Pressure and prolapse--the cause of solitary rectal ulceration

The cause of solitary rectal ulceration has been investigated using a method that radiologically visualises rectal voiding whilst simultaneously measuring intrarectal pressure and external anal sphincter electromyographic activity. Control subjects and patients with the solitary rectal ulcer syndrome, both with and without mucosal ulceration, have been studied. A high incidence of rectal prolapse (94%) was present in the patients who voided. Overactivity of the anal sphincter during evacuation contributed to the fact that patients with mucosal ulceration required higher intrarectal pressures to void than the controls and the patients without mucosal ulceration. The results indicate that a combination of rectal prolapse and a high voiding pressure may act to cause the mucosal ulceration in this syndrome by exposing the rectal wall to a high transmural pressure gradient.     

Colonic hemorrhage from a solitary minute ulcer. Report of three cases

Three patients with massive lower gastrointestinal bleeding are reported. In all cases, the bleeding source was localized by emergency selective mesenteric angiography. The histologic lesion found in the resected specimen consisted of a minute mucosal ulcer with an abnormally large eroded submucosal artery without evidence of true angiodysplastic changes. The clinicopathological picture is similar to the rare solitary stomach ulceration, described as "Exulceratio simplex Dieulafoy."     

Computed tomography in the differential diagnosis of the enlarged retrorectal space

The value of computed tomography (CT) in the differentiation of an enlarged retrorectal space was analyzed in 132 cases. Classification of barium enema findings into those with simultaneous mucosal alterations and those without any visible lesions of the rectal mucosa seems to be useful. Computed tomography helps in those cases without mucosal changes to differentiate between retrorectal fibrosis, tumorous masses, and inflammatory diseases of the colon. It also demonstrates the lack of pathologic lesions in equivocal cases of pelvic lipomatosis and so-called "normal variants." If simultaneous mucosal involvement on barium enema--especially in rectal carcinoma or recurrent carcinoma of the rectum--is found, CT may show the perirectal extension of tumorous masses and thus help to clarify local operability.     

Rectal stricture associated with the long-term use of ibuprofen suppositories

Here, we report the case of a 64-year-old woman who suffered from chronic lower backache for which she received ibuprofen suppositories. The patient was admitted to the hospital with a suspected rectal tumor. Clinical examination did not reveal any abnormal finding apart from a mild, bilateral peritibial edema. On rectal examination, an area of stenosis was detected approximately 7 cm above the anal verge. All laboratory parameters, including different tumor markers, were within normal range. Pelvic CT scan and colonoscopy revealed a circular rectal stenosis with severe destruction of the rectal mucosa. The rectal biopsy taken during endoscopy showed severe acute and chronic ulceration, chronic granulation and fibrosis with lymphocytic infiltration. After exclusion of sexually transmitted diseases such as syphilis and lymphogranuloma venerium or exposure to drugs as a possible cause of rectal stenosis, the history in this particular case suggests that the prolonged use of the cyclooxygenase (COX) inhibitor "ibuprofen" as a suppository is the cause of mucosal destruction and rectal stenosis.     

Anorectal manometry in active and quiescent ulcerative colitis

Anorectal function was measured in 11 patients with active medically intractable ulcerative colitis, seven patients with quiescent ulcerative colitis, and 18 healthy subjects. The anal resting pressure, squeeze pressure, and ability to defecate a balloon were similar in all groups. Significantly lower rectal distention volumes were required for rectal sensation, critical volume, and to induce rectal contractility in patients with active disease compared to controls or patients with quiescent disease. Rectal compliance was significantly reduced in patients with active and quiescent disease. The increased rectal sensitivity and contractility in patients with active colitis appear to be related to active mucosal inflammation and ulceration. Episodes of mucosal inflammation may be responsible for chronic changes in the rectal wall resulting in fibrosis and decreased compliance in patients with quiescent disease. The frequency and urgency of defecation and the fecal incontinence may be due to a hypersensitive, hyperactive, and poorly compliant rectum.     

Mechanism of stress ulcer

In previous reports from this laboratory, it has been proposed that stress ulceration results from a severe gastric mucosal energy deficit due to shock-induced mucosal ischemia. In the experiments described in this report, the hypothesis was further tested by studying stress ulceration and gastric mucosal energy metabolism in rabbits subjected to hemorrhagic shock with or without the concomitant administration of an -adrenergic blocking agent. Our data show that stress ulceration and gastric mucosal energy deficits are significantly less severe when shock is combined with -adrenergic blockade.This work was supported by grants AM-17955 and AM-17092 from the U.S.P.H.S.     

