Solitary Ulcer Syndrome Research Articles

Anteroposterior rectopexy in the treatment of solitary rectal ulcer syndrome without overt rectal prolapse.

There is evidence that the solitary rectal ulcer syndrome is associated with rectal prolapse either overt or internal. The anterior rectal wall is affected in most cases and a modified abdominal rectopexy has been used with the aim of supporting both the anterior and posterior aspects of the rectum. Fourteen patients aged 19-70 years (mean 34.2 years) in whom conservative treatment has failed, have been treated by anteroposterior rectopexy. Tenesmus, bleeding and the passage of mucus have been abolished or greatly improved in 12, 14 and 13 patients respectively. The number of attempts to defaecate per 24 h has fallen from 8.7 +/- 1.4(s.e.m.) pre-operatively to 3.4 +/- 1.0(s.e.m.) postoperatively (P less than 0.05) and the time spent in the lavatory has been reduced from 146 +/- 18(s.e.m.) min to 15 +/- 3(s.e.m.) min. Two patients have developed severe constipation postoperatively and two others have had persistent or recurrent tenesmus. Combined anteroposterior rectopexy has improved 12 out of 14 patients with the solitary ulcer syndrome without external rectal prolapse when assessed at 2-48 months postoperatively.

Anorectal Physiology in Solitary Ulcer Syndrome: A Case-Matched Series

Solitary ulcer syndrome is a rare condition characterized by inflammation and chronic ulcer of the rectal wall in patients suffering from outlet constipation. Despite similar surgical options (rectopexy, anterior resection), solitary ulcer syndrome may differ from overt rectal prolapse with regard to symptoms and pathogenesis. The present work analyzed differences between these conditions in a case-control physiology study. From 1997 to 2002, 931 consecutive subjects were investigated in a single physiology unit for anorectal functional disorders. Standardized questionnaires, anorectal physiology, and evacuation proctography were included in a prospective database. Diagnosis of solitary ulcer syndrome was based on both symptoms and anatomic features in 25 subjects with no overt rectal prolapse (21 females and 4 males; mean age, 37.2 +/- 15.7 years) and no past history of anorectal surgery. They were compared with age-matched and gender-matched subjects: 25 with outlet constipation (also matched on degree of internal procidentia), 25 with overt rectal prolapse without any mucosal change, and 14 with overt rectal prolapse and mucosal changes. Subjects with solitary ulcer syndrome reported symptomatic levels (digitations, pain, incontinence) similar to those of patients with outlet constipation, but they had significantly more constipation and less incontinence than patients with overt rectal prolapse. Compared with each of the three control groups (dyschezia, rectal prolapse without mucosal change, and rectal prolapse with mucosal change), subjects with solitary ulcer syndrome more frequently had an increasing anal pressure at strain (15 vs. 5, 3, and 1, respectively ; P < 0.01) and a paradoxical puborectalis contraction (15 vs. 9, 1, and 1, respectively; P < 0.05). With respect to evacuating proctography, complete rectal emptying was achieved less frequently in this group (5 vs. 12, 23, and 10, respectively; P < 0.05). Compared with patients with overt rectal prolapse, mean resting and squeezing anal pressures were significantly higher in both groups of subjects with solitary ulcer syndrome and with outlet constipation. Prevalence and levels of anatomic disorders (perineal descent, rectocele) did not differ among the four groups except for rectal prolapse grade and prevalence of enterocele (higher in overt rectal prolapse group). Interestingly, and despite matched controls for degree of intussusception, individuals with solitary ulcer syndrome had circular internal procidentia more often compared with those suffering from outlet constipation without mucosal lesions (15 vs. 8, P < 0.05). This case-controlled study quantifies functional anal disorders in patients suffering from solitary ulcer syndrome. Despite no proven etiologic factor, sphincter-obstructed defecation and circular internal procidentia both may play an important part in the pathogenesis and an exclusive surgical approach may not be appropriate in this context.

