Daniel J. Waintraub, MD, Richard M. Fazio, MD, MS, Jonathan Weinberger, MD, Roshan Srikanthan, MD, Jiangling Tu, MD, Rabin Rahmani, MD, Kadirawelp Iswara, MD
Maimonides Medical Center, Brooklyn, NY
Introduction: Solitary Rectal Ulcer Syndrome (SRUS) is an uncommon benign disease. The diagnosis is based on clinical features, proctosigmoidoscopy findings, and histopathology. Men and women are equally affected. The term SRUS is a misnomer as ulcers are only found in 40% of patients and a solitary ulcer is only identified in 20% of patients. Clinical features include rectal bleeding, mucus discharge, excess straining, perineal or abdominal pain, sensation of incomplete evacuation, constipation or rectal prolapse. Characteristic histologic features include obliteration of the lamina propria by fibrosis and smooth muscle fibers extending from a thickened muscularis mucosa to the lumen. We present a case of SRUS presenting as a rectal mass.
Case Description/Methods: A 70 year old female with a history of hepatitis C and colon polyps presented after a hospital admission for infectious colitis. Colonoscopy revealed a 3cm multi-lobulated rectal polyp with superficial ulceration approximately 10cm from the anal verge. Endoscopic mucosal resection was performed with complete piecemeal resection. Histopathology revealed solitary polypoid growth (Image 2), fibromuscular hyperplasia and obliteration of the lamina propria (Image 3) suggestive of solitary rectal ulcer syndrome. The patient was managed with a strict high fiber diet.
Discussion: The etiology of SRUS may include ischemia due to impacted stools and local trauma from self-disimpaction. 25% of SRUS cases may present as a polypoid lesion, 18% as patchy mucosal erythema and 30% as multiple lesions. Given the wide variety of presentations, rectal biopsies are critical for diagnosis. Anorectal physiology studies indicate 24-82% of patients with this condition may have dyssynergia with paradoxical anal contraction. Treatment options include diet and bulking agents, biofeedback therapy, and surgery. The differential diagnosis includes inflammatory bowel disease, ischemic colitis and malignancy. Our case highlights the variable presentations of SRUS and its ability to mimic advanced adenoma and rectal malignancy. Gastroenterologists must carry a high index of suspicion for SRUS when approaching rectal lesions in the proper clinical context.
Citation: Daniel J. Waintraub, MD, Richard M. Fazio, MD, MS, Jonathan Weinberger, MD, Roshan Srikanthan, MD, Jiangling Tu, MD, Rabin Rahmani, MD, Kadirawelp Iswara, MD. P1048 - AN INTERESTING PRESENTATION OF SOLITARY RECTAL ULCER SYNDROME MIMICKING A RECTAL MASS. Program No. P1048. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.