1. 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

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

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

4. 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

5. 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

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

7. Specific Conditions Radiation proctitis Pseudomembranous colitis
Acute self-limiting colitis

8. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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)

16. Mild Diarrhoea  Pseudomembranous Colitis  Fulminant Colitis  Toxic Megacolin  PerforationDx
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:

17. 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

18. ASLC

19. Crohn’s UC

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

22. 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

23. How should we approach proctitis?

24. 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

25. 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

26. Thank you