis and 17 with Crohn's disease. Normal colonoscopic and histopathologic findings were observed in 65 patients (24.3%), anal fissure in 63 (23.5%), and polypoid lesions in 30 (11.2%). Juvenile polyp was the most common polyp subtype. Diagnostic distribution differed significantly across age groups (p < 0.001). Inflammatory bowel disease was more frequent among adolescents, whereas polypoid lesions were most common in children aged 4-6 years. Exploratory sex-based analyses suggested a female predominance in ulcerative colitis and a male predominance in Crohn's disease and polypoid lesions. Conclusions: In children undergoing colonoscopic evaluation for lower gastrointestinal bleeding, inflammatory bowel disease, normal findings, anal fissure, and polypoid lesions were the leading diagnostic categories. Age- and sex-related patterns may help guide clinical evaluation and interpretation of colonoscopic and histopathologic findings.

A female in her early 80s presented with chronic anal fissures which were unresponsive to conservative therapies. Examination was concerning for possible perianal Crohn's disease, but subsequent colonoscopy and biopsies revealed Langerhans cell histiocytosis (LCH) involving the colon and anus, diagnosed per 2022 WHO Classification of Haematolymphoid Tumours criteria and confirmed by BRAF V600E mutation. Systemic staging identified two unrelated malignancies of the breast and kidney. The patient was treated with cladribine as systemic chemotherapy, resulting in complete remission of LCH symptoms and lesions.This case illustrates key diagnostic and therapeutic considerations for clinicians: LCH can mimic inflammatory bowel disease and should be included in the differential for atypical or refractory perianal disease, especially in older adults. Histological confirmation and molecular profiling are essential for accurate diagnosis and treatment planning. Additionally, cladribine is a well-tolerated and effective option for adult LCH with gastrointestinal tract involvement. Early recognition and systemic staging are critical to guide therapy and identify potential coexisting malignancies.

Background: Anal fissure is a common benign condition, yet its management varies widely. The International Society of University Colon and Rectal Surgeons (ISUCRS) conducted a global snapshot audit to describe contemporary real-world management patterns. Methods: During a 2-week period (June-July 2022), 56 colorectal surgeons from 21 countries prospectively recorded data for consecutive patients presenting with anal fissure. Exclusion criteria included inflammatory bowel disease, pregnancy or lactation, psychiatric disorders, immunosuppression, and anorectal sepsis. Acute fissure was defined as symptoms <6 weeks without sentinel pile; chronic fissure as >6 weeks or fibrotic edges/sentinel pile. The "Cure" was defined as complete symptom resolution or healed fissure on clinical or tele-follow-up. Results: A total of 302 patients were analyzed (mean age 41 ± 13 years; 52% women). Acute fissure was present in 42%, chronic in 58%. Conservative treatment (dietary advice, stool-softeners, topical agents, botulin toxin, pelvic-floor training) was initiated in 236 (78%) patients, while 66 (22%) underwent surgery, most commonly lateral internal sphincterotomy (LIS). At 8-week follow-up, 73% of patients treated conservatively and 88% of those treated surgically achieved clinical resolution of symptoms or healed fissure. Conclusions: Global management of anal fissure remains heterogeneous. Most surgeons favor conservative measures such as first-line therapy, reserving LIS for chronic or refractory fissures. Standardized definitions and outcome reporting are needed to improve comparability and guide future international guidelines.

Gastrointestinal Kaposi sarcoma is an uncommon but clinically relevant manifestation of human herpesvirus 8-associated disease in patients with human immunodeficiency virus (HIV) infection. Its diagnosis may be delayed because symptoms are often nonspecific and may overlap with other anorectal disorders, particularly in patients with condylomatous disease, fissures, proctitis, or anal malignancy. We report the case of a 25-year-old male with HIV infection on antiretroviral therapy and an undetectable viral load who presented with one month of anal pain and rectal bleeding. Initial colonoscopy demonstrated multiple irregular ulcerated lesions in the distal rectum, and biopsy confirmed Kaposi sarcoma associated with human herpesvirus 8. Despite referral to Medical Oncology and initiation of chemotherapy, the patient had persistent rectal bleeding, mucus discharge, anal condyloma, and fissure. Repeat proctologic evaluation and colonoscopy revealed elevated, irregular, ulcerated circumferential lesions extending from the anal canal to 10 cm proximally, with increased submucosal vascular pattern. Persistent gastrointestinal Kaposi sarcoma with suspicious anorectal tumoral involvement was identified, and the patient was referred for multidisciplinary oncologic management. This case highlights the diagnostic challenge of anorectal Kaposi sarcoma in patients with HIV infection, especially when symptoms overlap with benign anorectal disease or synchronous malignancy. Early endoscopic evaluation, biopsy, and immunohistochemistry are essential for timely diagnosis and appropriate multidisciplinary treatment.

Chronic anal fissure is a common, benign anorectal condition associated with impaired quality of life. Despite the availability of several therapeutic options, considerable variability persists in its management, particularly regarding the role of botulinum toxin type A administration within the current treatment algorithms. Although botulinum toxin type A injection is a widely used approach to achieve chemical sphincterotomy, its real-world efficacy and safety across different clinical scenarios remain insufficiently characterised.

