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Gaj F, Lai Q, Gelormini E, Ceci M, Di Saverio S, Quaresima S. Efficacy of surgical treatments for the management of solitary rectal ulcer syndrome: a network meta-analysis. Colorectal Dis 2024; 26:1515-1534. [PMID: 38957108 DOI: 10.1111/codi.17080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 05/11/2024] [Accepted: 05/27/2024] [Indexed: 07/04/2024]
Abstract
AIM Solitary rectal ulcer syndrome (SRUS) is a benign and poorly understood disorder with complex management. Typical symptoms include straining during defaecation, rectal bleeding, tenesmus, mucoid secretion, anal pain and a sense of incomplete evacuation. Diagnosis is based on characteristic clinical symptoms and endoscopic/histological findings. Several treatments have been reported in the literature with variable ulcer healing rates. This study aimed to evaluate the efficacy of different treatments for SRUS. MATERIALS AND METHODS A systematic review and network meta-analysis were performed according to the PRISMA guidelines. Studies in English, French and Spanish languages were included. Papers written in other languages were excluded. Other exclusion criteria were reviews, case reports or clinical series enrolling less than five patients, study duplications, no clinical data of interest and no article available. A systematic literature search was conducted from January 2000 to March 2024 using the following databases: PubMed/MEDLINE, Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and Scopus. The biases of the studies were assessed using the Newcastle-Ottawa scale or the Jadad scale when appropriate. Types of treatment and their efficacy for the cure of SRUS were collected and critically assessed. The study's primary outcome was to estimate the rate of patients with ulcer healing. RESULTS A total of 22 studies with 911 patients (men 361, women 550) diagnosed with SRUS were analysed in the final meta-analysis. The pooled effect estimates of treatment efficacy revealed that surgery showed the highest ulcer healing rate (70.5%; 95% CI 0.57-0.83). Surgery was superior in the cure of ulcers with respect to medical therapies and biofeedback (OR 0.09 and OR 0.14). CONCLUSION Solitary rectal ulcer syndrome is a challenging clinical entity to manage. Proficient results have been reported with the surgical approach, suggesting its positive role in cases refractory to medical and biofeedback therapy. Further studies in homogeneous populations are required to evaluate the efficacy of surgery in this setting. (PROSPERO registration number CRD42022331422).
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Affiliation(s)
- Fabio Gaj
- Department of General Surgery and Surgical Specialties 'Paride Stefanini', Sapienza University of Rome, AOU Policlinico Umberto I, Rome, Italy
| | - Quirino Lai
- Department of General Surgery and Surgical Specialties 'Paride Stefanini', Sapienza University of Rome, AOU Policlinico Umberto I, Rome, Italy
| | - Enza Gelormini
- Department of General Surgery and Surgical Specialties 'Paride Stefanini', Sapienza University of Rome, AOU Policlinico Umberto I, Rome, Italy
| | - Marino Ceci
- Department of General Surgery and Surgical Specialties 'Paride Stefanini', Sapienza University of Rome, AOU Policlinico Umberto I, Rome, Italy
| | - Salomone Di Saverio
- ASUR Marche, San Benedetto del Tronto Hospital, San Benedetto del Tronto, Italy
| | - Silvia Quaresima
- Department of General Surgery and Surgical Specialties 'Paride Stefanini', Sapienza University of Rome, AOU Policlinico Umberto I, Rome, Italy
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Zhang Y, Tian F, Li H. Solitary Rectal Ulcer Syndrome Coexisting with Colitis Cystica Profunda-Is Mucosal Resection Radical or Not? Inflamm Bowel Dis 2022:6777776. [PMID: 36305733 DOI: 10.1093/ibd/izac232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Indexed: 12/09/2022]
Abstract
Lay Summary
We highlight the key diagnostic features of solitary rectal ulcer syndrome coexisting with colitis cysticaprofunda in order to increase awareness of the postoperative recurrence of the diseases.
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Affiliation(s)
- Yajie Zhang
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Feng Tian
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Hui Li
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
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Maeda Y, Espin-Basany E, Gorissen K, Kim M, Lehur PA, Lundby L, Negoi I, Norcic G, O'Connell PR, Rautio T, van Geluwe B, van Ramshorst GH, Warwick A, Vaizey CJ. European Society of Coloproctology guidance on the use of mesh in the pelvis in colorectal surgery. Colorectal Dis 2021; 23:2228-2285. [PMID: 34060715 DOI: 10.1111/codi.15718] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 03/14/2021] [Accepted: 03/23/2021] [Indexed: 12/31/2022]
Abstract
This is a comprehensive and rigorous review of currently available data on the use of mesh in the pelvis in colorectal surgery. This guideline outlines the limitations of available data and the challenges of interpretation, followed by best possible recommendations.