Prolapsing mucosal polyps: an underrecognized form of colonic polyp--a clinicopathological study of 15 cases

OBJECTIVE: Prolapsing intestinal mucosa occurs in many forms throughout the GI tract. We describe 15 patients with polypoid masses in the sigmoid colon and histological features of mucosal prolapse. METHODS: Fifteen patients with colon polyps demonstrating endoscopic and histological features of mucosal prolapse were retrospectively identified from our database. RESULTS: Twelve patients presented with signs and symptoms that were nonspecific, but consistent with mucosal prolapse, such as occult or gross intestinal bleeding and lower abdominal pain. Three patients were asymptomatic. The polyps occurred in the sigmoid colon, usually in association with diverticular disease, and appeared more often in men. Endoscopically, the polyps appeared to be well-circumscribed, hyperemic masses that contrasted sharply with normal-appearing adjacent mucosa. Histological features include glandular crypt abnormalities, fibromuscular obliteration of the lamina propria, and thickened and splayed muscularis mucosa. CONCLUSIONS: Prolapsing mucosal polyps of the colon are histologically similar to other mucosal prolapsing conditions in the GI tract, such as the solitary rectal ulcer syndrome, inflammatory cloacogenic polyps, inflammatory "cap" polyps, and gastric antral vascular ectasia, and should therefore be designated as part of the "mucosal prolapse syndrome."     

Systematic review: anal and rectal changes after radiotherapy for prostate cancer

Purpose

Pelvic radiotherapy may lead to changes of anorectal function resulting in incontinence-related complaints. The aim of this study was to systematically review objective findings of late anorectal physiology and mucosal appearance after irradiation for prostate cancer.

Methods

MEDLINE, EMBASE, and the Cochrane library were searched. Original articles in which anal function, rectal function, or rectal mucosa were examined ≥3 months after EBRT for prostate cancer were included.

Results

Twenty-one studies were included with low to moderate quality. Anal resting pressures significantly decreased in 6 of the 9 studies including 277 patients. Changes of squeeze pressure and rectoanal inhibitory reflex were less uniform. Rectal distensibility was significantly impaired after EBRT in 7 of 9 studies (277 patients). In 4 of 9 studies on anal and in 5 of 9 on rectal function, disturbances were associated with urgency, frequent bowel movements or fecal incontinence. Mucosal changes as assessed by the Vienna Rectoscopy Score revealed telangiectasias in 73 %, congestion in 33 %, and ulceration in 4 % of patients in 8 studies including 346 patients, but no strictures or necrosis. Three studies reported mucosal improvement during follow-up. Telangiectasias, particularly multiple, were associated with rectal bleeding. Not all bowel complaints (30 %) were related to radiotherapy.

Conclusions

Low to moderate quality evidence indicates that EBRT reduces anal resting pressure, decreases rectal distensibility, and frequently induces telangiectasias of rectal mucosa. Objective changes may be associated with fecal incontinence, urgency, frequent bowel movements, and rectal bleeding, but these symptoms are not always related to radiation damage.     

Hapten-induced model of chronic inflammation and ulceration in the rat colon

We have developed a simple and reproducible rat model of chronic colonic inflammation by the intraluminal instillation of a solution containing a "barrier breaker" and a hapten. Administration of the hapten 2,4,6-trinitrobenzenesulfonic acid (5-30 mg) in 0.25 ml of 50% ethanol as the "barrier breaker" produced dose-dependent colonic ulceration and inflammation. At a dose of 30 mg, trinitrobenzenesulfonic acid/ethanol-induced ulceration and marked thickening of the bowel wall persisted for at least 8 wk. Histologically, the inflammatory response included mucosal and submucosal infiltration by polymorphonuclear leukocytes, macrophages, lymphocytes, connective tissue mast cells, and fibroblasts. Granulomas were observed in 57% of the rats killed 3 wk after induction of inflammation. Langhan's-type giant cells were also observed. Segmental ulceration and inflammation were common. The characteristics and relatively long duration of inflammation and ulceration induced in this model afford an opportunity to study the pathophysiology of colonic inflammatory disease in a specifically controlled fashion, and to evaluate new treatments potentially applicable to inflammatory bowel disease in humans.     

