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Solitary rectal ulcer syndrome

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Solitary rectal ulcer syndrome (SRUS, SRU), is a disorder of the rectum and anal canal, caused by straining and increased pressure during defecation. This increased pressure causes the anterior portion of the rectal lining to be forced into the anal canal (an Internal intussusception). The lining of the rectum is repeatedly damaged by this friction, resulting in ulceration. SRUS can therefore considered to be a consequence of internal intussusception (a sub type of rectal prolapse), which can be demonstrated in 94% of cases. It may be asymptomatic, but it can cause rectal pain, rectal bleeding, rectal malodor, incomplete evacuation and obstructed defecation (outlet obstruction).

Symptoms

Symptoms include: [1] [2] [3]

Prevalence

The condition is thought to be uncommon. It usually occurs in young adults, but children can be affected too. [4]

Cause

The essential cause of SRUS is thought to be related to too much straining during defecation.

Overactivity of the anal sphincter during defecation causes the patient to require more effort to expele stool. This pressure is produced by the modified valsalva manovoure (attempted forced exhalation against a closed glottis, resulting in increased abdominal and intra-rectal pressure). Patiest with SRUS were shown to have higher intra-rectal pressures when straining than healthy controls. [5] SRUS is also associated with prolonged and incomplete evacuation of stool. [6]

More effort is required because of concomitant anismus, or non-relaxation/paradoxical contraction of puborectalis (which should normally relax during defecation). [7] The increased pressure forces the anterior rectal lining against the contracted puborectalis and frequently the lining prolapses into the anal canal during straining and then returns to its normal position afterwards.

The repeated trapping of the lining can cause the tissue to become swollen and congested. Ulceration is thought to be caused by resulting poor blood supply (ischemia), combined with repeated frictional trauma from the prolapsing lining, and exposure to increased pressure are thought to cause ulceration. Trauma from hard stools may also contribute.

The site of the ulcer is typically on the anterior wall of the rectal ampulla, about 7–10 cm from the anus. However, the area may of ulceration may be closer to the anus, deeper inside, or on the lateral or posterior rectal walls. The name "solitary" can be misleading since there may be more than one ulcer present. Furthermore, there is a "preulcerative phase" where there is no ulcer at all. [8]

Pathological specimens of sections of rectal wall taken from SRUS patients show thickening and replacement of muscle with fibrous tissue and excess collagen. [9] rarely, SRUS can present as polyps in the rectum. [10] [11]

SRUS is therefore associated and with internal, and more rarely, external rectal prolapse. [6] Some believe that SRUS represents a spectrum of different diseases with different etiologies. [12]

Another condition associated with internal intussusception is colitis cystica profunda (CCF, proctitis cystica profunda), which is cystica profunda in the rectum. Cystica profunda is characterised by formation of mucin cysts in the muscle layers of the gut lining, and it can occur anywhere along the gastrointestinal tract. When it occurs in the rectum, some beleive to be an interchangeable diagnosis with SRUS since the histological features of the conditions overlap. [13] [14] Indeen, CCF is managead identically to SRUS. [15]

A group of conditions known as "Mucosal prolapse syndrome" (MPS) has now been recognized. It includes SRUS, rectal prolapse, proctitis cystica profunda, and inflammatory polyps. [16] [2] It is classified as a chronic benign inflammatory disorder. The unifying feature is varying degrees of rectal prolapse, whether internal intussusception (occult prolapse) or external prolapse.

Electromyography may show pudendal nerve motor latency. [2]

Complications

Complications are uncommon, but include massive rectal bleeding, ulceration into the prostate gland or formation of a stricture. [17] [18] [19] Very rarely, cancer can arise on the section of prolapsed rectal lining. [16]

Diagnosis & Investigations

SRUS is commonly misdiagnosed, and the diagnosis is not made for 5-7 years. [4] Clinicians may not be familiar with the conditon, and treat for Inflammatory bowel disease, or simple constipation. [20] [21]

The thickened lining or ulceration can also be mistaken for types of cancer. [22] [23] [24] [25]

The differential diagnosis of SRUS (and CCP) includes: [26]

Defecography, sigmoidoscopy, transrectal ultrasound, mucosal biopsy, anorectal manometry and electromyography have all been used to diagnose and study SRUS. [2] [7] Some recommend biopsy as essential for diagnosis since ulcerations may not always be present, and others state defecography as the investigation of choice to diagnose SRUS. [3] [14] [20]

Treatment

Although SRUS is not a medically serious disease, it can be the cause of significantly reduced quality of life for patients. It is difficult to treat, and treatment is aimed at minimizing symptoms.

