Solitary rectal ulcer syndrome

Introduction to isolated rectal ulcer syndrome Isolated rectal ulcer syndrome (SolitaryRectalUlcerSyndrome), also known as benign solitary solitary ulcer, rectal benign non-specific ulcer, is caused by acute and chronic ulceration of the anterior rectal wall of the rectum, causing abdominal pain, constipation, diarrhea, pus Bloody stools are the main manifestations. The disease is less common and occurs in middle-aged and older women. basic knowledge Sickness ratio: 0.1% Susceptible people: good for middle-aged women Mode of infection: non-infectious Complications: rectal prolapse

Causes of solitary rectal ulcer syndrome

Rectal prolapse (15%):

In 1912, Moschvowitz proposed that the rectal uterus sag allowed part of the anterior rectal wall to protrude into it. This protrusion developed with the moving mesorectum and sigmoid mesentery to develop rectal prolapse; in 1968, Broden and Snellman used rectal angiography to confirm that SRUS was the main cause. Intussusception, most scholars support the view that SRUS is closely related to rectal prolapse and intussusception. Rectal prolapse usually begins with the formation of intestinal fissure, and it will prolapse outward after long-term development. It is a recessive rectal prolapse. Some scholars believe that the inner ferrule is a precursor to rectal prolapse. Excessive force during defecation causes occlusion of the apical vascular apex of the rectal mucosa, causing ischemia and ulceration due to puborectal muscle relaxation. The tension of the anorectal maintains the anorectal angle at 90°. When the intra-abdominal pressure rises, the puborectal muscle contractes, the anorectal angle becomes sharper, the pressure on the anterior wall of the rectum increases, and the flap is formed on the upper end of the anal canal to make the exit channel. In the early stage of obstruction and rectal prolapse, the increase in defecation pressure causes damage to the anterior wall and prone to prolapse. Most of the clinical findings of SRUS occur in the anterior rectal wall. The top of the intestine prolapsed mucosa is invaded above the anal canal, and the strong contraction of the external sphincter can cause mucosal compression ischemia and necrosis. When a large amount of prolapse occurs, the submucosal blood vessels are stretched and the rupture can also cause ischemia. An ulcer can often form.

Damage (20%):

Some patients use their fingers to insert anal inducement in the case of difficulty in defecation, assist with defecation, or use the fingers to return the prolapsed rectal mucosa to cause mucosal damage, ulceration, sexual life, rectal massage of prostate and abdominal surgery. Causes rectal ulcers.

Abnormal activity of the pelvic floor muscles (16%):

Such as pelvic floor tendon, anal canal pressure increased, excessive force caused the anterior wall mucosa prolapse, external sphincter tendon contraction of the anal canal, leading to anterior wall mucosa wear, mucosal ischemic necrosis caused by SRUS.

Other factors (20%):

Inflammatory bowel disease, congenital rectal mucosal malformation, vascular abnormalities, bacterial and viral infections, and ischemic bowel disease are also thought to be involved in the development of SRUS.

Pathogenesis

The most obvious of SRUS is the lamina propria vascular occlusion, which is filled with fibrosis and mucosal myometrial hyperplasia and grows into the intestinal lumen. There are often ectopic glands under the mucosa that are cystic dilatation, so this disease is sometimes called deep sac. Colitis, general type of ulcer type, bulging type, mixed type, ulcer type is the most common, ulcers have more clear boundaries, superficial, mucosal smoothness around the ulcer, elastic, clear peripheral blood vessel texture, bulge type mucosa Soft and elastic, clear borders, generally do not cause intestinal fissure tissue and smooth muscle hyperplasia, comprehensive literature, inductive histological changes to:

1. The surface of the mucous membrane is shallow ulcer or erosion, accompanied by increased glandular body, elongation, bending, and partial arrangement disorder.

2. The lamina propria fibrous tissue hyperplasia, arranged disorderly, the polar direction is perpendicular to the mucosal surface, and interspersed between the glands or around the glands.

3. Mucosal muscle hypertrophy, hyperplasia, muscle layer widening, smooth muscle cells grow into the intrinsic membrane, and surround the intestine

4. The submucosal fibrous tissue proliferates and the arrangement is disordered.

5. Some have a mucous layer and a submucosal mucus pool.

6. Interstitial edema with lymphocytes, plasma cell infiltration, may be associated with glandular epithelial dysplasia.

Isolated rectal ulcer syndrome prevention

Eat a high-fiber diet to keep your stools open.