A case report of solitary ulcer syndrome of rectum to differentiate from rectal cancer by colonoscopy

A Case Report of solitary ulcer syndrome of rectum to differentiate from rectal cancer by colonscopy is reported. The patient was 40 years-old, male. He visited our hospital with complaint of occult blood of stool in 1997. Colonscopy was performed. It shows solitary ulcer in rectum. Biopsy is no malignancy. 4 years after (2001) he visited again with same complaint. Colonscopy shows tumor (like type 2 rectal carcinoma) with ulcer in rectum. Biopsy is no malignancy, but we highly suspected rectal cancer. We performed rectal biopsy 2 times, and huge specimen by snear. These show no malignancy in this rectal tumor. Then, we diagnose this case as solitary ulcer syndrome of rectum. It is important to perform biopsys frequently, suspected solitary ulcer syndrome of rectum.

Non-specific colitis, is it a justifiable diagnosis?

The terms non-specific and chronic colitis are often used by histopathologists. The aim of this study is to look into the validity of the label non-specific chronic colitis (NSCC), the consistency of its reporting, as well as its clinical usefulness in patients who, on review, have shown to have normal biopsies. Colonic and rectal biopsies from 35 patients who presented with acute onset diarrhoea, were initially diagnosed as nonspecific chronic colitis (NSCC) by a number of pathologists in one Department, and were reviewed by an outside pathologist (NYH) without the knowledge of the clinical details. A previously described set of histological criteria in reporting colonic biopsies in inflammatory conditions were used. Normal biopsies were found in 13 of the 35 patients (37%). These patients recovered without clinical intervention. In a further seven patients there was active inflammation with no features of chronicity, in 12 patients there were features of chronicity, in two patients there were hyperplastic polyps, and in one patient there were features of solitary ulcer syndrome. NSCC was used, without consistency, to cover a variety of conditions, including normal biopsies, sometimes relaying a wrong message. We suggest that histological criteria for chronicity should be adhered to when this label is used and the term Non-Specific Colitis should no longer be used.

A new grading of rectal internal mucosal prolapse and its correlation with diagnosis and treatment

The management of rectal internal mucosal prolapse (RIMP) is not based on an accepted classification of the lesion which helps to choose the appropriate treatment. The aim of this prospective study was to report a new endoscopic grading of RIMP and to evaluate its clinical value. Thirty-two patients (7 men, 25 women; mean age 56 years, range 28-72) affected by symptomatic RIMP were prospectively classified as follows: RIMP was defined as first degree when detectable below the anorectal ring on straining, as second degree when it reached the dentate line, and as third degree when it reached the anal verge. Anal manometry was carried out in 26 patients, and anal ultrasound and defecography in 6 prior to surgery. A correlation was found between the occurrence and severity of symptoms and the degree of the prolapse as obstructed defecation, bleeding and fecal soiling affected mainly patients with third-degree RIMP. At manometry the maximal resting tone was 60+/-23 mm Hg and voluntary contraction 96+/-41 mm Hg (mean+/-SEM). At anal ultrasound the mean internal sphincter thickness was 2.1+/-0.2 mm, and external sphincter thickness was 7.0+/-0.8 mm. A significant rectocele and rectal intussusception (n = 2) and a nonrelaxing puborectalis muscle on straining (n = 2) were observed at defecography in cases with third-degree RIMP. The anorectal angle was 100+/-75 degrees at rest, 63+/-20 degrees on squeezing, and 115+/-9 degrees on straining. A conservative treatment with high-fiber diet and/or rubber band ligation was carried out in all cases of first and in most patients with second-degree RIMP (n = 26). Those who required surgery, i.e., stapled transanal excision of the prolapse (n = 6), had either severely symptomatic third-degree RIMP with solitary ulcer syndrome (n = 4) or second-degree RIMP (n = 2). A positive outcome was achieved in 71% of cases. The proposed classification evaluated by the present study may be of clinical value in managing rectal internal mucosal prolapse.

Anorectal stenosis in patients with prolonged use of suppositories containing paracetamol and acetylsalicylic acid.

