This investigation is used to diagnose internal intussusception, or demonstrate a suspected external prolapse that could not be produced during the examination. [ 3 ]  It is usually not necessary with obvious external rectal prolapse. [ 10 ]   Defecography  may demonstrate associated conditions like  cystocele , vaginal vault prolapse or  enterocele . [ 5 ]


Colonic transit studies  may be used to rule out  colonic inertia  if there is a history of severe constipation. [ 3 ] [ 5 ]  Continent prolapse patients with slow transit constipation, and who are fit for surgery may benefit from subtotal colectomy with rectopexy. [ 5 ]


This investigation objectively documents the functional status of the sphincters. However, the clinical significance of the findings are disputed by some. [ 10 ]  It may be used to assess for pelvic floor dyssenergia, [ 5 ]  ( anismus  is a contraindication for certain surgeries, e.g. STARR), and these patients may benefit from post-operative  biofeedback  therapy. Decreased squeeze and resting pressures are usually the findings, and this may predate the development of the prolapse. [ 5 ]  Resting tone is usually preserved in patients with mucosal prolapse. [ 21 ]  In patients with reduced resting pressure, levatorplasty may be combined with prolapse repair to further improve continence. [ 10 ]


It may be used to evaluate incontinence, but there is disagreement about what relevance the results may show, as rarely do they mandate a change of surgical plan. [ 5 ]  There may be denervation of striated musculature on the electromyogram. [ 21 ]  Increased nerve conduction periods (nerve damage), this may be significant in predicting post-operative incontinence. [ 5 ]


Rectal prolapse is a "falling down" of the rectum so that it is visible externally. The appearance is of a reddened, proboscis-like object through the anal sphincters. Patients find the condition embarrassing. [ 10 ]  The symptoms can be socially debilitating without treatment, [ 5 ]  but it is rarely life-threatening. [ 10 ]


The true incidence of rectal prolapse is unknown, but it is thought to be uncommon. As most affected people are elderly, the condition is generally under-reported. [ 22 ]  It may occur at any age, even in children, [ 23 ]  but there is peak onset in the fourth and seventh decades. [ 3 ]  Women over 50 are six times more likely to develop rectal prolapse than men. It is rare in men over 45 and in women under 20. [ 21 ]  When males are affected, they tend to be young and report significant bowel function symptoms, especially  obstructed defecation , [ 5 ]  or have a predisposing disorder (e.g., congenital  anal atresia ). [ 10 ]  When children are affected, they are usually under the age of 3.


35% of women with rectal prolapse have never had children, [ 5 ]  suggesting that pregnancy and labor are not significant factors. Anatomical differences such as the wider pelvic outlet in females may explain the skewed gender distribution. [ 10 ]


Associated conditions, especially in younger patients include autism, developmental delay syndromes, and psychiatric conditions requiring several medications. [ 5 ]


Signs and symptoms include:


Initially, the mass may protrude through the anal canal only during defecation and straining, and spontaneously return afterwards. Later, the mass may have to be pushed back in following defecation. This may progress to a chronically prolapsed and severe condition, defined as spontaneous prolapse that is difficult to keep inside, and occurs with walking, prolonged standing, [ 5 ]  coughing or sneezing ( Valsalva  maneuvers). [ 3 ]  A chronically prolapsed rectal tissue may undergo pathological changes such as thickening, ulceration and bleeding. [ 5 ]


If the prolapse becomes trapped externally outside the anal sphincters, it may become strangulated and there is a risk of perforation. [ 21 ]   This may require an urgent surgical operation if the prolapse cannot be manually reduced. [ 5 ]  Applying granulated sugar on the exposed rectal tissue can reduce the  edema  (swelling) and facilitate this. [ 21 ]


The precise cause is unknown, [ 3 ] [ 10 ] [ 9 ]  and has been much debated. [ 5 ]  In 1912 Moschcowitz proposed that rectal prolapse was a sliding hernia through a pelvic  fascial  defect. [ 10 ]


This theory was based on the observation that rectal prolapse patients have a mobile and unsupported pelvic floor, and a hernia sac of peritoneum from the Pouch of Douglas and rectal wall can be seen. [ 5 ]   Other adjacent structures can sometimes be seen in addition to the rectal prolapse. [ 5 ]  Although a  pouch of Douglas   hernia , originating in the cul de sac of Douglas, may protrude from the anus (via the anterior rectal wall), [ 21 ]  this is a different situation from rectal prolapse.


Shortly after the invention of  defecography , In 1968 Broden and Snellman used  cinedefecography  to show that rectal prolapse begins as a circumferential intussusception of the rectum, [ 3 ] [ 10 ]  which slowly increases over time. [ 21 ]  The leading edge of the intussusceptum may be located at 6–8 cm or at 15–18 cm from the  anal verge . [ 21 ]  This proved an older theory from the 18th century by  John Hunter  and  Albrecht von Haller  that this condition is essentially a full-thickness rectal intussusception, beginning about 3 inches above the  dentate line  and protruding externally. [ 5 ]


Since most patients with rectal prolapse have a long history of constipation, [ 10 ]  it is thought that prolonged, excessive and repetitive straining during defecation may predispose to rectal prolapse. [ 3 ] [ 9 ] [ 21 ] [ 24 ] [ 25 ] [ 26 ]  Since rectal prolapse itself causes functional obstruction, more straining may result from a small prolapse, with increasing damage to the anatomy. [ 9 ]  This excessive straining may be due to predisposing pelvic floor dysfunction (e.g.  obstructed defecation ) and anatomical factors: [ 10 ] [ 21 ]


Some authors question whether these abnormalities are the cause, or secondary to the prolapse. [ 3 ]  Other predisposing factors/associated conditions include:


The association with uterine prolapse (10-25%) and cystocele (35%) may suggest that there is some underlying abnormality of the pelvic floor that affects multiple pelvic organs. [ 3 ]  Proximal bilateral pudendal neuropathy has been demonstrated in patients with rectal prolapse who have fecal incontinence. [ 5 ]  This finding was shown to be absent in healthy subjects, and may be the cause of denervation-related atrophy of the external anal sphincter. Some authors suggest that  pudendal nerve  damage is the cause for pelvic floor and anal sphincter weakening, and may be the underlying cause of a spectrum of pelvic floor disorders. [ 5 ]


Sphincter function in rectal prolapse is almost always reduced. [ 3 ]  This may be the result of direct sphincter injury by chronic stretching of the prolapsing rectum. Alternatively, the intussuscepting rectum may lead to chronic stimulation of the rectoanal inhibitory reflex (RAIR - contraction of the external anal sphincter in response to stool in the rectum). The RAIR was shown to be absent or blunted. Squeeze (maximum voluntary contraction) pressures may be affected as well as the resting tone. This is most likely a denervation injury to the external anal sphincter. [ 3 ]


The assumed mechanism of  fecal incontinence  in rectal prolapse is by the chronic stretch and trauma to the anal sphincters and the presence of a direct conduit (the intussusceptum) connecting rectum to the external environment which is not guarded by the sphincters. [ 5 ]


The assumed mechanism of obstructed defecation is by disruption to the rectum and anal canal's ability to contract and fully evacuate rectal contents. The intussusceptum itself may mechanically obstruct the rectoanal  lumen , creating a blockage that straining, anismus and colonic dysmotility exacerbate. [ 5 ]


Some believe that internal rectal intussusception represents the initial form of a progressive spectrum of disorders the extreme of which is external rectal prolapse. The intermediary stages would be gradually increasing sizes of intussusception. However, internal intussusception rarely progresses to external rectal prolapse. [ 30 ]  The factors that result in a patient progressing from internal intussusception to a full thickness rectal prolapse remain unknown. [ 5 ]  Defecography studies demonstrated that degrees of internal intussusception are present in 40% of asymptomatic subjects, raising the possibility that it represents a normal variant in some, and may predispose patients to develop symptoms, or exacerbate other problems. [ 31 ]


Surgery is thought to be the only option to potentially cure a complete rectal prolapse. [ 7 ]  For people with medical problems that make them unfit for surgery, and those who have minimal symptoms, conservative measures may be beneficial. Dietary adjustments, including increasing dietary fiber may be beneficial to reduce constipation, and thereby reduce straining. [ 7 ]  A bulk forming agent (e.g.  psyllium ) or stool softener can also reduce constipation. [ 7 ]


Surgery is often required to prevent further damage to the anal sphincters. The goals of surgery are to restore the normal anatomy and to minimize symptoms. There is no globally agreed consensus as to which procedures are more effective, [ 7 ]  and there have been over 50 different operations described. [ 5 ]


Surgical approaches in rectal prolapse can be either perineal or abdominal. A perineal approach (or trans-perineal) refers to surgical access to the rectum and sigmoid colon via an incision around the anus and  perineum  (the area between the genitals and the anus). [ 32 ]  Abdominal approach (trans-abdominal approach) involves the surgeon cutting into the  abdomen  and gaining surgical access to the  pelvic cavity . Procedures for rectal prolapse may involve fixation of the bowel (rectopexy), or resection (a portion removed), or both. [ 7 ]  Trans-anal (endo-anal) procedures are also described where access to the internal rectum is gained through the anus itself.


Abdominal procedures are associated with lower risk of postoperative recurrence of the prolapse, compared with perineal procedures (6.1% vs 16.3% in patients who are younger than 65 years of age at the time of surgery). [ 33 ]


The abdominal approach carries a small risk of impotence in males (e.g. 1-2% in abdominal rectopexy). [ 10 ]  Abdominal operations may be open or  laparoscopic  (keyhole surgery). [ 3 ]


Laparoscopic procedures
Recovery time following laparoscopic surgery is shorter and less painful than following traditional abdominal surgery. [ 32 ]  Instead of opening the pelvic cavity with a wide incision (laparotomy), a laparoscope (a thin, lighted tube) and surgical instruments are inserted into the pelvic cavity via small incisions. [ 32 ]  Rectopexy and anterior resection have been performed laparoscopically with good results.


