Solitary rectal ulcer syndrome in 102 patients: Do different phenotypes make sense?

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.

Incidental anal 18fluorodeoxyglucose uptake: Should we further examine the patient?

BACKGROUND: There are no studies on incidental anal 18F-fluorodeoxyglucose (18FDG) uptake. AIM: To assess the rate and aetiologies of incidental anal 18FDG uptake and to evaluate the correlation between 18FDG positron-emission tomography/computed tomography (PET/CT) parameters and the diagnosis of an anorectal disease. METHODS: The data from patients with incidental anal 18FDG uptake were retrospectively analysed. Patients who underwent anorectal examinations were identified and compared to those who did not undergo examinations. Patients who were offered treatment were then identified and compared to those who did not receive treatment. RESULTS: Among the 43020 18FDG PET/CT scans performed, 197 18FDG PET/CT scans of 146 patients (0.45%) reported incidental anal uptake. Among the 134 patients included, 48 (35.8%) patients underwent anorectal examinations, and anorectal diseases were diagnosed in 33 (69.0%) of these patients and treated in 18/48 (37.5%) patients. Among the examined patients, those with a pathology requiring treatment had significantly smaller metabolic volumes (MV) 30 and MV41 values and higher maximal and mean standardized uptake value measurements than those who did not require treatment. CONCLUSION: Incidental anal 18FDG uptake is rare, but a reliable anorectal diagnosis is commonly obtained when an anorectal examination is performed. The diagnosis of an anorectal disease induces treatment in more than one-third of the patients. These data should encourage practitioners to explore incidental anal 18FDG uptake systematically.

Anal ulcerations in Crohn's disease: Natural history in the era of biological therapy.

BACKGROUND: The natural history of anal ulcerations in Crohn's disease remains unknown. AIMS: To assess the long-term outcomes of anorectal ulcerations. METHODS: Data from consecutive patients with perineal Crohn's disease were prospectively recorded. The data of patients with anal ulceration were extracted. RESULTS: Anal ulcerations were observed in 154 of 282 patients (54.6%), and 77 cases involved cavitating ulcerations. The cumulative healing rates were 47%, 70% and 82% at 1, 2 and 3 years, respectively. Patients with a primary fistula phenotype had a shorter median time to healing of their anal ulceration (28 [13-83] weeks) than those with a stricture (81 [28-135] weeks) or those with isolated ulceration (74 [31-181] weeks) (p=0.004). Among patients with ulcerations but no fistula at referral (n=67), only 4 (6%) developed de novo abscesses and/or fistula during follow-up. There was no benefit associated with introducing or optimising biologics, nor with combining immunosuppressants and biologics. CONCLUSION: Anal ulceration in Crohn's disease usually requires a long time to achieve sustained healing. Determining the impact of biologics on healing rates will require dedicated randomised trials although it does not show a significant healing benefit in the present study.