Collagenous colitis: Clinical and histological spectrum in ten patients

Collagenous colitis is characterized by the presence of a thick subepithelial collagen band in the colonic mucosa. The condition was diagnosed on rectal biopsy in 10 patients (one male, nine females) who presented with watery diarrhoea. Although rectal mucosal erythema was present in three and ulceration in two, the mucosa was of normal endoscopic appearance in five of the patients. There was marked variability in the thickness of the submucosal collagen band, both between and within individuals. Empirical drug therapy included sulphasalazine, glucocorticoids and antidiarrhoeals. All patients reported symptomatic improvement.     

Barium enema and defaecography in the diagnosis and evaluation of the solitary rectal ulcer syndrome

Forty-three patients with histologically proven solitary ulcer syndrome of the rectum were examined by defaecography and 33 by barium enema. Barium enema showed changes in the rectum in all cases. Thickening of the rectal folds and spasm were most common, followed by ulceration and pseudopolypoid change. None of these changes is individually pathognomonic of the solitary ulcer syndrome, but viewed in conjunction they are highly suggestive of the condition. During defaecography, intussusception of the rectum was observed in 34 cases (79%). In 19 (44%) a complete external prolapse was present while intra-anal and intra-rectal intussusception was found in 15 (35%). Intussusception arose in most cases from the mid-rectum, and rarely from a rectal mucosal prolapse of the ampulla. Awareness of the abnormalities of the solitary ulcer syndrome on barium enema enables the radiologist to suggest the diagnosis and recommend defaecography to establish the functional disorder, which may help determine the appropriate medical or surgical treatment.     

Cystic fibrosis,Crohn's colitis,and adult meconium ileus equivalent

A 23-year-old man with cystic fibrosis developed massive rectal bleeding that continued intermittently, necessitating an emergency laparotomy and total colectomy. The resected colon was shortened by fibrosis and displayed widespread excessive production of mucus, forming a carpetlike layer over the mucosa as well as segmental discrete areas of mucosal ulceration with fissures, transmural inflammation, and multiple epithelioid granulomas, which are in keeping with Crohn's disease. One case, in a seven-year-old girl, had been reported previously.     

Aqueous suspension of anise ＂Pimpinella anisum＂ protects rats against chemically induced gastric ulcers

AIMTo substantiate the claims of Unani and Arabian traditional medicine practitioners on the gastroprotective potential effect of a popular spice anise,"Pimpinella anisum L." on experimentally-induced gastric ulceration and secretion in rats.METHODSAcute gastric ulceration in rats was produced by various noxious chemicals including 80% ethanol,0.2 mol/L NaOH,25% NaCl and indomethacin.Anti-secretory studies were undertaken using pylorusligated Shay rat technique.Levels of gastric non-protein sulfhydryls(NP-SH)and wall mucus were estimated and gastric tissue was also examined histologically.Anise aqueous suspension was used in two doses(250 and 500 mg/kg body weight)in all experiments.RESULTSAnise significantly inhibited gastric mucosal damage induced by necrotizing agents and indomethacin.The anti-ulcer effect was further confirmed histologically.In pylorus-ligated Shay rats,anise suspension significantly reduced the basal gastric acid secretion,acidity and completely inhibited the rumenal ulceration.On the other hand,the suspension significantly replenished ethanol-induced depleted levels of gastric mucosal NP-SH and gastric wall mucus concentration.CONCLUSIONAnise aqueous suspension possesses significant cytoprotective and anti-ulcer activities against experimentally-induced gastric lesions.The anti-ulcer effect of anise is possibly prostaglandin-mediated and/or through its anti-secretory and antioxidative properties.     

Rectal mucosal hemodynamics, evaluated by reflectance spectrophotometry, in patients with chronic hepatitis

