Argon plasma coagulation of hemorrhagic solitary rectal ulcer syndrome

Argon plasma coagulation: an effective treatment for solitary rectal ulcer syndrome

BACKGROUND

Solitary rectal ulcer syndrome (SRUS) is a very rare benign defecation disorder characterized by distinct clinical features and histological findings. Conventional measures are often shown to be ineffective for the treatment of ulcers. Argon plasma coagulation (APC) has recently been shown to be an effective treatment method for SRUS that is refractory to conventional therapy.

OBJECTIVES

Determine the efficacy of APC treatment for patients suffering from SRUS.

DESIGN

Prospective, single center.

SETTINGS

Gastroenterology department at a military hospital in Pakistan.

PATIENTS AND METHODS

This prospective study included patients with symptoms of rectal bleeding diagnosed with SRUS. Patients were recruited on the basis of clinical, sigmoidoscopic, and histological findings from September 2022 to March 2023. All patients had received conventional treatment initially and were assessed for persistence of symptoms. APC was performed only for those patients who were refractory to standard treatment.

MAIN OUTCOME MEASURES

Effectiveness of APC for resistant SRUS.

SAMPLE SIZE

99 patients.

RESULTS

The 99 patients diagnosed with SRUS had a median (minimum-maximum) age of patients was 20 (9-41) years. All the patients had undergone conventional treatment, which included the use of laxatives, drinking plenty of water and practicing biofeedback. After this standard treatment, 19 patients (19.19%) recovered fully. However, the remaining 80 patients did not show improvement and underwent APC sessions, out of which 61 patients (76.3%) achieved complete healing of ulcers, while the remaining 19 (23.8%) had no improvement at all. None of the patients reported post session complications.

CONCLUSION

APC is an effective therapy with very promising results for rectal ulcer hemorrhage. It also helps with ulcer healing and alleviates clinical symptoms. However, further controlled investigations are required to consolidate the use of APC in SRUS patients.

LIMITATIONS

Single centered.

The Impact of Argon Plasma Coagulation in the Treatment of a Solitary Rectal Ulcer Syndrome Revealed by Massive Hemorrhage

Solitary rectal ulcer syndrome (SRUS) is a rare and chronic rectal condition that can result in a pelvic static disorder. Massive rectal bleeding is a rare manifestation of SRUS. The diagnosis is based on a combination of clinical, endoscopic, and histological findings. The management of bleeding ulcers is usually insufficient with the conventional treatment. Argon plasma coagulation (APC) has been reported to control bleeding. However, its role in healing and improving defecation symptoms is not unanimous in studies. Our case report features a 35-year-old male with terminal constipation and chronic rectal pain, taking laxatives and analgesics, who presented abundant rectal bleeding with hemodynamic instability. The colonoscopy showed two large bleeding rectal ulcers. The histological study of the biopsies was in favor of a solitary rectal ulcer. We have performed multiple sessions of APC. The bleeding was stopped after the first session and there was progressive healing and improvement of the rectal symptoms after other sessions. At 18 months follow-up, the patient is asymptomatic, and no longer uses analgesics and laxatives. Argon plasma coagulation is an effective treatment to control rectal ulcer bleedings. It also improves the healing process and clinical symptoms. However, further controlled studies are needed to support this hypothesis.

Argon plasma coagulation-an effective treatment for solitary rectal ulcer syndrome: A single-center experience from western India

BACKGROUND AND AIM

Solitary rectal ulcer syndrome (SRUS) is an uncommon benign disorder of defecation. Management of ulcers is usually unsatisfactory with conventional treatment (laxatives, behavioral therapy, biofeedback, topical treatments, and surgery). Studies on the effectiveness of argon plasma coagulation (APC) for SRUS refractory to conventional treatment is lacking. The aim of the study was to examine the effect of APC with conventional therapy in controlling bleeding and healing of refractory SRUS.

METHODS

Fourteen patients of refractory SRUS diagnosed on clinical, colonoscopic, and histological findings, refractory to conventional therapy, were offered multiple sessions of APC in addition to conventional treatment. All patients were followed up to determine bleeding control and ulcer healing.

RESULTS

Fourteen patients with a mean duration of symptoms of 9.21 ± 6.94 months were included. All the patients were advised to have a high intake of fluids and laxatives and to undergo biofeedback in addition to the APC. Lesions were located anteriorly (66%), circumferentially (25%), and posteriorly (9%). Mean follow-up duration was 7 months (3 to 12 months). APC enabled bleeding control in all the patients (100%), complete healing of ulcer in 71% (10 patients), and reduction in ulcer size to less than 50% of the initial size in the remaining 29% patients. None of the patients had any procedure-related complications like bowel perforation, infections, or fistula formation.

CONCLUSIONS

APC with conventional therapy is effective in controlling bleeding and healing in SRUS refractory to conventional treatment.

A systematic literature review on solitary rectal ulcer syndrome: is there a therapeutic consensus in 2018?

