visitor, Other, 12:13AM Feb 14, 2014
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I recently got involved in the care of a 43 y/o female with PMH of morbid obesity s/p RYGB in 2006, GERD s/p Nissen fundoplication and a family history of ulcerative colitis (father) who herself has been plagued with chronic rectal bleeding and associated iron deficiency anemia.
The patient reports that the onset of her rectal bleeding occurred after she underwent some type of hemorrhoidal surgery in 2011 (details are unknown to us. The pt first presented to our health system in early November 2013 via hospital transfer for severe hematochezia and syncope and was admitted to the ICU and required a pRBC transfusion. A diagnositic colonoscopy was performed that demonstrated: a few small-mouthed diverticula were found in the sigmoid colon, the terminal ileum appeared normal, 3 linear rectal ulcer were noted with white exudates that were biopsied. Pathology demonstrated only REGENERATIVE/HYPERPLASTIC COLONIC MUCOSA.
The patient was treated with hydrocortisone and mesalamine suppositories without much benefit as her rectal bleeding persisted, and she represented to our hospital in the middle of January. I performed a flexible sigmoidoscopy that demonstrated diffuse ulceration only in the distal rectum, and biopsies demonstrated: ULCERATED COLONIC MUCOSA IN A BACKGROUND OF REACTIVE EPITHELIAL
On the same flex sig, I thought I saw a possible rectal fistula tract, and considering the possibility for IBD in this patient, a pelvic MRI was performed that showed: increased T2 signal and enhancement of the the rectal mucosa is likely inflammatory, with no evidence of perirectal or perianal fistula.
Upon further discussions with the pathologist for my biopsies, he shared with me that the above biopsies show colonic mucosa with ulceration and fibrinoinflammatory exudate. The background mucosa demonstrates reactive features and focal smooth muscle proliferation in the lamina propria suggestive of prolapse. The findings could represent changes secondary to mucosal prolapse (so-called solitary rectal ulcer syndrome).
I discussed the potential diagnosis of solitary rectal ulcer syndrome (SRUS) with the patient, who shared with me that she is sometimes constipated and has difficulty defecating. To further evaluate for the potential of SRUS, I had the patient complete a defecography exam, looking for rectal prolapse or incomplete or delayed rectal emptying that would predispose SRUS. Remarkably, her exam demonstrated normal initiation and evacuation of stool contents with NO evidence of rectal prolapse.
The patient represented again to our hospital early this week complaining of significant recurrent rectal bleeding, and was admitted to our ICU with severe anemia with a Hgb of 6.2. After receiving a couple units of pRBCs, the patient underwent a repeat colonoscopy that demonstrated: a single (solitary) ulcer in the rectum with what appeared to be a visible vessel, on which clips were placed. Additional biopsies were also obtained. No further mucosal disease was seen in the examined colon and terminal ileum, and an concurrent EGD was also normal.