Two articles in this month’s JPGN, along with the editorials, make it clear that when patients are having rectal bleeding, we should ask if they are spending an inordinate amount of time straining on the toilet.  (JPGN 2012: 54: 263-65, 266-70, 167-68, 169-70).  This question may help uncover Solitary Rectal Ulcer Syndrome (SRUS).

This syndrome which is often a misnomer because many cases have erythema rather than ulcers; and, lesions can be ulcerative or polypoid.  They can be single or multiple involving the distal rectum.  SRUS often has a delayed diagnosis, 1.7 years and 3.2 years respectively in the two studies.  The differential diagnosis includes polyps, infections, IBD, abuse, and rectal manipulation.  Histology features include muscularinization of lamina propia, mixed inflammatory infiltrate, thickened muscularis mucosa, and epithelial hyperplastic changes.

Treatment includes avoidance of straining/behavior modification, use of laxatives, and perhaps topical mesalamine.

Additional references:

• -Gastroenterol Clin North Am 2008; 37: 645-68. Rectal disorders/SRUS -review.
• -Gastrointest Endosc 2005; 5: 755-62,
• -Eur J Gastroenterol Hepatol 2008; 2: 89-92. SRUS in children.
• -Gut 2004; 53: 368-70.  Biofeedback for SRUS.
• -Pediatrics 2002; 110: e79.
• -Clinical Perspectives in Gastroenterology 1999; 2: 190.