Strategic Approach to Proctitis Joint Hospital Surgical Grand Round June 2004 Strategic Approach to Proctitis Department of Surgery Pamela Youde Nethersole Eastern Hospital Dr. Dennis Wong

Contents Classification & differential diagnoses Epidemiology Specific conditions Approach to proctitis Conclusions

Background Definition of proctitis: Natural history: Inflammation of the mucous membrane of the rectum Natural history: Asymptomatic Self-limiting Refractory

Background Presenting symptoms: PR bleeding 48% Diarrhoea 21% PR mucus 6% Abdominal pain 6% Symptomatic anaemia 6% Altered bowel habit 3% Urgency 3% Anal discomfort 3% Lam et al. Ann Coll Surg HK 2000; 4: 62-68

Classification & Differential Diagnoses CHRONIC Inflammatory bowel diseases (IBD) Crohn’s disease UC Radiation proctitis Diversion proctitis ACUTE Acute self-limiting (procto) colitis (ASLC) Infective proctocolitis Bacterial / viral / parasitic STD / non-STD Pseudomembranous colitis Radiation proctitis NSAID proctitis Ischaemic proctitis Solitary rectal ulcer

Epidemiology Common True incidence unknown Lack of prospective trials Asymptomatic cases & inconclusive tissue biopsies Variability in definition and grading systems

Specific Conditions Radiation proctitis Pseudomembranous colitis Acute self-limiting colitis

Radiation Proctitis Consequence of use of megavoltage irradiation therapy in pelvic malignancy (prostate, cervix, ovary, uterus & rectum) 2 – 25% (1 – 2% chronic) Babb RR. Am J Gastroenterol 1996 Rectum particularly vulnerable Fixed organ in pelvis Glandular-type epithelial cells undergo rapid turnover Radiation therapy factors Total radiation dose, dose fractionation, mode of delivery, no. of fields Dose effect is consistent finding in cervical and prostatic cancer Lawton CA et al. Int J Radiat Oncol Biol Phys. 1991; 21: 935-9

ACUTE radiation proctitis CHRONIC radiation proctitis Onset During or within 3 months of treatment Average 8 – 13 months after treatment Eifel et al 1995 Symptoms Diarrhoea Urgency Pain Bleeding (uncommon) Bleeding Mucous discharge Constipation (stricture) Natural history Spontaneous resolution in days to weeks Uncertain Milder cases: slow resolution Severe cases: no resolution Pathology Superficial epithelial cell depletion  Mucosa atrophy Obliterative arteritis leading to secondary ischaemic changes and neovasculature Treatment Symptomatic (eg. loperamide) Medical Surgical

Non-surgical Management of Late Radiation Proctitis Denton AS et al. British Journal of Cancer 2002; 87: 134 – 143 Systemic review 63 studies (electronic databases & Grey literature) Anti-inflammatory agents: First-line agents Kochhar et al 1991: Oral sulfasalazine + rectal steriods vs rectal sucralfate Rectal sucralfate superior both clinically & endoscopically Rougier et al 1992: Betamethasone vs hydrocortisone enemas No statistically significant difference Cavcic et al 2000: Metronidazole showed reduction in rectal bleeding

Sucralfate enemas: Formalin therapy: Highly sulphated polyanionic dissacharide Stimulate epithelial healing and formation of protective barrier Kochhlar et al 1991: Strongest evidence for use of sucralfate Formalin therapy: Produces local chemical cauterisation 15 references Technique and concentration varies – irrigation, direct application, 3.6%, 4% 10% solutions Beneficial ~5% serious s/e: anal ulceration, rectal stricture, incontinence, anal pain Duration of effect: minimum of 3 months

Thermal coagulation therapy: Coagulation of focal bleeding YAG laser, Argon plasma coagulation, bipolar and heater probes Several treatment sessions All statistically significant Jensen et al 1997: Mean of 4 sessions / case Recommendations:  Sucralfate > Anti-inflammatory agents  greater effect with Metronidazole To consider thermal coagulation, if medically unsuccessful

Indications for Surgery 1) Unresponsive to medical therapies 2) Complications: Massive haemorrhage - Rectovaginal fistula Perforation - Secondary malignancy Strictures Problems with surgery: High incidence of anastomotic dehiscence Poor tissue healing Chronic pelvic sepsis

Pseudomembraneous Colitis Clostridium difficile – gram-positive anaerobic bacillus ~ 1% asymptomatic carriers ~ 1% on antibiotics affected Antibiotics therapy changes faecal flora (esp broad- spectrum) Exotoxins (toxin A & B) are cytotoxic Produces mucosal inflammation and cell damage  epithelial necrosis  pseudomembrane (mucin, fibrin, leucocytes & cellular debris)

Mild Diarrhoea  Pseudomembranous Colitis  Fulminant Colitis  Toxic Megacolin  Perforation Dx Detection of toxin in stool by ELISA Rx Stop antibiotics Resuscitation Metronidazole (1st line) Vancomycin (2nd line) Surgery 10% relapse due to failure to eradicate / re-infection Bartlett JG. N Eng J Med 2002; 346: 334-339

Acute Self-limiting Colitis (ASLC) Idiopathic Difficult to distinguish from IBD Symptoms 20 – 40% of UC start as proctitis and spread proximally Up to 50% of Crohn’s have rectal involvement Histology Tytgat GNJ et al. Netherlands Journal of Medicine 1990; S37-42 Histological definition: Mucosal inflammation in the absence of both increased mucosal gland branching and glandular architecture distortion Dundas SA et al. Histopathology 1997; 37: 60-66

ASLC

Crohn’s UC

Histological criteria for ASLC and IBD Independent variables Surawicz CM et al. Mucosal biopsy diagnosis of colitis: ASLC & CIBD. Gastroenterology 1994

ASLC Clinical Outcome: 1/3 completely resolve by observations alone 1/3 improve by observations alone 1/3 require drug treatment (steroid enema / oral salicylates) 10% require long-term treatment 6% develop into IBD Lam TYD et al. Ann Coll Surg HK 2000; 4: 62-68

How should we approach proctitis?

PROCTITIS Infective Non-infective Others ASLC IBD -ve History (travel, drugs, RT, surgery) PR – fissures, fistulae, skin tags Sigmoidoscopy – ?piles, polyp, tumour PROCTITIS -ve Infective Non-infective Radiation proctitis Stool c/st, ova & cyst C difficile toxin Widal’s test Antiamoebic titre ESR, CRP Colonoscopy + random biopsies Small bowel enema? No response Rx +ve Others ASLC IBD Ischaemic Solitary rectal ulcer Diverticulosis Observation Drugs Rx +ve Repeat Bx

Conclusions Proctitis is common with many different causes It is important Debilitating symptoms Difficult to differentiate from IBD initially The decisions on the need for further investigation & initial treatment should be based on history and clinical assessment Prognosis is generally very good, however, for ASLC up to 10% may need long-term therapy up to 6%  IBD

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