Morphological and mucus secretion criteria for differential diagnosis of solitary ulcer syndrome and non-specific proctitis

[The solitary rectal ulcer syndrome]

The solitary rectal ulcer syndrome is a rare debilitating disorder of the rectum characterized by perianal chronic pain with passage of blood and mucus. The pathogenesis remains uncertain, rectal prolapse and trauma from straining are the main hypothesis. The diagnosis includes clinical symptoms associated with endoscopic lesion (erythema, ulcer or polypoïd lesion) and histological features. Mano-metric studies and defecography are helpful to determinate an underlying defecation disorder or rectal prolapse. The treatment is controversial including a conservative option (medications and behavioural therapy) with poor long term results, and the surgical option (treatment of a rectal prolapse with or without resection of the lesion), more aggressive with uncertain results in a long follow-up period.

Solitary rectal ulcer syndrome: an endoscopic and histological presentation and literature review

BACKGROUND

Although the clinicopathologic features of solitary rectal ulcer syndrome (SRUS) are well documented, the heterogeneous endoscopic appearance of lesions that the syndrome produces and its rare incidence may make for clinical confusion.

METHODS

Together with a literature review, we describe the variety of lesions experienced in our hospital with a series of endoscopic and histological illustrations and emphasize the diagnostic dilemma both clinically and histologically.

CONCLUSIONS

With comparison of different macroscopic presentations of SRUS, more correct diagnoses will be achieved and more successful treatments will be reported.

Malignant tumors in the rectum simulating solitary rectal ulcer syndrome in endoscopic biopsy specimens

Patients with solitary rectal ulcer syndrome (SRUS) frequently present with a mass that can be misinterpreted as cancer. In contrast, the occurrence and characteristics of SRUS-like histopathology produced by underlying malignancy have not been reported in detail. We report seven patients whose rectal mass that was induced by infiltrating carcinoma showed only histopathologic changes of SRUS on initial mucosal biopsy specimens. Carcinoma was evident in subsequent specimens after one to five repeat biopsies with delay in diagnosis from 1 week to 18 months in six patients. In one patient, infiltrating carcinoma was suggested on the first biopsy specimen by immunohistochemistry for cytokeratin. Three of the patients had primary rectal adenocarcinoma, two had metastatic carcinoma from stomach or ovary, and two had direct invasion of anal squamous cell carcinoma or prostatic adenocarcinoma. We conclude that the histopathology of SRUS may occasionally represent a characteristic but nonspecific mucosal reactive change to a deeper seated malignancy. The terminology "solitary rectal ulcer syndrome/mucosal prolapse changes" with a cautionary note may be useful for reporting biopsy results to emphasize the possibility of underlying primary or metastatic malignancy in the differential diagnosis.

Histochemical alterations of mucin in normal colon, inflammatory bowel disease and colonic adenocarcinoma

Loss of sialic acid o-acyl substitutions in colonic mucus was studied using specific histochemical techniques in individuals with a variety of large-bowel diseases and in a control population. Changes found included a focal or field (diffuse) loss of side-chain substitutions which were qualitatively similar in all groups studied. The results were tested statistically using a variety of assumptions that field and/or focal loss of o-acyl substitution may be either abnormal or a normal variant. No statistically significant differences in the prevalence of substitutions were detected between normal males and females or between normal individuals aged 0-29 years and 30-80 years. Significant differences were found between ascending and descending colon in both normal individuals and in the non-neoplastic mucosa of patients with cancer. There were also significant differences between the normal descending colon and cases with cancer of the descending colon. These differences seem unlikely to be due to non-specific factors, since for most assumptions there were also differences between colons containing cancer and those from patients with inflammatory bowel disease. In agreement with the work of other investigators, it seems likely that focal loss of o-acetylation results from an acquired gene mutation. It is not clear whether or not this plays a role in carcinogenesis.