The perineal approach generally results in less post-operative pain and complications, and a reduced length of hospital stay. These procedures generally carry a higher recurrence rate and poorer functional outcome. [ 5 ]  The perineal procedures include perineal rectosigmoidectomy and Delorme repair. [ 3 ]  Elderly, or other medically high-risk patients are usually treated by perineal procedures, [ 3 ]   as they can be performed under a  regional anesthetic , or even  local anesthetic  with  intravenous sedation , thus avoid the risks of a  general anesthetic . [ 10 ]  Alternatively, perineal procedures may be selected to reduce risk of nerve damage, for example in young male patients for whom sexual dysfunction may be a major concern. [ 5 ]


Perineal rectosigmoidectomy


The goal of Perineal rectosigmoidectomy is to resect or remove the redundant bowel. This is done through the perineum. The lower rectum is anchored to the sacrum through fibrosis in order to prevent future prolapse. [ 7 ]  The full thickness of the rectal wall is incised at a level just above the dentate line. Redundant rectal and sigmoid wall is removed and the new edge of colon is reconnected (anastomosed) with the anal canal with stitches or staples. [ 10 ]  This procedure may be combined with levatorplasty, to tighten the pelvic muscles. [ 7 ]  A combined a perineal proctosigmoidectomy with anterior levatorplasty is also called an Altemeier procedure. [ 3 ]  Levatorplasty is performed to correct levator diastasis which is commonly associated with rectal prolapse. [ 3 ]  Perineal rectosigmoidectomy was first introduced by Mikulicz in 1899, and it remained the preferred treatment in Europe for many years. [ 3 ]  It was Popularized by Altemeier. [ 10 ]  The procedure is simple, safe and effective. [ 3 ]  Continence levatorplasty may enhance restoration of continence (2/3 of patients). [ 3 ]  Complications occur in less than 10% of cases, and include pelvic bleeding, pelvic abscess and anastomotic dehiscence (splitting apart of the stitches inside), bleeding or leak at a dehiscence [ 3 ]  Mortality is low. [ 10 ]  Recurrence rates are higher than for abdominal repair, [ 3 ]  16-30%, but more recent studies give lower recurrence rates. [ 3 ]  Additional levatorplasty can reduce recurrence rates to 7%. [ 3 ]


Delorme Procedure


This is a modification of the perineal rectosigmoidectomy, differing in that only the mucosa and submucosa are excised from the prolapsed segment, rather than full thickness resection. [ 10 ]  The prolapse is exposed if it is not already present, and the mucosal and submucosal layers are stripped from the redundant length of bowel. The muscle layer that is left is plicated (folded) and placed as a buttress above the pelvic floor. [ 7 ]  The edges of the mucosal are then stitched back together. "Mucosal proctectomy" was first discussed by Delorme in 1900, [ 10 ]  now it is becoming more popular again as it has low morbidity and avoids an abdominal incision, while effectively repairing the prolapse. [ 3 ]  The procedure is ideally suited to those patients with full-thickness prolapse limited to partial circumference (e.g., anterior wall) or less-extensive prolapse (perineal rectosigmoidectomy may be difficult in this situation). [ 3 ] [ 10 ]  Fecal incontinence is improved following surgery (40%–75% of patients). [ 5 ] [ 10 ]  Post operatively, both mean resting and squeeze pressures were increased. [ 5 ]  Constipation is improved in 50% of cases, [ 5 ]  but often urgency and tenesmus are created. Complications, including infection, urinary retention, bleeding,  anastomotic  dehiscence (opening of the stitched edges inside),  rectal stricture  (narrowing of the gut lumen), diarrhea, and fecal impaction occur in 6-32% of cases. [ 5 ] [ 10 ]  Mortality occurs in 0–2.5% cases. [ 10 ]  There is a higher recurrence rate than abdominal approaches (7-26% cases). [ 5 ] [ 10 ]


Anal encirclement (Thirsch procedure)


This procedure can be carried out under  local anaesthetic . After reduction of the prolapse, a subcutaneous suture (a stitch under the skin) or other material is placed encircling the anus, which is then made taut to prevent further prolapse. [ 7 ]  Placing silver wire around the anus first described by Thiersch in 1891. [ 10 ]  Materials used include nylon, silk, silastic rods, silicone, Marlex mesh, Mersilene mesh, fascia, tendon, and Dacron. [ 10 ]  This operation does not correct the prolapse itself, it merely supplements the anal sphincter, narrowing the anal canal with the aim of preventing the prolapse from becoming external, meaning it remains in the rectum. [ 10 ]  This goal is achieved in 54-100% cases. Complications include breakage of the encirclement material, fecal impaction, sepsis, and erosion into the skin or anal canal. Recurrence rates are higher than the other perineal procedures. This procedure is most often used for people who have a severe condition or who have a high risk of adverse effects from general anesthetic, [ 7 ]  and who may not tolerate other perineal procedures.


Internal rectal intussusception  (rectal intussusception, internal intussusception, internal rectal prolapse, occult rectal prolapse, internal rectal  procidentia  and rectal invagination) is a medical condition defined as a funnel shaped infolding of the  rectal  wall that can occur during  defecation . [ 9 ]


This phenomenon was first described in the late 1960s when  defecography  was first developed and became widespread. [ 5 ]  Degrees of internal intussusception have been demonstrated in 40% of asymptomatic subjects, raising the possibility that it represents a normal variant in some, and may predispose patients to develop symptoms, or exacerbate other problems. [ 31 ]


Internal intussusception may be  asymptomatic , but common symptoms include: [ 3 ]


Recto-rectal  intussusceptions may be  asymptomatic , apart from mild obstructed defecation. "interrupted defaecation" in the morning is thought by some to be characteristic. [ 11 ]


Recto-anal  intussusceptions commonly give more severe symptoms of straining, incomplete evacuation, need for digital evacuation of stool, need for support of the  perineum  during defecation, urgency, frequency or intermittent  fecal incontinence . [ 11 ]


It has been observed that intussusceptions of thickness ≥3 mm, and those that appear to cause obstruction to rectal evacuation may give clinical symptoms. [ 36 ] [ 37 ]


There are two schools of thought regarding the nature of internal intussusception, viz: whether it is a primary phenomenon, or secondary to (a consequence of) another condition.


Some believe that it represents the initial form of a progressive spectrum of disorders the extreme of which is external rectal prolapse. The intermediary stages would be gradually increasing sizes of intussusception. The folding section of rectum can cause repeated trauma to the mucosa, and can cause  solitary rectal ulcer syndrome . [ 10 ]  However, internal intussusception rarely progress to external rectal prolapse. [ 30 ]


Others argue that the majority of patients appear to have rectal intussusception as a consequence of obstructed defecation rather than a cause, [ 38 ] [ 39 ]  possibly related to excessive straining in patients with obstructed defecation. [ 36 ]  Patients with other causes of obstructed defecation ( outlet obstruction ) like  anismus  also tend to have higher incidence of internal intussusception.  Enteroceles  are coexistent in 11% of patients with internal intussusception. [ 40 ]  Symptoms of internal intussusception overlap with those of  rectocele , indeed the 2 conditions can occur together. [ 41 ]


Patients with  solitary rectal ulcer syndrome  combined with internal intussusception (as 94% of SRUS patients have) were shown to have altered rectal wall biomechanics compared to patients with internal intussusception alone. [ 42 ]  The presumed mechanism of the  obstructed defecation  is by telescoping of the intussusceptum, occluding the rectal lumen during attempted defecation. [ 36 ]  One study analysed resected rectal wall specimens in patients with obstructed defecation associated with rectal intussusception undergoing  stapled trans-anal rectal resection . They reported abnormalities of the  enteric nervous system  and  estrogen receptors . [ 43 ]  One study concluded that intussusception of the  anterior  rectal wall shares the same cause as  rectocele , namely deficient recto-vaginal ligamentous support. [ 44 ]


The following conditions occur more commonly in patients with internal rectal intussusception than in the general population:


Unlike external rectal prolapse, internal rectal intussusception is not visible externally, but it may still be diagnosed by  digital rectal examination , while the patient strains as if to defecate. [ 11 ]  Imaging such as a  defecating proctogram [ 47 ]  or dynamic MRI defecography can demonstrate the abnormal folding of the rectal wall. Some have advocated the use of anorectal physiology testing ( anorectal manometry ). [ 5 ]


Nonsurgical measures to treat internal intussusception include pelvic floor retraining, [ 48 ]  a  bulking agent  (e.g.  psyllium ),  suppositories  or  enemas  to relieve constipation and straining. [ 21 ]  If there is  incontinence  ( fecal leakage  or more severe FI), or paradoxical contraction of the pelvic floor ( anismus ), then biofeedback retraining is indicated. [ 49 ]  Some researchers advise that internal intussusception be managed conservatively, compared to external rectal prolapse which usually requires surgery. [ 50 ]


As with external rectal prolapse, there are a great many different surgical interventions described. Generally, a section of rectal wall can be  resected  (removed), or the rectum can be fixed (rectopexy) to its original position against the  sacral vertebrae , or a combination of both methods. Surgery for internal rectal prolapse can be via the abdominal approach or the transanal approach. [ 51 ]


It is clear that there is a wide spectrum of symptom severity, meaning that some patients may benefit from surgery and others may not. Many procedures receive conflicting reports of success, leading to a lack of any consensus about the best way to manage this problem. [ 49 ]  Relapse of the intussusception after treatment is a problem. Two of the most commonly employed procedures are discussed below.


This procedure aims to "[correct] the descent of the posterior and middle pelvic compartments combined with reinforcement of the rectovaginal septum". [ 51 ]


Rectopexy has been shown to improve anal incontinence ( fecal leakage ) in patients with rectal intussusception. [ 52 ]  The operation has been shown to have low recurrence rate (around 5%). [ 53 ]  It also improves obstructed defecation symptoms. [ 54 ]


Complications include constipation, which is reduced if the technique does not use posterior rectal mobilization (freeing the rectum from its attached back surface). [ 55 ]


The advantage of the laparoscopic approach is decreased healing time and less complications. [ 53 ]


This operation aims to "remove the anorectal mucosa circumferentially and reinforce the anterior anorectal junction wall with the use of a circular stapler". [ 45 ] [ 46 ]  In contrast to other methods, STARR does not correct the descent of the rectum, it removes the redundant tissue. [ 51 ]  The technique was developed from a similar stapling procedure for prolapsing  hemorrhoids . Since, specialized circular staplers have been developed for use in external rectal prolapse and internal rectal intussusception. [ 56 ]


Complications, sometimes serious, have been reported following STARR, [ 57 ] [ 58 ] [ 59 ] [ 60 ] [ 61 ]   but the procedure is now considered safe and effective. [ 60 ]  STARR is   contraindicated  in patients with weak sphincters (fecal incontinence and urgency are a possible complication) and with  anismus  (paradoxical contraction of the pelvic floor during attempted defecation). [ 60 ]  The operation has been shown to improve rectal sensitivity and decrease rectal volume, the reason thought to create urgency. [ 51 ]  90% of patients do not report urgency 12 months after the operation. The anal sphincter may also be stretched during the operation. STARR was compared with biofeedback and found to be more effective at reducing symptoms and improving quality of life. [ 62 ]


Rectal mucosal prolapse  (mucosal prolapse, anal mucosal prolapse) is a sub-type of rectal prolapse, and refers to abnormal descent of the  rectal   mucosa  through the  anus . [ 21 ]  It is different to an internal intussusception (occult prolapse) or a complete rectal prolapse (external prolapse, procidentia) because these conditions involve the full thickness of the rectal wall, rather than only the mucosa (lining). [ 13 ]


Mucosal prolapse is a different condition to prolapsing (3rd or 4th degree)  hemorrhoids , [ 13 ]  although they may look similar.


Rectal mucosal prolapse can be a cause of  obstructed defecation  (outlet obstruction). [ 9 ]  and rectal malodor.


Symptom severity increases with the size of the prolapse, and whether it spontaneously reduces after defecation, requires manual reduction by the patient, or becomes irreducible. The symptoms are identical to advanced hemorrhoidal disease, [ 13 ]  and include:


The condition, along with complete rectal prolapse and  internal rectal intussusception , is thought to be related to chronic straining during  defecation  and  constipation .


Mucosal prolapse occurs when the results from loosening of the submucosal attachments (between the mucosal layer and the  muscularis propria ) of the  distal   rectum . [ 3 ]  The section of prolapsed rectal mucosa can become ulcerated, leading to bleeding.


