Fecal Evacuation Disorder Among Patients With Solitary Rectal Ulcer Syndrome: A Case-control Study

Argon plasma coagulation-an effective treatment for solitary rectal ulcer syndrome: A single-center experience from western India

BACKGROUND AND AIM

Solitary rectal ulcer syndrome (SRUS) is an uncommon benign disorder of defecation. Management of ulcers is usually unsatisfactory with conventional treatment (laxatives, behavioral therapy, biofeedback, topical treatments, and surgery). Studies on the effectiveness of argon plasma coagulation (APC) for SRUS refractory to conventional treatment is lacking. The aim of the study was to examine the effect of APC with conventional therapy in controlling bleeding and healing of refractory SRUS.

METHODS

Fourteen patients of refractory SRUS diagnosed on clinical, colonoscopic, and histological findings, refractory to conventional therapy, were offered multiple sessions of APC in addition to conventional treatment. All patients were followed up to determine bleeding control and ulcer healing.

RESULTS

Fourteen patients with a mean duration of symptoms of 9.21 ± 6.94 months were included. All the patients were advised to have a high intake of fluids and laxatives and to undergo biofeedback in addition to the APC. Lesions were located anteriorly (66%), circumferentially (25%), and posteriorly (9%). Mean follow-up duration was 7 months (3 to 12 months). APC enabled bleeding control in all the patients (100%), complete healing of ulcer in 71% (10 patients), and reduction in ulcer size to less than 50% of the initial size in the remaining 29% patients. None of the patients had any procedure-related complications like bowel perforation, infections, or fistula formation.

CONCLUSIONS

APC with conventional therapy is effective in controlling bleeding and healing in SRUS refractory to conventional treatment.

Solitary rectal ulcer syndrome

PURPOSE OF REVIEW

Solitary rectal ulcer syndrome (SRUS) is a rare disease which can puzzle the gastroenterologist. A review of the syndrome and new treatment options are discussed.

RECENT FINDINGS

Its association with dyssynergia in general supports an important role for pelvic floor biofeedback, which can be successful in patients with SRUS. No other novel.

SUMMARY

Awareness of this benign syndrome is important; endoscopic diagnosis and histological confirmation opens the way to a guided lifestyle therapy with regulation of defecation and pelvic floor biofeedback. A reluctance to proceed to surgery seems warranted. VIDEO ABSTRACT.

Solitary Rectal Ulcer Syndrome: A Narrative Review

Solitary rectal ulcer syndrome is a multifactorial pathology, which entails a variety of clinical, histologic and endoscopic aspects that needs step-wise logical approach for management especially in relapsing refractory cases. Apart from the diagnostic dilemma that may be faced due to similarities of presentation with inflammatory bowel diseases or colorectal neoplastic lesions, the syndrome also overlaps with dyssynergic defecation syndrome, health anxiety disorder, obsessive compulsive disorder, and latent mucosal rectal prolapse, a systematic composite treatment modality including psychological, pharmacological, physiological and possibly surgical interventions are sometimes essential. Selecting appropriate treatment in this condition not only affects clinical outcome but also patients’ experience and further stigma of SRUS life-long. In this review, we will discuss the detailed pathophysiology, diagnostic and therapeutic approaches in dealing with solitary rectal ulcer syndrome.

Fecal evacuation disorders in anal fissure, hemorrhoids, and solitary rectal ulcer syndrome

The causative factors for hemorrhoids, anal fissure, and solitary rectal ulcer syndrome (SRUS) are poorly understood. The study was done to identify the prevalence of fecal evacuation disorders in patients with anal fissure, hemorrhoids, and SRUS using anorectal manometry (ARM). Retrospective analysis of ARM data from three centers across India was done. Baseline demographic details and symptoms pertaining to bowel movements were noted. Limited colonoscopy details pertaining to hemorrhoids, fissure-in-ano, and SRUS were noted. The patients were divided into two groups-group I (those with fissure, hemorrhoids, or solitary rectal ulcer) and group II (normal study). ARM parameters of resting anal pressure, squeeze pressure, dyssynergic defecation, and abnormal balloon expulsion were compared between the two groups. Sub-analysis was done for ARM metric differences between those with hemorrhoids, chronic fissure, and SRUS. Appropriate statistical tests were used. A p-value of < 0.05 was considered significant. There were more men in group I (87%; p-value 0.01) with a higher resting anal pressure (80 vs. 69 mmHg, p-value 0.03). Functional evacuation disorders (p < 0.0001), dyssynergic defecation (77.2% vs. 46.8%, p < 0.0001) and abnormal balloon expulsion (66.7% vs. 20.3%, p < 0.0001) were significantly higher in group I. These were significantly more common in patients with anal fissure and SRUS compared to those with hemorrhoids (p-value 0.028). Functional evacuation disorders are frequently noted in patients with hemorrhoids, anal fissure, and SRUS.