We report five cases in which anorectal stenosis was associated with chronic administration of suppositories containing paracetamol and acetylsalicylic acid. All patients were females taking suppositories for chronic migraine. Patients experienced anal pain, tenesmus, fecal incontinence, and, in two cases, intestinal obstruction. Lesions were characterized by a severe circular narrowing of the distal rectum with superficial ulcerations. Radiographs demonstrated the presence of sinus-tract-like formations in the diseased segment and thickening of the rectal wall. Histologic examination showed signs of chronic inflammation with deep ulcerations associated with obliteration of the lamina propria by a fibromuscular proliferation, as was described in the solitary ulcer syndrome of the rectum. Rectal administration of suppositories was discontinued in all the patients. Two patients were improved by anorectal dilatation, but the remaining three required a left proctocolectomy with subsequent coloanal anastomosis. The use of such suppositories must be restricted.

Intussusception of the Rectum and the Solitary Ulcer Syndrome

A general review is given of the intussusception of the rectum, the paradoxical contraction of the pelvic floor syndrome and of the solitary ulcer syndrome. The latter is in most cases a symptom of the other two as is the descending perineum syndrome. The conditions are diagnosed by defecography, proctosigmoidoscopy and EMG. The etiologies are unknown. The treatment is either conservative or operative.

Solitary Ulcer Syndrome of the Rectum in Children

SUMMARYWe present two children with solitary ulcer syndrome of the rectum (SUSR): a 7‐year‐old and an 11‐year‐old. Although well recognized in the adult literature, the pediatric experience with this condition is limited. We review the clinicopathologic features of SUSR with emphasis on the pediatric experience. Greater awareness of this syndrome by both the pediatrician and pathologist may lead to more diagnosed cases in children.

Pathophysiology and Management of Solitary Ulcer Syndrome of the Rectum

Solitary ulcer syndrome of the rectum, solitary ulcer of the rectum, mucosal prolapse syndrome and colitis cystica profunda belong to the same disease category with typical clinical manifestations of blood/mucus discharge and abnormal bowel habit. The lesions are either ulcerated or polypoid, mostly present in the anterior rectal wall and often multiple. Overt or occult full-thickness rectal prolapse or partial mucosal prolapse is found to be underlying pathogenic mechanism and perineal descent is also a common feature. Abnormal bowel habit does exist in these patients characterized by straining at defecation. Fibromuscular obliteration of the lamina propriae is a diagnostic feature which makes differential diagnosis from carcinoma or adenoma easy. Conservaive treatment by normalizing bowel habit with laxatives and high roughage diet is usually satisfactory in most cases, but local excision of large polypoid/ulcerated lesion together with surgical procedure for overt rectal/mucosal prolapse, if present, is required when conservative treatment is unsatisfactory.

Disturbed Evacuation Caused by Abnormal Function of the Rectum

There are patients with disorders of continence or defecation. It has been noticed that some of these are functional disorders caused by anormal rectal movement. Those are called as rectocele, rectal intussusception (concealed rertal prolaps), descending perineum, spastic levator syndrome and also solitary ulcer syndrome of the rectum and so forth. They have been thought as conventional costipation, difficulty of defecatin, anal neurosis, annoyance of defecation etc, and treated ambiguously. To make precise diagnosis of those diseases, it is very important to ask the patients their complaints carfully and then defecography, Proctoscopy, histological examinations, manometric studies of the rectum should be performed. After then they might be treated conservatively or surgically.

High iron diamine-alcian blue mucin profiles in benign, premalignant and malignant colorectal disease.

The presence of mucosal hyperplasia and sialomucin goblet cell secretion (transitional mucosa) was assessed in various benign, premalignant and malignant colorectal tissues. Transitional mucosa was seen in diverticular disease, solitary ulcer syndrome of the rectum, ischaemic and irradiation colitis and other diseases including pneumatosis coli, endometriosis, haemorrhoids and a colostomy margin. Adenocarcinomas had a sulphomucin or mixed secretion pattern with transitional features in the adjacent mucosa mucosa (18/27). Premalignant adenomatous polyps showed mixed secretion with transitional glands incorporated in the stalk and sometimes in the adjacent mucosa. Epithelium showing dysplasia secreted sulphomucins and in amounts related to its degree of differentiation. Transitional mucosa may not be a primary premalignant phenomemon. The conclusion and unifying concept is that it is a secondary event related to goblet cell immaturity. This can occur, secondary to proliferation in mucosal inflammation, ischaemia and prolapse or as a phenotypic expression of growth derived from underlying dysplastic epithelium.

