Rectal Masses

Rectal Masses: Excerpt from In a Page: Signs and Symptoms

Any mass in the anal canal or rectum should be considered cancer until ruled out. Colorectal cancer must be considered, as it is the second leading cause of cancer death in the U.S., with greater than 40,000 mortalities each year. Early detection and aggressive treatment, and a multidisciplinary approach, are the keys to improving survival.

Differential Diagnosis

• Hemorrhoids
• Rectal prolapse
• Rectal cancer
• Rectal polyp
• Prostate cancer
• Prostatitis
• Endometriosis
• Presacral neurogenic tumor
• Rectal intussusception
• Anal cancer (2% of colorectal cancers)
  –Anal canal tumors (above the anal verge) include adenocarcinoma, melanoma, and epidermoid tumors
  –Anal margin tumors (below the anal verge) include squamous cell carcinoma, verrucous (from condyloma acuminatum), basal cell carcinoma, Bowen's disease, and Paget's disease of the anus

• Foreign body
• Less common diagnoses (“zebras”) include rectal carcinoid, lymphoid hyperplasia, malignant lymphoma, lipoma, dermoid cyst, teratoma, rectal duplication, and leiomyosarcoma

Workup and Diagnosis

• History should include changes in bowel habits or consistency of stool, and family history of colorectal cancer
  –Bleeding is the most common symptom associated with benign and malignant lesions; melena suggests upper GI bleeding, blood on toilet paper suggests anal fissure or hemorrhoids, bright red separate from stool suggests hemorrhoids, clots in stool suggests colonic source
  –Pain is usually associated with benign pathology

• Fecal occult blood testing may be used for screening
• Digital rectal exam and anoscopy are used initially to distinguish many anorectal lesions
• Endoscopy (sigmoidoscopy and/or full colonoscopy) with biopsy of all polyps and suspicious lesions
• Barium enema is indicated if colonoscopy unavailable
• Endorectal ultrasound is necessary to evaluate for potential rectal cancer, to appropriately stage tumor invasion and lymph node status, and to direct appropriate treatment
• Manometry may be indicated in incontinent patients

Treatment

• Rectal and anal cancers are treated by surgical resection (with sphincter preservation), radiation, and/or chemotherapy

• Hemorrhoid treatment is initially conservative: High-fiber diet, appropriate anal hygiene, Sitz baths, and topical steroids
  –Surgical options include rubber band ligation of internal hemorrhoids or surgical resection for large refractory hemorrhoids
  –Acute thrombosis of a hemorrhoid may require incision and drainage

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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