Inflammatory cloacogenic polyp in a child: part of the spectrum of solitary rectal ulcer syndrome

A 15-year-old boy with Marshall-Smith syndrome presented with increased frequency and urgency of stooling, hematochezia, and rectal pain. A polypoid mass was found at the anorectal junction and excised. Microscopically, the lesion was covered by both squamous and columnar mucosa. It was villiform in configuration with focal ulceration and strands of smooth muscle in the lamina propria. These features are characteristic of an inflammatory cloacogenic polyp, a lesion not previously reported in the pediatric age group. Inflammatory cloacogenic polyp is related to solitary rectal ulcer syndrome and is most likely due to prolapse of the anorectal transition zone. Although rare in this age group, solitary rectal ulcer and its variants should be considered in the differential diagnosis of anorectal and rectal lesions in the pediatric patient.

Effects of Yersinia enterocolitica infection on rabbit intestinal and colonic goblet cells and mucin: morphometrics, histochemistry, and biochemistry

The effects of Yersinia enterocolitica on intestinal goblet cells were investigated in New Zealand white rabbits. Animals infected with Y enterocolitica were compared with weight matched and pair fed controls. Goblet cell hyperplasia developed in the distal small intestine of infected rabbits on day 1, in the mid small intestine on day 3, and in the upper small intestine on day 6. In all regions hyperplasia persisted throughout the 14 day study. The degree of hyperplasia was greater in the distal small intestine than the upper and mid regions. Goblet cells in the proximal colon of infected animals seemed to respond as those in the distal small intestine. Thus goblet cell hyperplasia developed more rapidly and to a greater extent in the ileocaecal region where mucosal injury was most severe. These changes resulted directly from Y enterocolitica infection since goblet cell numbers did not increase in pair fed controls. Histochemically, goblet cell mucins from infected rabbits were unchanged at either six or 14 days. Biochemical analysis, however, established that purified mucins from animals on day 6 after infection were less sialylated (in the small intestine) and more sulphated (in the small intestine and proximal colon). In addition, mucins from the distal small intestine and the proximal colon seemed to contain fewer but longer oligosaccharide chains.

High iron diamine-alcian blue mucin profiles in benign, premalignant and malignant colorectal disease

The presence of mucosal hyperplasia and sialomucin goblet cell secretion (transitional mucosa) was assessed in various benign, premalignant and malignant colorectal tissues. Transitional mucosa was seen in diverticular disease, solitary ulcer syndrome of the rectum, ischaemic and irradiation colitis and other diseases including pneumatosis coli, endometriosis, haemorrhoids and a colostomy margin. Adenocarcinomas had a sulphomucin or mixed secretion pattern with transitional features in the adjacent mucosa mucosa (18/27). Premalignant adenomatous polyps showed mixed secretion with transitional glands incorporated in the stalk and sometimes in the adjacent mucosa. Epithelium showing dysplasia secreted sulphomucins and in amounts related to its degree of differentiation. Transitional mucosa may not be a primary premalignant phenomemon. The conclusion and unifying concept is that it is a secondary event related to goblet cell immaturity. This can occur, secondary to proliferation in mucosal inflammation, ischaemia and prolapse or as a phenotypic expression of growth derived from underlying dysplastic epithelium.

Mucin profiles in ulcerative colitis with dysplasia and carcinoma

Mucin secretion was assessed in Crohn's colitis, in ulcerative colitis with regeneration, dysplasia and carcinoma and in non-colitic adenocarcinoma. The high iron diamine-alcian blue (HID-AB) and periodate borohydride-saponification periodic acid Schiff (PB-KOH-PAS) techniques were used to demonstrate sulphomucins and sialomucins, and O-acylated sialomucins respectively. There was mucosal hyperplasia and increased sialomucin secretion in Crohn's disease, quiescent and active ulcerative colitis. In colitis with carcinoma inflamed mucosa away from the tumour had increased sialomucins as had colitis with dysplasia. They did not differ statistically from each other or from colitic controls without cancer. Dysplastic crypts frequently secreted sulphomucins and the increased sialomucins were in transitional-like glands in the surface fronds or adjacent to the dysplasia. A comparative study of the HID-AB technique gave total correct qualitative allocation of individual quantitatively assessed crypts. Routine HID-AB staining did not aid the recognition of dysplasia in ulcerative colitis. With the PB-KOH-PAS technique colorectal adenocarcinoma showed a significant diminution in O-acylated sialomucins compared with its adjacent mucosa. Mucosal dysplasia in ulcerative colitis displayed a similar trend in O-acylated sialic acid variants, differing with respect to age-and sex-matched colitic controls. The PB-KOH-PAS technique may be of help in assessing mucin secretion in ulcerative colitis as a guide to the evolution of malignancy.

