Tag Archives: solitary rectal ulcer syndrome

Solitary Rectal Ulcer Syndrome: How Often is It Solitary? How Often is There an Ulcer?

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A recent restrospective review of 140 pediatric cases (median age 12 years) of solitary rectal ulcer syndrome (SRUS) (U Poddar et al. JPGN 2020; 71: 29-33) highlights the fact that in many, there are multiple ulcerations and in some there are none.

Key findings:

  • Most had dsynergic defecation with prolonged sitting on the toilet (94%), excessive straining (98%), feeling of incomplete evacuation (93%) or “rectal digitation” (51%)
  • Rectal bleeding was presenting feature in 94%
  • Colonoscopy showed in 72% (n=101); a single ulcer was noted in (60%) (n=84)  -thus in those with an ulcer, 83% were solitary.
  • Of the 113 with adequate followup, 63% had clinical improvement and healing of ulcer was documented in 36/82 (44%)
  • The most common treatment was hydrocortisone enema with bulk laxative (n=73) with “improvement” in 52, “better” in 16, and no response in 5 (8.2%).  Other frequent treatments: sulfasalazine enema with bulk laxative (n=12), and bulk laxative alone (n=22)
  • Most children (95/140) were older than 10 years; only 2 were ≤5 years

My take: Asking carefully about dysnergic bowel habits will make this diagnosis much easier.  Many children with SRUS have erythema and not a solitary ulcer; in addition, lesions can be ulcerative or polypoid.

Related blog post: One more cause of rectal bleeding

One more cause of rectal bleeding

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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.