S4028 Case Report: Solitary Rectal Ulcer Syndrome Mimicking Malignancy With Concomitant Eosinophilic Esophagitis

Introduction: Solitary rectal ulcer syndrome (SRUS) is a rare, benign condition characterized by rectal bleeding, mucorrhea, and altered bowel habits, often linked to mucosal prolapse. Its endoscopic appearance may mimic malignancy. We present a 31-year-old man with iron deficiency anemia (IDA) and hematochezia, initially suspected to have rectal cancer, but ultimately diagnosed with SRUS in the setting of inflammatory cloacogenic polyps and pelvic floor dysfunction, along with eosinophilic esophagitis (EoE). Case Description/Methods: The patient presented with IDA (ferritin 33 ng/mL, iron saturation 15%) and intermittent rectal bleeding. Colonoscopy on September 27, 2023 revealed multiple large ulcerated rectal nodules concerning for malignancy. Biopsies showed acute colitis without dysplasia or malignancy. Infectious workup was negative, including stains for CMV, HSV, and rectal swabs for sexually transmitted infections. An esophagogastroduodenoscopy on October 30, 2023 for ongoing IDA showed EoE and multiple fundic gland polyps, likely PPI-related, without high-risk features. A follow-up esophagogastroduodenoscopy (EGD) on February 7, 2024 revealed iron pill gastropathy, and oral iron was discontinued after IDA resolved. Persistent anorectal symptoms and polypoid lesions prompted examination under anesthesia with transanal excision on April 9, 2024. Pathology revealed benign inflammatory cloacogenic polyps. In the context of mucosal prolapse, straining, and incomplete evacuation, the diagnosis of SRUS was made. Inflammatory bowel disease was considered but excluded due to absence of chronic inflammation or granulomas. EoE was initially managed with proton pump inhibitors, but repeat EGD on May 1, 2024 showed 62 eosinophils/hpf. Dupilumab was started on May 22, 2024. By July, dysphagia had resolved, and a follow-up EGD in November 2024 confirmed histologic remission. By March 2025, the patient reported improvement in rectal symptoms with Benefiber but had not yet begun pelvic floor physical therapy. He remained on weekly dupilumab with sustained EoE remission and reported good symptom control. His most recent esophageal biopsies from November 2024 showed no intraepithelial eosinophils, consistent with histologic remission. Discussion: This case highlights the importance of considering SRUS and inflammatory cloacogenic polyps in the differential diagnosis of rectal masses in young patients presenting with IDA and prolapse-related symptoms. Multidisciplinary evaluation is critical. Early diagnosis can improve outcomes through targeted therapy, including dietary management, fiber supplementation, and pelvic floor rehabilitation.