Stopping straining during bowel movements, by use of correct posture, dietary fiber intake (possibly included bulk forming laxatives such as psyllium), stool softeners (e.g. polyethylene glycol, [27] [28] and biofeedback retraining to coordinate pelvic floor during defecation.[29] [30]

Surgery may be considered, but only if non surgical treatment has failed and the symptoms are severe enough to warrant the intervention. Improvement with surgery is about 55-60%. [31]

Ulceration may persist even when symptoms resolve. [32]

See also

References

  1. ^ al.], edited by Tadataka Yamada ; associate editors, David H. Alpers ... [et (2009). Textbook of gastroenterology (5th ed. ed.). Chichester, West Sussex: Blackwell Pub. p. 1728. ISBN 978-1-4051-6911-0. {{cite book}}: |edition= has extra text (help); |first= has generic name (help)CS1 maint: multiple names: authors list (link)
  2. ^ a b c d Abid, S (2012 Jun 14). "The clinical, endoscopic and histological spectrum of the solitary rectal ulcer syndrome: a single-center experience of 116 cases". BMC gastroenterology. 12 (1): 72. PMID 22697798. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
  3. ^ a b Mackle, EJ (1986 Oct). "The pathogenesis and pathophysiology of rectal prolapse and solitary rectal ulcer syndrome". Clinics in gastroenterology. 15 (4): 985–1002. PMID 3536217. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
  4. ^ a b Ertem, D (2002 Dec). "A rare and often unrecognized cause of hematochezia and tenesmus in childhood: solitary rectal ulcer syndrome". Pediatrics. 110 (6): e79. PMID 12456946. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
  5. ^ Womack, NR (1987 Oct). "Pressure and prolapse--the cause of solitary rectal ulceration". Gut. 28 (10): 1228–33. PMID 3678951. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
  6. ^ a b Halligan, S (1995 Jan). "Evacuation proctography in patients with solitary rectal ulcer syndrome: anatomic abnormalities and frequency of impaired emptying and prolapse". AJR. American journal of roentgenology. 164 (1): 91–5. PMID 7998576. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
  7. ^ a b Van Outryve, MJ (1993 Oct). "Transrectal ultrasound study of the pathogenesis of solitary rectal ulcer syndrome". Gut. 34 (10): 1422–6. PMID 8244113. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
  8. ^ Madigan, MR (1969 Nov). "Solitary ulcer of the rectum". Gut. 10 (11): 871–81. PMID 5358578. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
  9. ^ Kang, YS (1996 Apr). "Pathology of the rectal wall in solitary rectal ulcer syndrome and complete rectal prolapse". Gut. 38 (4): 587–90. PMID 8707093. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
  10. ^ Brosens, LA (2009 Nov). "Mucosal prolapse syndrome presenting as rectal polyposis". Journal of clinical pathology. 62 (11): 1034–6. PMID 19861563. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
  11. ^ Saadah, OI (2010 Aug 15). "Solitary rectal ulcer syndrome presenting as polypoid mass lesions in a young girl". World journal of gastrointestinal oncology. 2 (8): 332–4. PMID 21160895. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
  12. ^ Kang, YS (1995). "Solitary rectal ulcer and complete rectal prolapse: one condition or two?". International journal of colorectal disease. 10 (2): 87–90. PMID 7636379. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  13. ^ Vora, IM (1992 Apr). "Solitary rectal ulcer syndrome and colitis cystica profunda--a clinico-pathological review". Indian journal of pathology & microbiology. 35 (2): 94–102. PMID 1483723. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
  14. ^ a b Levine, DS (1987 Jan). ""Solitary" rectal ulcer syndrome. Are "solitary" rectal ulcer syndrome and "localized" colitis cystica profunda analogous syndromes caused by rectal prolapse?". Gastroenterology. 92 (1): 243–53. PMID 3536653. {{cite journal}}: Check date values in: |date= (help)
  15. ^ Beck, DE (2002 Jun). "Surgical Therapy for Colitis Cystica Profunda and Solitary Rectal Ulcer Syndrome". Current treatment options in gastroenterology. 5 (3): 231–237. PMID 12003718. {{cite journal}}: Check date values in: |date= (help)
