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Gaj F, Lai Q, Gelormini E, Ceci M, Di Saverio S, Quaresima S. Efficacy of surgical treatments for the management of solitary rectal ulcer syndrome: a network meta-analysis. Colorectal Dis 2024; 26:1515-1534. [PMID: 38957108 DOI: 10.1111/codi.17080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 05/11/2024] [Accepted: 05/27/2024] [Indexed: 07/04/2024]
Abstract
AIM Solitary rectal ulcer syndrome (SRUS) is a benign and poorly understood disorder with complex management. Typical symptoms include straining during defaecation, rectal bleeding, tenesmus, mucoid secretion, anal pain and a sense of incomplete evacuation. Diagnosis is based on characteristic clinical symptoms and endoscopic/histological findings. Several treatments have been reported in the literature with variable ulcer healing rates. This study aimed to evaluate the efficacy of different treatments for SRUS. MATERIALS AND METHODS A systematic review and network meta-analysis were performed according to the PRISMA guidelines. Studies in English, French and Spanish languages were included. Papers written in other languages were excluded. Other exclusion criteria were reviews, case reports or clinical series enrolling less than five patients, study duplications, no clinical data of interest and no article available. A systematic literature search was conducted from January 2000 to March 2024 using the following databases: PubMed/MEDLINE, Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and Scopus. The biases of the studies were assessed using the Newcastle-Ottawa scale or the Jadad scale when appropriate. Types of treatment and their efficacy for the cure of SRUS were collected and critically assessed. The study's primary outcome was to estimate the rate of patients with ulcer healing. RESULTS A total of 22 studies with 911 patients (men 361, women 550) diagnosed with SRUS were analysed in the final meta-analysis. The pooled effect estimates of treatment efficacy revealed that surgery showed the highest ulcer healing rate (70.5%; 95% CI 0.57-0.83). Surgery was superior in the cure of ulcers with respect to medical therapies and biofeedback (OR 0.09 and OR 0.14). CONCLUSION Solitary rectal ulcer syndrome is a challenging clinical entity to manage. Proficient results have been reported with the surgical approach, suggesting its positive role in cases refractory to medical and biofeedback therapy. Further studies in homogeneous populations are required to evaluate the efficacy of surgery in this setting. (PROSPERO registration number CRD42022331422).
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Affiliation(s)
- Fabio Gaj
- Department of General Surgery and Surgical Specialties 'Paride Stefanini', Sapienza University of Rome, AOU Policlinico Umberto I, Rome, Italy
| | - Quirino Lai
- Department of General Surgery and Surgical Specialties 'Paride Stefanini', Sapienza University of Rome, AOU Policlinico Umberto I, Rome, Italy
| | - Enza Gelormini
- Department of General Surgery and Surgical Specialties 'Paride Stefanini', Sapienza University of Rome, AOU Policlinico Umberto I, Rome, Italy
| | - Marino Ceci
- Department of General Surgery and Surgical Specialties 'Paride Stefanini', Sapienza University of Rome, AOU Policlinico Umberto I, Rome, Italy
| | - Salomone Di Saverio
- ASUR Marche, San Benedetto del Tronto Hospital, San Benedetto del Tronto, Italy
| | - Silvia Quaresima
- Department of General Surgery and Surgical Specialties 'Paride Stefanini', Sapienza University of Rome, AOU Policlinico Umberto I, Rome, Italy
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Infectious Proctitis Masquerading as Solitary Rectal Ulcer Syndrome: A Potential Pitfall. ACG Case Rep J 2022. [DOI: 10.14309/crj.0000000000000891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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Solitary rectal ulcer syndrome in 102 patients: Do different phenotypes make sense? Dig Liver Dis 2021; 53:190-195. [PMID: 33199231 DOI: 10.1016/j.dld.2020.10.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 10/30/2020] [Accepted: 10/31/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Little is known about the pathophysiological mechanisms of solitary rectal ulcer syndrome (SRUS). AIMS We aim to identify the different phenotypes, taking into account complaints, anatomy and anorectal physiology. METHODS Complaints, endoscopy results, and physiology data of patients with histologically proven SRUS were collected and analysed. The associated anorectal diseases were faecal incontinence and obstructed defecation. The clinical aspects of SRUS were compared, and factors associated with anorectal diseases were identified. RESULTS Overall, 102 consecutive patients were included. The predominant lesion was a rectal ulcer (66%), and inflammation of the rectal wall was present in 42% of patients. Abnormal rectal capacities and/or rectal perception was observed in more than half. Nearly half (52%) of the patients met the criteria for obstructed defecation and they tended to more frequently have psychiatric disease (66.7% vs 33.3%; p=0.07). Patients with faecal incontinence (17%) reported more self-perception of anal procidentia (p=0.01) and were more likely to have inflammation of the rectal wall (p=0.02), high-grade internal rectal procidentia (p=0.06) and anal hypotonia (p=0.004); their maximum tolerable volume was lower (p=0.004). CONCLUSION The characteristics of patients with SRUS suggest different phenotypes. This may be a way to develop a comprehensive treatment strategy.
