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:
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

ACUTE CHRONIC
Acute self-limiting Inflammatory bowel
(procto) colitis (ASLC) diseases (IBD)
Crohns disease
Infective proctocolitis
UC
Bacterial / viral / parasitic
STD / non-STD
Radiation proctitis
Pseudomembranous
Diversion proctitis
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 Average 8 13 months after
treatment treatment
Eifel et al 1995

Symptoms Diarrhoea Bleeding

Urgency Mucous discharge
Pain Urgency
Bleeding (uncommon) Pain
Constipation (stricture)

Natural history Spontaneous resolution in days to Uncertain

weeks Milder cases: slow resolution
Severe cases: no resolution

Pathology Superficial epithelial cell depletion Obliterative arteritis leading to

Mucosa atrophy 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:
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 Crohns 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
Crohns

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?
 History (travel, drugs, RT, surgery)
PROCTITIS PR fissures, fistulae, skin tags
Sigmoidoscopy ?piles, polyp, tumour

-ve
Infective Non-infective Radiation proctitis
Stool c/st, ova & cyst ESR, CRP No response
C difficile toxin Colonoscopy + random biopsies
Widals test Small bowel enema? Rx
Antiamoebic titre

+ve Others ASLC IBD

Ischaemic Observation
Rx Solitary rectal ulcer
Drugs
Diverticulosis +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,

good however, for ASLC
up to 10% may need long-term therapy
up to 6% IBD
Thank you