Protruded variants in solitary ulcer syndrome of the rectum.

A review of 21 patients with protruded lesions in solitary ulcer syndrome of the rectum confirmed by resection is presented. Symptoms were usually the passage of blood and mucus per rectum, alteration of bowel habit, anorectal pain and rectal prolapse. Solitary or multiple polypoid lesions were found within 15 cm of the anal margin and were usually sited anteriorly. Fifteen of the patients were men and 8 were women with a mean age of 37.1 years. The diagnosis was made on the basis of histopathology; 1) fibrous obliteration of muscle fibers, 2) reactive hyperplasia of the mucous membrane with villous configuration or mild pseudoinvasion. These changes have been observed in complete rectal prolapse, colonic intussusception, and localized colitis cystica profunda, suggesting a common pathogenesis. The histological findings were almost the same as in the ulcerative lesions of this syndrome except for remarkable regenerative hyperplastic changes such as a relatively high incidence of mucous cell proliferation, dilatation of glands and serrate change in the cases showing protrusion. In the pathogenesis, the occult mucosal prolapse in association with excessive straining may be of particular importance, so that the lesions might be termed mucosal prolapse syndrome of the rectum.

Solitary ulcer syndrome

Solitary ulcer syndrome

Lectin expression in neoplastic and non-neoplastic lesions of the rectum

The expression of six lectins (Arachis hypogaea, B. simplicifolia I, concanavalin A, Dolichus biflorus, Triticum vulgaris, Lotus tetragonolobus) was studied in 24 adenocarcinomas, 24 adenomas, 20 metaplastic polyps, 17 specimens of mucosal prolapse (solitary ulcer syndrome) and 10 of normal mucosa, all taken from the rectum. Qualitative, quantitative and distributive differences in lectin expression were observed between adenocarcinoma and normal mucosa. These cancer-associated glycoprotein alterations were also observed, though to a lesser extent, in benign neoplastic and non-neoplastic lesions of the rectum. It appears therefore that the glycoprotein modifications associated with malignant transformation are not specific indicators of malignancy. It is suggested that the common denominator is a disturbance in the activities of enzymes, particularly the glycosyl-transferases and glycosidases, involved in the biosynthesis of glycoprotein. This disturbance can occur in situations where cells are less differentiated either through developmental immaturity, rapid cellular division or neoplastic de-differentiation. These changes are therefore more likely to reflect the state of differentiation rather than the malignant nature of the cells. It is shown that the greater the deviation of the lesion from normal the greater the glycoprotein alterations. The potential usefulness of lectin expressions as predictive indicators of biological behaviour of adenocarcinomas of the large bowel needs further studies.

STUDIES ON SEVEN CASES OF SOLITARY ULCER SYNDROME OF THE RECTUM

The condition known as solitary ulcer syndrome of the rectum, presenting peculiar polypoid lesions or ulcer, is uncommon and there are few references in the Japanese literature.During the past 3 years, 7 cases of this condition were treated in our department. These cases are described together with a review of the literature.The youngest was aged 15 years and oldest 86 years. The average age of these affected patients was 51 years and the male to female ratio was 5:2.The lesions involved the anterior or antero-lateral wall of the lower rectum and occurred within the first 8 cm on the oral side of the anal ring. These patients had a habit of straining upon defecation and the most common symptom in this disease was a sensation of incomplete evacuation in defecation, rectal bleeding, passage of mucus and disturbance of bowel habit.The histopathological characteristics of this disease are glandular proliferation, erosion of the mucosa and fibromuscular obliteration.The initial management of this disease is internal therapy but sometimes surgical treatment is needed.

