Gastroenterology clinical image challenge: A 30-year-old woman with sarcoidosis and chronic pain presented with tenesmus, rectal pain, and rectal bleeding. She was evaluated in the emergency department for new-onset constipation several days prior and was discharged with stool softeners and a hydrocortisone topical suppository owing to concern for internal hemorrhoids. Stool softeners did not relieve her constipation, so she used several over-the-counter products. Her daily home medicines include prednisone, hydrocodone, tramadol and ibuprofen.
Physical examination revealed a young woman in significant distress with the inability to sit down owing to pain. External evaluation of the anus was normal. Internal evaluation was refused. Laboratory testing revealed a normal basic metabolic panel, complete blood count and hepatic function panel. HIV and stool studies were negative. A computed tomography scan of the abdomen and pelvis was obtained revealing abnormal findings (figure), which prompted endoscopic evaluation. Flexible sigmoidoscopy was performed the following day (figure).
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