STERCORAL ULCER OR “What the Heck is That?”

Clinical case: MG is an 85 year old white female currently residing in local long term care facility. Patient has a long standing history of osteoarthitis, hypertension. Involved in MVA over 25 years ago and was told she wouldn’t survive. Serves cake each year on her birthday to the underserved. Asked to see the patient because of constipation and anemia. Labs include – Scheduled for EGD/colon Findings on endoscopy

Large ulcerative mass located at approximately 15- 20 cm in rectal canal. Not bleeding on contact.

Stercoral Ulcer or Solitary Rectal Ulcer Stercoral Ulcer or Solitary Rectal Ulcer Syndrome Uncommon rectal disorder that can cause: Bleeding Passage of mucus Incomplete evacuation Difficulty/straining with defecation No significant male:female differences 1/100,000 incidence

Clinical Manifestations Solitary Rectal Ulcer Syndrome often a misnomer as can be more than one present Usually within 10 cm of the anal verge on the anterior wall Often misdiagnosed as “nonspecific inflammation”, inflammatory bowel disease, or adenocarcinoma Rectal bleeding most common complaint (>50%) but pain, tenesmus, mucus other findings

Pathogenesis The posterior aspect of the rectum exposed by removing the lower part of the sacrum and the coccyx. (Puborectalis not labeled, but levator ani labeled at bottom right, and sphincter ani ext labeled at bottom center. The pelvic floor consists of a striated muscular sheet through which viscera pass. This striated muscle, the paired levator ani muscles, is actually subdivided into four muscles defined by the area of attachment on the pubic bone. The attachments span from the pubic bone, along the arcus tendineus (a condensation of the obturator fascia), to the ischial spine. The components of the levator ani are therefore named the pubococcygeus, ileococcygeus, and ischiococcygeus. The pubococcygeus is further subdivided to include the puborectalis. Between the urogenital viscera and the anal canal lies the perineal body. The perineal body consists of the superficial and deep transverse perinei muscles and the ventral extension of the external sphincter muscle to a tendinous intersection with the bulbocavernosus muscle. The postanal plate lies between the anus and the veterbral column and consists of the presacral fascia, the anococcygeal ligament, anococcygeal raphe (midline condensation of the ileococcygeus), and the dorsal extension of the puborectalis and external anal sphincter fibers to the coccyx. Levator ani

Pathogenesis (Continued) Unsure of true cause Is rectal prolapse causative or a coincidental finding? In both cases I have seen no rectal prolapse Possible paradoxical contraction of the puborectalis muscle with prolapse Shearing forces with defecation (rectocele?) Direct digital trauma

Histology Just important to note that there is an increase in collagen fibers within the lamina propria which can help differentiate between Crohn’s, UC or Ischemic Colitis.

Treatment Conservative – often an incidental finding Consider bulk laxative Retraining of bowel habits (often difficult because patients with dementia, other comorbid illnesses) Steroid enemas? Sulcrafate enemas? Not really effective If rectal prolapse obvious conservative therapy not likely to help

Treatment (continued) Surgery Simple resection of ulcer Diverting colostomy Rectopexy Laparoscopic mesh rectopexy promising.

Summary Very Uncommon Disorder May cause bleeding, passage of mucus, or may be completely asymptomatic Often confused with UC, Crohn’s, and ischemic colitis. No specific cause? Rectal prolapse? Constipation? Treatment = conservative, surgical

References Vaizey CJ, van den Bogaerde JB, Emmanuel AV, et al. Solitary rectal ulcer syndrome. Br J Surg 1998; 85:1617. Tjandra JJ, Fazio VW, Church JM, et al. Clinical conundrum of solitary rectal ulcer. Dis Colon Rectum 1992; 35:227.\ Tweedie DJ, Varma JS. Long-term outcome of laparoscopic mesh rectopexy for solitary rectal ulcer syndrome. Colorectal Dis 2005; 7:151. Malouf AJ, Vaizey CJ, Kamm MA. Results of behavioral treatment (biofeedback) for solitary rectal ulcer syndrome. Dis Colon Rectum 2001; 44:72. Torres C, Khaikin M, Bracho J, et al. Solitary rectal ulcer syndrome: clinical findings, surgical treatment, and outcomes. Int J Colorectal Dis 2007; 22:1389.