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Case Report | DOI: https://doi.org/10.31579/2641-5194/033
1Department of Internal medicine, Military Hospital of Gabes, Gabes 6000, Tunisia.
2 Sfax Faculty of Medicine, University of Sfax, Sfax 3029, Tunisia
*Corresponding Author: Salem Bouomrani, Department of Internal medicine, Military Hospital of Gabes, Gabes 6000, Tunisia.
Citation: Ourida S., Elleuch M., Lamloum I., Bouomrani S. (2021) Solitary Rectal Ulcer Syndrome: An Exceptional Entity in the Elderly. J. Gastroenterology Pancreatology and Hepatobilary Disorders 5(4) DOI:10.31579/2641-5194/033
Copyright: © 2021, Salem Bouomrani.This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 21 May 2021 | Accepted: 27 May 2021 | Published: 24 July 2021
Keywords: solitary rectal ulcer; solitary rectal ulcer syndrome; elderly
Solitary ulcer of the rectum or better the syndrome of solitary rectal ulcer syndrome (SRUS) is a rare benign pathology with a prevalence estimated at 1/100,000 inhabitants. It mainly affects young patients with a maximum incidence between the third and fourth decade of life, but can be seen at any age. It remains exceptional in the elderly with only few sporadic cases in the world literature.
We report an original case of SRUS occurring in a 70-year-old man with no particular pathological history, who was explored for rectal bleeding with anal pain that had been evolving for two years.
As rare as it is, this entity deserves to be known by any healthcare professional caring for elderly subjects because can sometimes progress unfavorably with severe and even fatal complications such as massive bleeding and perforation.
Solitary ulcer of the rectum or better the solitary rectal ulcer syndrome (SRUS) is a rare benign pathology [1, 2]. Its prevalence has been estimated at 1/100,000 inhabitants with a slight female predominance [2, 3]. This uncommon disorder of the rectum is little known by health professionals, and very difficult to manage with no consensus on its treatment [1-3]. The typical endoscopic presentation of SRUS is the single ulcer on the anterior wall of the rectum; however other less specific and more challenging aspects may be noted such as multiple rectal ulcers, mucosal hyperemia, giant ulcers, and polypoid lesions [1-3].
The SRUS is a disease of young adults with a maximum incidence between the third and fourth decade of life [1-4]. The forms of the child and the elderly remain exceptional [3, 4]. They pose a real diagnostic and therapeutic challenge for practitioners; particularly in the elderly where the SUSR can mimic a carcinoma of the rectum [5] and be a cause of sometimes serious digestive bleeding [6]. In addition, this syndrome significantly affects the quality of life of these patients [4-6].
We report the original observation of a solitary ulcer of the rectum occurring in a 70-year-old man.
A 70-year-old man, with no particular pathological history, was admitted to our department for exploration of rectal bleeding with anal pain that had been evolving for two years. The somatic examination was unremarkable. Examination of the anal margin showed anal mucous prolapse on exertion. The digital rectal examination revealed a sphincter hypotonia on voluntary contraction.
Baseline laboratory tests revealed mild normochromic normocytic anemia at 10.8g/dl. The rest of the tests were within normal limits: leukocytes, platelets, erythrocyte sedimentation rate, C-reactive protein, serum protein electrophoresis, transaminases, creatinine, serum calcium, ionogram, glycemia, lipid parameters, and thyroid hormones.
Colonoscopy showed an isolated ulceration measuring 2 × 3 cm and located 10cm from the anal margin with an erythematous rim, and prolapse of the rectal mucosa. The remainder of the colonoscopy was normal. Histological examination of the biopsies taken from the ulceration showed a nonspecific inflammatory change. Surgical excision was performed under general anesthesia after anal dilation. Pathological examination of the resection piece was consistent with the diagnosis of a solitary ulcer of the rectum. No malignant cells, granulomas, or microabcesses were noted. The evolution was favorable without subsequent recurrence.
Solitary rectal ulcer syndrome is a benign disease of the rectal mucosa that has recently been identified by Haskell & Rovner in 1965 [7]. It results in the occurrence of a rectal syndrome associating to varying degrees: dyssynergic defecation, tenesmus, rectal pain, mucoid secretion, rectal bleeding, obstructed defecation, faecal incontinence, self-perception of anal procidentia, diarrhea, pelvic discomfort, and painful defecation [1-6]. However, nearly 26% of patients can remain completely asymptomatic [2-4].
It is a rare entity that mainly affects young patients but can be seen at any age [3,4]. It remains exceptional in the elderly with only few sporadic cases in the world literature [8,9].
Its pathogenesis is still uncertain. It seems to be a complex and multifactorial problem involving prolonged straining during defecation, direct instrumentation or digital rectal trauma, chronic constipation, and rectal prolapse [1-6].
Diagnostic certainty of SRUS is based on histological examination [1-6] because clinical and endoscopic presentations can sometimes be misleading, especially for giant, circumferential, polypoid, or pseudotumoral forms simulating inflammatory bowel disease or rectocolic cancer [10-13].In addition to colon endoscopy, the exploration of SRUS must always be supplemented by the search for a disorder of the rectal statics, mainly by dynamic rectal examination: anorectal manometry, balloon expulsion test, and a defecography [2-4].
Usually considered a benign disease, SRUS can sometimes progress unfavorably with severe and even fatal complications (massive bleeding and perforation) [14, 15].
Therapeutic management remains debated without any consensus [16]. It schematically comprises two components: medical and surgical, and often requires a multidisciplinary team [2-6, 16].
Medical treatment consists of laxatives, behavioral therapy, topical treatments, sucralfate, human fibrin, biofeedback, sulfasalzine , and rehabilitation [2-6,16]. Chirurgical treatment eliminates ulceration and aims to correct rectal static disorders (rectopexy) [2-6, 16]. Argon plasma coagulation may represent a good alternative for SRUS refractory to conventional treatment [17].
As rare as it is, this entity deserves to be known by any healthcare professional caring for elderly subjects. It should be discussed in front of any defecation disorder, even minor. Only early and appropriate diagnosis and management can improve the prognosis of this disease, which risks compromising life in the elderly..
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