Episode 83 - Solitary Rectal Ulcer

Episode 83: Solitary Rectal Ulcer. Dr Singh explains how we can diagnose and treat solitary rectal ulcer syndrome (SURS) and Brandy gave an introduction regarding Elvis Presley’s death.  Introduction: Did Elvis Die Pooping?By Brandy Truong, MS4, Ross University School of Medicine. A pop culture trivia fact I always found interesting was that Elvis Presley may have died from trying to have a bowel movement. There are different statements on the cause of death ranging from cardiac arrest, drug overdose, anaphylactic shock, and straining to have a bowel movement. But we’re not here to figure out which one is accurate or debate all that. Elvis was found in the bathroom on the floor and many people described it as if he was on the toilet and then fell forward. If he died from pooping, how does that even happen? We’re going to explore that a little.When we strain to have a bowel movement, it’s called the Valsalva maneuver. This maneuver is divided into 4 stages. Phase 1 is when one first starts straining or bears down. This causes an increase in chest pressure and blood being forced out from the large veins. This is reflected in a rise in blood pressure and a decrease in heart rate. In phase 2, there is reduced venous return to the heart because the blood was forced out of the large veins. Because there is less return to the heart, the heart doesn’t pump out as much as it normally would which leads to a fall in blood pressure. The body senses this fall in blood pressure and will compensate by increasing the heart rate significantly. Phase 3 is when one stops bearing down which results in a release of chest pressure. This causes a fall in blood pressure which causes the heart rate to increase as a reflex. In phase 4, the decreased venous return seen in phase 2 is now restored, which causes an increase in blood pressure. The heart rate then decreases as a reflex response. Both blood pressure and heart rate will return to normal. This entire process occurs over a span of a little over 10 seconds.Elvis was known to have a drug addiction and later some doctors found that he had hypertrophic cardiomyopathy which is a condition in which the heart is unable to pump blood well. He abused a variety of pain medications including opioids. Opioids often cause constipation; therefore, if Elvis was constipated and straining, the Valsalva maneuver compounded by heart disease and other unhealthy lifestyles he had would have caused his cardiac arrest. Intense straining during the process of defecation can result in subarachnoid hemorrhage in people with congenital berry aneurysms, for example. If you end up googling to find out how Elvis died, let us know what you think and if you think he died from pooping. This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home.   Solitary Rectal Ulcer Syndrome.  By Parneeta Singh, MD, Ross University School of Medicine. Discussed with Hector Arreaza, MD.Solitary Rectal Ulcer Syndrome (SRUS) is a benign, rare, underdiagnosed disorder that can mimic and be incorrectly diagnosed as inflammatory bowel disease (IBD) or rectal cancer. The exact prevalence is unknown but in general, it is reported as an annual prevalence of one in 100,000 people. It mostly occurs in the third decade in men and fourth decade in women, with men and women being equally affected. However, cases have been identified in the pediatric and geriatric populations as well. SRUS is a misnomer because although some patients may present with a solitary ulcer, many present with multiple ulcers that may also involve the sigmoid colon. Presentation. Rectal bleeding (with the amount varying from a little fresh blood to severe hemorrhage that may require blood transfusions), mucus discharge, excessive straining, abdominal and perineal pain, constipation, or diarrhea, feeling of incomplete defecation, tenesmus, and rarely rectal prolapse are clinical symptoms associated with SRUS. Presentation may resemble intestinal parasites such as Entamoeba histolytica (amebiasis) and Enterobius vermicularis (pinworm).The underlying etiology is unknown, but a number of mechanisms have been suggested including ischemic injury from the pressure of impacted fecal matter and local trauma due to repetitive self-digitation, although the latter remains unproven. Ulcers usually occur in the mid-rectum which cannot be reached by self-digitation. Additionally, it has been proposed that the perineum’s descent along with the abnormal contraction of the puborectalis muscle during defecation results in trauma or a prolapsed rectum with mucosal prolapse being the most common underlying pathogenesis in SRUS. Diagnosis. The diagnosis of SRUS is based on clinical features and proctosigmoidoscopy findings, with histological examination and biopsies being the key to the diagnosis. Imaging