1. 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: • 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. 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 CHRONIC Inflammatory bowel diseases (IBD) Crohn’s disease UC Radiation proctitis Diversion proctitis Classification & Differential Diagnoses

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

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: • 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  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

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 • 1/3improve 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. 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 IBD ASLC Others 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