PURPOSE

To screen all treatments tested for solitary rectal ulcer syndrome (SRUS) without rectal prolapse and to assess their efficacy.

METHOD

A systematic review was performed according to the PRISMA guidelines, focusing on the treatment of SRUS without rectal prolapse. The types of treatment and their efficacy were collected and critically assessed.

RESULTS

A selection of 20 studies among the 470 publications focusing on SRUS provided suitable data for a total of 516 patients. Only 2 studies were randomised prospective trials that focused on argon plasma treatment. The mean follow-up was 21.8 months and ranged from 0.25 to 90 months. Most of the studies focused on surgery, including rectopexy, stapled transanal rectal resection, excision of the ulcer, the Delorme procedure, proctectomy, low anterior resection, and ostomy. Populations of the studies were heterogeneous and selected outcomes were specific (failure of medical or surgical treatment). Conservative treatment (high-fibre diet, laxatives, change of defecatory habits, and biofeedback treatment) induced a symptomatic improvement in 71/91 patients (63.6%) and healing of mucosal lesion in 17/51 patients (33.3%). Surgeries (all types) improved SRUS in 77% (54-100%) of patients. Argon plasma coagulation is a promising technique but longer follow-up is necessary.

CONCLUSIONS

The general quality of the studies focusing on the treatment of SRUS was poor due to the heterogeneity of the population, the sample size of the cohorts, and the heterogeneity of efficacy assessments. The therapeutic approach appears to be multimodal and multidisciplinary and validated in centres of expertise. Further studies evaluating multimodal strategies are needed.

Evaluation of argon plasma coagulation in healing of a solitary rectal ulcer in comparison with conventional therapy: a randomised controlled trial

Introduction

Argon plasma coagulation (APC) has been reported to be effective in the treatment of solitary rectal ulcer syndrome (SRUS). However, it has not appeared to be effective in healing ulcers.

Aim

This study aimed at assessing the effectiveness of APC in controlling rectal ulcer-induced bleeding, and at examining the ultimate effect of this approach in healing these lesions.

Material and methods

This randomised, controlled trial was conducted on 99 patients with SRUS. Patients were randomly enrolled into two groups of APC therapy (intervention) and conventional therapy (control). The control group (n = 58) received a high-fibre diet, laxatives, behaviour therapy, and sucralfate enemas, and the intervention group (n = 41) were treated with APC plus conventional therapy; in fact they received directed and focused argon gas in addition to a high-fibre diet and laxatives.

Results

Responses to treatment in the control group and in the APC-receiving group were 29.3% and 75.6%, respectively. The continuation of ulcer healing after 3 months in the control group was 10.3%, and it was 70.7% in the APC-treated group. There was a significant statistical difference between the two groups (p < 0.004), i.e. bleeding was controlled more frequently in the group receiving APC plus conventional therapies than in the group receiving only the conventional therapies. However, the results showed no statistically significant difference between the two groups in terms of pain relief (p < 0.36).

Conclusions

Argon plasma coagulation not only controlled bleeding in patients with SRUS, but also, in comparison with the conventional methods of treating SRUS, led to healing and continuation of healing of rectal ulcers.

Effective treatment of solitary rectal ulcer syndrome using argon plasma coagulation

Solitary rectal ulcer syndrome (SRUS) is a chronic, multiform, non-cancerous disorder of the rectum, the final diagnosis of which is based upon histopathological criteria. This disorder is often accompanied by latent proctoptosis. We present a patient who (in 1996) was the first case in which argon plasma coagulation (APC) was used for SRUS treatment. In the years 2004–2005 the same patient underwent 15 APC sessions (at monthly intervals) obtaining full recovery from SRUS, although she had been treated unsuccessfully for 17 years prior to that. Six-year observation did not show any relapse. Local therapy with APC seems to be an important alternative in SRUS treatment without prolapse of the rectum and could become a basic method for bleeding treatment in SRUS.

Solitary rectal ulcer: ultrasonographic and magnetic resonance imaging patterns mimicking rectal cancer

The objective of this study was to analyze a series of solitary rectal ulcer syndrome (SRUS) cases initially diagnosed as rectal cancer. We analyzed all the patients (1996-2008) initially referred to our colorectal unit with a diagnosis of rectal cancer but with a final diagnosis of SRUS. Demographic data, the diagnostic work-up, and treatment details were collected in a prospective database and analyzed retrospectively. Out of the 5035 patients registered in the colorectal unit database, 14 (0.28%) had a final diagnosis of SRUS. Nine of them had an initial diagnosis of rectal cancer. Out of these, six were preoperatively staged with endorectal ultrasound and/or magnetic resonance and were therefore analyzed for this study. Endorectal ultrasound was performed in all six patients and rectal cancer was diagnosed in five of them; MRI was performed in four patients and a diagnosis of rectal cancer was assessed in three of them; rectal cancer was finally ruled out in all cases by deep-forceps macrobiopsies. The incidence of misdiagnosis between SRUS and rectal cancer does not decrease with the regular use of imaging methods. Clinical judgment and deep-forceps macrobiopsies are essential in avoiding an erroneous diagnosis.

