Discussion:
In this report, we presented a rare case of polypoid lesion of the rectum as a variant of solitary rectal ulcer syndrome. The polypoid appearance of this lesion may be misdiagnosed with an inflammatory polyp, hyperplastic polyp, or rectal carcinoma leading to delayed diagnosis and treatment of the disease which can cause several complications.5
The diagnosis is based on the patient’s symptoms, colonoscopy, and histopathological findings. The most common symptom is rectal bleeding as mentioned in our case. The most common colonoscopic findings are solitary or multiple ulcers or polyps, however, some patients do not have any ulcers. The ulcer is usually located in the anterolateral wall of the rectum 3 – 10 cm from the anal verge.3,4
The colonoscopic finding of solitary rectal ulcer can be similar to inflammatory bowel disease and rectal carcinoma so it is necessary to have biopsies for a definite diagnosis. Histopathological findings are the gold standard for the definite diagnosis of solitary rectal ulcer. Histologic features are fibromuscular obliteration of the lamina propria, extension of muscle fiber upward between crypts, glandular crypt abnormalities, collagen deposition in lamina propria, surface erosion, and reactive hyperplasia.1,6,7
As described above, minimal inflammation in lamina propria and regenerative hyperplasia in crypt cells are seen in our case and this is important to distinguish from dysplasia. Sometimes this regenerative hyperplasia with the extension of smooth muscle fibers in lamina propria and around the crypts can give the false impression of invasive adenocarcinoma, so it is necessary to consult with an expert gastrointestinal pathologist to confirm the diagnosis.
Treatment is based on the severity of the disease. Conservative therapy is the first line of treatment in most cases and surgery can be used for patients who are unresponsive to conservative therapy or have rectal prolapse. Conservative therapy includes a high-fiber diet, intermittent use of laxatives, changing toilet habits, corticosteroids, sulfasalazine, and 5-aminosalicylate enemas are reported to be effective as topical therapies for solitary rectal ulcers. Procedures used for solitary rectal ulcers include rectopexy, Delorme’s procedure, local excision, and perineal proctectomy.1,4,8 Our patient was treated with a combination of lifestyle and topical therapies that relieved his symptoms.
In conclusion, for patients with a history of rectal bleeding and a suspicious mass observed in the colonoscopy, a biopsy must be taken to decide on the treatment plan, because the treatment plans differ based on the nature of the mass whether it is malignant or not.
Acknowledgments: The authors are thankful to the patient and Imam Reza hospital’s endoscopy ward staff for their collaboration.