Solitary Rectal Ulcer Syndrome

R. Fleischmann

CT C

t5 c

TO U

■ Definition

Solitary rectal ulcer syndrome describes a solitary ulcer surrounded by normal appearing rectal mucosa.

■ Clinical Picture

Patients present with tenesmus and a feeling of anal obstruction. Blood and mucus appear in stool.

Diagnosis

Using either a rigid rectoscope or a flexible sigmoidoscope the rectum should be inspected up to the rectosigmoid junction. An ulcer 0.5-2.0 cm in size can usually be found between 6 and 13 cm from the anus on the anterior rectal wall, surrounded by normal appearing mucosa.

Endoscopic diagnostic criteria

► flat ulcer with smooth border, usually covered with fibrinous exudate (Figs. 16.1,16.2).

Endoscopic examination procedure

perianal inspection, digital examination, rectoscopy/sigmoidoscopy, smear from the base of the ulcer, biopsy.

Causes. Solitary rectal ulcers have various causes, but they are most often caused by rectal or anal prolapse. Full-thickness rec tal prolapse—protrusion of the full thickness of the rectal wall through the anal ring—is always an indication for surgical intervention.

Anal prolapse is an eversion of hyperplastic anal corpus cavernosum into the anal lumen. Unlike rectal prolapse, the mucosa has radial folds and a starshaped appearance (Fig. 16.3). The stages in anal prolapse are:

► semicircular, and

It is not always possible to detect mucosal prolapse. Nonetheless, the presumed cause of a rectal ulcer is often a protrusion of the anterior rectal wall into the anal canal due to excessive pressure. This in turn leads to local mucosal ischemia and ultimately ulcer formation. Severe constipation and chronic excessive straining during bowel evacuation are the most common causes of rectal ulcers.

Occasionally a solitary rectal ulcer is caused by self-performed digital manipulation of the ampulla to relieve chronic constipation (Fig. 16.2). Solitary rectal ulcers are seldom caused by medication (i.e., ergotamine or NSAID suppositories).

Histology. Histology reveals a nonspecific inflammatory change with smooth muscle components extending to the lamina propria of the mucosa. Differential diagnosis should first exclude carcinoma or a Crohn-related ulcer (Tab. 16.1).

Asymptomatic patients do not require treatment. Symptomatic patients should be advised to avoid excessive straining during bowel evacuation. Measures for softening the stool are recommended (e.g., drinking more fluids, avoiding black tea, Indian Plantago, etc.).

Solitary Rectal Ulcer
Fig. 16.1 Flat rectal ulcer at 5 cm above the anus in mucosal prolapse.

Fig. 16.2 Moderately deep rectal ulcer covered with fibrinous exudate: mucosal prolapse and digital manipulation (surrounding mucosa is edematous).

Fig. 16.3 Anal prolapse (complete).

Table 16.1 Differential diagnosis of chronic solitary rectal ulcers

Diagnosis

Features

Chronic solitary rectal ulcer

Anterior rectal wall 6-13 cm from the anus Possible rectal or anal prolapse

Radiation ulcer (delayed radiation proctitis)

Three months to several years after exposure

Crohn disease

Seldom solitary

Rectal carcinoma

Usually elevated

Lymphoma

Histology for differential diagnosis

NSAID ulcer

Localization in rectum with suppository use

Ischemic colitis

Mid third of rectum to splenic flexure Obstruction of inferior mesenteric artery

Stercoral ulcer

In patients with severe constipation, often bedridden perforation risk!

Prior polypectomy

Ulcer appears up to four weeks after polypectomy

Inguinal lymphogranuloma (Durand-Nicolas-Favre disease)

Tropical STD (viral) Narrowing of rectal lumen Anal swelling

Syphilis, primary syphilitic sore

Three weeks after infection can be localized in anal or rectal area, dark-field microscopic examination of exudate, serology

Gonorrhea

Acute proctitis with numerous ulcers and discharge Gram stain

Herpes

Areas dotted with very small ulcers in the rectum ranging from tiny perianal blisters to ulcers PCR from smear and biopsy

Chancroid ulcer (soft chancre)

1-2 cm large painful ulcer with ragged, undermined borers Smear for detection of Hemophilus ducreyi

In severe cases of rectal prolapse with rectocele (detected by means of defecography) transabdominal rectopexy with or without resection is indicated. Resection is especially indicated for complete rectal prolapse.

Less severe cases of anal prolapse can be treated with band ligation or sclerotherapy. The most successful procedure appears to be transanal staple operation (Longo procedure).

References

1. Hafter E. Praktische Gastroenterologie. 7th ed., Stuttgart: Thieme 1988; pp. 262-81.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

Get My Free Ebook


Post a comment