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Affiliation(s)
- Yasuko Maeda
- Cumberland Infirmary and University of Edinburgh, Carlisle, UK
| | | | | | - Mia Kim
- Department of General, Gastrointestinal, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | | | - Lilli Lundby
- Department of Surgery Pelvic Floor Unit, Aarhus University Hospital, Aarhus, Denmark
| | - Ionut Negoi
- Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Gregor Norcic
- Department of Abdominal Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - P Ronan O'Connell
- Department of Surgery, St Vincent's University Hospital, Dublin, Ireland
| | - Tero Rautio
- Medical Research Center, University of Oulu, Oulu, Finland
| | | | | | - Andrea Warwick
- QEII Jubilee Hospital, Acacia Ridge, Queensland, Australia
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Sadeghi A, Biglari M, Forootan M, Adibi P. Solitary Rectal Ulcer Syndrome: A Narrative Review. Middle East J Dig Dis 2019; 11:129-134. [PMID: 31687110 PMCID: PMC6819965 DOI: 10.15171/mejdd.2019.138] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 06/16/2019] [Indexed: 12/12/2022] Open
Abstract
Solitary rectal ulcer syndrome is a multifactorial pathology, which entails a variety of clinical, histologic and endoscopic aspects that needs step-wise logical approach for management especially in relapsing refractory cases. Apart from the diagnostic dilemma that may be faced due to similarities of presentation with inflammatory bowel diseases or colorectal neoplastic lesions, the syndrome also overlaps with dyssynergic defecation syndrome, health anxiety disorder, obsessive compulsive disorder, and latent mucosal rectal prolapse, a systematic composite treatment modality including psychological, pharmacological, physiological and possibly surgical interventions are sometimes essential. Selecting appropriate treatment in this condition not only affects clinical outcome but also patients’ experience and further stigma of SRUS life-long. In this review, we will discuss the detailed pathophysiology, diagnostic and therapeutic approaches in dealing with solitary rectal ulcer syndrome.
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Affiliation(s)
- Anahita Sadeghi
- Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Biglari
- Department of Internal Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mojgan Forootan
- Department of Gastroenterology, Gastrointestinal and Liver Diseases Research Center (RCGLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Peyman Adibi
- Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Qari Y, Mosli M. A systematic review and meta-analysis of the efficacy of medical treatments for the management of solitary rectal ulcer syndrome. Saudi J Gastroenterol 2019; 26:4-12. [PMID: 31898642 PMCID: PMC7045767 DOI: 10.4103/sjg.sjg_213_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND/AIM Solitary rectal ulcer syndrome (SRUS) is a benign, poorly understood disorder that is difficult to manage. Medical interventions such as sucralfate, sulfasalzine, human fibrin, and a high fibre diet are reported as the first line of treatment. The aim of this study is to perform a systematic review and meta-analysis of the efficacy of medical treatments for SRUS. MATERIALS AND METHODS Databases including PubMed, Cochrane, and Embase were searched for randomised clinical trials (RCT) and observational studies that evaluated medical treatments for SRUS. Two authors independently performed selection of eligible studies based on eligiblity criteria. Data extraction from potentially eligible studies was carried out according to predefined data collection methods. Medical treatments, including sucralfate, sulfasalzine, human fibrin, a high fibre diet, and psyllium powder as a single or combination therapy were compared to placebo alone or combined with other treatments. The primary outcome was the proportion of patients with ulcer remission; this was presented as pooled prevalence (PP) with a 95% confidence interval (CI). The I2 value and Q statistic test were used to test for heterogeneity. In the presence of heterogeneity, a random-effects model was applied. RESULTS A total of 9 studies with 216 patients (males = 118, females = 98) diagnosed with SRUS were analysed in the final meta-analysis. The pooled effect estimate of treatment efficacy revealed that, of the patients receiving medical treatment, 57% had resolution of their ulcers (PP 0.57; 95% CI; 0.41 to 0.73). Statistically significant heterogeneity was observed (I2 = 63%; τ2 = 0.64, P= <0.01). The scarcity of RCTs comparing medical treatments with other interventions was a major limitation. CONCLUSIONS The majority of patients receiving medical treatment for the management of SRUS experience resolution of their ulcers.
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Affiliation(s)
- Yousef Qari
- Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mahmoud Mosli
- Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia,Address for correspondence: Dr. Mahmoud Mosli, Department of Medicine, King Abdulaziz University Hospital, King Abdulaziz University, Jeddah, Saudi Arabia. E-mail:
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6
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Abstract
BACKGROUND Solitary rectal ulcer (SRUS) may mislead the inflammatory bowel disease (IBD) or rectal polyps, which may reduce the actual prevalence of it. Various treatments for SRUS have been described that can be referred to therapeutic strategies such as biofeedback, enema of corticosteroid, topical therapy, and rectal mucosectomy. Nevertheless, biofeedback should be considered as the first stage of treatment, while surgical procedures have been offered for those who do not respond to conservative management and biofeedback or those who have total rectal prolapse and rectal full-thickness. METHODS A systematic and comprehensive search will be performed using MEDLINE, PubMed, Scopus, EMBASE, AMED, the Cochrane Library, and Google Scholar. RESULTS The results of this systematic review will be published in a peer-reviewed journal. CONCLUSION To our knowledge, our study discusses the factors involved in the pathogenesis, clinical symptoms, diagnosis, treatment, and management of patients. This review can provide recommended strategies in a comprehensive and targeted vision for patients suffering from this syndrome.
