Solitary rectal ulcer syndrome

　　The exact etiology of solitary rectal ulcer syndrome (SRUS) has not been fully elucidated. It is generally believed that the formation of ulcers may be related to the following factors.

　　1, Ischemia

　　The top of the rectal prolapse mucosa is impaled above the anal canal, and with the strong contraction of the external sphincter, it can cause ischemic and necrotic mucosal compression. In cases of large prolapse, the extension and rupture of the submucosal blood vessels can also cause ischemia. Local mucosal ischemia often leads to the formation of ulcers.

　　2, Injury

　　Some patients may cause mucosal injury and ulcer formation by inserting their fingers into the anus to induce defecation or to reset the prolapsed rectum when they have difficulty defecating.

　　In addition, SRUS may also be related to intestinal inflammation, vascular abnormalities, bacterial or viral infections, and other factors.

　　Patients with solitary rectal ulcer syndrome may develop complications such as intestinal perforation, acute hemorrhagic necrotizing enteritis, and rectal prolapse.

　　1, Intestinal perforation refers to the process where the intestinal lesions penetrate the intestinal wall, causing the intestinal contents to溢出 into the peritoneal cavity. It is one of the severe complications of many intestinal diseases, causing severe diffuse peritonitis, mainly manifested as severe abdominal pain, abdominal distension, and symptoms of peritonitis. Severe cases can lead to shock and death.

　　2, Acute hemorrhagic necrotizing enteritis is an acute enteritis associated with the infection of Clostridium perfringens type C. The disease mainly affects the small intestine, and its pathological changes are characterized by bleeding and necrosis of the intestinal wall. The main clinical manifestations include abdominal pain, hematochezia, fever, vomiting, and abdominal distension. Severe cases may present with shock, intestinal paralysis, and other toxic symptoms, as well as complications such as intestinal perforation.

　　2, Proctoptosis refers to a pathological condition where the anal canal, rectum, or even the distal sigmoid colon is displaced downward and protrudes outside the anus. Submucosal prolapse is incomplete prolapse, while complete prolapse refers to the full thickness of the rectum descending. The prolapsed part located within the rectum is called internal prolapse, and the part protruding outside the anus is called external prolapse.

　　Patients with solitary rectal ulcer syndrome may present with all symptoms of anal-rectal diseases, such as hematochezia, mucoid stools, constipation or difficulty defecating, tenesmus, rectal and anal pain, diarrhea, and may also have fecal incontinence and massive hemorrhage. Some patients may palpate a sigmoid colon fold in the lower left abdominal area with tenderness. Rectal examination may reveal thickened mucosal ulcers and tenderness on the anterior wall of the lower rectum. During defecation, the apex of prolapse can be palpated, and the gloves may be stained with blood and mucus.

　　To prevent solitary rectal ulcer syndrome, patients should maintain smooth bowel movements and regulate their diet in daily life.

　　1. Consume a high-fiber diet to maintain smooth bowel movements.

　　2. Eat more foods rich in vitamin C, such as fresh vegetables and fruits.

　　3. Eat in small, frequent meals, and avoid overeating. It is not advisable to eat too heavily at dinner.

　　4. Control the quality and quantity of fat intake. Saturated fatty acids can increase blood cholesterol levels, while polyunsaturated fatty acids can lower cholesterol levels. Therefore, the intake of saturated fatty acids such as lard and beef fat should be controlled in the diet.

　　5. Avoid eating indigestible foods, such as fried beans and hard pancakes, as they stay in the gastrointestinal tract for a longer period of time, which can easily trigger ulcers and inflammation.

　　Defecography can dynamically observe the functional changes of the anus and rectum during defecation, which is helpful to understand whether there are accompanying anatomical and functional abnormalities in patients with solitary rectal ulcer syndrome, such as anterior rectal prolapse and intussusception.