Chronic anal fissure (CAF) is a common anorectal disorder associated with severe pain and impaired quality of life. Botulinum toxin A (BTA) injection has emerged as a minimally invasive alternative to lateral internal sphincterotomy; however, data regarding high-dose Dysport® protocols and the clinical relevance of booster injections remain limited. This retrospective single-center observational study was conducted at the General Surgery Clinic of Mersin City Training and Research Hospital. Patients treated for CAF between January 1, 2025, and December 1, 2025, were identified through institutional medical records. Sixty consecutive patients were screened; 10 were excluded because they did not attend follow-up visits, and 50 patients with complete follow-up data were included in the final analysis. All patients received a standardized 75 IU Dysport® injection targeting the internal anal sphincter. At the first follow-up reassessment, a booster injection was considered when either <50% reduction in visual analog scale (VAS) pain score or incomplete fissure healing was present. Pain severity was assessed using the VAS, and fissure healing was evaluated clinically and anoscopically. Outcomes were analyzed. The mean age was 45.8 ± 12.3 years, and 28 patients (56%) were men. The mean VAS pain score decreased from 7.80 ± 0.99 (95% confidence interval [CI]: 7.52-8.08) at baseline to 3.18 ± 0.85 (95% CI: 2.94-3.42) at 1 month and 1.00 ± 0.67 (95% CI: 0.81-1.19) at 3 months. Repeated-measures analysis of variance demonstrated a statistically significant reduction in pain over time (F[2, 98] = 1512.68, P < .001, partial η2 = 0.969). Healing was observed in 34/50 patients (68.0%, 95% CI: 54.2-79.2) at 1 month and 45/50 patients (90.0%, 95% CI: 78.6-95.7) at 3 months. Booster injections were required in 30/50 patients (60.0%, 95% CI: 46.2-72.4). Recurrence was observed in 5/50 patients (10.0%, 95% CI: 4.3-21.4) during follow-up; these patients subsequently underwent lateral internal sphincterotomy. Transient mild incontinence occurred in 3/50 patients (6.0%, 95% CI: 2.1-16.2) and resolved with conservative management. High-dose Dysport® injection appears to be a safe and effective minimally invasive option for the short-term treatment of CAF. A booster-based stepwise strategy may improve outcomes in selected patients before escalation to surgery.

Background/Objectives: The objective of this study was to evaluate the efficacy of a rectal cream containing tribenoside and lidocaine (TL) in a rat model of anal fissure (AF) and to investigate the potential mechanisms of its therapeutic action compared with those of a standard care rectal cream containing 2% diltiazem (D). Methods: Treatment efficacy was assessed via macroscopic methods. The levels of the inflammatory factors IL-6 and IL-10 in the tissues were measured via ELISA. Histology assessment was performed with standard hematoxylin/eosin stain, Masson's trichrome method and picrosirius stain. The levels of NF-κB, VEGF, TGF-beta 1, HIF-1α and E-cadherin were measured via densitometric immunoblot analysis. Results: The results of this study show that the medical product TL has therapeutic efficacy in a preclinical model of acute complicated AF, which is likely related to its complex composition. The severity of pathology in the TL group was significantly lower than that in the control pathology (CP) group on the eighth day of treatment and remained significantly lower on the 11th and 12th days. There was no statistically significant difference between the TL group and the CP group (p = 0.186 for IL-6 and p = 0.078 for IL-10). The efficacy of TL and D groups showed no statistically significant difference. At the end of the experiment, after 12 days of treatment, the level of the proinflammatory marker NF-κB in the CP group was greater than that in the intact control (IC) group. In turn, the NF-κB level in the TL group was lower than that in the CP group and significantly lower than that in the D group. Other important markers evaluated in this study demonstrated a similar tendency. The histopathological analysis showed that TL ointment promoted superior tissue repair, resulting in healthier anodermal architecture with minimal scarring and reduced fibrosis. Conclusions: This study confirms the potential for conducting further pharmacological studies of the mechanism of action and further clinical trials of the rectal cream TL, which has certain advantages in terms of effectiveness in a model of acute complicated AF.

This prospective open-label comparative study evaluated the efficacy of various conservative treatments for acute anal fissure (AAF) in accelerating epithelialization and reducing pain. A total of 120 patients with symptom duration ≤6 weeks were randomized into four groups: control (hygiene only), dietary therapy (fiber-rich diet + psyllium), monotherapy with a sphincter relaxant (0.2% nitroglycerin ointment), and combined therapy (diet + nitroglycerin). The primary outcome was time to complete epithelialization; secondary outcomes included pain dynamics on the Visual Analog Scale (VAS) and incidence of chronic fissure. Results demonstrated that combined therapy achieved the shortest epithelialization time (10.5±1.5 days), which was significantly shorter than both monotherapy groups and the control (p<0.01). The combined regimen also produced the most pronounced pain reduction from day 3 onward and completely prevented the development of chronic fissure. Dietary modification and nitroglycerin alone improved outcomes but were inferior to the combined approach. In conclusion, the combination of dietary intervention and topical nitroglycerin represents the most effective conservative strategy for AAF, promoting faster healing, superior pain control, and prevention of chronicity.

Hemorrhoids are a common problem. The diagnosis and treatment can be challenging. Gastroenterologists have much to offer these patients. The purpose of this American Gastroenterological Association (AGA) Clinical Practice Update Expert Review is to provide best practice advice (BPA) covering the diagnosis and treatment of hemorrhoid disease.