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Affiliation(s)
- Mojgan Forootan
- Department of Gastroenterology, Gastrointestinal and Liver Diseases Research Center (RCGLD), Shahid Beheshti University of Medical Sciences
| | - Mohammad Darvishi
- Infectious Diseases and Tropical Medicine Research Center (IDTMRC), Department of Aerospace and Subaquatic Medicine, AJA University of Medical Sciences, Tehran, Iran
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Evans C, Ong E, Jones OM, Cunningham C, Lindsey I. Laparoscopic ventral rectopexy is effective for solitary rectal ulcer syndrome when associated with rectal prolapse. Colorectal Dis 2014; 16:O112-6. [PMID: 24678526 DOI: 10.1111/codi.12502] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Solitary rectal ulcer syndrome (SRUS) is uncommon and its management is controversial. The aim of this study was to evaluate the outcome of patients with SRUS who underwent laparoscopic ventral rectopexy (LVR). METHOD A review was performed of a prospective database at the Oxford Pelvic Floor Centre to identify patients between 2004 and 2012 with a histological diagnosis of SRUS. All were initially treated conservatively and surgical treatment was indicated only for patients with significant symptoms after failed conservative management. The primary end-point was healing of the ulcer. Secondary end-points included changes in the Wexner Constipation Score and Faecal Incontinence Severity Index (FISI). RESULTS Thirty-six patients with SRUS were identified (31 women), with a median age of 44 (15–81) years. The commonest symptoms were rectal bleeding (75%) and obstructed defaecation (64%). The underlying anatomical diagnosis was internal rectal prolapse (n = 20), external rectal prolapse (n = 14) or anismus (n = 2). Twenty-nine patients underwent LVR and one a stapled transanal rectal resection (STARR) procedure. Nine (30%) required a further operation, six required posterior STARR for persistent SRUS and two a per-anal stricturoplasty for a narrowing at the healed SRUS site. Healing of the SRU was seen in 27 (90%) of the 30 patients and was associated with significant improvements in Wexner and FISI scores at a 3-year follow-up. CONCLUSION Almost all cases of SRUS in the present series were associated with rectal prolapse. LVR resulted in successful healing of the SRUS with good function in almost all patients, but a significant number will require further surgery such as STARR for persistent obstructed defaecation.
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Affiliation(s)
- C. Evans
- Department of Colorectal Surgery; Oxford Pelvic Floor Centre; Oxford University Hospitals NHS Trust; Oxford UK
| | - E. Ong
- Department of Colorectal Surgery; Oxford Pelvic Floor Centre; Oxford University Hospitals NHS Trust; Oxford UK
| | - O. M. Jones
- Department of Colorectal Surgery; Oxford Pelvic Floor Centre; Oxford University Hospitals NHS Trust; Oxford UK
| | - C. Cunningham
- Department of Colorectal Surgery; Oxford Pelvic Floor Centre; Oxford University Hospitals NHS Trust; Oxford UK
| | - I. Lindsey
- Department of Colorectal Surgery; Oxford Pelvic Floor Centre; Oxford University Hospitals NHS Trust; Oxford UK
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9
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Kroesen AJ. [Pelvic floor and anal incontinence. Conservative therapy]. Chirurg 2013; 84:15-20. [PMID: 23329310 DOI: 10.1007/s00104-012-2348-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Conservative treatment of fecal incontinence and obstructive defecation can be treated by many conservative treatment modalities. This article presents the options of medication therapy, spincter exercises, electric stimulation, transcutaneous tibial nerve stimulation, anal irrigation and injection of bulking agents. These methods are presented with reference to the currently available literature but the evidence-based data level for all methods is low. For minor disorders of anorectal function these conservative methods can lead to an improvement of anorectal function and should be individually adapted.
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Affiliation(s)
- A J Kroesen
- Abteilung für Allgemein-, Viszeral- und Unfallchirurgie, Krankenhaus Porz am Rhein, Köln.
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10
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Dehghani SM, Malekpour A, Haghighat M. Solitary rectal ulcer syndrome in children: A literature review. World J Gastroenterol 2012; 18:6541-5. [PMID: 23236227 PMCID: PMC3516213 DOI: 10.3748/wjg.v18.i45.6541] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Revised: 09/20/2012] [Accepted: 09/29/2012] [Indexed: 02/06/2023] Open
Abstract
Solitary rectal ulcer syndrome (SRUS) is a benign and chronic disorder well known in young adults and less in children. It is often related to prolonged excessive straining or abnormal defecation and clinically presents as rectal bleeding, copious mucus discharge, feeling of incomplete defecation, and rarely rectal prolapse. SRUS is diagnosed based on clinical symptoms and endoscopic and histological findings. The current treatments are suboptimal, and despite correct diagnosis, outcomes can be unsatisfactory. Some treatment protocols for SRUS include conservative management such as family reassurance, regulation of toilet habits, avoidance of straining, encouragement of a high-fiber diet, topical treatments with salicylate, sulfasalazine, steroids and sucralfate, and surgery. In children, SRUS is relatively uncommon but troublesome and easily misdiagnosed with other common diseases, however, it is being reported more than in the past. This condition in children is benign; however, morbidity is an important problem as reflected by persistence of symptoms, especially rectal bleeding. In this review, we discuss current diagnosis and treatment for SRUS.