Mucosal prolapse can be differentiated from a full thickness external rectal prolapse (a complete rectal prolapse) by the orientation of the folds (furrows) in the prolapsed section. In full thickness rectal prolapse, these folds run circumferential. In mucosal prolapse, these folds are radially. [ 10 ]  The folds in mucosal prolapse are usually associated with internal hemorrhoids. [ 21 ]


EUA  (examination under anesthesia) of anorectum and banding of the mucosa with rubber bands.


Solitary rectal ulcer syndrome  (SRUS, SRU), is a disorder of the  rectum  and  anal canal , caused by straining and increased pressure during  defecation . This increased pressure causes the anterior portion of the rectal lining to be forced into the anal canal (an  internal rectal intussusception ). The lining of the rectum is repeatedly damaged by this friction, resulting in  ulceration . SRUS can therefore be considered to be a consequence of internal intussusception (a sub type of rectal prolapse), which can be demonstrated in 94% of cases. It may be  asymptomatic , but it can cause  rectal pain ,  rectal bleeding ,  rectal malodor , incomplete evacuation and  obstructed defecation  (rectal outlet obstruction).


Symptoms include: [ 18 ] [ 21 ] [ 63 ]


The condition is thought to be uncommon. It usually occurs in young adults, but children can be affected too. [ 64 ]


The essential cause of SRUS is thought to be related to too much straining during defecation.


Overactivity of the anal sphincter during defecation causes the patient to require more effort to expel stool. This pressure is produced by the modified valsalva manovoure (attempted forced exhalation against a closed glottis, resulting in increased abdominal and intra-rectal pressure). Patiest with SRUS were shown to have higher intra-rectal pressures when straining than healthy controls. [ 65 ]  SRUS is also associated with prolonged and incomplete evacuation of stool. [ 66 ]


More effort is required because of concomitant  anismus , or non-relaxation/paradoxical contraction of  puborectalis  (which should normally relax during defecation). [ 67 ]  The increased pressure forces the anterior rectal lining against the contracted puborectalis and frequently the lining prolapses into the anal canal during straining and then returns to its normal position afterwards.


The repeated trapping of the lining can cause the tissue to become swollen and congested. Ulceration is thought to be caused by resulting poor blood supply ( ischemia ), combined with repeated frictional trauma from the prolapsing lining, and exposure to increased pressure are thought to cause ulceration. Trauma from hard stools may also contribute.


The site of the ulcer is typically on the  anterior  wall of the  rectal ampulla , about 7–10 cm from the anus. However, the area may of ulceration may be closer to the anus, deeper inside, or on the lateral or posterior rectal walls. The name "solitary" can be misleading since there may be more than one ulcer present. Furthermore, there is a "preulcerative phase" where there is no ulcer at all. [ 68 ]


Pathological specimens of sections of rectal wall taken from SRUS patients show thickening and replacement of muscle with fibrous tissue and excess collagen. [ 69 ]  Rarely, SRUS can present as polyps in the rectum. [ 70 ] [ 71 ]


SRUS is therefore associated and with internal, and more rarely, external rectal prolapse. [ 66 ]  Some believe that SRUS represents a spectrum of different diseases with different causes. [ 72 ]


Another condition associated with internal intussusception is  colitis cystica profunda  (also known as CCP, or proctitis cystica profunda), which is  cystica profunda  in the rectum. Cystica profunda is characterized by formation of  mucin   cysts  in the muscle layers of the gut lining, and it can occur anywhere along the gastrointestinal tract. When it occurs in the rectum, some believe to be an interchangeable diagnosis with SRUS since the  histologic  features of the conditions overlap. [ 73 ] [ 74 ]  Indeed, CCP is managed identically to SRUS. [ 75 ]


Electromyography may show  pudendal nerve  motor latency. [ 18 ]


Complications are uncommon, but include massive rectal bleeding, ulceration into the prostate gland or formation of a  stricture . [ 76 ] [ 77 ] [ 78 ]  Very rarely, cancer can arise on the section of prolapsed rectal lining. [ 17 ]


SRUS is commonly misdiagnosed, and the diagnosis is not made for 5–7 years. [ 64 ]  Clinicians may not be familiar with the condition, and treat for Inflammatory bowel disease, or simple constipation. [ 79 ] [ 80 ]


The thickened lining or ulceration can also be mistaken for types of cancer. [ 81 ] [ 82 ] [ 83 ] [ 84 ]


The differential diagnosis of SRUS (and CCP) includes: [ 10 ]


Defecography ,  sigmoidoscopy ,  transrectal  ultrasound , mucosal  biopsy , anorectal  manometry  and  electromyography  have all been used to diagnose and study SRUS. [ 18 ] [ 67 ]  Some recommend biopsy as essential for diagnosis since ulcerations may not always be present, and others state  defecography  as the investigation of choice to diagnose SRUS. [ 63 ] [ 74 ] [ 79 ]


Although SRUS is not a medically serious disease, it can be the cause of significantly reduced  quality of life  for patients. It is difficult to treat, and treatment is aimed at minimizing symptoms.


Stopping straining during bowel movements, by use of  correct posture ,  dietary fiber  intake (possibly included bulk forming  laxatives  such as  psyllium ), stool softeners (e.g.  polyethylene glycol , [ 85 ] [ 86 ]  and  biofeedback  retraining to coordinate pelvic floor during defecation. [ 87 ] [ 88 ]


Surgery may be considered, but only if non surgical treatment has failed and the symptoms are severe enough to warrant the intervention. Improvement with surgery is about 55-60%. [ 89 ]


Ulceration may persist even when symptoms resolve. [ 90 ]


A group of conditions known as  Mucosal prolapse syndrome  (MPS) has now been recognized. It includes SRUS, rectal prolapse, proctitis cystica profunda, and inflammatory polyps. [ 17 ] [ 18 ]  It is classified as a chronic benign inflammatory disorder. The unifying feature is varying degrees of rectal prolapse, whether internal intussusception (occult prolapse) or external prolapse.


Rectal prolapse affects less than 0.5% of the general population. [ 91 ]  It affects women more commonly, with a female to male ratio of 9:1. [ 91 ]


Rosebud pornography and prolapse pornography (or rosebudding or rectal prolapse pornography) is an anal sex practice that occurs in some extreme anal pornography wherein a pornographic actor or actress performs a rectal prolapse wherein the walls of the rectum slip out of the anus. Rectal prolapse is a serious medical condition that requires the attention of a medical professional. However, in rosebud pornography, it is performed deliberately. Michelle Lhooq, writing for VICE, argues that rosebudding is an example of producers making 'extreme' content due to the easy availability of free pornography on the internet. She also argues that rosebudding is a way for pornographic actors and actresses to distinguish themselves. [ 92 ]  Repeated rectal prolapses can cause bowel problems and anal leakage and therefore risk the health of pornographic actors or actresses who participate in them. [ 92 ]  Lhooq also argues that some who participate in this form of pornography are unaware of the consequences. [ 92 ]


Prolapse refers to "the falling down or slipping of a body part from its usual position or relations". It is derived from the Latin  pro-  - "forward" +  labi  - "to slide".  "Prolapse" .  Merriam-Webster.com Dictionary . Merriam-Webster.   Prolapse  can refer to many different medical conditions other than rectal prolapse.


procidentia has a similar meaning to prolapse, referring to "a sinking or prolapse of an organ or part". It is derived from the Latin  procidere  - "to fall forward". [ 93 ]   Procidentia  usually refers to  uterine prolapse , but rectal procidentia can also be a synonym for rectal prolapse.


Intussusception is defined as  invagination  (infolding), especially referring to "the slipping of a length of intestine into an adjacent portion". It is derived from the Latin  intus  - "within" and  susceptio  - "action of undertaking", from  suscipere  - "to take up".  "Intussusception" .  Merriam-Webster.com Dictionary . Merriam-Webster.  Rectal intussusception is not to be confused with other  intussusceptions  involving  colon  or  small intestine , which can sometimes be a medical emergency. Rectal intussusception by contrast is not life-threatening.


Intussusceptum refers to the  proximal  section of rectal wall, which telescopes into the  lumen  of the  distal  section of  rectum  (termed the intussuscipiens). [ 10 ]  What results is 3 layers of rectal wall overlaid. From the lumen outwards, the first layer is the proximal wall of the intussusceptum, the middle is the wall of the intussusceptum folded back on itself, and the outer is the distal rectal wall, the intussuscipiens. [ 10 ]


A  rectal stricture  ( rectal stenosis ) [ 1 ]  is a chronic and abnormal narrowing or constriction of the  lumen  of the  rectum  which presents a partial or complete obstruction to the movement of bowel contents. A rectal stricture is located deeper inside the body compared to an  anal stricture . Sometimes other terms with wider meaning are used, such as  anorectal stricture ,  colorectal stricture  or  rectosigmoid stricture .


Rectal stricture has been defined as the inability to pass a rigid  proctoscope  (12 mm diameter) or a rigid  sigmoidoscope  (19 mm diameter) through the affected cross-section of rectum. [ 1 ]  If the rectal stricture is accessible during digital rectal examination, a rectal stricture may be defined as narrowing to less than one-finger breadth. [ 2 ]


Anal strictures are usually located at the anal verge in a narrow band, but sometimes they involve the entire length of the anal canal. [ 1 ]  Surgeons and anatomists have different definitions of the anal canal. [ 3 ]  Surgically and clinically, the anal canal is usually defined as the zone from the anal verge to the anorectal ring (at the level of the external anal sphincter and the  puborectalis muscle ). The anorectal ring is easy to identify when patients are asked to squeeze during  digital rectal examination . [ 3 ]  Anatomically, the anal canal is defined as the zone from the anal verge to the dentate line ( pectinate line ). [ 3 ]  This is a line formed by the lower ends of the anal columns and represents the embryological junction between the  hindgut  and the  proctodeum . [ 3 ]


Both rectal stricture and  anal stricture  (anal stenosis) are types of colonic stricture. They both can also be more widely categorized as gastrointestinal strictures. However, rectal strictures behave differently to colonic strictures because of the proximity of the rectum to the anal canal and pelvic organs, and because of different blood supply. [ 2 ]


There may be no symptoms (clinically silent stricture), [ 4 ]  or only minor symptoms, but may get worse over time. [ 2 ]  On the other hand, acute  bowel obstruction  may develop as the first major sign of a stricture. This may be the case with malignant strictures, and the condition may be a medical emergency which requires urgent treatment in order to avoid serious complications such as  bowel perforation . [ 5 ]  When symptoms are caused, the term "clinically relevant rectal stricture" is used. [ 1 ]  Possible symptoms include:


The first step is exclusion of malignant causes. This may involve tissue  biopsy ,  endorectal ultrasound ,  computed tomography , and  magnetic resonance imaging . [ 1 ]  The next step is assessment of the stricture. The distance from the anal verge, the diameter of the narrowest point of the stricture, and the longitudinal length are ascertained. The degree of narrowing can be assessed with a water-soluble  contrast enema . [ 1 ]


Rectal strictures are usually classified as benign or malignant (associated with cancer).