Immunohistologic study of ulcerative colitis with monoclonal antibodies against tumor-associated and/or differentiation antigens

We used monoclonal antibodies (MAbs) (19-9, 55-2, and 73-3) that detect tumor-associated or differentiation antigens, or both, to immunohistochemically study a well-defined group of patients with ulcerative colitis. Monoclonal antibody 19-9 detects the gastrointestinal cancer-associated antigen (sialylated Lewis A). Monoclonal antibody 55-2 detects the Lewis Y antigen and reacts with deep crypt cells in the normal colon. In the normal colon MAb 73-3 reacts with mature superficial columnar cells detecting the protein moiety of a 35,000-dalton glycoprotein. In cases of inactive or mildly active disease, MAbs 19-9, 55-2, and 73-3 had staining patterns similar to normal colon. In 72% and 44% of cases of severely active disease, MAb 19-9 and MAb 73-3, respectively, reacted with epithelial cells at all levels of the crypt, whereas MAb 55-2 reacted only with deep crypt cells. Monoclonal antibodies 19-9, 55-2, and 73-3 reacted with dysplastic epithelium in 70%, 10%, and 60% of cases, respectively. In severely active disease, proliferating epithelial cells "paradoxically" express markers of differentiated epithelium throughout the entire crypt. Similarly, colonic epithelial cells may have the ability to reversibly express tumor-associated antigens. Unfortunately, the MAbs used in this study cannot differentiate dysplasia from reactive epithelium.

Inflammatory cloacogenic polyp: relationship to solitary rectal ulcer syndrome/mucosal prolapse and other bowel disorders

The clinicopathologic features of nine patients with inflammatory polyps of the anorectal transition zone (inflammatory cloacogenic polyp, ICP) were reviewed. All polyps were characterized histologically by crypt hyperplasia and a thickened muscularis mucosa arising beneath a surface epithelium consisting of variable proportions of squamous, columnar, and often transitional epithelium. Tubulovillous architecture was characteristic. Sialomucin predominated over sulfomucin in eight of nine cases. One polyp displayed focal dysplasia and condylomatous features, while two others had associated hemorrhoids. Three cases had been previously diagnosed as adenomas. Seven patients were women, and two were men; their median age was 54 years (range, 17 to 85). Clinical presentation was most commonly intermittent rectal bleeding, and the clinical diagnosis was anal polyp or hemorrhoids in all cases. Six patients had the solitary rectal ulcer syndrome (SRUS) and/or evidence of mucosal prolapse. Papillomavirus was demonstrated by histochemical and immunohistochemical methods in one case in which multiple foci of dysplasia were also noted. Two patients had Crohn's disease, and the remaining patient had a coexistent adenocarcinoma located several centimeters proximal to his ICP. The pathologist and clinician must be aware that although ICP is often associated with SRUS/mucosal prolapse, it may occur in other clinical settings.

Histochemical procedures for the simultaneous visualization of neutral sugars and either sialic acid and its side chain O-acyl variants or O-sulphate ester. I. Methods based upon the selective periodate oxidation of sialic acids

