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| CASE REPORT |
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| Year : 2021 | Volume
: 24
| Issue : 8 | Page : 1255-1258 |
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A Rare Rectosigmoid Mass Mimicking Cancer; Solitary Rectal Ulcer
E Anilir
Liver Transplantation Center, Group Florence Nightingale Hospitals, Demiroglu Bilim University, Şişli, İstanbul, Turkey
| Date of Submission | 27-Jun-2020 |
| Date of Acceptance | 11-Jan-2021 |
| Date of Web Publication | 14-Aug-2021 |
Correspondence Address:
Dr. E Anilir
Esentepe, Büyükdere Street, Number: 120 34394, 34394, Şişli, Istanbul
Turkey
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/njcp.njcp_396_20
 Abstract | | |
Solitary rectal ulcer (SRU) is a rare, benign disease that has a rate of 1–3.6/100000. Perineal pain, rectal bleeding, mucosal discharge accompanied by incomplete defecation, rectal prolapse, obstructive symptoms, such as constipation and obstipation, may occur as clinical findings in SRU. Different methods, ranging from medical treatment to surgery, can be applied according to the severity of the disease and clinical findings. A 36-year-old female patient, who did not have any chronic disease or previous surgical operation, was admitted to our outpatient clinic due to complaints of abdominal pain, anorexia, constipation, occasional rectal bleeding, and weight loss, which had been ongoing for about 2 months. An obstructive polypoid mass was detected in colonoscopy. Low anterior resection was performed. The pathology result was SRU. The patient was discharged on the 12th day after healing without any complication. SRU should always be considered in patients who present lower gastrointestinal system symptoms. Surgery may be preferred in patients who do not respond to medical treatment or have an obstructive lesion and suspected malignancy.
Keywords: Cancer, mimicking, polypoid, rectal, solitary, ulcer
How to cite this article:
Anilir E. A Rare Rectosigmoid Mass Mimicking Cancer; Solitary Rectal Ulcer. Niger J Clin Pract 2021;24:1255-8 |
| Introduction | |  |
Solitary rectal ulcer (SRU) is a rare, benign disease that has a rate of 1- 3.6/100000. It occurs more often in young adults.[1] Perineal pain, rectal bleeding, mucosal discharge accompanied by incomplete defecation, rectal prolapse, obstructive symptoms, such as constipation and obstipation may occur as clinical findings in SRU. Solitary and multiple polypoid lesions, in varying appearance from erythema to ulceration, may be seen as endoscopic findings. Histopathological diagnosis is vital to be diagnosed because it can be confused clinically with carcinoma or inflammatory bowel disease. Treatment options, which range from drug treatment to surgical treatment, can be preferred according to clinical findings and severity of the disease.[2],[3] In this case, we aim to present the patient who undergoes low anterior resection due to suspicion of rectosigmoid tumor, but whose explant pathology results in as SRU.
| Case Presentation | | |
A 36-year-old female patient, who did not have any chronic disease or previous surgical operation, was admitted to our outpatient clinic due to complaints of abdominal pain, anorexia, constipation, occasional rectal bleeding, partial defecation, and weight loss, which had been ongoing for about 2 months. All physical examination, blood test, and tumor marker results were normal, except fecal occult blood test positivity. A polypoid, fragile, and hemorrhagic mass which completely clogged the lumen and did not allow the passage of the colonoscope, was detected at approximately 10–15 cm proximal to the anal verge. Hyperemic areas were observed in other colorectal segment examined [Figure 1]. Multiple biopsies were taken. In a biopsy, as well as tissue fragments containing edematous and locally inflamed cells in most areas of the lamina propria in the epithelium, glandular structures with focal mild distortion and minimal atypia were observed microscopically [Figure 2]. In abdominal magnetic resonance imaging (MRI), there was a focal ring wall thickening in the rectosigmoid junction with suspicion of malignancy [Figure 3]. In the abdominal exploration, a lesion extending beyond the serosa and extensively covering a 10 cm rectosigmoid colon segment was detected. When the pelvic peritoneum was opened, it was observed that the lesion progressed till upper 1/3 of the rectum. The segment infiltrated with the lesion was found to contain microperforated areas. At the same time, the omentum, uterus, appendix, and ileal segment of about 5–10 cm were adhered to the thickened and locally micro perforated rectosigmoid colon wall. The operation was completed by performing partial omentectomy, appendectomy, bridectomy, and total mesorectal excision [Figure 4]. In explant pathology, severe active chronic colitis and congestion, including fat necrosis observed in subserosal adipose tissue, foamy histiocytes, granulation tissue formation, and ulceration, observed microscopically. There was no cellular atypia to be a sign of malignancy. SRU was considered in the diagnosis finally [Figure 5]. The patient was discharged on the 12th day after healing without any complication. | Figure 1: (arrows): (a) Image of the polypoid mass that does not allow passage of the colonoscope with full obstruction at 20 cm from the anal verge. (b) Image of fragility and bleeding in the current mass. (c) Another hyperemic mucosal area observed