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Gouriou C, Chambaz M, Ropert A, Bouguen G, Desfourneaux V, Siproudhis L, Brochard C. A systematic literature review on solitary rectal ulcer syndrome: is there a therapeutic consensus in 2018? Int J Colorectal Dis 2018; 33:1647-1655. [PMID: 30206681 DOI: 10.1007/s00384-018-3162-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/03/2018] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Claire Gouriou
- Service des Maladies de l'Appareil Digestif, CHU Pontchaillou, Université de Rennes 1, 2 rue Henri le Guillou, 35033, Rennes Cedex, France
| | - Marion Chambaz
- Service des Maladies de l'Appareil Digestif, CHU Pontchaillou, Université de Rennes 1, 2 rue Henri le Guillou, 35033, Rennes Cedex, France
| | - Alain Ropert
- Service d'Explorations Fonctionnelles Digestives, CHU Pontchaillou, Université de Rennes 1, Rennes, France.,CIC 1414, INPHY, Université de Rennes 1, Rennes, France
| | - Guillaume Bouguen
- Service des Maladies de l'Appareil Digestif, CHU Pontchaillou, Université de Rennes 1, 2 rue Henri le Guillou, 35033, Rennes Cedex, France.,CIC 1414, INPHY, Université de Rennes 1, Rennes, France.,INSERM U1241, Université de Rennes 1, Rennes, France
| | - Véronique Desfourneaux
- Service de Chirurgie Viscérale, CHU Pontchaillou, Université de Rennes 1, Rennes, France
| | - Laurent Siproudhis
- Service des Maladies de l'Appareil Digestif, CHU Pontchaillou, Université de Rennes 1, 2 rue Henri le Guillou, 35033, Rennes Cedex, France.,CIC 1414, INPHY, Université de Rennes 1, Rennes, France.,INSERM U1241, Université de Rennes 1, Rennes, France
| | - Charlène Brochard
- Service des Maladies de l'Appareil Digestif, CHU Pontchaillou, Université de Rennes 1, 2 rue Henri le Guillou, 35033, Rennes Cedex, France. .,Service d'Explorations Fonctionnelles Digestives, CHU Pontchaillou, Université de Rennes 1, Rennes, France. .,CIC 1414, INPHY, Université de Rennes 1, Rennes, France. .,INSERM U1241, Université de Rennes 1, Rennes, France.