Solitary rectal ulcer syndrome complications Complications rectal prolapse

Acute massive bleeding, intestinal perforation, intestinal necrosis, rectal prolapse.

Symptoms of solitary rectal ulcer syndrome Common symptoms Anal pain, blood in the stool, acute constipation, right lower quadrant, tenderness, diarrhea, mucus, defecation, difficulty, lower abdominal pain, feces, pus

Almost all symptoms of anorectal disease can occur, the course of the disease is mostly chronic, ranging from several months to several years. Common symptoms are: blood in the stool, the incidence rate is 80% to 90%, the color is bright red, the amount is small, occasionally a large amount of bleeding; Difficulty or constipation, there is an anal rectal obstruction, and it is heavy and heavy. Sometimes you need to insert your fingers into the anus to help with bowel movements. Some have a defecation and need to have multiple bowel movements, but each time it takes less, even each time takes a long time. More patients with incontinence; some patients with left lower abdomen can sputum and sigmoid colon fistula, and tenderness; mucus; pain, often located in the rectum anus, perineum, ankle or left condyle.

Examination of isolated rectal ulcer syndrome

Defecography can dynamically observe the functional changes of the anus and rectum during defecation, and help to understand whether the patient has accompanying anatomical and functional abnormalities, such as anterior rectal bulging and intussusception.

1. Rectal examination may have a single ulcer at the junction of the anorectal and rectum, with a raised edge and tenderness. The mucosa is nodular around, and it may also touch the polyp, occasionally the lower rectum and the annular stenosis.

2. Endoscopic observation of the location, number, shape of the ulcer, and can be clamped to the living tissue for examination, a clear diagnosis, the lower edge of the ulcer is located within 3 ~ 15cm from the anal margin, high is rare, 70% of the ulcer is distributed in the rectum The anterior wall, 20% is located in the posterior wall, about 10% of the annular distribution, often riding across the rectal valve, in terms of the number of ulcers, 70% is single; multiple lesions are often scattered, high position, Morphologically, it can be divided into ulcer type, bulge type and mixed type. The formation of three types may be related to different stages of the lesion. The most common type of ulcer is the shallow ulcer, the boundary is clear, and the ulcer size is (1.0cm×1.0cm). ~ (2.0cm × 2.0cm), the shape is mostly round and oval, the mucosa around the ulcer is mild inflammation, edema and congestion, the blood vessel texture is clear, the texture is soft and elastic, the base is covered with gray-white moss; occasionally other Type, the bulge mucosa is soft and elastic, the border is clear, and the lumen is not narrow. The characteristic of SRUS is the occlusion of the lamina propria, the mucous membrane is thickened and filled with fiber, the myometrial fibrosis is thickened, and it can protrude into the intestinal lumen. There are ectopic glands under the mucosa, which is also true SRUS and distinct from rectal cancer, inflammatory bowel disease and other reliable evidence, the specimens should be sufficient to avoid misdiagnosis and missed diagnosis.

3. Non-specific examination of barium enema is not easy to distinguish with rectal cancer and inflammatory bowel disease. Examination can show rectal sputum, filling defect, stenosis, rough mucosal disorder, rectal mucosal thickening, polyps and nodules.

4. Rectal defecation angiography has become an important means to study the anorectal dynamics of the rectum. The anorectal angle of the anal canal is measured at rest or in the state of the screen. The relationship between the anal canal and the pubic tract is observed. Drop, rectocele, pelvic floor, perineal decline, intestinal fistula, rectal prolapse and ulceration, etc., have guiding significance for diagnosis and treatment, Kuijpers reported 39 cases of SRUS angiography positive rate of 95%, mainly for the inner set Stacking, pelvic floor tendon and other functional defecation disorders, proposed defecation angiography can confirm the diagnosis rate of SRUS, and can guide treatment. In 1986, Mahieu reported 43 cases of SRUS, angiography showed that the rectal intussusception accounted for 79%, pelvic floor Tendons account for 9%.

5. Rectal anal pressure measurement of anorectal pressure and physiological reflex between the rectal and anal canal to understand the functional status of the anorectal and rectum. Keighley reported 33 patients with SRUS, of which 16 were pressure-measured and 8 were unable to Rectal dilation with tolerance to 200 ml of gas, 6 cases of dilated reflex disappeared, 2 cases of rectal sensory threshold decreased, rectal threshold, maximum tolerated volume and sensory capacity of SRUS patients, and some patients lack rectal anal inhibition.