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Abstract
Abstract
Solitary rectal ulcer syndrome (SRUS) is a rare condition with various causes that results in ischemic injury. The aim of this study was to assess the clinical findings, diagnosis, and outcomes of treatment in patients with SRUS. Between 1992 and 2006, a retrospective review was undertaken for all patients diagnosed with SRUS. Fifty-eight patients were diagnosed with SRUS. Among patients with paradoxic rectal spasm (PRS), lesions disappeared in 1 of 3 given applied biofeedback treatment, and in 2 of 4 injected with Botulinum toxin (BotoxTM). Twenty-three patients underwent appropriate surgical treatment. Overall, postoperative improvement was seen in 18 patients (78.2%). In conclusion, every patient with SRUS must be assessed for causative disease. Treatment should include conservative approaches such as Botox injection; in patients with pelvic floor disorders, surgical treatment should be considered.
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12
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Abstract
Functional anorectal disorders include solitary rectal ulcer syndrome, rectocele, nonrelaxing puborectalis syndrome, and descending perineal syndrome. Patients usually present with "constipation," but the clinical picture of these disorders includes rectal pain and bleeding, digitalization, incomplete evacuation, and a feeling of obstruction. Diagnosis is difficult because many findings can be seen in normal patients as well. The diagnosis is made by using a combination of clinical picture, defecography, pathology, and occasionally anometry and pudendal terminal motor nerve latency. These disorders are generally treated medically with dietary changes and biofeedback. Surgical intervention is reserved for patients with intractable symptoms and has not been universally successful.
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Affiliation(s)
- Melissa L Times
- Division of Colon & Rectal Surgery, Henry Ford Hospital, Detroit, MI 48202, USA
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13
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Wang Y, Zhai C, Niu L, Tian L, Yang J, Hu Z. A modified Delorme's operation for the treatment of rectal mucosal prolapse. Int J Colorectal Dis 2010; 25:607-11. [PMID: 20020147 DOI: 10.1007/s00384-009-0869-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/24/2009] [Indexed: 02/04/2023]
Abstract
AIMS Many procedures have been described for the treatment of rectal internal mucosal prolapse (RMP), but the therapeutic effect is questionable. This work is to evaluate clinical and functional outcome of a modified Delorme's operation-trans-anal purse-string sutures for rectal mucosa and submucosa (TAS) for the treatment of RMP. METHODS The clinical data of 58 patients with rectal mucosal prolapse treated with rectal mucosa and submucosal tissue (TAS) between June 2004 and June 2008 were analyzed retrospectively. RESULTS No patient died. Satisfaction with surgery was high in 48 cases (82.8%), moderate in seven (12.1%), and low in three (5.17%). Prolapse relapse rate was 5.17%. Anal tenesmus and urge to defecate resolved in 52 (89.7%) patients. Constipation improved in 25 of 28 (89.3%) previously constipated patients. No surgery-associated constipation occurred. The mean operative time was 31 (range 22-46) min. Mean hospital stay was 3 days (range 2-6). Mean patient follow-up was 32 months (range 12-60). CONCLUSIONS From our data, TAS for the treatment of RMP showed encouraging results with little complications and an acceptable relapse rate. This economical procedure induces only mild trauma and is easy to perform, making it worthy of further practice and investigation.
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Affiliation(s)
- Yonggang Wang
- Department of Colorectal Surgery, Shanxi Provincial People's Hospital, Taiyuan, People's Republic of China, 030012.
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Edden Y, Shih SS, Wexner SD. Solitary rectal ulcer syndrome and stercoral ulcers. Gastroenterol Clin North Am 2009; 38:541-5. [PMID: 19699413 DOI: 10.1016/j.gtc.2009.06.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Colonic ulcerations can affect the entire colon and rectum, and have variable clinical presentation according to the anatomic location and underlying pathology. Diverse causes may lead to colonic ulceration, such as inflammatory bowel diseases, oral drugs (mostly nonsteroidal anti-inflammatory drugs), local or diffuse ischemia, and different intestinal microorganisms. An ulcer may also herald a concealed malignant disease. In most cases, colonic ulcerate is associated with diffuse colitis in the acute setup or with inflammatory bowel diseases, and to the lesser extent the ulceration is defined as solitary. This article focuses on two of the less commonly diagnosed diseases: solitary rectal ulcer syndrome and stercoral ulceration, both related to local tissue ischemia and often seen in the elderly population.