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Novel combined approach in the management of non-healing solitary rectal ulcer syndrome - laparoscopic resection rectopexy and transanal endoscopic microsurgery. Wideochir Inne Tech Maloinwazyjne 2015; 10:295-8. [PMID: 26240632 PMCID: PMC4520839 DOI: 10.5114/wiitm.2015.52060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 03/03/2015] [Accepted: 03/30/2015] [Indexed: 01/29/2023] Open
Abstract
Solitary rectal ulcer syndrome (SRUS) is an uncommon chronic disorder with a wide range of endoscopic findings, clinical presentations and characteristic histopathological features. There is no clear consensus regarding SRUS management, because of its poorly understood pathogenesis and frequent association with various pelvic floor disorders. Laparoscopic resection rectopexy and transanal endoscopic microsurgery (TEM) were used for the treatment of non-healing SRUS. The present paper reports a case of non-healing SRUS due to obstructive defecation syndrome based on combined pelvic floor disorders (rectocele, enterocele, internal rectal prolapse and dolichosigma) successfully managed by a novel combined mini-invasive approach which has never been previously reported in the literature (laparoscopic resection rectopexy and TEM). The new minimally invasive concept seems to be safe and feasible – laparoscopic resection rectopexy results in effective correction of the obstructive defecation syndrome, while TEM allows comfortable access for radical resection of a rectal ulcer.
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Zhu QC, Shen RR, Qin HL, Wang Y. Solitary rectal ulcer syndrome: Clinical features, pathophysiology, diagnosis and treatment strategies. World J Gastroenterol 2014; 20:738-744. [PMID: 24574747 PMCID: PMC3921483 DOI: 10.3748/wjg.v20.i3.738] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 11/10/2013] [Accepted: 12/13/2013] [Indexed: 02/06/2023] Open
Abstract
Solitary rectal ulcer syndrome (SRUS) is an uncommon benign disease, characterized by a combination of symptoms, clinical findings and histological abnormalities. Ulcers are only found in 40% of the patients; 20% of the patients have a solitary ulcer, and the rest of the lesions vary in shape and size, from hyperemic mucosa to broad-based polypoid. Men and women are affected equally, with a small predominance in women. SRUS has also been described in children and in the geriatric population. Clinical features include rectal bleeding, copious mucus discharge, prolonged excessive straining, perineal and abdominal pain, feeling of incomplete defecation, constipation, and rarely, rectal prolapse. This disease has well-described histopathological features such as obliteration of the lamina propria by fibrosis and smooth muscle fibers extending from a thickened muscularis mucosa to the lumen. Diffuse collage deposition in the lamina propria and abnormal smooth muscle fiber extensions are sensitive markers for differentiating SRUS from other conditions. However, the etiology remains obscure, and the condition is frequently associated with pelvic floor disorders. SRUS is difficult to treat, and various treatment strategies have been advocated, ranging from conservative management to a variety of surgical procedures. The aim of the present review is to summarize the clinical features, pathophysiology, diagnostic methods and treatment strategies associated with SRUS.
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The clinical, endoscopic and histological spectrum of the solitary rectal ulcer syndrome: a single-center experience of 116 cases. BMC Gastroenterol 2012; 12:72. [PMID: 22697798 PMCID: PMC3444426 DOI: 10.1186/1471-230x-12-72] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Accepted: 05/22/2012] [Indexed: 02/06/2023] Open
Abstract
Background Solitary rectal ulcer syndrome (SRUS) is an uncommon although benign defecation disorder. The aim of this study was to evaluate the variable endoscopic manifestations of SRUS and its association with other diseases. Methods All the patients diagnosed with SRUS histologically from January 1990 to February 2011 at The Aga Khan University, Karachi were included in the study. The medical records were reviewed retrospectively to evaluate the clinical spectrum of the patients along with the endoscopic and histological findings. Results A total of 116 patients were evaluated. The mean age was 37.4 ± 16.6 (range: 13–80) years, 61 (53%) of the patients were male. Bleeding per rectum was present in 82%, abdominal pain in 49%, constipation in 23% and diarrhea in 22%. Endoscopically, solitary and multiple lesions were present in 79 (68%) and 33 (28%) patients respectively; ulcerative lesions in 90 (78%), polypoidal in 29 (25%), erythematous patches in 3 (2.5%) and petechial spots in one patient. Associated underlying conditions were hemorrhoids in 7 (6%), hyperplastic polyps in 4 (3.5%), adenomatous polyps in 2(2%), history of ulcerative colitis in 3 (2.5%) while adenocarcinoma of colon was observed in two patients. One patient had previous surgery for colonic carcinoma. Conclusion SRUS may manifest on endoscopy as multiple ulcers, polypoidal growth and erythematous patches and has shown to share clinicopathological features with rectal prolapse, proctitis cystica profunda (PCP) and inflammatory cloacogenic polyp; therefore collectively grouped as mucosal prolapse syndrome. This may be associated with underlying conditions such as polyps, ulcerative colitis, hemorrhoids and malignancy. High index of suspicion is required to diagnose potentially serious disease by repeated endoscopies with biopsies to look for potentially serious underlying conditions associated with SRUS.