A systematic literature review on solitary rectal ulcer syndrome: is there a therapeutic consensus in 2018?

PURPOSE

To screen all treatments tested for solitary rectal ulcer syndrome (SRUS) without rectal prolapse and to assess their efficacy.

METHOD

A systematic review was performed according to the PRISMA guidelines, focusing on the treatment of SRUS without rectal prolapse. The types of treatment and their efficacy were collected and critically assessed.

RESULTS

A selection of 20 studies among the 470 publications focusing on SRUS provided suitable data for a total of 516 patients. Only 2 studies were randomised prospective trials that focused on argon plasma treatment. The mean follow-up was 21.8 months and ranged from 0.25 to 90 months. Most of the studies focused on surgery, including rectopexy, stapled transanal rectal resection, excision of the ulcer, the Delorme procedure, proctectomy, low anterior resection, and ostomy. Populations of the studies were heterogeneous and selected outcomes were specific (failure of medical or surgical treatment). Conservative treatment (high-fibre diet, laxatives, change of defecatory habits, and biofeedback treatment) induced a symptomatic improvement in 71/91 patients (63.6%) and healing of mucosal lesion in 17/51 patients (33.3%). Surgeries (all types) improved SRUS in 77% (54-100%) of patients. Argon plasma coagulation is a promising technique but longer follow-up is necessary.

CONCLUSIONS

The general quality of the studies focusing on the treatment of SRUS was poor due to the heterogeneity of the population, the sample size of the cohorts, and the heterogeneity of efficacy assessments. The therapeutic approach appears to be multimodal and multidisciplinary and validated in centres of expertise. Further studies evaluating multimodal strategies are needed.

Indian consensus on chronic constipation in adults: A joint position statement of the Indian Motility and Functional Diseases Association and the Indian Society of Gastroenterology

The Indian Motility and Functional Diseases Association and the Indian Society of Gastroenterology developed this evidence-based practice guideline for management of chronic constipation. A modified Delphi process was used to develop this consensus containing 29 statements, which were generated by electronic voting iteration as well as face to face meeting and review of the supporting literature primarily from India. These statements include 9 on epidemiology, clinical presentation, and diagnostic criteria; 8 on pathophysiology; and the remaining 12 on investigations and treatment. When the proportion of those who voted either to accept completely or with minor reservation was 80% or higher, the statement was regarded as accepted. The members of the consensus team believe that this would be useful for teaching, clinical practice, and research on chronic constipation in India and in other countries with similar spectrum of the disorders.

Risk Factors for Acute Hemorrhagic Rectal Ulcer Syndrome and Its Prognosis: A Density Case-Control Study

Acute hemorrhagic rectal ulcer syndrome (AHRUS) can cause fatal gastrointestinal bleeding. However, there have been few epidemiological studies investigating risk factors of AHRUS. To determine the risk factors and predict one-year survival after onset of AHRUS, we conducted a retrospective density case-control study in a tertiary referral hospital. Patients with hematochezia, bloody stool, and rectal ulcer confirmed by colonoscopy between 2003 and 2011 were diagnosed as AHRUS (n = 38). Patients with malignancies, infectious colitis, ulcerative colitis, or solitary rectal ulcer syndrome were excluded. Control subjects (n = 123) without rectal ulcer were selected by risk set sampling for each AHRUS. Multivariate logistic regression analyses revealed that the significant adjusted odds ratio (95% confidence interval) of hospitalization, antithrombotic drug use, and one gram increase of serum albumin was 15.7 (2.25–108.9), 12.1 (1.53–94.4), and 0.11 (0.02–0.52), respectively. Endoscopic hemostasis for rectal bleeding was performed in 8 cases (21%). Seventeen percent of patients died within one year after the episode of AHRUS from non-AHRUS causes. This study revealed that hospitalization, antithrombotic drug use, and lower serum albumin value were significant risk factors for AHRUS, and that AHRUS was an unfavorable prognostic condition. This information could be helpful in recognizing high-risk patients of rectal bleeding and applying preventive measures.

