Naval Medical Center San Diego Lemoore, CA, United States
Jeffrey Kwan, MD1, Benjamin Fiore, MD2, Derek Grady, MD2, Angela Bachmann, MD2, Rashad Wilkerson, DO2 1Naval Medical Center San Diego, Lemoore, CA; 2Naval Medical Center San Diego, San Diego, CA
Introduction: Solitary rectal ulcer syndrome (SRUS) is a rare diagnosis that usually presents clinically as rectal bleeding, strained defecation, and tenesmus. Pathogenesis of SRUS is not fully understood and may be related to paradoxical contraction of the puborectalis muscle or shear forces on the rectal mucosa during rectal prolapse. SRUS is diagnosed clinically via history and physical, endoscopy, and histology. Treatment is typically conservative with high fiber diet and patient education. Occasionally symptoms persist and MR defecography or endoscopic ultrasound are used to diagnose rectal intussusception, which may require surgical intervention.
Case Description/Methods: A 21-year-old active-duty Marine male presented with melena, hematochezia, tenesmus, and urgency to an out of network civilian gastroenterologist. Colonoscopy demonstrated several clean based rectal ulcers with histologic evidence of hypertrophy of the muscularis mucosae and architectural distortion suggestive of mucosal prolapse. Attempts to treat the patient conservatively with a high fiber diet and mesalamine failed resulting in the patient not being able to engage in military training exercises, in the desert, while eating low fiber Meals Ready to Eat (MREs). He was ultimately referred to a military gastroenterologist as his symptoms were affecting his ability to perform his duties and deploy with his unit. Repeat colonoscopy confirmed 2 clean based rectal ulcers with normal surrounding mucosa and was otherwise unremarkable excluding alternative etiologies to rectal bleeding (Image A). Pathology was suggestive of mucosal prolapse (Image B). MR defecography was pursued and notable for short segment intussusception of the distal rectum (Image C &D). Patient underwent laparoscopic resection rectopexy with colorectal surgery and within 6 months was able to return to duty symptom free.
Discussion: Although this patient was diagnosed with SRUS on initial visit with gastroenterology, failure to treat conservatively was due to lack of proper food choices complicated by rectal intussusception. This case demonstrates the importance of military physicians’ insight into the unique demands of active-duty service members and the effects on the patient’s ability to maintain dietary and lifestyle modifications in austere environments. This case additionally reinforces how internal rectal intussusception should be considered as an underlying cause in SRUS especially when symptoms persist despite conservative measures.
Figure: a. Flexible sigmoidoscopy demonstrating 2 linear, clean-based ulcers with surrounding erythema, in the distal rectum. The largest of which measured 4 mm by 10 mm. The visualized rectal mucosa proximal to these lesions was normal. b. The surface epithelium demonstrates erosion and ulceration with acute inflammatory cells and a fibrinous exudate (arrows). The lamina propria between the colonic crypts is replaced by collagen and mild chronic inflammation. (H&E 100x). c. Sagittal images demonstrate a normal appearing rectal vault mid-defecation. The rectum (outlined in green) is filled with Sonogel. d. Rectal intussusception occurs with terminal defecation. Normal rectal wall is outlined in green, the intussusceptum is outlined in red, and the intussuscipiens is outlined in blue.
Jeffrey Kwan indicated no relevant financial relationships.
Benjamin Fiore indicated no relevant financial relationships.
Derek Grady indicated no relevant financial relationships.
Angela Bachmann indicated no relevant financial relationships.
Rashad Wilkerson indicated no relevant financial relationships.
Jeffrey Kwan, MD1, Benjamin Fiore, MD2, Derek Grady, MD2, Angela Bachmann, MD2, Rashad Wilkerson, DO2. P2252 - Solitary Rectal Ulcer Syndrome: Complicated by Unique Dietary Constraints, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.