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Abstract
Abstract
Solitary rectal ulcer syndrome (SRUS) is a rare condition with various causes that results in ischemic injury. The aim of this study was to assess the clinical findings, diagnosis, and outcomes of treatment in patients with SRUS. Between 1992 and 2006, a retrospective review was undertaken for all patients diagnosed with SRUS. Fifty-eight patients were diagnosed with SRUS. Among patients with paradoxic rectal spasm (PRS), lesions disappeared in 1 of 3 given applied biofeedback treatment, and in 2 of 4 injected with Botulinum toxin (BotoxTM). Twenty-three patients underwent appropriate surgical treatment. Overall, postoperative improvement was seen in 18 patients (78.2%). In conclusion, every patient with SRUS must be assessed for causative disease. Treatment should include conservative approaches such as Botox injection; in patients with pelvic floor disorders, surgical treatment should be considered.
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Abstract
Solitary rectal ulcer syndrome (SRUS) is an uncommon disorder which can present in patients being evaluated for defecatory disorders or which can present as a primary process often involving hematochezia, rectal pain and tenesmus. Unfortunately the diagnosis of this disorder is often delayed due to misdiagnosis and/or physician unfamiliarity with the condition. We present a 24-year-old female who presented with 6 months of bloody diarrhea and weight loss. She had been receiving treatment for a presumed diagnosis of inflammatory bowel disease (IBD) due to an endoscopic picture of rectal thickening, edema and ulceration and had been on prednisone for 2 months prior to presentation without relief of her symptoms. After further testing including repeat endoscopy with biopsies, defecography and anorectal manometry, the diagnosis of SRUS was made and treatment was changed. Medical management was unsuccessful and she ultimately required surgical intervention. This case highlights the difficulty in diagnosing SRUS due to its resemblance to other gastrointestinal diseases and should serve as a reminder that if a patient is not responding to IBD therapy, another etiology should be considered.
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Affiliation(s)
- S B Umar
- Mayo Clinic Arizona, Scottsdale, Ariz., USA
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Sood SK, Garner JP, Amin SNO. Spontaneous resolution of solitary rectal ulcer syndrome during pregnancy: report of a case. Dis Colon Rectum 2008; 51:1149-52. [PMID: 18392597 DOI: 10.1007/s10350-008-9268-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2006] [Revised: 10/18/2006] [Accepted: 11/26/2006] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Sumit K Sood
- Department of Colorectal Surgery, Northern General Hospital, Sheffield, United Kingdom
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Boccasanta P, Venturi M, Calabro G, Maciocco M, Roviaro GC. Stapled transanal rectal resection in solitary rectal ulcer associated with prolapse of the rectum: a prospective study. Dis Colon Rectum 2008; 51:348-54. [PMID: 18204882 DOI: 10.1007/s10350-007-9115-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2007] [Revised: 06/06/2007] [Accepted: 08/25/2007] [Indexed: 02/06/2023]
Abstract
PURPOSE At present, none of the conventional surgical treatments of solitary rectal ulcer associated with internal rectal prolapse seems to be satisfactory because of the high incidence of recurrence. The stapled transanal rectal resection has been demonstrated to successfully cure patients with internal rectal prolapse associated with rectocele, or prolapsed hemorrhoids. This prospective study was designed to evaluate the short-term and long-term results of stapled transanal rectal resection in patients affected by solitary rectal ulcer associated with internal rectal prolapse and nonresponders to biofeedback therapy. METHODS Fourteen patients were selected on the basis of validated constipation and continence scorings, clinical examination, anorectal manometry, defecography, and colonoscopy and were submitted to biofeedback therapy. Ten nonresponders were operated on and followed up with incidence of failure, defined as no improvement of symptoms and/or recurrence of rectal ulceration, as the primary outcome measure. Operative time, hospital stay, postoperative pain, time to return to normal activity, overall patient satisfaction index, and presence of residual rectal prolapse also were evaluated. RESULTS At a mean follow-up of 27.2 (range, 24-34) months, symptoms significantly improved, with 80 percent of excellent/good results and none of the ten operated patients showed a recurrence of rectal ulcer. Operative time, hospital stay, and time to return to normal activity were similar to those reported after stapled transanal rectal resection for obstructed defecation, whereas postoperative pain was slightly higher. One patient complained of perineal abscess, requiring surgery. DISCUSSION The stapled transanal rectal resection is safe and effective in the cure of solitary rectal ulcer associated with internal rectal prolapse, with minimal complications and no recurrences after two years. Randomized trials with sufficient number of patients are necessary to compare the efficacy of stapled transanal rectal resection with the traditional surgical treatments of this rare condition.