Benign rectal strictures can be further subcategorized as primary (caused by diseases) and secondary (caused by complication of surgery). Secondary strictures very often occur at the site of a previous surgical anastomosis. Primary strictures have various causes, including different inflammatory disease processes. Causes of benign strictures include:


Acute bowel obstruction is a common presenting manifestation of colorectal cancer which is locally advanced. [ 5 ]  Malignant strictures may also develop in the context of inflammatory bowel disease. Treatment for malignant strictures is ideally resection (surgical removal) with or without radiotherapy. If resection is not possible or not sensible, symptoms of the stricture may be palliated with radiotherapy, stents, or debulking. [ 1 ]  Possible malignant processes which may cause rectal stricture include:


The narrowing may be because of an intrinsic process occurring within the lumen of the rectum (luminal), within the wall of the rectum (mural), or it can be due to an extrinsic process that is compressing the rectum from the outside (extramural). [ 1 ] [ 8 ]  In the case of external compression of the bowel, the term pseudostricture may be used. [ 9 ]


According to one review of a total of 730 cases, those which formed after anastomosis represented 74% of all reported benign rectal strictures. [ 2 ]  The next most common cause of benign rectal stricture was inflammatory bowel disease, accounting for 20% of all cases. [ 2 ]  This means all other causes of rectal stricture are, by comparison, rare.


Rectal stricture is reported to develop after colorectal resection at a rate of 3-30%. Such strictures mostly form after resection due to rectal cancer with colorectal or coloanal anastomosis. Stricture is also possible as a complication following resection because of diverticular disease. According to some reports, rectal strictures are more likely following stapled anastomosis compared to hand sutured anastomosis. [ 2 ]  However, a Cochrane review found no significant difference in the rate of rectal stricture between hand sewn and stapled  ileocolic anastomosis  (usually performed after right‐sided  colon cancer  and  Crohn's disease ). [ 10 ]


Inflammatory bowel diseases (IBD) include Crohn’s disease, which affects only the colon, and ulcerative colitis, which may affect any section of the gastrointestinal tract. The relapsing-remitting, chronic inflammation in the bowel wall non uncommonly leads to the development of colonic strictures, including rectal strictures. [ 6 ]  Rectal strictures are more common in Crohn's disease than in ulcerative colitis. [ 2 ]  There is a risk of malignancy developing at the site of stricture. Therefore, tissue biopsy of strictures is carried out in order to check for dysplasia or malignancy.


Stricture may occur following trauma such as caustic burns caused by chemical agents. [ 11 ] [ 12 ]  If they cause inflammation, chronic use of  suppositories  may cause rectal stricture, [ 2 ]  but overall this is a safe method of drug delivery. [ 13 ]


Thermal burns are possible if hot water enemas are attempted by patients or practitioners of alternative medicine in the belief that they will provide a stronger stimulus for evacuation of stool. [ 11 ]  The rectal mucosa is vulnerable to thermal burns in such cases because it is sensitive only to distension (stretching) and not to thermal stimuli. [ 11 ]  Usually a burn of the rectal wall heals after 2–3 weeks without permanent stricture. Such burns may be treated with bowel resting, antibiotics, stool softeners, liquid diet and steroid suppository to reduce inflammation. [ 11 ]  Sometimes thermal burns progress to chronic stricture. [ 11 ]


The rectum is very close to the prostate in males and the uterus and cervix in females, and therefore it frequently receives radiation during radiotherapy for cancers in the pelvic region.  Radiation proctitis  (chronic radiation enterocolitis) usually appears after several months of treatment, and is characterized by rectal bleeding or obstructed defecation secondary to the formation of strictures. [ 7 ]  Such rectal strictures are usually located in the proximal rectum, and are one of the most common features of late radiation damage. [ 14 ]  The mechanism of stricture formation is  obliterative endarteritis , lymphatic dilation, and tissue ischemia and necrosis. [ 7 ]  Then there is collagen deposition and fibrosis in the submucosal layer. [ 7 ]  They are often associated with a fistula. [ 14 ]  Post-irradiation strictures may cause symptoms such as diarrhea, tenesmus, narrow feces, abdominal pain, and vomiting. [ 7 ]  The risk of intestinal obstruction due to strictures in patients receiving radiotherapy in the pelvis is reported as 1–15%. [ 7 ]


Sexually transmitted infections  may sometimes cause rectal strictures in persons who engage in anoreceptive sex. [ 2 ]   Lymphogranuloma venereum  usually affects the genital mucosa. However, it may rarely present as the anorectal variant, termed "lymphogranuloma venereum proctitis". Lymph nodes are enlarged and suppurative (produce pus). The condition is similar to Crohn's disease with rectal stricture formation (eventually), bowel perforation and fistulae. [ 15 ]  In one report,  herpes simplex virus 2  was implicated as the cause of a rectal stricture. [ 2 ]  Rarely, rectal stricture may develop in  actinomycosis  infection. [ 2 ]


If a foreign body becomes stuck there is reactive inflammation and fibrosis, which eventually may lead to the formation of a stricture. [ 2 ]  In  endometriosis , if ectopic endometrial tissue is present in the rectal wall it may cause rectal stricture. [ 2 ]   Solitary rectal ulcer syndrome  may also sometimes be associated with rectal stricture. [ 2 ]


Rectal stricture may sometimes be a complication of surgical procedures other than anastomosis. For example, endoscopic submucosal dissection, which is a minimally invasive treatment for colorectal cancer, may rarely cause development of a rectal stricture. [ 2 ]  Other surgical procedures which may cause the development of a stricture include  ventral rectopexy , [ 8 ]   Delorme’s procedure , [ 16 ]  and  hemorrhoidectomy .


How a rectal stricture is treated depends on the exact cause, the distance from the anal verge, the degree of narrowing, the severity of symptoms, and the health of the patient. [ 1 ]  Short strictures are more responsive to dilation. Longer strictures may require more significant surgical procedures. [ 1 ]  Generally, benign rectal strictures may not require treatment if they do not cause symptoms. [ 1 ]  For example, a non symptomatic stricture may be detected as an incidental finding during colonoscopy for an unrelated reason. [ 1 ]  Treatment options fall into 3 main categories: dilatation, stenting, or surgery. [ 11 ]


The treatment depends on the cause. For example, strictures caused by infections may respond well to  antibiotics . [ 2 ]  Use of  stool softeners ,  laxatives  and high fiber diet is a general measure for most strictures, and is also sometimes advised for prevention of recurrence of stricture even after treatment. [ 2 ]  Non surgical treatment may be combined with other procedures such as dilation.  Steroids  may be injected into the stricture. It is unknown exactly how the steroid helps to prevent recurrence of the stricture, but it may involve inhibition of collagen formation and cross-linking, and increase of collagen breakdown. In combination, this reduces contraction of scar tissue. [ 7 ]   TNF inhibitors  such as  infliximab  have also been injected into strictures endoscopically. However, this is not a common treatment. [ 6 ]  Healing of rectal strictures in inflammatory bowel disease with TNF inhibitor occurs in 59% of cases. [ 2 ]   Mitomycin C  has been used as a topical application, in combination with manual dilation. [ 17 ]


For rectal strictures which are mild and close to the anal verge (<6 cm), digital dilation (with fingers) or dilation with instruments is possible. [ 1 ]  Such instruments include Hagar's dilators, esophageal dilators, St Marks anal dilators, and bougie dilators. [ 16 ] [ 1 ] [ 2 ]  Sometimes the patient can be shown how to perform this dilation at home, but this is may be difficult for them, and rarely gives good long term results. [ 16 ]  Dilation with instruments by the surgeon may be performed under sedation or under general aesthesia for moderate strictures. [ 16 ]  This treatment is often the first to be attempted, and is successful about 50% of the time. [ 2 ]  Hegar dilators come in multiple sizes with different diameters. This enables progressive dilation over time which reduces the risk of bowel perforation. [ 1 ]


Balloon dilation is the most common method of mechanical dilation, [ 11 ]  and is also often considered the first line treatment. [ 2 ]  This treatment is simple, but repeat procedures may be needed. [ 11 ]  Balloon dilation may be combined with intralesional steroid injection. [ 7 ]  Injection of steroid seems to increase the effectiveness of balloon dilation, and increases the length of time before relapse. [ 7 ]  The success rate of balloon dilation for benign rectal strictures overall is about 78%. [ 2 ]  In rectal strictures in the context of Crohn's disease, the long-term success rate of balloon dilation is about 80%. However, it may be ineffective for very tight, fibrotic strictures. [ 17 ]  Fluoroscopic guidance can be used during the procedure to improve visualization. [ 2 ]  The risk of bowel perforation is about 1%. [ 2 ]


Surgical procedures are indicated if multiple other treatments have failed, or if the stricture involves a long section of bowel. [ 11 ]  Surgical procedures may be carried out by the transanal approach or via the transabdominal approach. [ 11 ]  Debulking of malignant strictures may be carried out with laser ablation or with argon beam plasma coagulation. [ 1 ]  Various procedures and methods have been used to surgically treat strictures, including:


Self-expandable metallic stents  (SEMS) are sometimes used, but they are usually considered not suitable for very low rectal strictures. [ 14 ]  However, this view is now challenged. [ 18 ]  Stents may be used as the definitive treatment of a stricture, or as a temporary measure to stabilize a patient with acute obstruction before another procedure is carried out. [ 11 ]  Stents are not commonly used for benign rectal strictures. [ 11 ]  Sometimes they are used when strictures are associated with malignancy. In such cases, use of a stent may avoid or delay the need for  colostomy . [ 19 ]


A  rectovestibular fistula , also referred to simply as a  vestibular fistula , is an anorectal  congenital disorder  where an abnormal connection ( fistula ) exists between the  rectum  and the  vulval vestibule  of the female genitalia.