6. Electromyography measures the amplitude and frequency of the external sphincter when the autonomic contraction increases; the pubic rectum does not reflect when the defecation is performed, and the sphincter cannot relax.

7. The degree of rectal intussusception was measured by intra-anal ultrasound. The thickness of the invaginal mucosa was more than 3 mm. The diameter and cross-sectional area of the internal sphincter of the anal canal were increased compared with normal people. The external anal canal sphincter had similar changes. The ratio of sphincter thickness is significantly reduced. For patients with defecation disorder as the main manifestation, ultrasonography found that anal sphincter hypertrophy contributes to the diagnosis of SRUS.

8. Biopsy: non-specific chronic inflammatory changes, mucosal surface erosion, ulcer formation, pseudomembrane-like structure on the surface, thickened mucosal muscle layer, fibrous tissue hyperplasia between glands, lymphocytes, plasma cell infiltration The late rectal gland cells are obviously proliferating and have certain heterogeneity. They can be transferred into the interstitium of the mucosa and submucosa, which is easily misdiagnosed as cancerous lesions.

Diagnosis and diagnosis of isolated rectal ulcer syndrome

diagnosis

The possibility of SRUS should be considered when having the following characteristics:

1. Symptoms are bloody stools, mucus, difficulty in defecation, accompanied by clinical manifestations such as anal pain

2. Endoscopy examination of the anterior or anterior wall of the rectum has localized erosion or ulceration.

3. Pathological examination is consistent with the basic characteristics of the histology of the disease.

According to clinical manifestations and histological features, combined with endoscopy and other examinations can often make a diagnosis, most of the disease combined with hemorrhoids, for patients with blood in the stool can not only be satisfied with the diagnosis of hemorrhoids.

Differential diagnosis

1. Crohns disease can involve any part of the gastrointestinal tract, endoscopic seeing segmental whole wall inflammation; fissure ulcer (knife-cut longitudinal ulcer); non-cheese necrotic sarcoidosis-like granuloma, X-ray angiography The cobblestone of the mucous membrane changes, the intestinal wall is thickened by chronic inflammation, causing stenosis of the lumen. If it occurs in the rectal area of the anal canal, accompanied by diarrhea, abdominal pain, blood in the stool or constipation, it is easy to be confused with SRUS.

2. Ulcerative colitis lesions are diffusely distributed, intestinal mucosa has multiple shallow ulcers, various body shapes, varying sizes, with pus and bloody secretions, mucosal congestion, edema; mucosal rough granules, texture crisp, touch Easy bleeding; visible inflammatory polyps, biopsy inflammatory reactions, erosion, ulcers, crypt abscess, glandular epithelial hyperplasia and goblet cell reduction, the main symptoms are diarrhea with mucus pus and blood.

3. Rectal cancer SRUS ulcer type is similar to Borrmann type II intestinal cancer. The former is more than 3.0cm in diameter. The marginal mucosa is elastic, smooth, and the blood vessel texture is clear. The latter boundary is not uniform, brittle and hard, easy to bleed, and attached with dirt. Moss, the uplift type SRUS diameter is less than 2.0cm, the boundary is clear, the surrounding mucosa is soft and elastic; the rectal cancer is more common in the uplift type, while the rectal cancer is mostly irregular cauliflower-like, involving a large range, more than 3.0cm It grows around the intestinal wall, the boundary is unclear, and the intestinal lumen is narrow.

4. AIDS In AIDS patients, there are often a variety of digestive symptoms, mainly due to related gastrointestinal infections and tumors, invading the colon can show diarrhea, endoscopic mostly focal hyperemia or a bit of bleeding Occasionally, small vesicles or erosions, severe cases often show scattered ulcers, intestinal Kaposi sarcoma, lymphoma, etc., can also cause bleeding due to intestinal obstruction caused by tumor or intestinal mucosal ulcer, HIV Comprehensive analysis of pathogens, physical examinations, combined with medical history and immunodeficiency can confirm the diagnosis.

5. Sexually-acquired lymphogranuloma can cause ulcers, inflammation, stenosis and even obstruction when the rectum is involved. The pathogen test, physical examination and combined medical history can be diagnosed.

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