Barium enema and defaecography in the diagnosis and evaluation of the solitary rectal ulcer syndrome.

Forty-three patients with histologically proven solitary ulcer syndrome of the rectum were examined by defaecography and 33 by barium enema. Barium enema showed changes in the rectum in all cases. Thickening of the rectal folds and spasm were most common, followed by ulceration and pseudopolypoid change. None of these changes is individually pathognomonic of the solitary ulcer syndrome, but viewed in conjunction they are highly suggestive of the condition. During defaecography, intussusception of the rectum was observed in 34 cases (79%). In 19 (44%) a complete external prolapse was present while intra-anal and intra-rectal intussusception was found in 15 (35%). Intussusception arose in most cases from the mid-rectum, and rarely from a rectal mucosal prolapse of the ampulla. Awareness of the abnormalities of the solitary ulcer syndrome on barium enema enables the radiologist to suggest the diagnosis and recommend defaecography to establish the functional disorder, which may help determine the appropriate medical or surgical treatment.

Pathological features and mucin histochemistry of primary gastric stump carcinoma associated with gastritis cystica polyposa. A study of six cases.

Six unusual cases of primary gastric stump carcinoma associated with gastritis cystica polyposa and arising in old gastrojejunostomy stomas are presented. The clinical data, the gross and microscopic pathological features, and the histochemical mucin profile of these two lesions are described in detail. A review is undertaken of the most relevant and previously published reports concerning, separately, either primary gastric stump carcinoma or gastritis cystica polyposa. The findings available in these reports are compared with those observed in our six cases. Some aspects of gastritis cystica polyposa are not unlike those seen in the solitary ulcer syndrome of the rectum and Ménétrier's disease. The histological type and mucin profile of primary gastric stump carcinoma parallel those recorded in gastric cancer arising in the unoperated stomach. However, the role of intestinal metaplasia and its histochemical typing appear somewhat different in primary gastric stump carcinoma.

Treatment of solitary rectal ulcer syndrome with high-fiber diet and abstention of straining at defecation.

Twenty-one patients with a solitary ulcer of the rectum were treated with instructions for a high-fiber diet and abstention of straining at defecation, since there is evidence that the solitary ulcer syndrome is caused by chronic mechanical and ischemic trauma, by hard stools, and intussusception of the mucosa. In 15 patients disappearance of symptoms and complete ulcer healing was obtained in an average period of 10.5 months (range 2.5-21 months). In the other six patients the lesions remained unchanged. The results demonstrate that softening of stools and normalization of defecation habits should be the mainstay in the treatment of this otherwise chronic disorder with poor healing tendency.

Mucosal prolapse syndrome--a unifying concept for solitary ulcer syndrome and related disorders.

Nineteen cases of classical solitary ulcer of the rectum syndrome (SURS) and sixteen examples of rectal mucosal prolapse are described. Similarities in the histological and histochemical features of the two groups lead us to suggest that the term "mucosal prolapse syndrome" be used to describe this group of disorders in which mucosal prolapse--overt or occult is the common underlying pathogenetic mechanism.

"The evolution of the solitary ulcer of the rectum"--an endoscopic and histopathological study.

A follow-up study of fourteen out of twenty-seven cases of solitary ulcer syndrome of the rectum was performed at one year's interval from the previous endoscopic and histologic examination. Most of the lesions consistently changed their aspect, resulting in incomplete irregular narrowings, polypoid protrusions or linear ulcers. The symptoms remained unchanged or slightly diminished. A striking difference was found in the histological pattern of the "evolved" ulcer in comparison to the active one, the former showing features of hyperplastic (metaplastic) colonic polyps as well as of the so called "transitional mucosa". It is suggested that chronic ischemia occurring in solitary ulcer of the rectum leads to "transitional mucosa" as an exaggerated regenerative phenomenon, hyperplastic (metaplastic) mucosa representing a later maturative phase. Possibly "transitional" mucosa may undergo dysplastic changes under the influence of environmental factors.