Introduction

Solitary rectal ulcer syndrome (SRUS), often mistakenly classified as a rectal motility disorder, arises from defecatory irregularities and presents with diverse clinical manifestations. This prospective study conducted at a leading medical center aims to elucidate the spectrum of clinical presentations, potential risk factors, colonoscopic findings, histopathological characteristics, and therapeutic approaches in individuals affected by SRUS.

Aims & Methods

The prospective analysis included all patients diagnosed with SRUS at the Advanced Gastroenterology Institute (AGI) - The GASTROCITI, Ludhiana, over 48 months from March 2020 to February 2024. Cases were identified using the comprehensive database of the Endoscopy Department. Data retrieval from medical records provided insights into clinical symptoms, endoscopic observations, and histopathological features.

Results

From approximately 7000 diagnostic sigmoidoscopies & colonoscopies, a meticulous identification of 48 patients with SRUS was achieved. The average age was 48.5 years (±18.5), with 75% (36) being males. Rectal bleeding was reported by 77% (37) of patients, 64.5% (31) experienced constipation, and 50% (24) described bowel movement difficulties, with an average symptom duration of 13.7 months. Associated factors included constipation (75%), digital rectal manipulation (43.75%), high-pressure water jet usage (25%), prior rectal surgeries (10.5 %), and rectal prolapse (10.5%). Endoscopic findings revealed solitary ulcers in 64.5% of cases, multiple ulcers in 27 %, and polypoidal appearance in 10.5%. Two patients presented with a proliferative mass-like anomaly (pseudotumor) and two had a circumferential rectal stricture. The finding of difficult-to-take endoscopic biopsies due to underlying submucosal fibrosis showed a robust positive predictive value (PPV) exceeding 90% for SRUS diagnosis. Histopathological analysis revealed surface ulceration (90%), lamina propria fibrosis (70%), architectural distortions (60%), and increased muscle hypertrophy with mucin production (50%). Conservative interventions were effective in all cases, without the need for surgical intervention.

Conclusion

SRUS, often misinterpreted as a rectal motility disorder, presents with diverse manifestations. Management strategies including high-dose laxatives, avoidance of digital evacuation and high-pressure water jet usage, adoption of a fiber-rich diet, and localized application of mesalamine/sucralfate and biofeedback therapy have shown efficacy. This study highlights the complex nature of SRUS and emphasizes the importance of a comprehensive approach to diagnosis and management.

References

Introduction

The cornerstone of acute cholangitis treatment is antibiotic therapy combined with biliary drainage. The Tokyo Guidelines 2018 provide severity grading criteria that help predict prognosis and identify patients requiring early biliary drainage. While mild cholangitis can often be managed initially with antibiotics alone, moderate and severe cases typically require early and emergent drainage, respectively. Our aim is to explore factors influencing the timing of ERCP in acute cholangitis and its impact on clinical outcomes.

Aims & Methods

This retrospective single-center cohort study included patients diagnosed with acute cholangitis who underwent ERCP between March 2022 and March 2023 in a tertiary hospital with ERCP. Diagnosis and severity grading were based on the Tokyo Guidelines 2018. Descriptive and statistical analyses were performed to evaluate patient characteristics, severity classification, timing to ERCP and related clinical outcomes.

Results

A total of 104 patients underwent ERCP for acute cholangitis; 55 were female (52.9%) and the median age was 77 years. Based on the Tokyo 2018 criteria, 28 patients (26.9%) had grade III cholangitis, 52 (50%) grade II and 24 (23%) grade I. Only 5 patients (4.8%) underwent ERCP within 24 hours of admission—2 with grade III, 1 with grade II and 2 with grade I. Within 72 hours, 31 patients (29.8%) had undergone ERCP—9 with grade III, 16 with grade II and 6 with grade I. Notably, 70.8% of grade III cases were submitted to ERCP more than 72 hours after admission, with a median of 3 days of antibiotics before the procedure. There was no statistically significant association between ERCP timing and patient age, cholangitis severity, intensive/intermediate care admission or anticoagulant/antiplatelet use. However, admission on a Friday or Saturday was significantly associated with delayed ERCP (p=0.007), with 91% of these patients undergoing ERCP after 72 hours, compared to 56% for admissions on other days. Cholangitis severity correlated significantly with total hospital stay (grade I: 7 ± 3 days, grade II: 8 ± 3.8 days, grade III: 10.5 ± 9 days; p=0.001). ERCP timing was also associated with total antibiotic duration (<24h: 9 ± 2.6 days, 24–72h: 8 ± 3 days, >72h: 10 ± 4.8 days; p=0.043). The 30-day mortality rate was 4.8%, with no significant association with ERCP timing or severity grade.

Conclusion

In this real-world cohort, ERCP was frequently delayed beyond the recommended window, even in severe acute cholangitis. Weekend admission was a significant contributor to this delay. However, no association was found between ERCP timing and 30-day mortality, likely due to small sample size. These findings highlight the need for optimized access to biliary drainage, particularly during weekends, to better meet guideline recommendations.

Introduction

Acute cholangitis (AC) is a life-threatening condition requiring urgent biliary drainage. Endoscopic biliary drainage (EBD) with endoscopic sphincterotomy (EST) is often performed to facilitate bile flow and prevent post-ERCP pancreatitis (PEP). However, patients with sepsis-induced coagulopathy (SIC) are at increased risk of bleeding, raising concerns about the safety of EST in this population^{1, 2}. This study aimed to evaluate the risk of adverse events (AEs) and clinical outcomes of EBD with versus without EST in AC patients with SIC.

Aims & Methods

A multicenter retrospective cohort study was conducted using propensity score matching. AC patients with SIC who underwent EBD with EST (EST group) or without EST (non-EST group) were analyzed. The primary endpoint was to compare the AE rate of EBD with EST versus EBD without EST in AC patients with SIC using propensity score matching. Secondary endpoints included the comparison of clinical outcomes (Ethics Committee Approval No. 2876-D38).

Results

Among 238 patients, 72 underwent EST and 166 did not. The incidence of AEs was significantly higher in the EST group than in the non-EST group (16.7% vs. 1.8%, P < .001), particularly for bleeding AEs (11.1% vs. 0.6%, P < .001). PEP incidence was similar (4.2% vs. 1.2%, P = .143). Propensity score-matched analysis confirmed these findings. No significant differences were observed in clinical success or 28-day survival rates.

Conclusion

EST significantly increases bleeding risk in AC patients with SIC without reducing PEP or improving clinical outcomes. Given these findings, EBD without EST should be recommended to minimize bleeding risk while ensuring effective biliary drainage.

References

1 Testoni PA, Mariani A, Aabakken L et al. Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2016; 48: 657-683. doi:10.1055/s-0042-108641
2 Veitch AM, Vanbiervliet G, Gershlick AH et al. Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines. Gut 2016; 65: 374-389. doi:10.1136/gutjnl-2015-311110