　　1. Rectal examination

　　A single ulcer may be palpable at the anal-rectal junction, with elevated edges and tenderness. The surrounding mucosa may present nodular changes, and polypoid masses may also be palpable. Occasionally, a circumferential stricture can be felt at the lower end of the rectum.

　　2. Endoscopy

　　Observe the location, number, and morphology of the ulcers, and take viable tissue for examination to make an accurate diagnosis. The lower margin of the ulcers is often located within 3 to 15 cm from the anal margin, with high positions being rare. 70% of the ulcers are distributed on the anterior wall of the rectum, 20% on the posterior wall, and about 10% are in a ring-shaped distribution, commonly crossing over the rectal valves. In terms of the number of ulcers, 70% are solitary; the multiple lesions are often scattered, located at higher positions, and can be divided into ulcerative, elevated, and mixed types, with the formation of the three types possibly related to different stages of the lesion. The ulcerative type is the most common, characterized by superficial ulcers with clear boundaries, ulcer sizes ranging from (1.0cm×1.0cm) to (2.0cm×2.0cm), and the morphology is mostly circular and oval. The surrounding mucosa shows mild inflammation, edema, and congestion, with clear vascular patterns, soft and elastic texture, and a grayish-white film covering the base. Other types are occasionally seen, such as elevated mucosa with soft and elastic texture, clear boundaries, and no stenosis in the lumen. The characteristic feature of SRUS is the obliteration of the mucosal固有层, thickening of the muscularis mucosae, and fibrosis and thickening of the muscular layer, which can protrude into the intestinal lumen. There are ectopic glands in the submucosa, which are reliable evidence for diagnosing SRUS and distinguishing it from rectal tumors, inflammatory bowel diseases, and other conditions. The specimen should be sufficient to avoid misdiagnosis and missed diagnosis.

　　3. Barium enema

　　Non-specific examination, which is difficult to distinguish from rectal cancer and inflammatory bowel disease. The examination can show signs such as rectal shadowing, filling defects, stenosis, rough and disordered mucosa, thickened rectal mucosa, polyps, and nodules.

　　4. Rectal defecation contrast enhancement

　　This has become an important method for studying the dynamics of the rectum and anal canal, measuring the angle of the anal canal and rectum under resting or forced-urination state, observing the changes in the relationship between the anal canal and the pubococcygeal line, and can find changes such as rectal prolapse, anterior rectal bulging, pelvic floor spasm, perineal descent, intestinal hernia, rectal prolapse, and ulcer, which have guiding significance for diagnosis and treatment. Kuijpers reported that 39 cases of SRUS had a positive rate of 95% in contrast enhancement examination, mainly due to internal intussusception, pelvic floor muscle spasm, and functional defecation disorders. It was proposed that defecation contrast enhancement could clearly diagnose SRUS and guide treatment.

　　5. Rectal anal manometry

　　To detect the anal and rectal pressure and physiological reflexes between the rectum and anal canal, in order to understand the functional status of the anal and rectal canal. Keighley reported 33 cases of SRUS patients, of which 16 underwent pressure measurement, 8 could not tolerate 200ml of rectal expansion, 6 had disappeared of the reflex expansion, 2 had decreased rectal sensory threshold. The rectal threshold, maximum tolerance volume, and sensory volume of SRUS patients decreased, and some patients lacked rectal anal inhibitory reflex.

　　6. Electromyography measurement

　　When the intestinal tract contracts autonomously, the current amplitude and frequency of the external sphincter increase; during defecation, there is no reflex from the puborectalis muscle, and the sphincter cannot relax.

　　7. Anal canal ultrasound

　　To measure the degree, severity, and whether the rectal intussusception mucosa enters the anal canal or thickness exceeds 3mm, the diameter and cross-sectional area of the anal canal internal sphincter can be increased compared to normal people, and the external anal sphincter has similar changes; the thickness ratio of the external and internal sphincters decreases significantly. For patients with defecation disorders as the main manifestation, ultrasonic examination shows that the hypertrophy of the anal canal sphincter is helpful for the diagnosis of SRUS.