If the fistula occurs within the  hymen , it is known as a  rectovaginal fistula , a much rarer condition. [ 1 ]


If a colostomy is not performed immediately after birth, patients with rectovestibular fistulae may present later in life with complications including severe  constipation  and  megacolon  (abnormal dilation of the colon), requiring colostomy or further surgery. [ 2 ]


A rectovestibular fistula occurs when the  colon  or  rectum  deviates anteriorly. [ 1 ]  This leads to the formation of an abnormal connection between the rectum and the  vulval vestibule , immediately posterior to the  hymen , so that an  ectopic anus  opens into the  fourchette , or frenulum, of the  labia minora . [ 3 ]  A common wall is shared between the rectum and  vagina  above the site of the fistula. [ 2 ]  Although the opening of the rectum into the  anal canal  is shorter and narrower than normal, the rectum itself is completely normal. [ 2 ]


The diagnosis of a rectovestibular fistula can be made in female newborns if the vulva is stained with  meconium  (the earliest form of  stool  in an infant). [ 3 ]  The opening of the  anus  may be difficult to see due to its small size and position, but it may be visible as a thickening of the median  perineal raphe  with an obvious anal dimple. [ 3 ] [ 2 ]  Patients with rectovestibular fistulae are commonly misdiagnosed with rectovaginal fistulae. [ 1 ]


Colostomy  is recommended by most surgeons, and has a good prognosis, with 90% of patients regaining normal bowel control. [ 4 ]  Since the rectal opening and  anal orifice  in a vestibular fistula tend to be short and narrow, a colostomy is usually performed to allow decompression of the bowel unless the orifice is wide enough to allow normal defecation. [ 2 ]  Colostomy is often followed by  posterior sagittal anorectoplasty  (PSARP), a surgical procedure to repair the anal orifice, at a later date. [ 4 ] [ 5 ]  Some surgeons prefer to perform an immediate PSARP without a colostomy first, while others perform neither a colostomy nor a PSARP and instead opt for a simple dilatation of the orifice to allow stool to pass and the bowel to decompress. [ 5 ]  It has been suggested that only experienced surgeons should perform repair without an initial colostomy. [ 1 ]


Rectovestibular fistula is the most common defect of the rectum and anal canal in females. [ 3 ]


Sigmoidocele  (also known as  pouch of Douglas  descent) is a medical condition in which a  herniation  of  peritoneum  containing loops of redundant  sigmoid colon  descends (prolapses) into the  rectouterine pouch  (in females), between the  rectum  and the  vagina . [ 1 ] [ 2 ]  This can obstruct the rectum and cause  obstructed defecation syndrome . [ 3 ]


Sigmoidocele may be internal if it is only detectable on  defecography , or external if it detectable without imaging and associated with a  rectocele  or  rectal prolapse . [ 2 ]  It is a type of posterior compartment prolapse. [ 4 ]


Sigmoidocele may be classified according to size relative to the pubococcygeal line. [ 2 ] [ note 1 ]


The severity of sigmoidocele can be described with reference to the position of the lowest loop of the sigmoid relative to lines drawn on defecography:


Sigmoidocele may not cause any symptoms. [ 5 ]


The phenomenon is caused by a weak section of   fascial supports  of the vagina (the uterosacral cardinal ligament complex and rectal vaginal septum), which allows a section of peritoneum containing the sigmoid colon to prolapse out of normal position and descend between the rectum and the vagina. [ 1 ]


The  mesentery  of the sigmoid colon (the structure which attaches the colon to the abdominal wall) is termed the mesosigmoid. This structure is very flexible, which means that the sigmoid colon is very mobile and may change position. During defecation it may be pushed down, eventually causing sigmoidocele. [ 7 ]


Sigmoidocele may be associated with  descending perineum syndrome . [ 8 ]


It is not possible to differentiate between a  rectocele  and a sigmoidocele on  vaginal examination .   Defecating proctography  will demonstrate a sigmoidocele during straining. [ 1 ]


Surgery is considered if there is a significant hernia combined with symptoms of obstructed defecation. [ 9 ]


Laparoscopic  ventral mesh rectopexy  has been used to correct sigmoidocele. [ 7 ]  This procedure involves inserting a mesh between the rectum and the vagina. The mesh is suspended from the sacral promontory without tension. This acts to support the recto-vaginal septum and elevate a deep pouch of Douglas. [ 7 ]  If there is prolapse of the middle compartment,  sacrocolpopexy  may be carried out to surgically correct all pelvic prolapse problems in the same procedure. [ 9 ]


Other treatment options are  anterior resection , [ 4 ]   sigmoidopexy  with rectocele repair, [ 4 ]  or  sigmoidectomy . [ 1 ]


Sigmoidocele normally occurs in females, and is uncommon. [ 1 ]  Sigmoidocele is detected about 4-5% of the time when defecography is carried out. [ 3 ] [ 1 ]


Solitary rectal ulcer syndrome  ( SRUS  or  SRU ) is a chronic disorder of the rectal  mucosa  (the lining of the rectum). [ 1 ]  Very often but not always it occurs in association with varying degrees of  rectal prolapse . The condition is thought to be caused by different factors, such as long term  constipation , straining during defecation, and  dyssynergic defecation  (anismus). Treatment is by normalization of bowel habits,  biofeedback , and other conservative measures. In more severe cases, various surgical procedures may be indicated. The condition is relatively rare, affecting approximately 1 in 100,000 people per year. It affects mainly adults aged 30–50. Females are affected slightly more often than males. The disorder can be confused clinically with  rectal cancer  or other conditions such as  inflammatory bowel disease , even when a  biopsy  is done. [ 2 ]


The signs and symptoms are variable, and in up to 25% of patients there may be no symptoms. [ 3 ]  The most common signs and symptoms are bleeding, which can vary from minor to severe, rectal prolapse and incomplete evacuation (35%-76% of cases). [ 4 ]  According to one report, constipation is present in about 55% of cases, but diarrhea is present in 20%–40% of cases. [ 1 ]  Reported symptoms are:


The exact cause is unclear and the condition is not fully understood. [ 3 ]  There are thought to be multiple factors which simultaneously cause the condition. [ 3 ]  Long term injury to the rectal mucosa and ischemic trauma are thought to be the main mechanisms. [ 5 ]  In a report of 36 patients with SRUS, the underlying cause was internal prolapse (intussusception) in 20 patients, external rectal prolapse in 14 patients, and dyssynergic defecation (anismus) in 2 patients. [ 7 ]


Self-digitation is when individuals with constipation resort to inserting a finger into the rectum in order to "hook out" fecal pellets or to apply pressure to an obstructing lesion (see:  obstructed defecation ). The rectal mucosa is fragile and vulnerable to trauma when such manoeuvres are performed chronically. It is thought that this self-induced trauma is one possible mechanism of SRUS. [ 1 ]  However, since sometimes the location of SRUS lesion(s) is much further than a finger could reach means that this cannot be the only cause. [ 5 ]  In constipation, the stools may be very hard and this is another possible mechanism of trauma. [ 1 ]


People with constipation or certain anatomical anomalies are more likely to end up using excessive straining during defecation attempts. [ 5 ]  Prolonged straining may cause direct trauma to the rectal mucosa. [ 5 ]  Most patients with SRUS have  dyssynergic defecation  (previously termed anismus). [ 8 ]  This is a failure of relaxation (or paradoxical contraction) of the  puborectalis muscle  during defecation attempts. This pelvic floor muscle is normally supposed to relax, thereby straightening the anorectal angle and allowing rectal contents to be evacuated. Dyssynergic defecation causes high pressure in the rectum and in the anal canal, [ 1 ]  which causes lengthening [ 1 ]  and compression of the rectal tissues, which in turn leads to ischema of the mucosa. [ 8 ]  There is also a shearing movement of the rectum against the pelvic floor muscles. [ 8 ]  In the long term this leads to repeated mucosal damage. [ 8 ]  Inappropriate contraction of puborectalis in the squatting position causes traumatic compression of the rectal wall against the anal canal. [ 5 ]  Also, it is reported that individuals with SRUS have not only increased pressure when squeezing, but also higher resting pressure compared to normal controls. [ 5 ]


SRUS is usually accompanied by prolapse (e.g. external prolapse or rectoanal intussusception/internal prolapse) or other pelvic-floor disorders. [ 1 ] [ 7 ]  This is association is common, but not always present. [ 9 ]  Some state that if SRUS is not treated, it would always tend to progress to rectal prolapse. [ 5 ]  The relationship of SRUS with  rectal prolapse  and rectal cystitis profunda is debated. [ 8 ]  Some see SRUS and prolapse as synonymous, while others see them as separate entities, [ 8 ]  and state that they do not share the same physiology. [ 6 ]  For example, the mucosal changes that occur with external rectal prolapse can be separated from the mucosal changes seen in SRUS. [ 6 ]


The excessive pressure caused by straining (i.e. dyssynergic defecation and constipation) may in the long term lead to development of the spectrum of rectal prolapse conditions (mucosal versus full-thickness prolapse, internal versus external rectal prolapse). [ 5 ]  These conditions create chronic vascular trauma (ischemia or hypoperfusion) in the rectal mucosa, [ 1 ]  which predisposes it to ulceration, [ 8 ]  and pressure necrosis. [ 4 ]  Even the initial small areas of an intussusception can lead to vascular injury and reduce blood supply to the region. [ 5 ]  This is the first stage of ulcer development. [ 5 ]


Psychological factors are also thought to be involved, since patients with SRUS sometimes have psychological disorders such as  obsessive-compulsive disorder . [ 1 ]  Also, some unknown factors may also be involved, such as hormonal factors related to pregnancy. [ 5 ]  Other possible factors are rectal hypersensitivity, [ 4 ]  and impaired rectal evacuation of stool. [ 9 ]


Diagnosis is difficult because of rarity of the condition and because of the variability of the symptoms and the histologic appearance. [ 1 ] [ 5 ]  The condition is sometimes misdiagnosed. [ 1 ]  Clinicians may not be familiar with the condition, and treat for  inflammatory bowel disease , or simple constipation. [ 10 ] [ 11 ]  Diagnosis may be delayed by many years as a result. [ 4 ]


The  differential diagnosis  is as follows:


Investigations used in the diagnosis of SRUS include  defecography ,  endoanal ultrasound ,  colonoscopy  and histological examination of a  biopsy . [ 3 ]


The macroscopic appearance of SRUS is very variable. [ 8 ]  Indeed, the condition has been referred to as “the three-lies disease”, [ 4 ]  because the name of the condition is sometimes misleading. In reality, there may be more than one lesion, which may not be  ulcerative , [ 12 ]  and the condition may appear in different parts of the gastrointestinal tract (i.e. other than the  rectum ). [ 3 ]


Classically, there is a solitary ulcer. But only 20% of patients have a single ulcer whereas in other cases there may be multiple lesions. [ 6 ]  The size of the ulcers is usually 0.5–4 cm. [ 5 ]  The lesion is most often located on the anterior (front) or lateral (side) rectal wall, centered on a rectal fold, [ 1 ]  usually 10 cm from the anal verge. [ 8 ]  Less commonly there may be ulcers in the  anal canal  or even in the  sigmoid colon . [ 5 ]  The nature of the tissue changes can vary from simple  erythema  (redness) /  hyperaemia  (increased blood flow) of the mucosa in 18% of cases, [ 1 ]  to a chronic-appearing, small, shallow ulcer with nodular margins and a white or sloughing base. [ 8 ] [ 1 ]  In up to 33% of cases there is no ulceration but instead one or more well-developed polyps or mass lesions. [ 8 ] [ 5 ]  There is usually mild  proctitis  (inflammation of the rectal mucosa) surrounding the ulcer. [ 2 ]


Conventional defecography or magnetic resonance defecography may be used. [ 1 ]  Between 50-100% of patients with SRUS will have abnormal defecography results. [ 5 ]  Defecography findings in SRUS may include:


Endoanal ultrasound  can determine the depth of the ulcer and the structure of the external and internal anal sphincters. [ 8 ]  Endoanal ultrasound findings in SRUS include:


As a diagnostic investigation, anorectal manometry can evaluate defecation function. It can highlight excessive and prolonged straining effort during defecation attempts, and also record any improvement in function before and after treatment interventions. [ 13 ]  It is uncommonly used to diagnose SRUS, although biofeedback is still commonly used as a treatment.


