Overview.
Isolated rectal ulcer syndrome (SRUS), also known as benign isolated ulcer of the rectum and benign nonspecific ulcer of the rectum, is a chronic, benign rectal disorder caused by benign isolated acute and chronic ulcers of the anterior wall of the rectum with gastrointestinal disturbances, characterized by bloody stools, mucus stools, difficulty in fecal evacuation, and painful anal swelling. It is mostly seen in young people, with no gender difference and low morbidity.
Etiology
The exact etiology of SRUS has not been fully elucidated. It is generally believed that the formation of ulcers may be related to the following factors.
1. Ischemia
The tip of the prolapsed mucosa of the rectum is embedded in the anal canal, coupled with the strong contraction of the external sphincter, which can lead to compressive ischemia and necrosis of the mucosa. A large number of prolapse intestinal submucosal blood vessel stretching, rupture can also cause ischemia. Local mucosal ischemia can often form ulcers.
2. Injury
In some patients, when they have difficulty in defecation, they insert their fingers into the anus to induce defecation or reset the prolapsed rectum, resulting in mucosal injury and ulcer formation.
In addition, SRUS may be associated with intestinal inflammation, vascular abnormalities, bacterial or viral infections.
Symptoms
Symptoms of all anorectal diseases may be present. There may be blood in the stool, mucus stool, constipation or difficulty in passing stool, urgency, rectal and anal pain, diarrhea, and also fecal incontinence and hemorrhage. In some patients, bowel loops of the sigmoid colon can be detected in the left lower abdomen with tenderness. Rectal palpation may detect thickened mucosal ulcers on the anterior wall of the lower part of the rectum, with tenderness, and the tip of the prolapse may be detected during fecal maneuvers, and the finger cuffs may be bloodstained and mucous.
Examination
1. Endoscopic examination
Most of the ulcers are shallow, with clear borders, covered with gray-white necrotic material at the base, and the mucosa around the ulcers is mildly inflamed and may be nodular. Therefore, it can be synthesized into four typical manifestations: mucus, blood, mucosal redness and edema in the rectal cavity.
2. X-ray examination
(1) Barium enema shows rectal stenosis, coarseness of mucosal granules and thickening of rectal valve.
(2) Dyspareunia is of unique significance. dyspareunia with SRUS can reveal changes such as endorectal prolapse, anterior proptosis of the rectum, pelvic floor spasm, perineal descent, intestinal hernia, and rectal prolapse.
3. Rectoanal manometry and electromyography
There is no change in the resting pressure of the anal canal of the patient, the maximum systolic pressure of the anal canal decreases, the puborectalis muscle contracts paradoxically when doing defecation, the density of single fibers of the external anal sphincter increases, and the terminal motor latency of the pubic nerve is prolonged.
4. Pathologic examination
This is the only reliable basis for distinguishing SRUS from tumor and inflammatory bowel disease and confirming the diagnosis. Its characteristic manifestations are fibrous occlusion of the lamina propria of the mucosa, thickening and filling of the mucosal muscle with fibers, fibrosis and thickening of the muscularis propria, which may protrude into the intestinal lumen, and ectopic glands under the mucosa.
Diagnosis
The diagnosis can often be made on the basis of the characteristics of the clinical manifestations and histologic changes of the disease, combined with endoscopic and other examinations. It is generally recognized that SRUS should be considered when the following conditions are present:
1. Clinical manifestations such as bloody stool, mucus stool, fecal impaction and anal pain are the main manifestations;
2. endoscopic examination reveals limited erosion or ulceration of the mucosa of the anterior or anterior lateral wall of the rectum;
3. pathologic findings consistent with the aforementioned basic features of histologic changes in the syndrome.
Differential diagnosis
Advanced clinical manifestations and pathologic features may resemble rectal cancer and should be differentiated.
Complications
Acute hemorrhage, intestinal perforation, intestinal necrosis, rectal prolapse can be complicated.
Treatment
1. Conservative treatment
Internal medicine is the main treatment. Eat a high-fiber diet, keep the bowel clear, apply laxatives when defecation is difficult, apply 1:5000 potassium permanganate sitz bath, when secondary infection occurs. Take anti-inflammatory drugs. After the internal medicine treatment is invalid serious patients feasible local surgical resection, but easy to recurrence. Accompanied by rectal prolapse, rectal fixation is feasible.
2. Surgical treatment
Since most patients with SRUS have rectal prolapse or internal prolapse, it is now advocated to use rectal immobilization to treat prolapse, supplemented by biofeedback method to treat abnormal contraction of normal muscles.
Prognosis
Once formed, ulcers have a tendency to persist for years or even decades.