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Affiliation(s)
- Yair Edden
- Department of Colorectal Surgery, Cleveland Clinic, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA
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15
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Al-Brahim N, Al-Awadhi N, Al-Enezi S, Alsurayei S, Ahmad M. Solitary rectal ulcer syndrome: a clinicopathological study of 13 cases. Saudi J Gastroenterol 2009; 15:188-92. [PMID: 19636181 PMCID: PMC2841419 DOI: 10.4103/1319-3767.54749] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND/AIMS Solitary rectal ulcer syndrome (SRUS) is a rare disorder that has a wide spectrum of clinical presentation and variable endoscopic findings. To further characterize the clinical and pathological features, a retrospective, hospital-based clinicopathological study was conducted. MATERIALS AND METHODS All cases of SRUS diagnosed at Farwania Hospital, Kuwait, between 2002 and 2007 were retrieved from the computerized filing system. The histological slides were reviewed by two authors to confirm the diagnosis. Immunohistochemical stain for smooth muscle actin (SMA) was performed. The clinical files were reviewed for clinical features and endoscopic findings. RESULTS Thirteen cases were identified: 8 males and 5 females. The age range was 15-85. Rectal bleeding, constipation, and abdominal pain were the most common presenting symptoms and were seen, either alone or in various combinations, in 12 of the 13 cases. Rectal ulceration was the most common endoscopic finding, being seen in 9 of the 3 cases; 3 of these cases had multiple ulcerations. Two patients had rectal polyps, with one of them having multiple polyps. The histological examination revealed surface serration, fibromuscular obliteration of the lamina propria, and crypts' distortion in all the cases. Seven of the cases had diamond crypts. Ectatic mucosal vessels were a common finding. Positivity for SMA in the lamina propria was seen in all examined cases. CONCLUSION SRUS is a rare disorder and only 13 cases were diagnosed in Farwania hospital over a 6-year period. The clinical presentation of our patients was variable. The presence of polyps and multiple ulcerations on endoscopy is further evidence that SRUS is a misnomer. Surface serration, fibromuscular obliteration, and crypts' distortion are the most characteristic features. The presence of diamond crypts is an additional diagnostic feature.
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Affiliation(s)
| | - Naser Al-Awadhi
- Department of Pathology, Gastroenterology Unit, Farwania Hospital, Kuwait
| | - Saleh Al-Enezi
- Department of Medicine, Gastroenterology Unit, Farwania Hospital, Kuwait
| | - Saqer Alsurayei
- Department of Medicine, Gastroenterology Unit, Farwania Hospital, Kuwait
| | - Mahmoud Ahmad
- Department of Pathology, Gastroenterology Unit, Farwania Hospital, Kuwait
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Abstract
AbstractSolitary rectal ulcer syndrome (SRUS) is a syndrome with symptoms such as rectal bleeding, obstructed defecation, straining at stool and incomplete evacuation, and rectal polyps. In the present study, the clinical features of SRUS among Iranian patients is reviewed. Records of 112 patients diagnosed with SRUS between 1997 and 2007 admitted to a special coloproctology clinic have been analyzed retrospectively. Of 112 patients with SRUS, 61 were male (54.4%) and 51 female (45.6%) with a mean age of 32.2 years (range, 16–64 years). The mean interval between onset of symptoms and final diagnosis of SRUS was 3.8 years (range, 1–14 years). Rectal bleeding (67%) was the most common symptom in both genders, while a feeling of fullness was the least common symptom, observed only in one woman (2%). Incontinence was observed in 4 women (7.8%) and 3 men (4.9%), comprising 6.25% of the total clinical presentations. There were 38 patients (33.9%) with mucosal prolapse and 2 patients (1.8%) with total rectal prolapse. In conclusion, rectal bleeding in the presence of constipation or diarrhea is the main sign for diagnosis of SRUS. This syndrome is usually misdiagnosed; it is frequently confused with inflammatory bowel disease (IBD) because the rectal macroscopic and microscopic lesions and true polyps of rectum are similar. We suggest that most of patients who are treating for IBD and true polyps without any response are suffering from SRUS. Regarding misdiagnosis between SRUS and IBD or rectal polyp, the exact prevalence of SRUS has been mistakenly underestimated.
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Abstract
Solitary rectal ulcer syndrome (SRUS) is an uncommon disorder which can present in patients being evaluated for defecatory disorders or which can present as a primary process often involving hematochezia, rectal pain and tenesmus. Unfortunately the diagnosis of this disorder is often delayed due to misdiagnosis and/or physician unfamiliarity with the condition. We present a 24-year-old female who presented with 6 months of bloody diarrhea and weight loss. She had been receiving treatment for a presumed diagnosis of inflammatory bowel disease (IBD) due to an endoscopic picture of rectal thickening, edema and ulceration and had been on prednisone for 2 months prior to presentation without relief of her symptoms. After further testing including repeat endoscopy with biopsies, defecography and anorectal manometry, the diagnosis of SRUS was made and treatment was changed. Medical management was unsuccessful and she ultimately required surgical intervention. This case highlights the difficulty in diagnosing SRUS due to its resemblance to other gastrointestinal diseases and should serve as a reminder that if a patient is not responding to IBD therapy, another etiology should be considered.