Chronic constipation in Rome IV era: The Indian perspective

Chronic constipation (CC) is a common problem in the community and in gastroenterology practice all over the world including India. After release of Rome IV guidelines in April 2016, there is increasing interest among gastroenterologists and physicians in India to look into special issues on CC in the Indian perspective. There are important differences in the bowel habit, definition, epidemiology, and pathophysiology including dietary factors and management of CC in India as compared to the West. As severity and frequency of abdominal pain, a symptom essential to diagnose constipation-predominant irritable bowel syndrome (IBS-C) rather than functional constipation (FC), is less common among Indian patients, FC is commoner than IBS-C in India. The pathophysiological mechanisms of CC may include slow colon transit, fecal evacuation disorder (FED), or a combination of these; though CC in a third to half of patients presenting to tertiary care facilities may result from these pathophysiological mechanisms, most patients presenting to primary care may have lifestyle and dietary issues. The current Rome IV algorithm dictates to explore the underlying physiological factors in the pathogenesis of functional gastrointestinal disorders including CC, which may translate to its personalized management. However, the availability of the methods to explore pathophysiological factors and manage CC caused by FED non-pharmacologically (using biofeedback) in India is limited. Though several pharmacological agents are available in India to manage CC, there are several unmet needs in its treatment. This review explores CC in India in relation to these issues, some of which are unique in the Indian perspective.

Evaluation of argon plasma coagulation in healing of a solitary rectal ulcer in comparison with conventional therapy: a randomised controlled trial

Introduction

Argon plasma coagulation (APC) has been reported to be effective in the treatment of solitary rectal ulcer syndrome (SRUS). However, it has not appeared to be effective in healing ulcers.

Aim

This study aimed at assessing the effectiveness of APC in controlling rectal ulcer-induced bleeding, and at examining the ultimate effect of this approach in healing these lesions.

Material and methods

This randomised, controlled trial was conducted on 99 patients with SRUS. Patients were randomly enrolled into two groups of APC therapy (intervention) and conventional therapy (control). The control group (n = 58) received a high-fibre diet, laxatives, behaviour therapy, and sucralfate enemas, and the intervention group (n = 41) were treated with APC plus conventional therapy; in fact they received directed and focused argon gas in addition to a high-fibre diet and laxatives.

Results

Responses to treatment in the control group and in the APC-receiving group were 29.3% and 75.6%, respectively. The continuation of ulcer healing after 3 months in the control group was 10.3%, and it was 70.7% in the APC-treated group. There was a significant statistical difference between the two groups (p < 0.004), i.e. bleeding was controlled more frequently in the group receiving APC plus conventional therapies than in the group receiving only the conventional therapies. However, the results showed no statistically significant difference between the two groups in terms of pain relief (p < 0.36).

Conclusions

Argon plasma coagulation not only controlled bleeding in patients with SRUS, but also, in comparison with the conventional methods of treating SRUS, led to healing and continuation of healing of rectal ulcers.

Solitary rectal ulcer syndrome in a patient with anorexia nervosa: A case report

This case report describes the clinical presentation, diagnosis, and management of a 26-year-old patient with anorexia nervosa (AN) diagnosed with Solitary Rectal Ulcer Syndrome (SRUS). To our knowledge, this is the first case report to document SRUS in AN, whose pathogenesis in this case seems to have been determined by the patient's malnourished and underweight state. Furthermore, SRUS symptoms appear to have interacted with the eating disorder psychopathology, increasing the need to exert control over eating. Cognitive behavioral strategies and procedures were accordingly used to address the eating disorder psychopathology and to promote complete weight restoration, which brought about a significant reduction in the size of the ulcer and the complete resolution of SRUS symptoms. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2016; 49:731-735).