Nimish Thakral, MD, Howard Baikovitz, MD; Memorial Healthcare System, Pembroke Pines, FL
Introduction: Solitary rectal syndrome is an enigmatic medical condition first described by 1829 when Cruveiher reported four cases of unusual rectal ulcers.The exact prevalence of this condition is not known due to its rarity, but has been estimated to be around 1 in 100,000. Patients characteristically present with rectal bleeding, passage of mucous, perineal or rectal pain, tenesmus, incomplete evacuation, straining on defecation and rectal prolapse.The condition presents with polypoid lesions in 44 %, ulcerations in 29% and edematous, non-ulcerated hyperemic mucosa in 27%. As such, Solitary Rectal Ulcer is a misnomer because the lesion is neither solitary nor ulcerated in the majority of cases.
Methods: We highlight two elusive cases with solitary rectal ulcer syndrome. The first patient is a 54-year-old HIV positive male who presented with tenesmus and rectal bleeding. On further evaluation he was found to have proctitis, rectal mucosal hyperemia with a whitish exudate on endoscopy which lead to an initial diagnosis of Lymphogranuloma Venerum. Failure of prolonged antibiotic treatment prompted further investigation which showed a histopathological picture of Solitary rectal ulcer syndrome. Patient continued to have symptoms despite multiple medical treatment modalities. Partial control of the patient’s symptoms was achieved post low anterior resection and ileostomy with later reversal. The second patient is a 63-year-old male who presented with weight loss and microscopic hematuria who on digital rectal examination had rectal induration. A CT scan done for further evaluation revealed pre-sacral and peri-rectal soft tissue thickening. A subsequent colonoscopy showed a 1.5 cm triangular rectal ulcer,with edematous and erythematous edges, at approximately 8 cm from the anal verge. Pathology results were consistent with solitary rectal ulcer syndrome. The patient’s course was complicated by the development of recurrent peri–rectal abscesses requiring surgical intervention and prolonged antibiotic therapy. Patient then went on to develop superimposed Clostridium difficle colitis. Discussion: Solitary rectal ulcer syndrome is a rare and benign syndrome with an extremely varied presentation that can prompt an easy misdiagnosis of malignancy, infection or inflammatory bowel disease. Treatment is not well defined and most cases eventually require surgical intervention. A high degree of suspicion is required to avoid an easy misdiagnosis with resultant prolonged morbidity.
Patient 1: Polypoidal inflammation with whitish surface exudate.
Patient 2: Triangular area of ulceration, 8 mm proximal to the anal verge.
Histopathology showing smooth muscle proliferation in lamina propria with surface ulceration and chronic inflammatory infiltrate.
Disclosures: Nimish Thakral indicated no relevant financial relationships. Howard Baikovitz indicated no relevant financial relationships.