The defecographic and clinical aspects of the solitary rectal ulcer syndrome

Background: Solitary rectal ulcer syndrome is a complex evacuation disorder characterized by a benign ulcerative lesion of the distal rectum; the main symptom is rectal bleeding, but mucus discharge and difficult evacuation may be associated. The clinical, endoscopic and radiologic findings of solitary rectal ulcer syndrome are evaluated in this study. The role of defecography in the diagnosis of mucosal ulceration and morphofunctional alterations such as rectal prolapse and intussusception are investigated.

Methods: In the last 5 years, 27 patients (19 women and 8 men; mean age: 38 years; range: 13-70 years) complaining of obstructed evacuation and rectal bleeding were examined with fibrosigmoidoscopy with biopsy, and defecography combined with videoproctography. Defecography was carried out sitting the patients on a defecographic chair with the pelvis in lateral projection. The images were acquired at rest, under straining, during squeezing and evacuation.

Results: Endoscopy and biopsy showed 21 cases of solitary ulcer (77.8%), 3 cases of multiple ulcers (11.1%), 2 cases of granular proctitis (7.4%) and 1 case of pseudopolyp of rectum (3.7%). Among anorectal dynamic alterations, only 1 case (3.7%) of large rectocele was detected at endoscopy under straining. Histo-pathological changes were compared according to Rutter and Riddel criteria; the "colitis cystica profunda" appearance was observed in 2 cases (7.4%). Defecography showed 18 cases (16.6%) of solitary ulcer, 1 case (3.7%) of multiple ulcers and 2 cases (7.4%) of granular proctitis; but it missed 3 cases (11.1%) of small solitary ulcer, 2 cases (7.4%) of small multiple ulcers, and 1 case (3.7%) of pseudopolyp. The dynamic abnormalities shown by defecography were 11 cases (40.7%) of rectal intussusception, 7 cases (25.9%) of recto-anal intussusception, 6 cases (22.2%) of external rectal prolapse and 8 cases (29.6%) of mucosal prolapse. In 16 patients (59.2%) videoprotography emphasized how the ulcer wall was the first to take part in the invagination complex.

Conclusions: Double contrast barium enema represents a useful radiologic method to diagnose solitary rectal ulcer, but air insufflation and pharmacological hypotonia prevent the functional study of rectal walls. Endoscopy permits to detect mucosal ulcerations, erythema, pseudopolyps and granular proctitis; biopsy provides an accurate diagnosis. We suggest combined defecography and videoproctography as a useful tool for evaluating solitary rectal ulcer syndrome as a whole; defecography is necessary to identify associated functional abnormalities, such as rectal prolapse and intussusception, not detectable by other instrumental and radiologic investigations and considered by many authors the likely cause of the disease.