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