The histological appearance is as follows:


If the biopsy includes polypoid lesions, there are villiform structures visible. [ 5 ]  Gland entrapment in the submucosa is sometimes seen, which is termed  colitis cystica profunda . [ 5 ]


Treatment of SRUS is difficult and there is a lack of evidence-based guidelines. [ 4 ]  The treatment is based on the pathophysiology of SRUS, [ 5 ]  and the main aim is restoration of a normal pattern of defecation. [ 1 ]  The exact treatment depends on the severity of the symptoms, the severity/type of SRUS, and whether rectal prolapse is present or absent. [ 5 ]


Conservative measures are the first line treatment for patients with no symptoms or only mild to moderate symptoms, and those who have no significant anatomical defect. [ 1 ]  Conservative measures by themselves may improve symptoms and prevent the condition getting worse. [ 1 ]  Where conservative measures fail, or with severe disease and symptoms, or with significant anatomical defects, surgical options may be indicated. [ 5 ] [ 1 ]  Improvement in symptoms does not always equate to healing of the ulcer as seen on endoscopy. [ 5 ]


Conservative management is focused on education of the patient and behavioral modification. Where indicated, conservative management may also involve treatment of psychological problems, [ 5 ]  and avoidance of anoreceptive sex (to prevent trauma to the rectum). [ 8 ]


Biofeedback targets pelvic floor behaviors and enables a reprogramming of autonomic neurologic pathways associated with defecation. [ 8 ]  The treatment is particularly helpful for dyssynergic defecation (anismus). Research studies have shown that there is improved blood flow to the rectal mucosa after biofeedback therapy. [ 1 ]  The overall rate of complete resolution of both symptoms and ulceration varies at 50-75%. [ 8 ]  Stool frequency and straining effort decrease after this treatment. [ 1 ]  In about 56% of cases, biofeedback treatment stops rectal bleeding. [ 1 ]  Some patients are able to cease relying on digitation. [ 1 ]  Biofeedback is more effective in children with SRUS compared to adults. [ 1 ]


A randomized controlled study compared topical agents (dexamethasone, sucralfate and bismuth) with biofeedback. Overall, biofeedback gave 80% improvements in evacuation difficulty, need for digitation, sensation of incomplete evacuation, evacuation time, and appearance of mucosa on colonoscopy compared to the topical agents (50% improvement). [ 13 ]  However, the degree of long term improvement is not known. [ 13 ]


Several different topical treatments have been reported, with variable outcomes. [ 1 ]  These are substances applied directly to the ulcer, usually administered by enema. [ 8 ]  They may be helpful for short term management of acute symptoms in SRUS. [ 8 ]  They are thought to work by reducing inflammation and physically forming a barrier over the surface of the ulcer to protect it from irritants, thereby allowing it to heal. [ 4 ] [ 5 ]  However, the long term efficacy is unknown. According to a systematic review, 57% of SRUS patients who received medical treatment had resolution of ulceration. [ 4 ]  Topical agents which have been used for SRUS include:


According to one report, topical agents had an efficacy between 28 and 90%. Sucralfate had a 45-81% resolution rate compared to sulfasalazine (30-64%) and combination of other topical agents (20-79%). [ 13 ]


Surgery may be indicated for severe cases of SRUS (either severe symptoms, severe ulceration, or significant associated anatomical defect such as prolapse), or when conservative measures fail. [ 8 ] [ 5 ]  Some authors state that most patients do not benefit from surgery. [ 5 ]  Overall, up to 33% of SRUS patients end up requiring surgery. [ 8 ]  A systematic review reported that SRUS improved in 77% of patients who underwent any type of surgery. [ 6 ]  However, recurrence of the condition later developed in 52% of cases. [ 6 ]  It has been suggested that any treatment which only addresses the ulcer without correcting the underlying causes will typically lead to recurrence. [ 8 ]


There are multiple different surgical procedures which have been reported for SRUS, [ 5 ]  including:


Various local treatments for SRUS have been reported. According to one report, such measures have generally unfavorable results, and sometimes the ulcer returns deeper and larger than before the treatment. [ 8 ]


Excision (removal) of the ulcer and suturing the resulting defect with surrounding healthy mucosa has been reported. However, there may not be any long-term benefit. [ 8 ]  Ulcers in the upper part of the rectum may be accessible to local excision using a transanal minimally invasive approach (TAMIS). [ 8 ]  Excision with  neodymium yttrium-aluminium garnet laser  has also been reported. [ 6 ]


Rectopexy is a surgery for rectal prolapse. [ 3 ]  A newer version of the procedure is termed ventral mesh rectopexy, which has also been used for SRUS. [ 14 ]  It may be performed with or without anterior resection (removal of a portion of the front wall of the rectum). [ 9 ]  A mesh may be used to reinforce the anterior rectal wall. [ 8 ]  It can be done as an open procedure or with a laparoscopic abdominal approach. [ 8 ]


Some authors state rectopexy is suitable in highly select cases, [ 9 ]  while others say it is the procedure of choice, [ 7 ]  since it directly addresses the most likely cause. [ 8 ]  There is not much evidence for the use of laparoscopic ventral rectopexy to treat SRUS, [ 13 ]  but there is more evidence to support the its use compared to other surgical procedures. [ 8 ]  Approximately 55-83% of patients with SRUS get reduced symptoms after rectopexy, [ 8 ]  and these benefits appear to be long term. [ 3 ]  In one study, 11 people with SRUS underwent laparoscopic ventral rectopexy. All of the patients showed resolved symptoms and mucosal injury one year after the procedure. In the long term, 1 patient developed recurrence after 4 years, and the other 7 who were evaluated in the long term did not develop recurrence. [ 13 ]  Another study combined laparoscopic ventral rectopexy and biofeedback for 48 patients with SRUS. In all cases there was healing of the mucosa 3 months after the procedure. In 65% of cases there was improvement in symptoms of obstructed defecation and in 45% of cases there was improved quality of life. The rate of recurrence was 4-8% after an average follow up time of 33 months. [ 15 ]


The stapled transanal rectal resection (STARR) procedure has been used both as an alternative to ventral mesh rectopexy and as a secondary procedure when ventral mesh rectopexy failed to completely resolve the condition. [ 16 ]  In one study, STARR gave improvement in all cases where biofeedback had not worked. [ 13 ]  In comparison with ventral mesh rectopexy, STARR may result in higher rates of bowel  urgency , recurrence and other complications, some of which may be serious. [ 13 ]


The following "last resort" surgical procedures (which may have significant consequences) have been reported in severe, persistent or recurrent cases of SRUS:


The condition is relatively rare, but the exact prevalence is not known. [ 3 ]  Prevalence has been estimated as 1 in 100,000 people per year. [ 3 ]  SRUS can occur at any age, but it is most common in adults aged between 30-50. [ 3 ]  Males and females are affected almost equally, [ 3 ]  or females slightly more. [ 1 ]


Misdiagnosis  as  inflammatory bowel disease  (IBD) or  rectal polyps  may hide the true prevalence of SRUS. [ 3 ]


Stapled hemorrhoidopexy  is a  surgical  procedure that involves the cutting and removal of anal hemorrhoidal vascular cushion, whose function is to help to seal stools and create continence. Procedure also removes abnormally enlarged  hemorrhoidal tissue , followed by the repositioning of the remaining hemorrhoidal tissue back to its normal anatomic position. Severe cases of hemorrhoidal prolapse will normally require surgery. Newer surgical procedures include  stapled transanal rectal resection  (STARR) and procedure for prolapse and hemorrhoids (PPH).  Both STARR and PPH are  contraindicated  in persons with either  enterocele  or  anismus . [ 1 ]


This procedure is for internal hemorrhoids only and not for external hemorrhoids or anal fissures. [ citation needed ]  During the procedure the external anal sphincter muscle is pulled in when the anal cushion is cut followed tight stapling with 2 rows of 28 staples so if external hemorrhoids are present they also get pulled in and get hidden inside and get tucked inside the anal canal and reappear when the staples fall after a few months when the external anal sphincter comes to its normal position.


Previously a lot of surgeons thought that this procedure is for external hemorrhoids also as they disappear but instead they are hidden inside and fool the eye and reappear after the staples fall off. [ citation needed ]


Hemorrhoids  are amongst the most common anal disorders. Patients may complain of bleeding,  prolapse , personal discomfort and minor  anal leakage . Where traditional non-surgical measures such as rest, suppositories and dietary advice fail to improve the condition, there is then a choice of further treatments. Opinion on the best management for patients varies considerably. While many treatments for hemorrhoids may be performed without  anesthetics , the lasting effect of these conservative therapies has been questioned. Many patients treated with  rubber band ligation  or injection  sclerotherapy  require multiple treatments and there is high recurrence rate following these procedures.


Conventional hemorrhoidectomy provides permanent symptomatic relief for most patients, and effectively treats any external component of the hemorrhoids. However, the wounds created by the surgery are usually associated with considerable post-operative pain which necessitates a prolonged recovery period.  This can put a stress on a  general practitioner ’s resources, may alienate the patient and delays the patient's return to a full, normal lifestyle and the workplace. Because of this, surgeons will generally reserve formal  excision  for the most severe cases of prolapse, or for patients who have failed to respond to conventional treatments. [ medical citation needed ]


Obstructed defecation  syndrome (ODS) can be caused by structural deformities in the rectum resulting in chronic constipation. STARR can treat ODS using minimally invasive methods. STARR is a surgical procedure developed by Antonio Longo, an Italian surgeon, that is performed through the anus, requires no external incisions, and leaves no visible scars. Using a surgical stapler, the procedure removes the excess tissue in the rectum, reducing the anatomical defects that can cause ODS.


In a study of 90 patients undergoing the STARR procedure, patients were hospitalized one to three days, experienced minimal postoperative pain after the procedure, and resumed employment or normal activity in 6 to 15 days. In this study, most ODS patients experienced a significant improvement in their ODS symptoms following STARR.  [ citation needed ]


PPH uses a circular stapler to reduce the degree of prolapse. The procedure avoids the need for wounds in the sensitive perianal area thus reducing post-operative pain considerably, and facilitates a speedier return to normal activities. This procedure is for internal hemorrhoids only and not for external hemorrhoids or anal fissures.
 [ 2 ] [ 3 ] [ 4 ]


This procedure was first described by an Italian surgeon – Dr.  Antonio Longo , Department of Surgery, University of Palermo – in 1993 and since then has been widely adopted through Europe. This procedure avoids the need for wounds in the sensitive perianal area and, as a result, has the advantage of significantly reducing the patient's post operative pain. [ 2 ] [ 3 ] [ 4 ]  Follow-up on relief of symptoms indicate a similar success rate to that achieved by conventional haemorrhoidectomy. [ 2 ] [ 5 ]  Since PPH was first introduced it has been the subject of numerous clinical trials and in 2003 the National Institute of Clinical Evidence (NICE) in the UK issued full guidance on the procedure stating it was  safe and efficacious .


PPH is generally indicated for the more severe cases of internal hemorrhoidal prolapse (3rd and 4th degree) where surgery would normally be indicated. It may also be indicated for patients with minor degree haemorrhoids who have failed to respond to conservative treatments.  The procedure may be contra-indicated when only one cushion is prolapsed or in severe cases of fibrotic piles which cannot be physically repositioned.


In addition to correcting the symptoms associated with the prolapse, problems with bleeding from the piles are also resolved by this excision.  Although the cushions may be totally or partially preserved, the blood supply is interrupted or venous drainage is improved by the repositioning.  Any external component which remains will usually regress over a period of 3–6 months.  Prominent skin tags may, on occasion, be removed during the operation but this may increase the postoperative pain so is not routinely performed.


