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Mucosal Prolapse Syndrome

GI Clinic Visit. 86 y/o female with hx/o chronic constipation and pancreatic insufficiency of unclear etiologyC/o red blood on toilet paper after BMsPoor historianStool firm and light brownIncreased stool frequency, spends long time on toilet with incomplete evacuationRecent abd xray: stool fil

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Mucosal Prolapse Syndrome

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    1. Mucosal Prolapse Syndrome Rachel Mepani, MD Walter Hogan, MD June 2, 2008

    2. GI Clinic Visit 86 y/o female with hx/o chronic constipation and pancreatic insufficiency of unclear etiology C/o red blood on toilet paper after BMs Poor historian Stool firm and light brown Increased stool frequency, spends long time on toilet with incomplete evacuation Recent abd xray: stool filled colon

    3. HPI (continued) Colonoscopy 1/03 & 5/03: 2.5 x 3 x 5cm sessile, hepatic flexure polyp with central dimpling No clear margins, assurance of complete resection impossible. Biopsies taken. Villous tubular adenoma without HGD Surgery advised but patient refused CT A/P 5/03 & 4/07: No colonic or intra-abdominal lesions, atrophic pancreas

    4. Medical History PMHx Chronic Constipation Pancreatic Insufficiency with Steatorrhea Diverticulosis HTN Diabetes Hypothyroidism Breast cancer s/p resection Osteoporosis Social History Former smoker, quit many years ago Allergies PCN, Sulfas, Contrast Dye

    5. Medications Norvasc Pancrease ASA Fosamax Gabapentin Glyburide/Metformin Labetalol Levothyroxine Lisinopril K Cl

    6. Physical Exam VSS Perineum: no erythema or skin disruption Proliferation of skin tags Rectal: empty ampulla Minimal sphincter tone

    7. Unsedated Flex Sig

    8. Unsedated Flex Sig Rest of colonic mucosa was normal to 30cm Retroflexion not performed due to patient discomfort

    9. Pathology Colonic mucosa with fibrosis and smooth muscle present within the lamina propria and encircling some crypts Mucosal injury with focal areas of volcanic fibrin exudate extending from the mucosa in a volcano-like fashion Adjacent to the mucosa shows reactive changes Dysplasia or malignancy absent Imp: Consistent with mucosal prolapse syndrome

    10. Mucosal Prolapse Syndrome Describes a spectrum of disorders in which overt or occult mucosal prolapse is the common underlying pathogenetic mechanism, including: Rectal prolapse Solitary rectal ulcer syndrome May not be solitary or ulcerated Inflammatory cloacogenic polyp Colitis Cystica Profunda ?Inflammatory Cap Polyposis

    11. Mucosal Prolapse Syndrome Symptoms: bleeding, prolapse, hemorrhoids, mucous discharge, tenesmus, obstructive defecation, excessive straining, hx/o rectal digitation May mimic inflammatory conditions or malignancy Macroscopically: ulcer (50%), polyp, or erythema Can extend up to 120mm from the anal verge Defecography revealed rectal prolapse in 94% of SRUS patients (Womack N et al. Pressure and Prolapse- the cause of Solitary Rectal Ulceration. Gut 1987;28:1228-33). SRUS predilection for younger adults because voiding pressures are highest (decrease with increasing age). SRUS predilection for younger adults because voiding pressures are highest (decrease with increasing age).

    12. Mechanism for Prolapse & Ulceration Excessive straining ? high intra-abdominal pressure ? forces the anterior rectal mucosa firmly into the contracting puborectalis muscle & into anal canal

    13. Mechanism for Prolapse & Ulceration Theories for ulceration: Large pressure gradient across rectal wall ? high pressure ? distention of submucosal blood vessels ? rupture with bleeding and devitalisation of rectal mucosa Prolapse through anal canal ? strangulation ? congestion, edema, and ulceration Cycle of healing and subsequent re-injury

    14. Diagnosis Rectal Biopsy: Definitive diagnosis Defecography: Occult rectal prolapse Endoscopic US Demonstrates smooth, diffuse thickening of 3rd layer of the rectal wall Preservation of five-layer structure Enables differentiation from other conditions (malignancy, IBD)

    15. Pathology Fibromuscular obliteration of the lamina propria Extension of smooth muscle fibers into the lamina propria Disorientation of muscularis mucosae Histologic features of mucosa in SRUS (n=19) and Prolapse (n=16)

    16. Treatment Laparoscopic rectopexy Prolapsed rectum is raised and secured with to adjacent fascia Transanal excision of prolapsing mucosa Conservative Treatment: Submucosal sclerotherapy Glycerine suppositories Rubber band ligation

    17. References Du Boulay et al. Mucosal Prolapse Syndrome- a Unifying Concept for Solitary Ulcer Syndrome and Related Disorders. J Clin Pathol 1983;36:1264-8. Hizawa K. Mucosal Prolapse Syndrome: Dx with Endoscopic Ultrasound. Radiol 1994;191:527-30. Kang Y. Pathology of the Rectal Wall in SRUS and Complete Rectal Prolapse. Gut 1996;38:587-90. Singh B. Histopathological Mimicry in Mucosal Prolapse. Histopathol 2007;50:97-102. Womack N et al. Pressure and Prolapse- the cause of Solitary Rectal Ulceration. Gut 1987;28:1228-33.

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