Five new methods, based upon the selective oxidation of sialic acid residues with 0.4 mM periodic acid in approximately 1 M hydrochloric acid at 4 degree C for 1 h (PA), have been devised for the simultaneous visualization of neutral sugars and either sialic acid and its side chain O-acyl variants or O-sulphate ester. In the first of these, the selective periodate oxidation-borohydride reduction-saponification-selective periodate oxidation-Thionin Schiff-saponification-borohydride reduction-periodic acid-Schiff (PA-Bh-KOH-PA-T-KOH-Bh-PAS) technique, sialic acids with O-acyl substituents at C7, C8 or C9 (or which have two of three side chain O-acyl substituents) stain blue while neutral sugars with periodate-sensitive vicinal diols (hexose, 6-deoxyhexose, and N-acetylhexosamine) stain magenta. The second method, the saponification-selective periodate oxidation-Thionin Schiff-saponification-borohydride reduction-periodic acid-Schiff (KOH-PA-T-KOH-Bh-PAS), stains all sialic acids blue and neutral sugars magenta. In the third procedure, the selective periodate oxidation-Thionin Schiff-borohydride reduction-periodic acid-Schiff-saponification (PA-T-Bh-PAS-KOH) method, sialic acids without side chain substituents (or which have an O-acyl substituent at C7) stain blue and neutral sugars stain magenta. In the fourth method, the saponification-selective periodate oxidation-borohydride reduction-Alcian Blue pH 1.0-periodic acid-Schiff (KOH-PA-Bh-AB1.0-PAS) technique, O-sulphate esters stain aquamarine blue and neutral sugars stain magenta. In all of these techniques mixtures of the components stain in various shades of purple.(ABSTRACT TRUNCATED AT 250 WORDS)

Solitary rectal ulcer syndrome. Twenty cases seen at an oncology center

A retrospective study of 20 cases of biopsy-proven solitary rectal ulcer syndrome seen at a large oncology hospital which highlight the clinicopathologic features is presented. Thirty five percent of patients were in their sixth decade and there was a male preponderance of 2.3:1. All patients presented with anorectal symptoms. Eighty five percent had normal abdominal findings and seventy five percent had positive findings on rectal examinations. Fifty four percent had a diagnosis of carcinoma of the rectum on barium enema studies. On sigmoidoscopy, a solitary ulcer was found in 80 percent; 50 percent had lesions between 6 and 10 cm from the anal verge, and 40 percent had the lesion on the anterior rectal wall. All patients were treated conservatively and 35 percent were disease free at the end of five years, while 30 percent had persisting symptoms.

Lectin and mucin histochemistry as an aid to cancer surveillance in ulcerative colitis

In a preliminary study, we assessed 10 lectins for the identification of dysplasia in colectomy specimens from patients with ulcerative colitis. Peanut agglutinin (PNA) binding was found in all cases of dysplasia. In the main study the relationship between PNA staining, high iron-diamine/alcian blue (HID-AB) histochemistry, and dysplasia was investigated in 115 pre-operative colonoscopic biopsies and the subsequent resection specimens from patients with ulcerative colitis complicated by carcinoma (n = 6) and patients undergoing proctocolectomy for failure of medical management (n = 8). Peanut lectin was of no value in the assessment of pre-malignant changes or cancer risk. However, the HID-AB stain appears to clarify the interpretation of less severe pre-malignant changes and may be usefully applied to the interpretation of colonoscopic biopsies for cancer surveillance in ulcerative colitis.

The histochemical assessment of sulphated and non-sulphated sialomucin in intestinal epithelium

A new method (KOH/AB 1.0/PAPS) for the simultaneous detection of sulphated and non-sulphated sialomucins in intestinal epithelium was compared to the standard high iron diamine/alcian blue(HID/AB) technique. Although there was no difference in the sensitivity of the methods in detecting cells containing only one type of mucin, detection of cells containing both types was twice as effective with the KOH/AB 1.0/PAPS method. This indicates that previous investigations using only HID/AB may have seriously underestimated mucosal non-sulphated mucin content and raises doubts about the validity of some of the conclusions reached concerning the pre-neoplastic potential of 'transitional' mucosa of the colon.

A prospective study of dysplasia and carcinoma in the rectal biopsies and rectal stump of eight patients following ileorectal anastomosis in ulcerative colitis

The present study concerns eight patients with ulcerative colitis treated by total colectomy and ileorectal anastomosis and subjected to follow-up rectal biopsies who later developed precancer (two cases) or carcinoma in the retained rectum. We report the results of the biopsies and the detailed mapping of lesions in the resected rectal stump to highlight certain features which may lead to increased detection rate of early malignancy. Two groups of patients emerged. Group A: in all four cases the follow-up biopsies showed increasing severity of dysplasia; altered mucin secretion with predominance of sialomucins was seen in the biopsies even in the absence of inflammation or dysplasia; the biopsy findings (morphological and secretory) mirrored those observed in the rectal stump; in three, the lesions were villous polypoid growths, of which two were invasive carcinomas. Group B: in none of the cases was dysplasia seen in the biopsies and mucus secretion was normal; similar features were seen in the rectal stump; all had invasive carcinoma of which three were flat ulcerated lesions. The different behaviour of carcinoma in the two groups almost certainly reflects the different tumour phenotype characteristics and this is a matter for further study. From the practical point of view we emphasize the risk of relying on biopsy evidence of dysplasia alone as an indicator of malignancy and the need for additional immunological or histochemical tests to assess the individual risk of cancer in colitis.

