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