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Solitary rectal ulcer syndrome (SRUS) is a chronic, benign disorder characterized by the presence of a benign abnormality of the rectum in persons who have a long history of straining during defecation. it is a misnomer but has gained wide acceptance.
Only 35% of cases have a solitary ulceration of the rectal wall. Twenty-two percent have several ulcerations.43% have no ulcers at all. It typically occurs in young adults. There is slight increased female predilection.
Aetiology : Two functional disorders of defecation has been recognised:
1. Rectal intussusception.
2. Spastic pelvic floor syndrome.
The rectal wall invaginates in the distal portion of the rectal lumen or in the anal canal. Invagination of the rectal wall causes stretching of submucosal vessels, ischaemia, and ulceration.
The rectal abnormality has specific histologic features:
- replacement of the lamina propria by fibroblasts .
- marked thickening of the muscularis mucosae .
A definitive diagnosis of the syndrome therefore can be made only on rectal biopsy.
Diagnosis is delayed in many cases because of its rarity, nonspecific signs, and symptoms and various causes. However, chronic constipation, strenuous defecation, rectal bleeding and mucous secretions from the rectum, and nonspecific pelvic pain are the major complaints encountered by physicians. Symptoms rise suspicion are sensation of incomplete emptying of the rectum, often combined with a feeling of obstruction.
Fluoroscopy - Barium enema
- findings on barium enema may be normal or nonspecific, consisting of a thickened valve of Houston, nodularity, and rectal stricture. Circular narrowing of distal rectum may be noted. Ulcer may or may not be seen.
- defecogram during straining adds no significant increase of anorectal during straining (100 +/- 10 )(normal angle at rest is around 90 degree) in case of spastic pelvic floor syndrome. InfoldIngs on anterior and or posterior rectal wall, forming an intussusception
- dietary and behavioural modifications are especially effective in patients with mild to moderate symptoms and with absence of significant mucosal prolapse; patient education, high-fiber diet and bulk laxatives. avoidance of straining, regulation of toilet habits, and attempt to discuss any psychosocial factors.
- for resistant symptoms, a more organised form of behavioural therapy such as biofeedback therapy may be warranted.
- advanced grade of rectal intussusception, extensive inflammation, established fibrosis and/or reducible external prolapse; surgical treatment and BotoxTM injection may be a possible options.
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