Solitary rectal ulcer

Solitary rectal ulcer is a benign disease of the colorectum.

It is also known as solitary ulcer syndrome of the rectum (abbreviated SUS) and solitary rectal ulcer syndrome.

Mucosal prolapse syndrome may be used as a synonym; however, it encompasses other entities.

General

• Clinically may be suspected to a malignancy - biopsied routinely.
• Mucosal ulceration.
• "Three-lies disease":

1. May not be solitary.
2. May not be rectal -- can be in left colon.
3. May not be ulcerating -- non-ulcerated lesions: polypoid and/or erythematous.

Note: Each of the words in solitary rectal ulcer is a lie.

Epidemiology

• Typically younger patients - average age of presentation ~30 years in one study.
• Rare.

Clinical presentation

• Usually presents as BRBPR ~ 85% of cases.
• Abdominal pain present in approx. 1/3.
  • May be very painful.

Treatment:

• Usually conservative, i.e. non-surgical.
• Resection - may be done for fear of malignancy.

Gross

• Classically, anterior or anterolateral wall of the rectum.

Microscopic

Features:

• Fibrosis of the lamina propria.
• Thickened muscularis mucosa with abnormal extension to the lumen.
• +/-Mucosa ulceration.
• +/-Submucosal fibrosis.

DDx:

• Inflammatory pseudopolyp (inflammatory polyp).
  • Associated with inflammatory bowel disease.
• Rectal prolapse.
• Well-differentiated adenocarcinoma.

IHC

• p53 -ve.
  • May be used to help exclude adenocarcinoma.

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Verbose form

Rectum, Biopsy:
     - Colonic mucosa with mild active inflammation, ulceration, 
       fibromuscular hyperplasia and necro-inflammatory debris.
     - NEGATIVE for dysplasia and NEGATIVE for evidence of malignancy.

Comment:
The findings are compatible with solitary rectal ulcer/mucosal prolapse in 
the proper endoscopic context.

See also

• Colon.
• Rectum.