Strategic Approach to Proctitis Department of Surgery Pamela Youde Nethersole Eastern Hospital Dr....

Strategic Approach to ProctitisStrategic Approach to Proctitis

Department of Surgery

Pamela Youde Nethersole Eastern Hospital

Dr. Dennis Wong

Joint Hospital Surgical Grand Round

June 2004

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 bleedingPR bleeding 48%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: 62-68Lam et al. Ann Coll Surg HK 2000; 4: 62-68

Classification & Differential Diagnoses

• ACUTE

– Acute self-limiting Acute self-limiting (procto) colitis (ASLC)(procto) colitis (ASLC)

– Infective proctocolitis• Bacterial / viral / parasitic• STD / non-STD

– Pseudomembranous Pseudomembranous colitiscolitis

– Radiation proctitisRadiation proctitis– NSAID proctitis– Ischaemic proctitis– Solitary rectal ulcer

• CHRONIC

– Inflammatory bowel diseases (IBD)

• Crohn’s disease

• UC

– Radiation proctitisRadiation proctitis

– Diversion proctitis

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 1996Babb 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: 935-9Lawton 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 DiarrhoeaUrgency

Pain

Bleeding (uncommon)

BleedingMucous discharge

Urgency

Pain

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

• Systemic review

• 63 studies (electronic databases & Grey literature)

• Anti-inflammatory agents:– First-line agents

– Kochhar et al 1991: Kochhar et al 1991:

Oral sulfasalazine + rectal steriods vs rectal sucralfateOral sulfasalazine + rectal steriods vs rectal sucralfate• Rectal sucralfate superior both clinically & endoscopically

– Rougier et al 1992:Rougier et al 1992:

Betamethasone vs hydrocortisone enemasBetamethasone vs hydrocortisone enemas • No statistically significant difference

– Cavcic et al 2000:Cavcic et al 2000:• MetronidazoleMetronidazole showed reduction in rectal bleeding

Denton AS et al. British Journal of Cancer 2002; 87: 134 – 143Denton AS et al. British Journal of Cancer 2002; 87: 134 – 143

• Sucralfate enemas:– Highly sulphated polyanionic dissacharide

– Stimulate epithelial healing and formation of protective barrier

– Kochhlar et al 1991:Kochhlar et al 1991: • Strongest evidence for use of sucralfate

• Formalin therapy:– Produces local chemical cauterisation

– 15 references15 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:Jensen et al 1997: • Mean of 4 sessions / case

Recommendations: Sucralfate > Anti-inflammatory agents greater effect with MetronidazoleTo 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: 334-339Bartlett 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

• HistologyTytgat GNJ et al. Netherlands Journal of Medicine 1990; S37-42Tytgat 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 distortionDundas SA et al. Histopathology 1997; 37: 60-66Dundas SA et al. Histopathology 1997; 37: 60-66

ASLC

Crohn’s

UC

Histological criteria for ASLC and IBD

Surawicz CM et al. Mucosal biopsy diagnosis of colitis: ASLC & CIBD. Gastroenterology 1994Surawicz CM et al. Mucosal biopsy diagnosis of colitis: ASLC & CIBD. Gastroenterology 1994

Independent variables

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: 62-68Lam TYD et al. Ann Coll Surg HK 2000; 4: 62-68

How should we approach proctitis?How should we approach proctitis?

PROCTITIS

Infective Non-infective

History (travel, drugs, RT, surgery)PR – fissures, fistulae, skin tagsSigmoidoscopy – ?piles, polyp, tumour

Stool c/st, ova & cystC difficile toxinWidal’s testAntiamoebic titre

+ve

Rx

ESR, CRPColonoscopy + random biopsiesSmall bowel enema?

ASLC IBDOthersIschaemic Solitary rectal ulcer

Diverticulosis

ObservationDrugs

Repeat Bx

Radiation proctitis-ve

Rx

No response

+ve

Conclusions• Proctitis is commoncommon with many different causes

• It is importantimportant • 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 assessmentbased on history and clinical assessment

• Prognosis is generally very goodvery good, however, for ASLC– up to 10% may need long-term therapy

– up to 6% IBD

Thank youThank you