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.

Acute abdominal and pelvic pain during pregnancy presents a unique diagnostic challenge. Many pathologies may mimic signs and symptoms attributed to maternal physiologic adaptations and physical examination findings can be confounded by the gravid uterus. While US and MRI are preferred first-line imaging modalities, CT remains appropriate in selected time-sensitive situations when benefits outweigh risks, particularly when MRI is unavailable or for suspected perforation, ischemia, or complicated obstruction. Etiologies are variable and include obstetric-gynecologic disorders as well as other common entities such as gastrointestinal (including hepatobiliary), genitourinary, or even vascular causes. Prompt diagnosis plays a crucial role in appropriate treatment to ensure optimal maternal and fetal outcomes. This paper will explore the depth and breadth of acute abdominopelvic pathologies during pregnancy.

Acute intermittent porphyria (AIP) is a rare metabolic disorder characterized by neurovisceral manifestations, most commonly severe abdominal pain. Thrombotic complications are not typically associated with AIP and are infrequently reported in atypical venous territories. Gonadal vein thrombosis (GVT) is an uncommon condition most frequently observed in the postpartum period or in association with pelvic infections and malignancy; its occurrence in patients with AIP is exceptionally rare. GVT is a potentially serious form of deep vein thrombosis, often underdiagnosed due to its nonspecific presentation. We report the case of a 53-year-old woman with genetically confirmed AIP, a history of recurrent venous thromboembolism, and poorly controlled type 2 diabetes mellitus, who presented with acute lower abdominal pain radiating to the groin and back, accompanied by gastrointestinal symptoms. Contrast-enhanced computed tomography demonstrated an acute right GVT and a concurrent nonocclusive pulmonary embolism. Initial laboratory investigations revealed hyponatremia, mild transaminitis, and hyperglycemia. The overlapping abdominal manifestations of AIP initially complicated the diagnostic process; however, the presence of focal groin and back pain prompted further evaluation, leading to a timely diagnosis. The patient was managed with porphyria-safe antibiotics, therapeutic anticoagulation, and supportive care, resulting in clinical improvement. This case underscores the importance of maintaining a high index of suspicion for uncommon thrombotic complications in patients with AIP who present with new or atypical pain patterns. Early recognition and careful selection of porphyria-safe therapeutic strategies are critical to prevent complications and optimize clinical outcomes.

Struma ovarii is a rare monodermal ovarian teratoma predominantly composed of thyroid tissue, accounting for <5% of mature ovarian teratomas. Malignant transformation, most commonly to papillary thyroid carcinoma, occurs in 5%-10% of cases and represents an exceptionally rare entity with no established management consensus. We report a 40-year-old woman presenting with acute pelvic pain and a 13 cm heterogeneous left adnexal mass with elevated CA-125 (125 U/ml). Emergency laparotomy with left salpingo-oophorectomy revealed a 1 cm papillary thyroid carcinoma arising within an 11 cm struma ovarii, without capsular or vascular invasion. Postoperative thyroid workup was normal. Despite multidisciplinary recommendations for completion thyroidectomy and contralateral adnexectomy, the patient declined further surgery, opting for clinical and biochemical surveillance alone. This case underscores the importance of managing malignant struma ovarii according to thyroid carcinoma protocols while respecting patient autonomy.