  16. ^ a b Nonaka, T (2011). "A case of rectal cancer arising from long-standing prolapsed mucosa of the rectum". Internal medicine (Tokyo, Japan). 50 (21): 2569–73. PMID 22041358. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  17. ^ Gilrane, TB (1987 Dec). "A benign rectal ulcer penetrating into the prostate--diagnosis by prostate-specific antigen". Gastrointestinal endoscopy. 33 (6): 467–8. PMID 2450805. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
  18. ^ Tseng, CA (2004 Jun). "Acute hemorrhagic rectal ulcer syndrome: a new clinical entity? Report of 19 cases and review of the literature". Diseases of the colon and rectum. 47 (6): 895–903, discussion 903-5. PMID 15129312. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
  19. ^ Yagnik, VD (2011 Jul-Aug). "Massive rectal bleeding: rare presentation of circumferential solitary rectal ulcer syndrome". Saudi journal of gastroenterology : official journal of the Saudi Gastroenterology Association. 17 (4): 298. PMID 21727744. {{cite journal}}: Check date values in: |date= (help)
  20. ^ a b Blackburn, C (2012 Feb). "Clinical presentation of and outcome for solitary rectal ulcer syndrome in children". Journal of pediatric gastroenterology and nutrition. 54 (2): 263–5. PMID 22266488. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
  21. ^ Umar, SB (2008 Sep 30). "An interesting case of mistaken identity". Case reports in gastroenterology. 2 (3): 308–13. PMID 21490861. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
  22. ^ Amaechi, I (2010 Nov). "Solitary rectal ulcer syndrome mimicking rectal neoplasm on MRI". The British journal of radiology. 83 (995): e221-4. PMID 20965892. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
  23. ^ Lokuhetty, D (1998 Dec). "Solitary rectal ulcer syndrome (SRUS) masquerading as a carcinomatous stricture". The Ceylon medical journal. 43 (4): 241–2. PMID 10355182. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
  24. ^ Blanco, F (2011 Nov). "Solitary rectal ulcer: ultrasonographic and magnetic resonance imaging patterns mimicking rectal cancer". European journal of gastroenterology & hepatology. 23 (12): 1262–6. PMID 21971372. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
  25. ^ Levine, DS (1988 Nov). "Diffuse excess mucosal collagen in rectal biopsies facilitates differential diagnosis of solitary rectal ulcer syndrome from other inflammatory bowel diseases". Digestive diseases and sciences. 33 (11): 1345–52. PMID 2460300. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
  26. ^ al.], senior editors, Bruce G. Wolff ... [et (2007). The ASCRS textbook of colon and rectal surgery. New York: Springer. ISBN 0-387-24846-3. {{cite book}}: |first= has generic name (help)CS1 maint: multiple names: authors list (link)
  27. ^ Bishop, PR (2002 Jun). "Nonsurgical Therapy for Solitary Rectal Ulcer Syndrome". Current treatment options in gastroenterology. 5 (3): 215–223. PMID 12003716. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
  28. ^ van den Brandt-Grädel, V (1984 Nov). "Treatment of solitary rectal ulcer syndrome with high-fiber diet and abstention of straining at defecation". Digestive diseases and sciences. 29 (11): 1005–8. PMID 6092015. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
  29. ^ Jarrett, ME (2004 Mar). "Behavioural therapy (biofeedback) for solitary rectal ulcer syndrome improves symptoms and mucosal blood flow". Gut. 53 (3): 368–70. PMID 14960517. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
  30. ^ Vaizey, CJ (1997 Dec). "Prospective evaluation of the treatment of solitary rectal ulcer syndrome with biofeedback". Gut. 41 (6): 817–20. PMID 9462216. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
  31. ^ Sitzler, PJ (1998 Sep). "Long-term clinical outcome of surgery for solitary rectal ulcer syndrome". The British journal of surgery. 85 (9): 1246–50. PMID 9752869. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
  32. ^ Vaizey, CJ (1998 Dec). "Solitary rectal ulcer syndrome". The British journal of surgery. 85 (12): 1617–23. PMID 9876062. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
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