　　8. Biopsy

　　It shows non-specific chronic inflammatory changes, with erosion and ulceration on the mucosal surface, covered by a pseudomembrane-like structure. The mucosal muscular layer thickens, there is an increase in fibrous tissue between glands, with infiltration of lymphocytes and plasma cells. In the late stage, the rectal gland cells show significant hyperplasia, with certain heterogeneity, which can extend into the interstitium between the mucosal muscular layer and submucosal layer, and is prone to be misdiagnosed as a cancerous lesion.

　　Patients with solitary rectal ulcer syndrome can eat more millet, corn, Job's tears, wheat,小米, red beans, mung beans, broad beans, bitter melon, cucumber, winter melon, kohlrabi, amaranth, cauliflower, and chard. It is taboo to eat indigestible and irritant foods such as gas-producing, high-fiber, greasy, cold, spicy, fried, and deep-fried foods, as well as strong spirits, milk, and tea or coffee. Patients with solitary rectal ulcer syndrome can also relieve symptoms through dietary therapy (the information is for reference only, please consult a doctor for details).

　　1. Red bean Job's tears drink

　　30 grams of red bean, 30 grams of Job's tears, add water and simmer over low heat for 30 minutes, then take out 100 milliliters of juice, simmer for another 30 minutes and pour out the remaining 100 milliliters of juice. Mix the two juices together and drink warm or cold.

　　2. Chrysanthemum winter melon soup

　　20 grams of dried chrysanthemum, cut into segments, soak in boiling water for 20 minutes, then add 50 grams of winter melon shreds to the boiling soup, cook for a moment, add salt, monosodium glutamate, and a few drops of sesame oil.

　　3. Stir-fried bitter melon

　　200 grams of fresh bitter melon, sliced, soak in boiling water for a moment to remove the bitterness, then fried in oil until almost done, remove from heat, pour sauce (containing salt, monosodium glutamate) over it.

　　In clinical practice, the drugs and specific treatment methods for treating rectal ulcers in traditional Chinese medicine also include a variety of options, which are completely determined by the patient's own condition. Traditional Chinese medicine emphasizes differentiation and treatment, and the treatment methods and medical practices for the same disease in different people are different. Moreover, traditional Chinese medicine treatment can generally only temporarily alleviate related symptoms, with a long course of treatment, heavy economic burden, and patients are also prone to develop a strong dependence on drugs, which is not conducive to effective treatment. Therefore, patients should be cautious when choosing treatment methods.

　　There is a prescription for rectal ulcer, the ingredients are 10 grams of carbonized Sanguisorba officinalis, 10 grams of whole Angelica sinensis, 10 grams of Cortex Mahoniae, 15 grams of fried Flos Sophorae, 15 grams of pericarp of Punica granatum, 3 grams of Coptis chinensis. Soak in an appropriate amount of water for 15 minutes, then boil directly, remove the dregs and concentrate to 50-100 milliliters. Retain enema 1 time before going to bed every night, 3 times as a course. There are generally 3 methods for treating rectal ulcers in traditional Chinese medicine:

　　1. Strengthening the body and firming the intestines, regulating the balance of intestinal microflora, promoting the regeneration and repair of intestinal mucosa, and improving the body's immunity.

　　2. Detoxifying and degrading, clearing heat and drying dampness, promoting Qi and relieving pain, constricting and moistening, harmonizing the intestines and stomach, and stopping diarrhea.

　　3. Invigorating the spleen and kidney, replenishing qi and removing dampness is the fundamental treatment method, clearing heat and detoxifying, and promoting blood circulation and removing blood stasis are used for symptomatic treatment. Differentiation of symptoms and treatment should be avoided, and it is most忌 to use strong bitter and cold remedies for a long time. It can also be combined with Chinese medicine injections to reinforce the body.