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Affiliation(s)
- S B Umar
- Mayo Clinic Arizona, Scottsdale, Ariz., USA
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18
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Meurette G, Siproudhis L, Regenet N, Frampas E, Proux M, Lehur PA. Poor symptomatic relief and quality of life in patients treated for "solitary rectal ulcer syndrome without external rectal prolapse". Int J Colorectal Dis 2008; 23:521-6. [PMID: 18274765 DOI: 10.1007/s00384-008-0445-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/17/2008] [Indexed: 02/04/2023]
Abstract
BACKGROUND Solitary rectal ulcer syndrome (SRUS) is a chronic disabling condition. Several therapeutic options have been advocated including conservative approaches and surgery, bringing into question their functional outcomes. This study aimed to assess treatment procedures on both anorectal complaints and quality of life (QoL) using standardised self-administered questionnaires. MATERIALS AND METHODS Forty-one patients who underwent treatments for SRUS in two referral centres were reviewed. A standardised self-administered questionnaire including incontinence (Cleveland Clinic), constipation (Knowles-Eccersley-Scott symptom, KESS) and gastrointestinal quality of life index validated scoring systems was mailed to each patient (median follow-up, 36 months). Correlation between treatment options, functional results and quality of life was analysed. RESULTS The mean Cleveland Clinic and KESS scores were respectively 5.3+/-5.8 (normal 0) and 19.1+/-8 (normal<9). The mean QoL score reached 89+/-28.8 (normal 125). A linear correlation between the QoL score and functional results was observed. There was no influence of treatment options on QoL results. A multivariate analysis identified five parameters predictive of a better QoL: presence of paradoxical puborectalis contraction, absence of descending perineum, absence of procidentia, age<40 and treatment exclusively based on laxatives. CONCLUSION Despite several therapeutic options including surgery, patients with SRUS still frequently complain of disturbed anorectal function and significant alteration of their QoL.
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Affiliation(s)
- G Meurette
- Clinique de Chirurgie Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif (CCDE-IMAD), Nantes University Hospital, Hotel-Dieu, Nantes, France.
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Boccasanta P, Venturi M, Calabro G, Maciocco M, Roviaro GC. Stapled transanal rectal resection in solitary rectal ulcer associated with prolapse of the rectum: a prospective study. Dis Colon Rectum 2008; 51:348-54. [PMID: 18204882 DOI: 10.1007/s10350-007-9115-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2007] [Revised: 06/06/2007] [Accepted: 08/25/2007] [Indexed: 02/06/2023]
Abstract
PURPOSE At present, none of the conventional surgical treatments of solitary rectal ulcer associated with internal rectal prolapse seems to be satisfactory because of the high incidence of recurrence. The stapled transanal rectal resection has been demonstrated to successfully cure patients with internal rectal prolapse associated with rectocele, or prolapsed hemorrhoids. This prospective study was designed to evaluate the short-term and long-term results of stapled transanal rectal resection in patients affected by solitary rectal ulcer associated with internal rectal prolapse and nonresponders to biofeedback therapy. METHODS Fourteen patients were selected on the basis of validated constipation and continence scorings, clinical examination, anorectal manometry, defecography, and colonoscopy and were submitted to biofeedback therapy. Ten nonresponders were operated on and followed up with incidence of failure, defined as no improvement of symptoms and/or recurrence of rectal ulceration, as the primary outcome measure. Operative time, hospital stay, postoperative pain, time to return to normal activity, overall patient satisfaction index, and presence of residual rectal prolapse also were evaluated. RESULTS At a mean follow-up of 27.2 (range, 24-34) months, symptoms significantly improved, with 80 percent of excellent/good results and none of the ten operated patients showed a recurrence of rectal ulcer. Operative time, hospital stay, and time to return to normal activity were similar to those reported after stapled transanal rectal resection for obstructed defecation, whereas postoperative pain was slightly higher. One patient complained of perineal abscess, requiring surgery. DISCUSSION The stapled transanal rectal resection is safe and effective in the cure of solitary rectal ulcer associated with internal rectal prolapse, with minimal complications and no recurrences after two years. Randomized trials with sufficient number of patients are necessary to compare the efficacy of stapled transanal rectal resection with the traditional surgical treatments of this rare condition.
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Affiliation(s)
- Paolo Boccasanta
- 1st Department of General Surgery, Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, IRCCS Foundation, Milan, and the University of Milan, Milan, Italy.