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 | Figure 2: Focal active chronic colitis at 40× magnification in the top (a) and (b) hematoxylin & eosin (H&E) stained colonoscopic biopsy preparation, lower (c) and (d) glandular structures showing focal distortion between focal active chronic colitis and fibrin at 100× magnification in hematoxylin & eosin (H&E) stained colonoscopic biopsy preparation
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 | Figure 3: Appearance in favor of focal annular wall thickening in a short segment of the sigmoid colon in MRI images. (a) Coronal section. (b) Axial section
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 | Figure 4: Total mesorectal excision material (arrows microperforation areas in the upper rectum)
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 | Figure 5: Severe active chronic colitis, granulation tissue formation and ulceration at 40× magnification in hematoxylin & eosin (H & E) stained excisional biopsy preparation. (a), (b), (e) at the left side. Severe active chronic inflammation and congestion, including fat necrosis observed in subserosal adipose tissue upper (c), (d) at the right side. Foamy histiocytes stained excisional biopsy preparation at 100× magnification, followed by fat necrosis in subserosal adipose tissue. (f) (g) at the lower right side
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| Discussion | | |
SRU is a rare disease that may be confused with inflammatory bowel diseases and malignancies.[4] A polypoidal variant may occur in up to 32% of patients with SRU.[4],[5] Moreover, appearance may be confused with inflammation or hyperplastic polyp, or rectal carcinoma, resulting in a delay of diagnosis and treatment. Perineal pain, rectal bleeding, tenesmus, partial defecation, recurring anal, or rectal discomfort, constipation and mucosal discharge are frequent symptoms of SRU, but polypoidal variant may be asymptomatic. In our case, complaints were abdominal pain, constipation, occasional rectal bleeding and partial defecation, weight loss, and anorexia. These types of polyps have malignant transformation potential and therefore excision is recommended.[6]
Diagnosis of SRU is based on clinical features, findings on colonoscopy, and histological examination, imaging investigations, such as MRI or anorectal functional studies.[3] Evidences may vary as mucosal erythema, solitary or multiple ulcers, solitary or multiple polyps.[5] The mucosa surrounding an SRU is usually edematous, slightly hyperemic, and often fragile. Ulceration is superficial and the adjacent mucous membrane may appear as nodular, lumpy, or granular. Clinicians should be aware of SRU and consider it in the differential diagnosis of any type of these lesions.[3],[7] In our case, polypoid mass and erythematous areas were observed, and also mucosa around the polypoid mass was fragile and edematous in colonoscopy; in abdominal MRI, there was a focal ring wall thickening in the rectosigmoid junction. Although these findings could be confused with the malignancy clinic, symptoms and colonoscopy findings were significant for SRU.
The key histological features which distinguish SRU from colorectal cancer are structural distortion, fibromuscular obliteration of lamina propria, and absence of tumor cell infiltration. Another point of histopathology includes hypertrophied muscularis mucosa with the extension of muscle fibers upward between the crypts and glandular crypt abnormalities. Diffuse collagen deposition in lamina propria and abnormal smooth muscle fiber extensions are sensitive markers for differentiating SRU from other conditions.[3],[8],[9] Severe inflammation with foamy histiocytes and abnormality in glandular crypt structures were significant in terms of SRU in our case. In addition, this feature was different from inflammatory bowel disease. The absence of cellular atypia was also important to exclude malignancy. When the explant pathology result was evaluated together with colonoscopic biopsy, SRU was taken into consideration.
The choice of treatment depends upon the severity of symptoms, presence of rectal prolapse, or a lesion with potential for malignancy. Surgery is preferred in case of inability of a conservative treatment to control serious symptoms, or clinic results of SRU, rectal intussusception, extensive inflammation, established fibrosis, external prolapse, and obstructive lesion.[3] The surgical approach may vary depending on how the disease manifests itself. Ulcer excision, rectal prolapse inversion, and diversion colostomy are general surgical approaches. However, in the case series, surgical approaches such as rectopexy, Delorme procedure (mucosal resection), Altemeier procedure (perineal proctectomy), and anterior resection were applied according to the clinical results of the disease.[10] Low anterior or anterior resection may be preferred in patients with treatment-resistant rectal pain and bleeding, non-responding to other surgical treatments, recurrent polypoid lesions, and potential for malignancy.[3],[5],[6] The suspicion of malignancy was the most important reason for us to decide on surgery. In addition, the presence of a hemorrhagic and totally obstructive mass and desmoid invasion to surrounding tissues increased the need for surgery. Evidence for which approach is the first step in SRU is uncertain. It is necessary to decide according to the clinical manifestations of the disease.[10]
| Conclusion | | |
SRU should always be considered in patients presenting with lower gastrointestinal symptoms. Surgery should be preferred in patients who are unresponsive to medical treatment or have an obstructive suspected mass.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
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