studies including defecating proctography, dynamic MRI and anorectal functional studies also aid in the diagnosis with the latter showing that 25% to 82% of SRUS patients have dyssynergia with paradoxical anal contraction. A thorough evaluation is important in ruling out IBD, ischemic colitis, and malignancy.Histology evaluation of biopsy establishes the diagnosis of solitary rectal ulcer syndrome. Findings include fibromuscular obliteration of the lamina propria. This obliteration causes hypertrophy and disorganization of the muscularis mucosa and regenerative changes. There is an abnormal crypt organization. In cases were polypoid lesions are prevalent, the mucosa has a villiform configuration, and in some cases, the glands may be trapped in the submucosa, which is called colitis cystica profunda.Treatments.Various treatment options are available for SRUS with the treatment choice depending on symptom severity and the presence of rectal prolapse. The initial steps, especially in asymptomatic patients, include patient education and behavioral modifications which include a high-fiber diet, straining discontinuation, and a discussion of psychosocial factors. Biofeedback is the next step in those who fail to respond to conservative measures. Biofeedback seems to help by altering efferent autonomic pathways to the gut that reduces straining with defecation by correcting abnormal pelvic-floor behavior. Topical treatments used include corticosteroids, salicylate, sulfasalazine, mesalazine, sucralfate suppositories and topical fibrin sealant. Unfortunately, surgery is necessary in almost one-third of adults with associated rectal prolapse who do not respond to the above treatment options. Surgical treatments include ulcer excision, treatment of internal or overt rectal prolapse, and de-functioning colostomy. Open rectopexy and mucosal resection have shown a success rate of 42% to 100%. In conclusion, SRUS is an uncommon disease that can mimic IBD and rectal cancer. Thus, a thorough and complete patient history and work-up is required to accurately diagnose SRUS, following which patient education, reassurance that the lesion is benign and a conservative, stepwise individualized approach is important in the management of this syndrome.Conclusion: Now we conclude our episode number 83 “Solitary Rectal Ulcer.” Rectal bleeding, constipation, diarrhea, abdominal pain… yes, it sounds like Chron’s syndrome, but your list of differentials may be very long. You may want to add to that list Single Rectal Ulcer Syndrome. The treatment goes beyond medications for inflammation and includes pelvic floor training. Even without trying, every night you go to bed being a little wiser.Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email [email protected], or visit our website riobravofmrp.org/qweek. This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Brandy Truong, and Parneeta Singh. Audio edition: Suraj Amrutia. See you next week! _____________________References:“Elvis Presley.” Wikipedia, Wikimedia Foundation, 21 Jan. 2022, https://en.wikipedia.org/wiki/Elvis_Presley#Cause_of_death.  Markel, Dr. Howard. “Elvis' Addiction Was The Perfect Prescription for an Early Death.” PBS, Public Broadcasting Service, 16 Aug. 2018, https://www.pbs.org/newshour/health/elvis-addiction-was-the-perfect-prescription-for-an-early-death.   Srivastav, Shival. “Valsalva Maneuver.” StatPearls [Internet]., U.S. National Library of Medicine, 28 July 2021, www.ncbi.nlm.nih.gov/books/NBK537248/.  Zipes, Douglas. “Valsalva Maneuver.” Valsalva Maneuver - an Overview, ScienceDirect Topics, www.sciencedirect.com/topics/neuroscience/valsalva-maneuver . Qing-Chao Zhu, Rong-Rong Shen, Huan-Long, Yu Wang. Solitary rectal ulcer syndrome: Clinical features, pathophysiology, diagnosis, and treatment strategies. World J Gastroenterology. 2014 Jan 21; 20(3): 738–744. doi: 10.3748/wjg.v20.i3.738. PMID: 24574747; PMCID: PMC3921483. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3921483/ Young Min Choi, Hyun Joo Song, Min Jung Kim, Weon Young Chang, Bong Soo Kim, Chang Lim Hyun. Solitary Rectal Ulcer Syndrome Mimicking Rectal Cancer. The Ewha Medical Journal. 2016 Jan 29; 39(1): 28-31. doi: https://doi.org/10.12771/emj.2016.39.1.28. Department of Internal Medicine, Surgery, Radiology and Pathology, Jeju National University School of Medicine, Jeju, Korea. https://synapse.koreamed.org/articles/1058669 Sachin B Ingle, Yogesh G Patle, Hemant G Murdeshwar, Chitra R Hinge Ingle. An unusual case of solitary rectal ulcer syndrome mimicking inflammatory bowel disease and malignancy. Arab J Gastroenterol. 2012 Jun 13(2):102. doi: 10.1016/j.ajg.2012.02.004. Epub 2012 Apr 11. Department of Pathology. PMID: 22980604. https://pubmed.ncbi.nlm.nih.gov/22980604/      Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!