Chemical and histochemical studies of normal and diseased human gastrointestinal tract. III. Changes in the histochemical and chemical properties of the epithelial glycoproteins in the mucosa close to colonic tumours

Histochemical, chemical and histological studies were performed on 26 specimens of human colonic tumours and 62 specimens of mucosa taken at distances of 0.5-5.0 cm from the tumour. The tumour glycoproteins were divided almost equally between three anionic types, sulphomucin, sialomucin and mixed sialomucin and sulphomucin. All showed a reduction in staining for side chain O-acylated sialic acid. In 56% of the tumours, this was accompanied by loss of glycoprotein while, in 44%, abundant mucin was still present. Histochemical examination of the mucosal specimens indicated that in 24.2% the side chain O-acylated sialic acids did not differ from normal. In 41.9% there was a focal change and in 33.9% there was a generalized field reduction in the proportion of side chain O-acyl sialic acids. The latter were subdivided into moderate and severe. Chemical analyses correlated well with the histochemical classification of the mucosal specimens and showed that, on average, the classifications focal and severe field change were not due to sampling error. Forty-five per cent of the cases showed only focal change and 40% only field change. Mucosal specimens associated with 60% of the moderately differentiated tumours showed only focal change while those associated with 75% of well-differentiated tumours showed only field change. Abnormal patterns of staining for side chain O-acylated sialic acids (a) were largely independent of the distance from the tumour, (b) occurred in the presence of a normal pattern of staining for sialomucins and sulphomucins and (c) were associated with 61.4% of the specimens that showed no discernible evidence of histological abnormality. In contrast, only one specimen showed evidence of histological change without a corresponding change in O-acylated sialic acids. The data suggest that abnormal patterns of staining for O-acylated sialic acids may represent premalignant change but their precise significance and specificity requires further studies of non-neoplastic diseases of the colon.

Sialomucins in the assessment of dysplasia and cancer-risk patients with ulcerative colitis treated with colectomy and ileo-rectal anastomosis

The clinical notes and histology of 374 patients treated by colectomy and ileo-rectal anastomosis for ulcerative colitis were reviewed. Only those with definite diagnosis of ulcerative colitis and follow-up rectal biopsies were included (171 cases). Morphology and patterns of mucin secretion were investigated to assess whether abnormal mucin with predominance of sialomucins is a useful indicator of malignancy-risk. Carcinoma has developed in six patients and 'precancer' in seven. The results show coexistence of dysplasia and sialomucin even in the absence of inflammation in all but three biopsies; in contrast the presence of both dysplasia and normal mucin profile was found in less than 1%. A significant correlation was noted between an inflamed mucosa and the development of cancer or precancer, the presence of sialomucins and the appearance of dysplasia. Sialomucins showed a greater sensitivity in detecting cancer than dysplasia (75% versus 30%). However, dysplasia was notably more specific (94% compared with 50%), hence its greater predictive value as indicator of malignancy (50% as against 15% for a positive sialomucin result). Mucin stains on routine fixed paraffin-embedded tissue provide a simple screening method to sharpen the assessment of dysplasia and cancer-risk in patients with ulcerative colitis despite the limitations referred to above. The lack of definite evidence of dysplasia in four patients who developed malignancy without premalignant changes in the rectal biopsies emphasises the need for frequent multiple biopsies in patients with an ileo-rectal anastomosis for ulcerative colitis.