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Torres C, Khaikin M, Bracho J, Luo CH, Weiss EG, Sands DR, Cera S, Nogueras JJ, Wexner SD. Solitary rectal ulcer syndrome: clinical findings, surgical treatment, and outcomes. Int J Colorectal Dis 2007; 22:1389-93. [PMID: 17701045 DOI: 10.1007/s00384-007-0344-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/14/2007] [Indexed: 02/04/2023]
Abstract
BACKGROUND Solitary rectal ulcer syndrome (SRUS) is a rare disorder often misdiagnosed as a malignant ulcer. Histopathological features of SRUS are characteristic and pathognomonic; nevertheless, the endoscopic and clinical presentations may be confusing. The aim of the present study was to assess the clinical findings, surgical treatment, and outcomes in patients who suffer from SRUS. MATERIALS AND METHODS A retrospective chart review was undertaken, from January 1989 to May 2005 for all patients who were diagnosed with SRUS. Data recorded included: patient's age, gender, clinical presentation, past surgical history, diagnostic and preoperative workup, operative procedure, complications, and outcomes. RESULTS During the study period, 23 patients were diagnosed with SRUS. Seven patients received only medical treatment, and in three patients, the ulcer healed after medical treatment. Sixteen patients underwent surgical treatment. In four patients, the symptoms persisted after surgery. Two patients presented with postoperative rectal bleeding requiring surgical intervention. Three patients developed late postoperative sexual dysfunction. One patient continued suffering from rectal pain after a colostomy was constructed. Median follow-up was 14 (range 2-84) months. CONCLUSION The results of this study show clearly that every patient with SRUS must be assessed individually. Initial treatment should include conservative measures. In patients with refractory symptoms, surgical treatment should be considered. Results of anterior resection and protocolectomy are satisfactory for solitary rectal ulcer.
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Affiliation(s)
- Carlos Torres
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950, Cleveland clinic Blvd., Weston, FL 33332, USA
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Lachman RS. S. TAYBI AND LACHMAN'S RADIOLOGY OF SYNDROMES, METABOLIC DISORDERS AND SKELETAL DYSPLASIAS 2007. [PMCID: PMC7315357 DOI: 10.1016/b978-0-323-01931-6.50027-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Inan N, Arslan AS, Akansel G, Anik Y, Gürbüz Y, Tugay M. Colitis cystica profunda: MRI appearance. ACTA ACUST UNITED AC 2006; 32:239-42. [PMID: 16947072 DOI: 10.1007/s00261-006-9048-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2006] [Accepted: 04/25/2006] [Indexed: 10/24/2022]
Abstract
Colitis cystica profunda (CCP) is an uncommon benign condition characterized by mucin-filled cysts located in the submucosa, frequently associated with the solitary ulcer and rectal prolapse syndromes. The diagnosis of this entity is important as it can mimic rectal cancer and therefore may result in unnecessary surgical resection. Endoscopic examination and barium enema findings are suggestive but not specific, neither are superficial biopsy findings. Transrectal ultrasound is helpful in the diagnosis by imaging the layers of the rectal wall. The authors report a 16-year-old male with a rectal lesion mimicking malignant mass on endoscopic examination. The lesion was defined as CCP, based on MR imaging findings which disclosed multiple noninfiltrating submucosal cysts, confirmed by histopathological examination. To our knowledge, this is the first case of CCP in the radiology literature describing MRI findings.
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Affiliation(s)
- Nagihan Inan
- Radiology, Kocaeli University School of Medicine, Kocaeli, Turkey.
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Choi HJ, Shin EJ, Hwang YH, Weiss EG, Nogueras JJ, Wexner SD. Clinical presentation and surgical outcome in patients with solitary rectal ulcer syndrome. Surg Innov 2006; 12:307-13. [PMID: 16424950 DOI: 10.1177/155335060501200404] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Solitary rectal ulcer syndrome is a poorly understood clinical condition, and the schema of treatment has not yet been defined. This study reviewed the clinical spectra and outcome of various surgical treatments in patients with solitary rectal ulcer syndrome. The medical records of all patients with solitary rectal ulcer syndrome between 1992 and 1998 were retrospectively reviewed. Patients in the study population with symptoms and histopathologic findings suggestive of solitary rectal ulcer syndrome were placed in the primary solitary rectal ulcer syndrome group, and patients who underwent surgery for other diseases in whom histopathology confirmed concomitant solitary rectal ulcer syndrome were in the incidental group. Clinical features and outcomes of surgical treatment were documented. Improvement was considered as resolution of presenting symptoms, and non-improvement was considered if presenting symptoms persisted or worsened. The study cohort comprised 49 patients: 20 in the primary group and 29 in the incidental group. Ulcerative morphology was seen predominantly in the primary group (70%); erythematous (45%) and polypoid lesions (34%) were predominant in the incidental group (P = .0025). Clinical improvement after surgery was seen in 74% of patients with primary and 79% with incidental solitary rectal ulcer syndrome (P = NS). Manifestations such as tenesmus and digitation correlated with poorer outcome after surgery in both groups. Solitary rectal ulcer syndrome is a clinical condition associated with functional anorectal evacuatory disorders. The results of this study show the positive role of surgical treatment for underlying functional disorders in the improvement of incidental solitary rectal ulcer syndrome.