PPH employs a unique circular stapler which reduces the degree of prolapse by excising a circumferential strip of mucosa from the proximal anal canal.  This has the effect of pulling the hemorrhoidal cushions back up into their normal anatomical position.
Usually, the patient will be under general anesthetic, but only for 20–30 minutes.  Many cases have been successfully performed under local or regional anesthesia and the procedure is suited to day case treatment.  [ citation needed ]


Due to the low level of post-operative pain and reduced analgesic use, patients will usually be discharged either the same day or on the day following surgery. Most patients can resume normal activities after a few days when they should be fit for work.  The first bowel motion is usually on day two and should not cause any great discomfort.  Staples may be passed from time to time during defecation.  This is normal and should not be a cause for concern. [ medical citation needed ]


Since 2002 more than 100 articles have been published reporting complications during and after stapled hemorrhoidectomy.


Bleeding is the most common postoperative complication. Severe postoperative pain could be caused by dehiscence of the anastomosis or due to the fact that the anastomosis is too near to the linea dentata. [ citation needed ]  A rare complication stemming from PPH is intra- abdominal  bleeding. [ 6 ]


Many long-term complications have been described. Most of them are related to either an incorrect indication for surgery or technical errors. Several authors stated that although it seems to be an easy operation to perform, it should only be done by experienced surgeons. Severe complications leading to death have been described but are rare. Irreversible urge incontinence due to lesions of the sphincter muscle or a diminished rectal capacity due to resection of too much mucosa, are quite common complications if the procedure is not performed properly. Rectovaginal fistulas and anastomotic diverticula are very rare but possible.


Argon plasma coagulation  ( APC ) is a medical  endoscopic  procedure used to  control bleeding  from certain lesions in the  gastrointestinal tract . It is administered during gastrointestinal  endoscopy  such as   esophagogastroduodenoscopy  or  colonoscopy .


APC involves the use of a jet of  ionized   argon  gas ( plasma ) directed through a probe passed through the  endoscope . The probe is placed at some distance from the bleeding lesion, and argon gas is emitted, then ionized by a high-voltage discharge (approx 6 kV ). [ 1 ]  High-frequency  electric current  is then conducted through the jet of gas, resulting in coagulation of the bleeding lesion. As no physical contact is made with the lesion, the procedure is safe if the bowel has been cleaned of colonic gases, [ 2 ] [ 3 ]  and can be used to treat bleeding in parts of the gastrointestinal tract with thin walls, such as the  cecum .


Assisted feeding , also called  hand feeding  or  oral feeding , is the action of a person feeding another person who cannot otherwise feed themselves. The term is used in the context of some medical issue or in response to a  disability , such as when a person living with  dementia  is no longer able to manage eating alone.
The person being fed must be able to eat by mouth, but lacks either the cognitive or physical ability to self-feed. Individuals who are born with a disability like cerebral palsy, or arthrogryposis multiplex congenita (AMC) may be unable to feed themselves. Also, those who acquire a disability due to an accident or a disease like amyotrophic lateral sclerosis (ALS) may require hand feeding because they may become unable to pick-up and bring food to their own mouth.


A feeding tube is a medical device used to provide nutrition to patients who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation. [ 1 ]  Patients who are able to use assisted feeding should have that in preference to tube feeding whenever possible. [ 1 ]


Oral assisted feedings are preferable to  percutaneous feeding  in individuals with advanced dementia. [ 2 ]


In the United States a study reviewed a set of patients and found that the expenses to arrange assisted feeding for patients was higher than the cost of using a feeding tube. [ 3 ]


Balloon tamponade  is the use of  balloons  inserted into the  esophagus ,  stomach  or  uterus , and inflated to alleviate or stop  refractory  bleeding.


Balloon tamponade is considered a bridge to more definitive treatment modalities, and is usually administered in the emergency department or in the  intensive-care unit  setting, due to the illness of patients and the complications of the procedure.


In the uterus, balloon tamponade can alleviate or stop  postpartum hemorrhage  (PPH). Inflating a  Sengstaken–Blakemore tube  in the uterus successfully treats atonic postpartum hemorrhage refractory to medical management in approximately 80% of cases. [ 2 ]  Such procedure is relatively simple, inexpensive and has low surgical morbidity. [ 2 ]  A  Bakri balloon [ 3 ]  is a balloon tamponade specifically constructed for uterine postpartum hemorrhage.


The Bakri balloon tamponade (BBT), designed for postpartum hemorrhage, is an effective life-saving balloon. [ 4 ]  A recent study involving 50 cases was carried out by the department of Obstetrics and Gynecology at University Central Hospital in Helsinki, Finland. With an overall success rate of 86%, the authors concluded that the Bakri balloon tamponade is "a simple, readily available, effective and safe procedure" in the management of postpartum hemorrhage. The research also indicates that BBT is able to provide practitioners with "time for other interventions or transportation from local hospital to tertiary centre". The authors of the study recommend BBT be included in the PPH protocol. [ 5 ]


An alternative to the Bakri is the BT-Cath (balloon-tamponade catheter) which has an easy-fill system allowing single person inflation and saving time in the theatre setting. The BT-Cath is more pear-shaped and contours to the uterus more easily than the Bakri.


A low-cost alternative is a condom balloon tamponade, a form of intrauterine tamponade, created from a catheter, a male latex condom, and a string to tie the condom to the catheter. The method was developed in Bangladesh in 2001 by  Sayeba Akhter  and has since been supported by health workers worldwide as an effective method to stop postpartum hemorrhage, particularly in low-resource settings. [ 6 ]


Biliary endoscopic sphincterotomy  is a procedure where the  sphincter of Oddi  and the segment of the  common bile duct  where it enters the  duodenum  are cannulated and then cut with a sphincterotome, a device that includes a wire which cuts with an electric current ( electrocautery ). [ 1 ]


This procedure was developed in both Germany and Japan and was first published in each nation in 1974. [ 2 ] [ 3 ]  It has become a very common technique, useful for treatment of a wide variety of conditions of the biliary system such as the evacuation of gallstones within the bile duct ( choledocholithiasis ), biliary or papillary strictures,  sphincter of Oddi dysfunction , bile leaks, and others. In addition, it is commonly performed during an  endoscopic retrograde cholangiopancreatography  (ERCP), and it may be used for facilitating diagnostic procedures such as transpapillary bile duct biopsy, papillary tumor biopsy, and insertion of a cholangioscope. [ 1 ]


Extraction of choledocholithiasis and/or intrahepatic stones:  choledocholithiasis is the presence of  gallstones  within the common bile duct. They can be either primary (formed within the duct) or secondary (entering the duct from the  gallbladder ). Biliary endoscopic sphincterotomy allows for opening of the sphincter of Oddi, allowing stones to be removed. [ 4 ]


Treatment of benign biliary/papillary strictures:  diseases such as  primary sclerosing cholangitis  can lead to fibrosis and stricture of the ducts of the  biliary tree . These strictures can cause  cholestasis  which can lead to  jaundice ,  pruritus ,  cholangitis , and gallstone formation. Biliary endoscopic sphincterotomy is sometimes used, with or without  stenting , to relieve the obstruction, but systematic reviews have not demonstrated consistent benefits. [ 5 ]


Treatment of sphincter of Oddi dysfunction:  this is a diagnosis of exclusion which encompasses a broad spectrum of hepatobiliary disorders including spasms, strictures, or inappropriate relaxation. Sphincterotomy appears to be safe and effective for the treatment of sphincter of Oddi dysfunction. [ 6 ]


Treatment of bile leaks:  leakage of bile into the abdominal cavity is a complication of  laparoscopic cholecystectomy . The purpose of biliary endoscopic sphincterotomy in the treatment of a bile leak is to reduce or eliminate the pressure gradient between the bile duct and the duodenum, encouraging transpapillary bile flow and allowing the leak to heal. [ 7 ]


Others:


Bleeding/coagulopathy:   platelet count  and  international normalized ratio  (INR) should be checked before the procedure. Discontinuation of antiplatelet therapy or  anticoagulation  requires consideration of the risks of  hemorrhage  vs.  thrombosis  and management should be based on current guidelines. [ 8 ] [ 9 ]


Sphincterotomes:  a sphincterotome (also called a papillotome) is a  catheter  with a cutting wire at its far end. They have various configurations based on cutting wire length, outer diameter, number of lumens, and presence of other features such as the ability to rotate. The sphincterotome is connected to an electrosurgical generator, allowing the cutting wire to function as a knife when an electrical current is applied. Additional lumens allow the addition of a  guidewire  and injection of radio-opaque contrast. They can be broadly categorized as pull-type, push-type, or needle-knife. [ 1 ]


Pull-type:  pull-type sphincterotomes consist of a steel cutting wire within a  Teflon  catheter. The wire exits the catheter approximately 3 cm before its distal end and re-enters the catheter approximately 3 mm from its tip. When tension is applied to the wire, the distal portion of the catheter becomes curved so that the exposed wire is brought upwards into contact with the biliary sphincter and  papilla , away from the catheter. [ 1 ]


Push-type:  push-type sphincterotomes have a similar design to pull-type, but instead tightening the wire pushes it out to form a bow oriented downwards. This is useful for patients with  Billroth II  anatomy. [ 1 ]


Needle-knife:  a needle-knife sphincterotome has a retractable cutting wire of 3 to 5 mm with a Teflon sheath. They are most often used for a pre-cut sphincterotomy when standard methods of cannulation fail. [ 1 ]


Standard sphincterotomy:  the sphincterotome is inserted into the bile duct. A  cholangiogram  is then used to evaluate any biliary abnormalities requiring further intervention. The papilla is then incised with the cutting wire by applying electrocautery. [ 1 ]


Pre-cut sphincterotomy:  pre-cut biliary endoscopic sphincterotomy refers to the techniques used to cut the papillary mucosa and biliary sphincter in order to expose the underlying bile duct and gain access to it when standard cannulation fails. [ 1 ]


Transpancreatic biliary sphincterotomy (septotomy):  when the guidewire is unintentionally inserted into the  main pancreatic duct  the sphincterotome is then placed in the pancreatic duct and used to cut the  septum  between the pancreatic duct and bile duct. It is then withdrawn and re-directed through the incision site into the bile duct with the guidewire. [ 1 ]


Needle knife papillotomy:  a needle knife sphincterotome is placed en face to the biliary papilla. An incision is then made stepwise, starting at the upper margin of the papillary orifice and extending towards the biliary sphincter, creating an incision to allow the bile duct to be cannulated. [ 1 ]


Needle knife fistulotomy:  a needle knife  fistulotomy  has two different technique which are used. For the first technique an incision is made a few millimeters above the opening to the duct and then extended upwards. The other option is to make an incision in the roof of the papilla and then extend it either up or down without cutting the papillary orifice itself. [ 1 ]  The rate of  pancreatitis  after ERCP was significantly lower after fistulotomy, compared to other precut techniques. [ 1 ]


Periampullary diverticulum:  periampullary diverticulum makes the procedure more difficult because it becomes harder to assess the incision. [ 10 ]  Needle-knife fistulotomy or pancreatic stent placement followed by precut sphincterotomy are two of several techniques that have been used to account for the increased difficulty. [ 11 ]