Healing of solitary rectal ulcers with multiple sessions of argon plasma coagulation

BACKGROUND

Solitary rectal ulcer syndrome (SRUS) is an uncommon disorder of evacuation. Management of bleeding ulcers is usually unsatisfactory with conventional treatment. Argon plasma coagulation (APC) has been reported to control bleeding; however, it has not been shown to result in ulcer healing. The aim of the present study was to: (i) to investigate the efficacy and safety of APC in controlling bleeding from SRUS; and (ii) to study its efficacy in the healing of ulcer/s.

METHODS

Twenty-four patients with bleeding SRUS diagnosed on clinical, colonoscopic, and histological findings were randomized to receive either standard care alone (12 patients) or to undergo multiple sessions of APC in addition (12 patients). All patients were followed up to determine ulcer healing.

RESULTS

Twenty-four patients with a mean duration of symptoms of 12.6 +/- 4.8 months were included. Bleeding was controlled with one (n = 5) or two sessions (n = 7) of APC. Reduction in size and depth of ulcer was noted. Eight out of 12 patients who received APC had complete healing of ulcers after four to eight sessions, carried out 2-4 weeks apart. The remaining four patients had a reduction in size and depth of ulcers compared to their pretreatment appearance. All patients were advised to have a high intake of fluids, fiber and laxatives, and to undergo biofeedback and behavior modification therapy in addition to the treatment.

CONCLUSIONS

APC controls bleeding in patients with SRUS and it also improves the healing of these ulcers.

Healing of a bleeding solitary rectal ulcer with multiple sessions of argon plasma

BACKGROUND

Solitary rectal ulcer syndrome (SRUS) is an uncommon disorder of evacuation. Management of bleeding ulcers is usually unsatisfactory with conventional treatments. Argon plasma coagulation (APC) has been reported in case reports to control bleeding; however, it has not been shown to result in ulcer healing.

OBJECTIVE

To investigate the efficacy and safety of APC in controlling bleeding from SRUS and to study its efficacy in eventual healing of ulcers.

DESIGN

A randomized, controlled trial of the management of 24 consecutive patients with SRUS.

SETTING

The gastroenterology unit at 2 tertiary care hospitals.

PATIENTS

Twenty-four patients with bleeding SRUS.

MAIN OUTCOME MEASUREMENTS

Control of bleeding and endoscopic healing of SRUS.

METHODS

Twenty-four patients with bleeding SRUS, whose diagnoses were based on clinical, colonoscopic, and histologic findings, were randomized to receive either standard care only (12 patients, biofeedback therapy [BT] group) or multiple sessions of APC in addition to BT (12 patients, APC group). All patients were advised to intake a high level of fluids and fibers, laxatives, biofeedback, and behavior modification therapy in addition to the treatment. Patients were followed to determine whether ulcers healed.

RESULTS

Twenty-four patients with symptoms that lasted 12.6 +/- 4.8 months were included. Bleeding was controlled in all 12 patients in the APC group, but only in 5 of 12 patients in BT group. We also made the following observations about healing of the ulcers: 8 of 12 patients in the APC group had complete healing of their ulcers after 4 to 8 sessions, whereas in the BT group, ulcers healed in only 2 of 12 patients.

CONCLUSIONS

APC controls the bleeding in patients with SRUS and also improves the healing of these ulcers.

Spontaneous resolution of solitary rectal ulcer syndrome during pregnancy: report of a case

Solitary rectal ulcer syndrome is a rare condition that is associated with disordered defecation and is thought to be an ischemic injury from repeated mucosal trauma. Treatment is designed to alleviate the underlying defecatory problems and is only moderately successful. We report an interesting case of solitary rectal ulcer syndrome in a young woman, which was resistant to standard nonoperative management but completely resolved during two pregnancies only to recur when she was not pregnant, and we suggest a possible hormonal explanation for this unique occurrence.

Solitary rectal ulcer syndrome in childhood: a rare, benign, and probably misdiagnosed cause of rectal bleeding. Report of three cases

Solitary rectal ulcer syndrome is an uncommon and often underdiagnosed condition that usually presents with hematochezia, mucous discharge, and tenesmus. Its etiology is unknown but it seems related to excessive straining with defecation. Prolonged efforts force the anterior rectal mucosa into the anal canal with strangulation and appearance of congestion, edema, and ulceration. Histologic findings (fibromuscular obliteration of lamina propria and disorientation of muscle fibers) are characteristic, which helps to differentiate these lesions from other rectal entities. Although solitary rectal ulcer syndrome is rarely reported in children, it must be suspected in patients with rectal discharge of blood and mucus and previous disorders of evacuation. We present three children (aged 9, 10, and 14 years) with solitary rectal ulcer syndrome that had presented with rectal bleeding. A careful inquiry about evacuation habits and a high index of suspicion in children presenting with hematochezia helps to diagnose this possibly unrecognized or misdiagnosed entity in children. Endoscopy and histologic examination confirms this condition.