Mary-Alice Tully, MSN, PNP-BC
Oscar, a healthy, developmentally normal, 13-year-old boy, presented to our gastrointestinal (GI) and nutritional clinic with a chief complaint of mucous discharge from his rectum for 6 months. He did not recall any precipitating event; he just noticed one day that he had a lot of mucous from his rectum not associated with bowel movements. Over the months, his symptom worsened having five to six discharges a day. He never saw any blood throughout this period. He was typically not bothered when he was in school and it did not interfere with activities; he was able to play baseball without a problem. He had no constipation or diarrhea but said that sometimes his stool felt hard. He occasionally had lower abdominal pain, but this was always when he was pushing hard because he felt like he had more mucus to expel. He was waking at night, perhaps two to three times a week, to go to the bathroom because he felt that he was going to pass some mucous. He had no weight loss and a good appetite.
On physical examination, Oscar was found to have a rectal prolapse with Valsalva maneuver, and upon further questioning, he said that intermittent prolapse had been occurring for 2 months. Laboratory results from his primary doctor were normal: Two stool cultures were negative for ova and parasites, Escherichia coli, Clostridium difficile, Campylobacter, Salmonella, and Shigella; he had a normal complete blood cell count with differential; liver function tests were normal with an albumin level of 4.4 g/dl; his sedimentation rate was 4 mm/hour; and his serum chemistries were normal. His anteroposterior upright and supine radiographs of the abdomen were normal; he had a mild to moderate amount of stool throughout the entire colon.
Our initial impression was that Oscar's rectal prolapse and mucous discharge were related to straining with constipation because this is the most common cause of rectal prolapse in children. In one retrospective review of 54 children with rectal prolapse, prolapse was attributed to chronic constipation in 28%, to diarrheal disease in 20%, to cystic fibrosis in 11%, and to neurologic or anatomic conditions in 24%; no underlying cause was identified in the remaining 17% (Felt-Bersma & Cuesta, 2001; Siafakas, Vottler, & Andersen, 1999). We started him on MiraL AX (polyethylene glycol 3350), one capful one to two times per day. We also suggested using hydrocortisone cream for relief from feeling like he needed to push. We screened for celiac disease, and although our level of suspicion was quite low, we also scheduled a sweat test to rule out cystic fibrosis. The results of these tests were negative.
When Oscar's condition did not improve, he underwent colonoscopy, which revealed a variety of foreign bodies located at his cecum (Figure 1). His biopsy results were all normal, with minor changes in the rectum consisting of colonic mucosa with modest architectural atypia (branched crypts), suggestive of healed injury. Upon questioning, Oscar's parents said he was always one to have things in his mouth, chewing on a pen or a pencil. Oscar reluctantly admitted that he sometimes swallowed foreign objects but was skeptical that this was the cause of his problem because he swallowed things his whole life and never had a problem before. Although uncertain, my colleagues and I felt that his rectal prolapse and mucous discharge were related to ingesting foreign bodies. We asked him to try to stop this behavior, and we provided him with a referral to a behavioral psychologist to help him with this habit. We asked him to try Metamucil (psyllium fiber dietary supplement) to see if that gave better relief than GlycoLax (polyethylene glycol 3350).
Persistent ingestion or mouthing of nonfood substances is called pica. The etiology of this eating disorder is unknown and many factors have been implicated. The word pica comes from the Latin word for magpie, a bird known for its large and indiscriminate appetite. In children younger than 2 years and in some cultures, it is not considered to be pathologic. Oscar's case was surprising because pica occurs more commonly in individuals with mental retardation and autism. Not surprisingly, many patients, as in Oscar's case, are reluctant to report the practice, and so the prevalence of pica is unknown. Pica is a serious behavioral problem because it can result in significant complications such as lead poisoning, soil-borne parasitic infections such as toxoplasmosis and toxocariasis, and mild to severe GI and nutritional problems. Gastrointestinal complications include constipation, obstruction, perforations, hemorrhages, and ulcerations caused by bezoar formation and the presence of undigestible materials in the intestinal tract. Nutritional effects include iron- and zinc-deficiency syndromes and malnutrition, but there is no firm evidence regarding the direction of cause and effect (Ellis & Schnoes, 2006).
We were very impressed by the amount of mucous Oscar was producing and considered a rare complication of rectal prolapse: solitary rectal ulcer syndrome. This is a benign condition usually diagnosed in adolescents who complain of rectal bleeding, pain, and passage of mucous. It may begin as occult rectal prolapse with these complaints and progress to the development of single or multiple localized areas of necrosis and ulceration of the mucosa, which are apparent on endoscopy (Zempsky & Rosenstein, 1988). Oscar did not have any pain or bleeding and no ulcer was found during colonoscopy. An ulcer could be missed but treatment would be the same. We also obtained additional imaging to exclude any extraluminal or intraluminal lesions with a computed tomographic examination of the abdomen and the pelvis with intravenous contrast. The study revealed mild rectal wall thickening with mild mucosal enhancement suggestive of proctitis. Otherwise, it was an unremarkable study. Ultimately, we prescribed hydrocortisone rectal suppositories, which, in addition to a daily fiber supplement, helped alleviate Oscar's symptoms.
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