Surgically altered anatomy (Billroth II):  if a patient has undergone a partial  gastrectomy  with Billroth II anastomosis, the papilla may appear to be upside down from the perspective of the endoscope compared to normal. Cannulation may need to be performed in a reverse position with the bile duct oriented downwards. [ 1 ]


The reported overall incidence of complications associated with ERCP and biliary endoscopic sphincterotomy has ranged from 3 to 12 percent. [ 12 ]


Pancreatitis:   biliary endoscopic sphincterotomy is not an independent risk factor for pancreatitis after ERCP. [ 1 ]


Bleeding:  immediate bleeding occurs during or immediately after biliary endoscopic sphincterotomy. It is seen in up to 30% of patients and self-limiting most of the time. Delayed bleeding occurs from a few hours up to 2 wk after the procedure. [ 13 ]


Perforation:  the incidence of sphincterotomy related  perforation , also named Type 2 duodenal perforation, is between 0% and 1.8%. [ 12 ]


Cholangitis/sepsis:  the incidence of cholangitis after biliary endoscopic sphincterotomy is between 1% and 3%. [ 1 ]


Late complications:  long-term complication vs of biliary endoscopic sphincterotomy include recurrent common bile duct stone, cholecystitis, cholangitis,  hepatic abscess , papillary stenosis and biliary stricture. [ 12 ]


Balloon Dilation:  balloon dilation is an alternative often used in patients with a coagulation disorder or if their anatomy makes a traditional sphincterotomy more difficult. Balloon dilation is associated with fewer long term complications owing to preservations of sphincter function. [ 14 ]


Diagnostic peritoneal lavage  ( DPL ) or  diagnostic peritoneal aspiration  ( DPA ) is a surgical diagnostic procedure to determine if there is free floating fluid (most often blood) in the  abdominal cavity . [ 1 ]


This procedure is performed when intra-abdominal bleeding ( hemoperitoneum ), usually secondary to trauma, is suspected. [ 2 ]  In a hemodynamically  unstable patient with high-risk mechanism of injury, peritoneal lavage is a means of rapidly diagnosing intra-abdominal injury requiring laparotomy, but has largely been replaced in trauma care by the use of a  focused assessment with sonography for trauma  (FAST scan) due to its repeatability, non-invasiveness and non-interference with subsequent  computed tomography  (CT scan). Abdominal CT and  contrast duodenography  may complement lavage in stable patients, but in an unstable or uncooperative persons, these studies are too time-consuming or require ill-advised sedation.  Magnetic resonance imaging  is extremely accurate for the anatomic definition of structural injury, but logistics limit its practical application in acute abdominal trauma. [ 3 ] [ 4 ]
The procedure was first described in 1965 by Hauser Root. [ 5 ] [ 6 ]


After the application of  local anesthesia , a vertical skin incision is made one third of the distance from the  umbilicus  to the  pubic symphysis .  The  linea alba  is divided and the  peritoneum  entered after it has been picked up to prevent bowel perforation. A catheter is inserted towards the pelvis and aspiration of material attempted using a syringe. If no blood is aspirated, 1 litre of warm 0.9% saline is infused and after a few (usually 5) minutes this is drained and sent for analysis. [ 7 ]


If any of the following are found then the DPL is positive and operative exploration is warranted: [ 8 ]


Duodenal-Jejunal Bypass Liner , or  Gastric Bypass Stent [ 1 ] , Common brand names include  EndoBarrier , is an  implantable   medical device  in the form of a thin flexible 60 cm-long tube that creates a physical barrier between ingested food and the  duodenum / proximal jejunum . The duodenal-jejunal bypass liner prevents the interaction of food with enzymes and hormones in the proximal intestine to treat  type 2 diabetes  and  obesity . The duodenal-jejunal bypass liner is delivered  endoscopically  and has been tested on the morbidly obese (those with a  body mass index  [BMI] greater than 40) as well as obese patients with a BMI less than 40, particularly those with difficult-to-manage type 2 diabetes. Despite a handful of serious adverse events such as gastrointestinal bleeding, abdominal pain, and device migration — all resolved with device removal — initial clinical trials have produced promising results in the treatment's ability to improve weight loss and  glucose homeostasis  outcomes. [ 2 ] [ 3 ]


The device is connected at one end to the beginning of the duodenum (first portion of the small intestine from the stomach) and at the other the mid-jejunum (the secondary stage of the small intestine). A  nitinol  anchor secures the bag at the duodenum, ensuring the liner doesn't migrate and that the  chyme  (the semifluid mass of partially digested food that exits the stomach) completely enters into the liner. This prevents the partially digested food from entering the first and initial part of the secondary stage of the small intestine, mimicking the effects of the  biliopancreatic portion  of  Roux en-Y gastric bypass  (RYGB) surgery. This reduces the amount of calories absorbed and causes bile and pancreatic fluids to be redistributed later in the mid-jejunum for reduced breakdown and absorption of the chyme. [ 2 ] [ 3 ] [ 4 ]


Initial clinical research by Rubino  et al.  in 2006 produced two hypotheses for why duodenal-jejunal bypass is effective in improving glucose homeostasis. Their "hindgut hypothesis" claims that by expediting the delivery of chyme to the  distal intestine , the secretion of the gut hormone  GLP-1  and glucose-dependent insulin is more effectively promoted, improving glucose metabolism. The "foregut hypothesis," on the other hand, states that by bypassing the duodenum and proximal jejunum (the initial parts of the small intestine), the inhibiting hormone  GIP  is secreted less, resulting in improved glucose tolerance. [ 5 ] [ 6 ]  As of 2015 [update] , those hypotheses continue to be tested, with Xiong  et al.  finding elements of both being involved. [ 7 ]


A specialized study of the product noted that the rate of adverse events could reach 84.4% of the 1,056 cases counted, with a moderate adverse event rate of 20.5% and a serious adverse event rate of 3.7%. [ 8 ]


Common adverse event, other than those related to surgery, were mainly implant rejections (e.g., abdominal pain, vomiting),  gastrointestinal bleeding , anchor displacement,  ulceration , and  perforation , as well as liner-related adverse events (e.g., obstruction, ectopia) and inflammatory conditions such as  pancreatitis ,  cholecystitis , and  cholangitis .


Severe adverse events includes perforation of the  esophagus ,  gastrointestinal hemorrhage , anchor tissue overgrowth, perforation of the duodenal bulb, hepatic abscess and acute pancreatitis, the majority (85%) of serious adverse events were directly or indirectly related to anchor.


Endoscopic foreign body retrieval  refers to the removal of ingested objects from the  esophagus ,  stomach  and  duodenum  by  endoscopic  techniques.  It does not involve  surgery , but rather encompasses a variety of techniques employed through the  gastroscope  for grasping  foreign bodies , manipulating them, and removing them while protecting the esophagus and  trachea . [ 1 ]   It is of particular importance with children, [ 2 ]  people with  mental illness , [ 3 ]  and  prison  inmates [ 4 ]  as these groups have a high rate of foreign body ingestion.


Commonly swallowed objects include  coins ,  buttons ,  batteries , and small bones (such as fish bones), [ 1 ]  but can include more complex objects, such as  eyeglasses , [ 5 ]   spoons , [ 6 ]  and  toothbrushes [ 5 ]  (see image).


Some patients at risk for foreign body ingestion may not be able to give an accurate  medical history  of ingestion, either due to  age  or mental illness.  It is important that physicians treating these patients recognize the  symptoms  of esophageal foreign body impaction requiring urgent intervention. Most frequently, these include drooling and the inability to swallow  saliva , neck tenderness,  regurgitation  of food,  stridor  and  shortness of breath  if there is compression of the trachea. [ 1 ] [ 7 ]


There are several situations in which endoscopic techniques are not indicated, such as for small blunt objects less than 2.5 cm which have already passed into the stomach (as these usually do not obstruct anywhere else), when there is  perforation of the esophagus  or  mediastinitis  (inflammation of structures around the esophagus), and for  narcotic -containing bags or  condoms  that have been ingested, because of the risk of overdose if they are ruptured. [ 1 ]


Foreign bodies should be removed from the esophagus within 24 hours of ingestion because of a high risk of complication. [ 8 ]


Prior to undertaking endoscopy, attempts should be made to locate the foreign body with  x-rays  or other  non-invasive techniques . [ 1 ]   For radio-opaque objects, x-rays of the neck, chest and abdomen can be used to locate the foreign body and assist endoscopy. [ 9 ]   Alternative approaches, including the use of  metal detectors , have also been described. [ 10 ]


X-rays are also useful for identifying the type of foreign body ingested and complications of foreign body ingestion, including mediastinitis and perforation of the esophagus. [ 1 ]


Endoscopic  retrieval involves the use of a gastroscope or an optic fiber  charge-coupled device  camera. This instrument is shaped as a long tube, which is inserted through the  mouth  into the esophagus and stomach to identify the foreign body or bodies.  This procedure is typically performed under  conscious sedation .  Many techniques have been described to remove foreign bodies from the stomach and esophagus.  Usually the esophagus is protected with an overtube (a plastic tube of varying length), through which the gastroscope and retrieved objects are passed. [ 11 ]


Once the foreign body has been identified with the gastroscope, various devices can be passed through the gastroscope to grasp or manipulate the foreign body. Devices used include  forceps , which come in varying shapes, sizes and grips, [ 12 ]   snares , and oval loops that can be retracted from outside the gastroscope to  lasso  objects, [ 13 ]  as well as  Roth baskets  (mesh nets that can be closed to trap small objects), [ 14 ]  and   magnets  placed at the end of the scope or at the end of  orogastric tubes . [ 12 ] [ 15 ]  Some techniques have been described that use  foley catheters  to trap objects, or use two snares to orient foreign bodies. [ 6 ]


In  veterinary medicine  or when there is no endoscope available to extract  foreign bodies  economically without operation the  Hartmann alligator forceps  can be used. [ 16 ]


Endoscopic retrograde cholangiopancreatography  ( ERCP ) is a technique that combines the use of  endoscopy  and  fluoroscopy  to diagnose and treat certain problems of the  biliary  or  pancreatic ductal  systems. It is primarily performed by highly skilled and specialty trained gastroenterologists. Through the endoscope, the physician can see the inside of the  stomach  and  duodenum , and inject a  contrast medium  into the ducts in the biliary tree and/or  pancreas  so they can be seen on  radiographs .


ERCP is used primarily to diagnose and treat conditions of the bile ducts and main pancreatic duct, [ 1 ]  including  gallstones , inflammatory strictures (scars), leaks (from trauma and surgery), and cancer.
ERCP can be performed for diagnostic and therapeutic reasons, although the development of safer and relatively non-invasive investigations such as  magnetic resonance cholangiopancreatography  (MRCP) and  endoscopic ultrasound  has meant that ERCP is now rarely performed without therapeutic intent. [ 2 ]


The following represent indications for ERCP, particularly if or when less invasive options are not adequate or definitive:


ERCP may be indicated in the above diagnostic scenarios when any of the following are needed:


Hypersensitivity to iodinated contrast medium or a history of iodinated contrast dye  anaphylaxis  is not a contraindication of ERCP, though it should be discussed with your health provider, and you should tell them you are allergic to iodine, as an alternative contrast iodine-free material ("dye") is then injected gently into the ducts (pancreatic or biliary) and x-rays are taken. [ 7 ]