Int J Colorect Dis (1993) 8:9-12 Intentional Journal of Col6 etal Disease O Springer-Verlag 1993 Gastric heterotopic mucosa in the rectum with helicobacter pylori-like organisms: a rare cause of rectal bleeding A. Kestemberg, G. Marifio, E. de Lima, E T. Garcia, E. Carrascai, and J. L. Arredondo Hospital Universitario del Valle, Universidad del Valle, Cali, Colombia, South America Accepted: 27 November 1992 Abstract. We report the case of a 9-year-old boy who presented with chronic rectal bleeding. On proctosig- moidoscopy, a polypoid elevation in the rectal ampulla measuring 5 x 3 cm was found. Biopsies were reported to show gastric mucosa. The Giemsa stain showed Heli- cobacter pylori-like organisms. Including our patient, there are now 30 similar cases reported in the medical literature. The usual manifestations of this rare entity are chronic bleeding and rectal pain. In one-half of cases there is chronic rectal ulceration. The recommended treatment is transanal surgical resection unless there is rectal peptic ulceration. H2 receptor blockers are then advised. Surgical excision is carried out after healing has taken place. R6sum6. Nous rapportons le cas d'un gargon de 9 ans qui prrsentait une hrmorragie rectale chronique en procto- sigmoidoscopie. Une formation polypoide de l'ampoule rectale mesurant 5 x 3 cm a 6t6 trouvre. Les biopsies montr~rent une muqueuse gastrique. La coloration de Giemsa montrait des organismes ressemblant fi des hrli- cobacter pylori. En incluant notre malade on retrouve 30 cas similaires rapportrs dans la littrrature mrdicale. Les signes habituels de cette entit6 rare sont une hrmorragie chronique et des douleurs rectales. Dans la moiti6 des cas il y avait une ulcrration rectale chronique. Le traitement recommand6 est une rrsection chirurgicale trans-anate lorsqu'existe une ulcrration peptique rectale, les antirr- cepteurs H2 sont utilisrs et l'excision est rralis6 aprrs gurrison de l'ulcrration. The presence of gastric heterotopic mucosa (GHM) with fundic glands in the rectum is rare cause of rectal bleed- ing. To date, the number of reported cases is small. In- cluding the present patient, there are only 30 such cases in the literature [1]. Case report A 9-year-old boy, with chronic rectal bleeding of several years' duration also complained of perineal and sacral pain. External physical examination was normal. Proctosigmoidoscopy showed polypoid elevation in the antero-lateral part of the rectal ampulla. It was of an intense pink color. Biopsies were reported as showing gastric mucosa with fundic glands and a mild focal chronic infiltrate of lymphocytes and plasma cells. A mild acute activity was also present. The adjacent rectal tissue was normal. The Giemsa stain revealed Helicobacter pylori-like organisms (Fig. 1). Congo red instilled into the rectum stained the lesion black. A scan was negative after injection of technetium-99. Cimetidine was given for 2 months, with improvemen t of the bleeding and the pain. A transanal resection of the lesion, measuring 5 x 3 cm and 0.5 cm in thickness, was performed. Histopathological examination re- vealed fundic-type mucosa with evidence of chronic and acute in- flammation. Helicobacter pylori-like organisms were also present in the crypts and around the border of the gastric-type glands (Figs. 2, 3). They were not present in the surrounding rectal mucosa. The post-operative course was excellent, and the patient did not experi- ence any further bleeding or pain. Discussion In children only 10% of gastrointestinal bleeding origi- nates above the ligament of Treitz, one-third arises in the small intestine, and approximately 50% in the large bow- el and anus [2]. In this age group the most common causes of bleeding in order to frequency are: benign anorectal lesions such as anal fissure, juvenile polyps, intussuscep- tion, Meckel's diverticulum, and infectious diarrhea [3]. Rectal gastric heterotopic mucosa is a rare cause. To date, only 29 cases have been reported [1], and the major- ity (19 cases) have been children [4-10]. Gastric hetero- topic mucosa can occur in the bladder, pancreas, gall- bladder, spinal cysts, thorax, mouth, esophagus, small intestine, colon, and rectum [10]. Rectal gastric hetero- topic mucosa was reported for the first time by Ewell and Jackson in 1939 [11]. One theory is that it is an example of disontogenetic tissue resulting from an error of differ- entiation of the endoderm in the developing hindgut. This is supported by the immunocytochemical studies of Carlei et al. [12], who demonstrated that the metabolic and functional activity of gastric heterotopic mucosa re- garding the production of acid and mucin is identical to