When is IBD not necessarily the IBD you thought it was by Dr Matt W. Johnson
Topics of Discussion Proctitis Sigmoiditis
Proctitis Definition = Inflammation of the lower 15cm of rectum = E1 Symptoms can vary greatly, but include;- Painful defaecation Soreness in the ano-rectal region Sense of incomplete evacuation + Tenesmus Involuntary spasms and cramping during bowel movements Bleeding, and possibly a discharge. Involuntary straining Proximal constipation
Physical Assessment Anal + Rectal erythema + oedematous mucosa Injected mucosa Ano-Rectal erosions or ulcers Blood or Mucus on stools Mucopurulent or blood-stained rectal discharge
BSG - Treatment 1st Line = Topical 5ASA 2nd Line = Topical Steroids 3rd Line = PO 5ASAs or Steroids Antibiotics Immunomodulators Surgery Carter MJ. Gut 2004;53:v1-v16 on behalf of the IBD Section of the BSG Regueiro MD. Clin Gastroenterol Oct;38(9):
IBD Differential Diagnoses Proctitis Non specific, self resolving Food allergy Solitary rectal ulcer syndrome Post-Infectious (eg. CDT, Campylobacter, Shigella, Escherichia coli, Salmonella, and amebiasis) STDs (HSV, HIV, Syphilis, LGV, Gonorrhoea, Chancroid, TB) Trauma XR + Ischaemia + Drug induced (NSAIDS) Sigmoiditis Diverticular disease associated colitis
Non-Specific Self Resolving Proctitis Paediatric study of 38 11/38 29% extended into distal UC after median 6y FU Progression tends to occur in 1st 2y Progression rare after 5y Hyams J, Pediatr Gastroent Nutr Aug;25(2): Hyams J Adult studies Proctitis accounted for 20-55% of UC patients Langholz - Progression was seen 27% 5y, 41% 10y, 53% 15y 12% underwent Colectomy CRC is not increased (unlike in UC) Meucci - Progression into sigmoid 8% at 5y and 30% at 10y 10% at 10y E3 (extensive progression) Majority “burn out” in time Russell M G, Dis Colon Rectum. 1998;41:33–40. Langholz E, Scand J Gastroenterol. 1996;31:260–266. Meucci G, Am J Gastroenterol. 2000;95:469–473. Whitlow CB. Clin Col Rect Surg Feb; 17(1): 21–27.
Allergic Proctitis Markedly increased number of IgE containing cells in the lamina propria of rectal mucosa biopsies. 8/12 were sucessfully treated with disodium cromoglycate (DSCG). The remaining 4 had mild proctitis and did not require Rx. P C Rosekrans, GUT 1980 December; 21(12): 1017–1023. P C Rosekrans Diagnosis requires objective improvement on withdrawing suspected food Ag and recurrence with subsequent reintrduction
Solitary Rectal Ulcer Syndrome
Post-Infectious Campylobacter CDT Tinea (thread worms) ShigellaSalmonellaAmoebia
STDs 10% of S. London men have paid for sex 18% of US men have had unprotected anal sex Causes 45% no STDs Gonorrhoea 20% - 50% are asymptomatic Herpes 13% - Very painful Chlamydia 11% Syphillis 9% - Snail track ulcers, condylomata lata Mixed 8% BSG 2005
STDs HSV - 2>1SyphillisLGV
STDs HIVGonorrhoeaChancroid
Practicalities Serology HIV 1+2 HSV + HVZ CMV HepB Histopathological Staining CMV PCR TB Chlamydia + LGV
STD Ix + Rx GonorrhoeaCiprofloxacin 500mg stat Chlamydia Doxycycline 100mg bd + Azithromycin 1g stat SyphillisBenzyl Penicillin HSVAciclovir 400mg x5 for 10/7 EmpiricalCipro 500mg or Cefixim 400mg stat Azithr 1g stat or Dox 100mg bd 1w Aciclovir 400mg x5 10/7
TB
Trauma
XR - Radiation Proctography
Ischaemia
NSAID Induced
Sigmoiditis
DD associated Colitis An immunologically mediated process Typically it does not effect the rectum Can proceed the development of the diverticulae by several years Many patients respond to treatment directed toward diverticulitis A subset of patients require immunosuppressive therapy and /or surgery
DD associated Colitis A small subset progresses to develop classic ulcerative / Crohn’s colitis. It is essential that endoscopists provides a full description of the macroscopic appearance of the inflammatory changes at endoscopy limitations of extent to a segment of diverticular disease So that the pathologist can provide a more informative interpretation
DD associated Colitis Good Clinical Care: Diverticular Disease. T. Banerjee, S Verma, M. W. Johnson. Foundation Years Journal. 2011: 5(8); 29–35.