To evaluate rectal mucosal hemodynamics in patients with chronic hepatitis, we employed reflectance spectrophotometry and examined the results in relation to the presence and severity of chronic hepatitis. Twenty-six patients with histologically diagnosed chronic hepatitis and 21 controls were examined for rectal vascular findings by endoscopy. Indices (I) of rectal mucosal oxygen saturation (ISO₂) and rectal mucosal hemoglobin (IHb) concentration were measured. To minimize the effects of systemic anemia, the IHb was divided by blood Hb concentration, giving the rectal index for Hb (RHb). The relationship between rectal mucosal hemodynamics and the histological grade of chronic hepatitis was studied. Rectal vascular lesions were observed in three patients with chronic hepatitis (11.5%). The RHb in patients with chronic hepatitis was significantly higher than that in the controls (5.74 ± 0.71 and 4.82 ± 1.12, respectively; P < 0.01). There was no significant difference in ISO₂ levels (44.23 ± 5.84 and 41.94 ± 4.91, respectively). No significant correlation was observed between rectal mucosal hemodynamics and the histological severity of chronic hepatitis, although rectal mucosal hemodynamics changed in patients with chronic hepatitis. Early vascular changes were observed in the rectal mucosa of patients with chronic hepatitis. (Received Oct. 23, 1997; accepted Dec. 19, 1997)     

Omeprazole heals mucosal ulcers associated with endoscopic injection sclerotherapy

Endoscopic injection sclerotherapy (EIS) is a standard and definitive therapy for bleeding esophageal varices. While the overall complication rate of the procedure is low, a substantial minority of patients treated by EIS develop refractory mucosal ulceration and/or esophageal strictures. However, despite the prophylactic use of H2 blockers and sucralfate in our EIS protocol, we observed a number of patients who developed nonhealing esophageal and/or gastroduodenal ulceration. We conducted an open trial in which we enrolled nine patients who had refractory ulcer disease. Patients that enrolled in the trial exhibited complete healing of their mucosal ulcers. These results suggest that acid is an important contributory factor in the pathogenesis and perpetuation of EIS-associated mucosal ulceration. Patients with alcohol-associated liver disease may be at increased risk for the development of EIS-associated complications.     

Necrotizing duodenitis--a stress-associated lesion?

We report three cases of stress ulceration exhibiting primarily mucosal abnormalities of the duodenum with duodenal ulceration and linear ulcerations on the duodenal folds which is unique in our experience. We hypothesize that vascular insufficiency during low flow states decreases the ability of mucosa to buffer back-diffused hydrogen ion, leading to mucosal injury and ulceration. The duodenal folds receive an end-arteriole supply and are thus affected before other areas of the duodenum. Given the degree of necrosis associated with these lesions on pathological examination, we have chosen the term necrotizing duodenitis to describe the lesions observed.     

Endoscopic Evaluation of Rectal Mucosal Reddening in Patients with Liver Cirrhosis

Background: Colonic mucosal lesions observed in patients with portal hypertension have been reported as portal hypertensive colopathy. We studied the rectal mucosa in patients with liver cirrhosis to evaluate the prevalence of mucosal reddening which looks like gastric red spots in the portal hypertensive gastropathy and to determine whether there is a correlation between this lesion and portal hypertension or the severity of liver disease. Methods: Seventy‐two patients with liver cirrhosis and 50 control subjects were examined. Colonoscopy was performed to evaluate the presence of mucosal reddening in the rectum. We investigated the relations between rectal mucosal reddening and esophageal varices, portal hypertensive gastropathy and the severity of liver cirrhosis. Results: Rectal mucosal reddening was observed in eight of 72 patients with liver cirrhosis but in none of the 50 control subjects; its prevalence in cirrhosis patients was significantly higher than that in the control subjects (P < 0.05). Cirrhosis patients with esophageal varices were more likely to have rectal mucosal reddening than cirrhosis patients without esophageal varices (P < 0.05). In addition, the occurrence of rectal mucosal reddening correlated with the severity of cirrhosis, based on Child–Pugh's classification (P < 0.05). Conclusion: We have shown that rectal mucosal reddening develops in patients with liver cirrhosis and is associated with the existence of esophageal varices and the severity of liver cirrhosis. These results suggest the possibility that portal hypertension and impaired liver function may play an important role in the pathogenesis of rectal mucosal reddening in patients with cirrhosis.     

Endoscopic submucosal resection with an endoscopic variceal ligation device for the treatment of rectal neuroendocrine tumors

Background

Endoscopic resection is recommended for rectal neuroendocrine tumors <?1 cm in diameter; the three techniques (mucosal resection, submucosal dissection, and mucosal resection with variceal ligation device) of endoscopic resection of neuroendocrine tumor were reported; however, the optimal endoscopic technique remains unclear.

Purpose

We compared the efficacy and safety of three endoscopic rectal neuroendocrine tumor resection methods.