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Affiliation(s)
- Paolo Boccasanta
- 1st Department of General Surgery, Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, IRCCS Foundation, Milan, and the University of Milan, Milan, Italy.
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Abstract
SRUS is a rare condition in children, which usually presents with a symptom complex of rectal bleeding, passage of mucus and straining on defecation, tenesmus, perineal and abdominal pain, sensation of incomplete defecation, constipation and rectal prolapse. The underlying etiology of SRUS is not fully understood but it is likely to be secondary to ischemic changes in the rectum associated with paradoxical contraction of pelvic floor and external anal sphincter muscles and rectal prolapse. Conservative measures like high intake of fluids and fibers, laxatives, biofeedback and behavior modification therapy may be beneficial for treatment of constipation. Excision of rectal ulcer and surgery of overt rectal prolapse, however, may be required in refractory cases not responding to conservative treatments. A therapeutic role for botulinum toxin injection into the external anal sphincter for treatment of SRUS associated with constipation and paradoxical contraction of pelvic floor and external anal sphincter muscles in children, may exist.
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Affiliation(s)
- Alireza S Keshtgar
- University Hospital Lewisham, National Health Service Trust, London, UK.
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Latos W, Kawczyk-Krupka A, Ledwoń A, Sieroń-Stołtny K, Sieroń A. Solitary rectal ulcer syndrome—The role of autofluorescence colonoscopy. Photodiagnosis Photodyn Ther 2007; 4:179-83. [DOI: 10.1016/j.pdpdt.2007.03.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2006] [Revised: 02/21/2007] [Accepted: 03/03/2007] [Indexed: 01/19/2023]
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Alam I, Shanoon D, Alhamdani A, Boyd A, Griffiths AP, Baxter JN. Severe proctitis, perforation, and fatal rectal bleeding secondary to cytomegalovirus in an immunocompetent patient: report of a case. Surg Today 2007; 37:66-9. [PMID: 17186350 PMCID: PMC7102328 DOI: 10.1007/s00595-006-3335-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2005] [Accepted: 07/25/2006] [Indexed: 01/30/2023]
Abstract
Cytomegalovirus (CMV) infection is associated with significant morbidity and mortality in immunocompromised patients. In immunocompetent individuals, the infection is usually subclinical but it can sometimes be life threatening. We describe a case of fatal CMV proctitis in a 71-year-old man following an Ivor-Lewis esophagectomy. After surgery he developed renal failure, methicillin-resistant Staphylococcus aureus pneumonia, and acute respiratory distress syndrome. He recovered but developed melena and massive fresh rectal bleeding. Sigmoidoscopy revealed severe proctitis and a biopsy was consistent with ischemia. Despite undergoing a proctectomy he continued to bleed and died despite every effort. The final histological examination of the rectum revealed a CMV infection.
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Affiliation(s)
- Imran Alam
- Department of Surgery, Morriston Hospital, Swansea, SA6 6NL, UK
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