Staple Line Polyposis and Cytomegalovirus Infection after Stapled Haemorrhoidectomy

Abstract

Early bleeding after stapled haemorrhoidectomy (SH) is not uncommon. Late and persistent bleeding occurring weeks or months after SH, however, is rare; it has only been described in more than 10% of cases. It is attributed to the development of inflammatory polyps at the staple line. Occurrence of rectal bleeding in the presence of palpable polypoid lesions at the stapled anastomotic line can cause diagnostic confusions, and it is not uncommon that such lesions are initially confused with rectal carcinoma. We report a case of a 38-year-old male who presented with persistent rectal bleeding some 6 months after SH performed in another hospital. Rectal and colonoscopic examinations revealed polypoid lesions at the anastomotic line. The biopsy failed to confirm malignancy, but identified cytomegalovirus (CMV) infection. The development of multiple inflammatory polypoid lesions in conjunction with CMV infection at the stapled anastomotic line has caused a diagnostic confusion, but - after exclusion of cancer - this complication was efficiently treated by CMV infection eradication combined with surgical excision of the remaining polyps due to persistence of bleeding. This case is reported to highlight late bleeding due to inflammatory polyps after SH and to increase the awareness of surgeons and gastroenterologists of this benign but somewhat common complication.

Fig. 1

Colonoscopic view of the anastomotic line polyposis at presentation. Note the close resemblance to polypoid rectal cancer. The histopathology of the biopsy revealed an inflammatory response with CMV infection.

Fig. 2

Axial CT scan (a) following rectal and intravenous contrast with coronal reconstructed images (b), showing multiple polypoid lesions in the lower third of the rectal lumen (arrows). Those lesions correspond well to the polypoid lesions which are seen during colonoscopy. The rectal wall is minimally thickened as a result of the inflammation.

Fig. 3

Colonoscopic view of the anastomotic line 6 weeks after treatment with anti-CMV therapy (ganciclovir), showing near complete resolution of the polyps. Note the remaining staples at the anastomotic line which may be the cause of continuous bleeding due to trauma during defaecation rather than the persistence of the polyps.