Methods

We retrospectively enrolled 52 patients with rectal neuroendocrine tumors treated by endoscopy at Aichi Medical University Hospital and Nagoya City University Hospital between May 2003 and June 2017. We compared clinical outcomes in three groups based on the endoscopic treatment method.

Results

Fifty-two patients underwent endoscopic rectal neuroendocrine tumor treatment (mucosal resection, 14; submucosal dissection, 19; mucosal resection with an endoscopic variceal ligation device, 19). In the endoscopic mucosal resection, submucosal dissection, and mucosal resection with variceal ligation device groups, R0 resection occurred in 50.0, 94.7, and 89.5%, respectively (mucosal resection vs. mucosal resection with variceal ligation device, p <?0.05; mucosal resection vs. submucosal dissection, p <?0.01), while the median procedure times were 6.5, 43, and 6.0 min, respectively (submucosal dissection vs. mucosal resection with variceal ligation device procedure times, p?<?0.01; mucosal resection vs. submucosal resection procedure times, p <?0.01). Postoperative bleeding occurred after endoscopic mucosal resection (1/14) and endoscopic submucosal dissection (4/19), but not after endoscopic mucosal resection with a ligation device.

Conclusion

Endoscopic mucosal resection with an endoscopic variceal ligation device was a safe, effective treatment for rectal neuroendocrine tumors.

     

Trimming of a migrated metal stent for malignant colonic stricture using argon plasma coagulation

We report the first case of trimming of a migrated metal colonic stent for stent induced severe anorectal pain. We present a case of a 54-year-old female with history of metastatic colorectal carcinoma who had stent placement secondary to obstruction. Subsequent distal migration of the stent caused ulcerations into the rectal mucosa and excruciating anorectal pain. We used argon plasma coagulation (APC) to successfully trim the exposed distal portion of the metal stent and rat tooth forceps to retrieve the stent fragments. The use of APC for trimming metallic stents is an effective procedure that can be used to trim migrated rectal stents that result in significant rectal pain. To date, few studies have been published that use APC to trim metallic stents placed in the gastrointestinal tract. To the best of our knowledge, ours is the only known case in which the indication for stent trimming was severe stent induced rectal pain. The procedure resulted in complete relief of patient symptoms. Therefore, APC is a safe and effective way to trim colo-rectal stents to definitively relieve the symptom of stent induced rectal pain in patients who have experienced distal stent migration and mucosal ulceration.     

Intracellular pH in isolated Necturus antral mucosa in simulated ulcerogenic conditions

Intracellular pH (pHi) was measured with proton-sensitive liquid sensor microelectrodes in isolated Necturus antral mucosa, paying special attention to arranging experimental conditions to simulate conditions frequently associated with in vivo "stress ulceration." Intracellular pH in mucosas perfused under standard conditions (Ringer's solution containing HCO3-/CO2) was 7.22 + 0.02 (n = 27). Removal of Na+ and HCO3- or addition of amiloride or 4-acetamido-4-isothiocyanostillbene-2,2-disulfonic acid (blockers of Na+/H+ and Cl-/HCO3-exchangers) had no influence on steady-state pHi, suggesting that these ion exchangers do not significantly contribute to the maintenance of pHi in the presence of normal external pH. Acidification of mucosal (luminal) perfusate to pH 3 (mimicking the presence of gastric acid) had no influence on pHi, but mucosal pH 2 (10 mM HCl) acidified pHi to 6.93 +/- 0.07. Acidification of serosal (nutrient) perfusate to pH 6 (mimicking intramucosal acidosis caused by back-diffusion of luminal H+) acidified pHi to 6.72 +/- 0.10. Removal of Na+ from and addition of amiloride to the serosal perfusate during exposure to serosal pH 6.0 induced further acidification of pHi, suggesting that in this acidotic situation (with very low ambient HCO3- concentration) a Na+/H+ exchanger does contribute to the maintenance of steady-state pHi. Increased PCO2 (10% vol/vol in the gas) in a slightly acidic milieu (mimicking mucosal ischemia) likewise acidified pHi to 6.73 +/- 0.05. A combination of mucosal acid (pH 3), high PCO2 (10% CO2), and low serosal pH (pH 6) (mimicking conditions that prevail, for example, during hemorrhagic shock) acidified pHi and ultimately resulted in cell death. These derangements of intracellular acid-base balance may have pathogenetic importance also in in vivo stress ulceration.