Solitary Rectal Ulcer Syndrome with a Visible Vessel: An Uncommon Cause of Lower GI Bleeding

Abstract

Solitary Rectal Ulcer Syndrome with a Visible Vessel: an Uncommon Cause of Lower GI Bleeding Introduction: Solitary rectal ulcer syndrome (SRUS) is a rare condition affecting both healthy and immunocompromised patients. Presenting symptoms are diverse but can include rectal bleeding in up to 25% of patients. Case: A 51 year old man with PMH including HIV on HAART, HCV cirrhosis, c.difficile colitis and solitary rectal ulcer syndrome (SRUS) presented to the emergency room with new onset hematochezia and clot passage for 3 days. He reported associated tenesmus and constant left lower quadrant abdominal pain. His medical history was notable for diverticulosis and left hemicolectomy with renanastamosis 15 years prior. He reported recent anal intercourse with 1 partner and had used an enema for constipation prior to symptom onset. On evaluation, the patient was tachcardic and hypotensive. Physical exam was significant for left lower quadrant tenderness without rebound, guarding, or masses. Rectal exam showed gross blood, with mild tenderness on inspection and no hemorrhoids or fissures. Lab work demonstrated hemoglobin of 7.7 g/dL, WBC count of 2.1K/mcL, platelets of 57K/mcL and INR of 1.5. He received IV fluid and blood products and was admitted for further workup. Colonoscopy revealed persistent sharp angular ulcerations in the rectum without erythema or colitis. A prominent visible vessel seen in an ulcer bed. A hemoclip was placed successfully. Ulcer histopathology demonstrated mucosal prolapse without architectural distortion. Stains were negative for viral pathogens. The patient's hemoglobin stabilized and he was advised to avoid rectal trauma.Figure 1Figure 2Discussion: Symptoms of SRUS can include bleeding, mucoid discharge, perineal and abdominal pain, feeling of incomplete defecation, constipation and overt rectal prolapse. The pathogenesis is poorly understood but may be related to trauma or shear forces during defecation in combination with mucosal ischemia. Treatment options include bulking agents, topical therapies, biofeedback, and surgery. Bleeding from SRUS has been reported, but visualization of a visible vessel is rare. Dieulafoy-like lesions have been described in the context of stercoral ulcers but to our knowledge, no case of a visible vessel has been reported in SRUS. Endoscopic hemoclip placement was successful for acute treatment in this patient with follow up colonoscopy showing ulcer improvement after 6 weeks.