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.