Unusual polypoid mass lesion in the rectum.

A 22-year-old male presented with constipation and bleeding per rectum. He had a history of self-digitation. Digital rectal examination revealed an irregular hard polypoid lesion in the rectum. Colonoscopy revealed multiple polypoid mass lesions in the rectum (Fig. 1A), while endoscopic biopsies were non-contributory. Positron emission computed tomography revealed a fluorodeoxyglucose-avid mass lesion in the rectum (Fig. 1B; arrow). Endoscopic ultrasound (EUS) revealed an ill-defined hypoechoic lesion arising from the mucosa (Fig. 2A; arrows). The muscularis propria was not involved and mass was hard on EUS elastography (Fig. 2B; blue color; arrows). The mass was hypo-enhancing on contrast-enhanced EUS (Fig. 2C; arrows). EUS-guided fine-needle aspiration was also non-contributory. The large polypoid lesion was removed using a snare and histopathological examination revealed features suggestive of solitary rectal ulcer syndrome (SRUS). The patient was started on laxatives, behavioral therapy, and topical sucralfate. As bleeding persisted, argon plasma coagulation (APC) was used to coagulate the lesions. The bleeding subsided and sigmoidoscopy after 6 sessions of APC revealed a marked reduction in size as well as a number of polypoid lesions.

Figure 1

(A) Colonoscopy: multiple polypoid mass lesions in rectum. (B) Positron emission computed tomography: fluorodeoxyglucose-avid mass lesion in rectum (arrows)

Figure 2

(A) Endoscopic ultrasound (EUS): ill-defined hypoechoic lesion arising from the mucosa (arrows). (B) Mass was hard on EUS elastography (blue color; arrows). (C) Mass was hypo-enhancing on contrast-enhanced EUS (arrows)

The endoscopic appearance of SRUS is variable and it may manifest as hyperemia, ulceration or a polypoid lesion that can mimic cancer [1]. EUS findings of polypoid SRUS have not been described but, being fibrotic, it should be hard and hypo-enhancing, as in the index case.