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Ulcerative Proctitis

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Dr. Nada Alshalabi

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Proctitis is inflammation of the rectal mucosa, distal to the rectosigmoid junction, within 15-18 cm of the anal verge

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Montreal classification (E, S, A)

E1

E2

E3

25-40% (5-10y)

> three relapses/y or need for systemic steroid or immunosuppressants

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Feeling of rectal fullness

Anal and rectal pain

Pain in the lower left abdomen

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Frequent or continuous urge to have a bowel movement

Diarrhea, usually frequent, small amounts

Passing mucus through the rectum

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Rectal bleeding

Systemic symptoms are uncommon

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Acute proctitis

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Infectious proctitis

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STDs

Neisseria gonorrhoeae Chlamydia trachomatis

HSV types 1 and 2

syphilis

Foodborne infections Salmonella

Shigella

Campylobacter

Amebiasis

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Clostridium difficile

opportunistic infections

CMV

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Radiation proctitis

Acute Chronic

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  • Acute = during or within six weeks of radiation therapy
  • Risk factors

- Dose of radiation : > 45 Gy

- Area of exposure and Method of delivery : External beam radiation or brachytherapy

- Other potential risk factors : inflammatory bowel disease and HIV/AIDS

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  • Drug-induced proctitis : NSAIDS

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  • ischemic proctitis : rare / surgery involving the abdominal aorta

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Patients with a prior diagnosis of inflammatory bowel disease who sustain a worsening of symptoms may have an additional etiology superimposed on their underlying disease

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WORKUP

  • Inflammatory bowel disease
  • Pelvic irradiation
  • Sexual history
  • Medications (eg, NSAIDs or antibiotics)
  • HIV status / immunocompromised

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  • A family history of IBD or other gastrointestinal (GI) diseases is extremely important.

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WORKUP

  • Rule out infectious etiologies

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  • Stool culture
  • NAAT for gonorrhea and chlamydia
  • Venereal Disease Research Laboratory (VDRL)/rapid plasma reagin (RPR) tests
  • CMV PCR
  • C difficile toxin titers
  • Microscopic identification of cysts and trophozoites in the stool / E. histolytica antigens in stool /Enzyme immunoassay (EIA) kits for Entomoeba histolytica antibody detection

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WORKUP

  • A full colonoscopy is recommended for patients with proctitis.

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  • To exclude other causes

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  • To establish the diagnosis

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  • To determine the extent and severity of disease

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WORKUP

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  • continuous, circumferential involvement of the rectal mucosa that extends proximally
  • Mucosal abnormalities include erythema, loss of vascular pattern, friability, ulcerations, and granularity
  • Often a sharp demarcation between inflammation and normal mucosa

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Amebic colitis

HIV-proctitis

N.Gonorrhoeae proctitis

Chlamydia-proctitis

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  • Rectal biopsies are useful for differentiating IBD from infectious colitis.
  • Crypt distortion with forked glands, crypt atrophy, and a villiform surface appearance support the diagnosis of IBD and are not usually seen with infectious colitis.
  • A mixed inflammatory infiltrate in the lamina propria is also associated with IBD.
  • Changes in crypt architecture occur early in the course of the disease, being seen as soon as seven days after the onset of symptoms in patients with acute onset IBD

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mesalamine suppository, (1) gram once daily/at night

Improvement within 2 weeks ?

Increase dose to twice daily

Improvement within 2 weeks ?

Maintenance with mesalamine supp/once daily

Add hydrocortisone supp,(25)mg/once daily

Reduce mesalamine supp to once daily Improvement within 2-4 weeks ?

Maintenance with mesalamine supp/once daily

Discontinue hydrocortisone Maintenance with mesalamine supp/once daily

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Add oral 5-ASA agent (>3g)

Continue topical 5-ASA+glucocorticoid regimen

Improvement within 2-4 weeks ?

Maintenance with oral 5-ASA

Discontinue topical therapy

Add budesonide

OR

Oral systemic glucocorticoid

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Maintenance therapy

  • For patients with ulcerative proctitis who responded to topical mesalamine for induction of remission and who have >1 flare per year, we use a maintenance regimen of one mesalamine suppository (1 gram) every night.

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  • For patients who are unwilling to use daily topical therapy for long-term maintenance, we reduce the dosing frequency (suppository given every other day or twice weekly)

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  • For patients who required an oral 5-ASA agent to achieve remission, we continue oral 5-ASA therapy to maintain remission.

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  • We assess patients clinically and with colonoscopy in 6 to 12 months after achieving clinical remission

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FAILURE TO RESPOND

  • Compliance

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  • Refractory disease = no symptomatic improvement with systemic glucocorticoids ( prednisone 40 mg per day) within one to two weeks of initiating therapy are regarded as having glucocorticoid-refractory disease.

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  • Treatment options include a biologic agent (eg, anti-tumor necrosis factor agent) or a small molecule (tofacitinib).

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