Abnormal goblet cell glycoconjugates in rectal biopsies associated with an increased risk of neoplasia in patients with ulcerative colitis: early results of a prospective study

A group of 18 patients with stable ulcerative colitis involving the entire colon for at least eight years was subjected to a biopsy of normal appearing rectal mucosa and followed prospectively over four years for the development of either dysplasia or cancer. Goblet cell glycoconjugate structure was examined in the rectal biopsies using fluorescein conjugated lectins. At the beginning of the study, 13 of the 18 patients had abnormalities of goblet cell mucin or cytoplasmic glycoconjugates in the rectal biopsies. Dysplasia subsequently developed in six and carcinoma in one of these patients. Among the five patients with normal lectin binding studies in the initial rectal biopsies, colonic dysplasia has subsequently developed in one. The abnormalities seen in the rectal goblet cells resembled in part those previously seen in immature and neoplastic colonic cells. The dysplastic tissues all contained the form of mucin which has been found in other neoplastic colonic tissues. This preliminary report after four years of prospective study suggests that abnormalities of glycoconjugate structure may be associated with, and may precede, neoplastic events in the setting of chronic ulcerative colitis.

Mucin profiles in the mucosa adjacent to large bowel non-adenocarcinoma neoplasias

Morphological features and mucin secretion patterns were investigated in the colonic mucosa adjacent to or overlying mesenchymal or primary epithelial neoplasias, other than adenomas and adenocarcinomas. The material included 15 cases of non-adenocarcinoma tumours examined during 1978-1981. Increased sialomucins and morphological features similar to those described in the so-called 'transitional' mucosa adjacent to primary colorectal adenocarcinomas were observed in only two cases. In contrast our previous studies have demonstrated 'transitional' profiles in 98% of adenocarcinomas.

Antigenic and structural features of goblet-cell mucin of human small intestine

With the use of a newly developed solid-phase radioimmunoassay method, the major antigenic determinants of human small-intestinal goblet-cell mucin were investigated and related to the overall tertiary structure of the mucin. Preliminary hapten inhibition studies with various oligosaccharides of known sequence and structure suggested that the determinants did not reside in carbohydrate. Exhaustive thiol reduction, however, almost abolished antigenicity, caused breakdown of the mucin into small heterogeneous glycopeptides, and liberated a 'link' peptide of Mr 118000. Western 'blots' of reduced mucin from polyacrylamide gels on to nitrocellulose sheets showed that a small amount of residual antigenicity remained in large-Mr glycopeptides (Mr greater than 200000). The 'link' peptide was not antigenic. Timed Pronase digestion of native mucin resulted in a progressive loss of antigenic determinants. Gel electrophoresis revealed that after 8h of digestion the 118000-Mr peptide had disappeared, whereas antigenicity, which was confined to large-Mr glycopeptides, was destroyed much more slowly with time (70% by 24h, 100% by 72h). Despite the loss of antigenicity, 72h-Pronase-digested glycopeptides retained all of the carbohydrate of the native mucin. Therefore the antibody to human small-intestinal mucin appears to recognize a 'naked' (non-glycosylated and Pronase-susceptible) peptide region(s) of mucin glycopeptides. For full antigenicity, however, disulphide bonds are required to stabilize a specific three-dimensional configuration of the 'naked' region.

Mucosal prolapse syndrome--a unifying concept for solitary ulcer syndrome and related disorders

Nineteen cases of classical solitary ulcer of the rectum syndrome (SURS) and sixteen examples of rectal mucosal prolapse are described. Similarities in the histological and histochemical features of the two groups lead us to suggest that the term "mucosal prolapse syndrome" be used to describe this group of disorders in which mucosal prolapse--overt or occult is the common underlying pathogenetic mechanism.

Mucin secretion in inflammatory bowel disease: correlation with disease activity and dysplasia

When rectal biopsies from 65 patients with ulcerative colitis and 20 patients with Crohn's disease was stained for mucins, an abnormal pattern (excess of sialomucins) was seen in about half of them. This is in contrast with 65 cases of non-specific proctitis where the mucin pattern of rectal biopsies was normal in all except one case. The abnormal mucin secretion in patients with ulcerative colitis was apparently related to the activity, duration, and extent of the disease. All biopsies with dysplasia showed predominant sialomucin staining except one. All biopsies showing sialomucins during remission also had dysplasia, while during active disease a number of biopsies had increased sialomucins without the evidence of dysplasia. It is not known if such cases will subsequently develop morphological atypia.