A sore looking rectum !

This 70 year old gentleman presented with PR bleeding and mucus. 
WHAT IS THE DIAGNOSIS?

■ Rectal prolapse

Nope, doesn't look like this!

■ Active proctitis

Seriously? How long have you been scoping?

■ Solitary rectal ulcer syndrome

SRUS can look almost like anything but not like this!

■ Rectal adenoma

Yes, to be specific it's a villous adenoma!

■ Rectal carcinoma

That polyp is big but not ugly!

explanation

Perhaps something of a 'noddy' question as any endoscopists worth his salt should recognise this as a large villous adenoma.  However, many endoscopists would not see beyond the sheer size of the lesion and conclude that the lesion must be malignant SOMEWHERE!   The truth is that it's precisely because the lesion is inherently innocent that it has grown to this size WITHOUT turning malignant!  

So how to deal with it?  An endoscopic resection would include a circumferential resection for about 12cm, starting at the anal verge.   There are several options;  

■ Perhaps you could remove it in sections?  For example, removing a quarter and then bring the patient back after a few month to do another section?  I've tried it!  Sadly, they grow back so quickly that by the time the patient returns, it has already re-grown to recover the previously cleared surface !   

■ Perhaps you could use APC, not to clear the lesion but to reduce the amount of blood-stained mucus it produces?  I've tried that too!!!  Unfortunately, APC tends to make the mucus production worse !!! 

■ There is one more thing which I have learnt with large villous adenomas like this. They tend not to lift very well!  As the lift is always 'shallow', you end up with a very narrow submucosal window to dissect through.  Similarly, a piecemeal EMR is almost impossible unless the VA is much smaller. 

■ The only thing which we haven't tried in Leeds is a joint effort whereby 2-3 endoscopists take it in turns to dissect the lesion over a 8-10 hour period, perhaps under GA. A daunting prospect and I doubt that it's actually feasible.  Naturally, a TEMS procedure is similarly unlikely to succeed and the patient is probably most likely to wake up without a rectum at all. 

However, loosing the rectum to benign disease at the age of 75 would be a bitter pill.   Perhaps that's why most choose to put up with the mucus ?