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Affiliation(s)
- Hong Jo Choi
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL 33331, USA
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Chiang JM, Changchien CR, Chen JR. Solitary rectal ulcer syndrome: an endoscopic and histological presentation and literature review. Int J Colorectal Dis 2006; 21:348-56. [PMID: 16133006 DOI: 10.1007/s00384-005-0020-6] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/03/2005] [Indexed: 02/04/2023]
Abstract
BACKGROUND Although the clinicopathologic features of solitary rectal ulcer syndrome (SRUS) are well documented, the heterogeneous endoscopic appearance of lesions that the syndrome produces and its rare incidence may make for clinical confusion. METHODS Together with a literature review, we describe the variety of lesions experienced in our hospital with a series of endoscopic and histological illustrations and emphasize the diagnostic dilemma both clinically and histologically. CONCLUSIONS With comparison of different macroscopic presentations of SRUS, more correct diagnoses will be achieved and more successful treatments will be reported.
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Affiliation(s)
- Jy-Ming Chiang
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan
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Sharara AI, Azar C, Amr SS, Haddad M, Eloubeidi MA. Solitary rectal ulcer syndrome: endoscopic spectrum and review of the literature. Gastrointest Endosc 2005; 62:755-62. [PMID: 16246692 DOI: 10.1016/j.gie.2005.07.016] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2005] [Accepted: 07/01/2005] [Indexed: 02/08/2023]
Affiliation(s)
- Ala I Sharara
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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Abstract
OBJECTIVE To determine the long-term outcome of laparoscopic mesh rectopexy for solitary rectal ulcer syndrome (SRUS). PATIENTS AND METHODS A retrospective review of 11 patients who underwent laparoscopic mesh rectopexy for refractory SRUS between 1993 and 1996. All patients were followed up initially with rigid sigmoidoscopy and seven were involved in long-term evaluation (follow-up at 71-106 months, median 89 months) involving a sickness impact profile questionnaire. RESULTS Complete endoscopic healing of the ulcer was demonstrated in all 11 patients up to one year postoperatively but one suffered recurrence later. Of seven assessed long-term, none experienced endoscopic recurrence. Six continued to enjoy a significant reduction in symptoms and an improved quality of life. One had persistent problems and demonstrated little symptomatic improvement. CONCLUSION Laparoscopic mesh rectopexy offers a minimally invasive option for selected patients who remain severely symptomatic despite maximal conservative therapy for SRUS, with demonstrable ulcer healing and long-term improvement in symptoms and quality of life. Larger studies are required to fully evaluate its efficacy compared to 'conventional' surgical options.
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Affiliation(s)
- D J Tweedie
- University Hospital of North Durham, Durham, UK
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Conroy S. A case of misdiagnosis: solitary rectal ulcer misdiagnosed as a carcinoma at barium enema. Radiography (Lond) 2004. [DOI: 10.1016/j.radi.2004.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Bishop PR, Nowicki MJ. Nonsurgical Therapy for Solitary Rectal Ulcer Syndrome. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2002; 5:215-223. [PMID: 12003716 DOI: 10.1007/s11938-002-0043-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The treatment of solitary rectal ulcer syndrome (SRUS) remains problematic and is less than ideal. Prospective, well-designed studies assessing the efficacy of treatment for SRUS are few; most of the knowledge imparted for treating SRUS is experiential. As such, firm treatment recommendations can not be made. Rather, a conservative, stepwise, individualized approach must be employed. Diagnostic modalities should be incorporated in the management scheme to direct treatment when indicated. Management must include patient reassurance that the underlying lesion is benign, because complete "cures" are uncommon in those with SRUS. The goals of therapy should be discussed with the patient prior to initiating treatment. Although the ultimate goal is macroscopic and microscopic healing, a realistic goal is cessation or minimization of symptoms. We outline a reasonable approach to the management of SRUS. Histologic confirmation of SRUS should prompt a discussion of the presumed pathogenic mechanisms with the patient. Conservative therapy with dietary fiber, bowel retraining, and bulk laxatives should be employed. If symptoms persist, the patient should receive a trial of sucralfate enemas for 6 weeks. Individuals who respond should continue conservative therapy. However, if symptoms persist, defecography can be done to assess for inappropriate puborectalis contraction and occult rectal mucosal prolapse. Patients with inappropriate contraction of the puborectalis can be offered biofeedback. Patients with occult rectal mucosal prolapse can be considered for surgery. However, the risks, benefits, and success rates of surgery should be discussed at length, prior to any procedure being performed. Rectopexy or Delorme's procedure offer the best success rates to date; however, the choice of surgical procedure must take into account the experience of the surgeon and wishes of the patient.
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Affiliation(s)
- Phyllis R. Bishop
- Pediatric Gastroenterology and Nutrition, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA.
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