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PubMed1997

Chronic radiation proctitis treated with hyperbaric oxygen.

Chronic proctitis is a well-known complication of therapeutic irradiation. The results of hyperbaric oxygen therapy (HBO2) used in the treatment of chronic radiation proctitis are reported. From 1992 to 1995, 14 patients with chronic radiation-induced proctitis were treated with HBO2. Nine patients were treated in a monoplace chamber at 2.0 atm abs (203 kPa O2), and five patients were treated at 2.36 atm abs (239 kPa O2). Eight patients experienced complete resolution of symptoms and one patient had substantial improvement for a total response rate of 64%. Follow-up ranged from 5 to 35 mo. (mean 17 mo.). Five patients (36%) were classified as non-responders. Three experienced significant improvement during treatment but relapsed soon after therapy was discontinued, whereas two had no symptomatic improvement. Responders who had sigmoidoscopy after therapy showed documented improvement whereas no non-responders showed improvement. The authors conclude that HBO2 therapy should be considered in patients with chronic radiation proctitis.

Aged↗
PubMed1998

Radiation proctitis. Clinical and pathological manifestations, therapy and prophylaxis of acute and late injurious effects of radiation on the rectal mucosa.

BACKGROUND: Often the rectum is the dose-limiting organ in curative radiation therapy of pelvic malignancies. It reacts with serous, mucoid, or more rarely bloody diarrhea. METHODS: A research for reports on prophylactic and supportive therapies of radiation-induced proctitis was performed (Medline, Cancerlit, and others). RESULTS: No proven effective prophylactic local or systemic therapies of radiation proctitis exist. Also, no reasonable causal medication is known. In the treatment of late radiation sequelae no clinically tested certain effective therapy exists, too. Antiinflammatory, steroidal or non-steroidal therapeutics as well as sucralfate can be used as topical measures. They will be successful in some patients. Side effects are rare and the therapy is cost-effective. Treatment failures can be treated by hyperbaric oxygen. This will achieve good clinical results in about 50% of the cases. Single or few mucosal telangiectasias with rectal bleeding can be treated sufficiently by endoscopic catheterization. CONCLUSION: Besides clinical studies acute proctitis should be treated just symptomatically. Radical surgery should be performed only when all conventional treatments have been uneffective, although no certain effective therapies of radiation-induced late proctitis exist.

Acute Disease↗
PubMed1993

A simple and effective treatment for hemorrhagic radiation proctitis using formalin.

Radiation proctitis is a common complication of radiotherapy for pelvic malignancy. In the more severe form, it leads to intractable or massive hemorrhage, which may require repeated hospital admissions and blood transfusions. Medical therapy in patients with radiation proctitis is usually ineffective, whereas surgery is associated with a high morbidity and mortality. Eight patients (seven females and one male) with hemorrhagic radiation proctitis were treated over a six-month period with endoluminal formalin. The technique used ensured minimal contact with formalin. The median age of the patients was 68 years (range, 42-73 years). Seven patients had had cancer of the uterine cervix, and one patient had had cancer of the prostate treated with radiotherapy at a median time of 30 months (range, 9-46 months) previously. The median duration of time of symptomatic rectal hemorrhage before formalin therapy was eight months (range, 1-12 months). The median number of units of blood transfused previously per patient was four (range, 2-32). The time taken for formalin therapy was 20 minutes (range, 10-70 minutes). One patient required repeat formalin application at two weeks. Bleeding ceased immediately in seven patients after formalin treatment. No further bleeding was noted, nor was any blood transfusion needed, at follow-up at four months (range, 1-6 months). Formalin therapy is a simple, inexpensive, and effective treatment for hemorrhagic radiation proctitis.

Adult↗
PubMed1998

Use of mesalazine slow release suppositories 1 g three times per week to maintain remission of ulcerative proctitis: a randomised double blind placebo controlled multicentre study.

BACKGROUND: Daily administration of rectal formulations of mesalazine is effective in preventing relapse of ulcerative proctitis. Maintenance of remission with lower doses would be an advantage. AIM: The efficacy of mesalazine suppositories (Pentasa) 1 g three times a week v placebo to maintain remission in patients with cryptogenetic proctitis was studied. METHODS: Ninety five patients with cryptogenetic proctitis were randomised within two weeks of remission to receive for one year or until relapse three suppositories per week of either Pentasa (n = 48) or placebo (n = 47). In the case of a relapse, the patients received one suppository/day. RESULTS: It was found that 25 of 48 subjects v 18 of 47 remained in remission in the mesalazine and placebo groups respectively. The relapse rate was lower in the mesalazine group for the following time intervals: 0-90 days (19% v 38%, p = 0.035), 0-180 days (29% v 54%, p = 0.017), 0-270 days (38% v 60%, p = 0.031), and 0-365 days (48% v 62%, p = 0.18). Treatment of relapse with one suppository/day induced remission in 11 of 18 and 2 of 26 patients in the mesalazine and placebo groups respectively (p = 0.001). Overall, 61% v 28% patients remained in the protocol and were in remission at one year (p = 0.001). Tolerance was good. CONCLUSION: Mesalazine suppositories 1 g three times a week are effective for preventing relapses of cryptogenetic proctitis. Increasing the dose to 1 g/day is effective in a high proportion of subjects who relapsed.

Adult↗
PubMed1992

Low incidence of ulcerative colitis and proctitis in Bangladeshi migrants in Britain.

To assess the incidence of ulcerative colitis and proctitis in a defined migrant population, a retrospective, epidemiological community study was performed in the London Borough of Tower Hamlets from 1972 to 1989. The population of 164,000 includes 28,000 Bangladeshis. Potential cases were identified from hospital departments of pathology and medical records. There were 107 cases of ulcerative colitis in Europeans and 5 in Bangladeshis. There were 74 and 2 cases of proctitis in these communities, respectively. The mean standardised incidence of ulcerative colitis in Bangladeshis (1.8 cases/10(5)/year) was marginally lower than in Europeans (6.2 cases/10(5)/year, Z = 0.7, n.s.). The mean standardised incidence of proctitis in Bangladeshis was 0.6 cases/10(5)/year and in Europeans 3.2 cases/10(5)/year (Z = 0.6 n.s.). Anatomical extent of colitis was similar in all ethnic communities, although complications were less likely in minority groups. These findings suggest that the incidence of ulcerative colitis and proctitis in Bangladeshis, in Britain, is amongst the lowest in the world.

Age Factors↗
PubMed1988

Radiation proctitis in the rat. Sequential changes and effects of anti-inflammatory agents.

Female Wistar rats were treated with single exposure irradiation to 2 cm of distal colon to cause radiation proctitis. All animals were evaluated by examination, colonoscopy and histologic evaluation for changes post-irradiation. Exposures of 10, 12.5, 15, 17.5, 20, 22.5, 25, 27.5 and 30 Gy caused dose-related clinical and histologic changes peaking at 7 to 15 days post-exposure. Rats treated with 20 Gy were colonoscoped and biopsied daily and showed sequential post-irradiation endoscopic changes ranging from mucosal edema and mild inflammatory changes to erosion and ulcers. Histologically, crypt abscess and mural wall necrosis similar to changes found in the human rectum after radiotherapy were noted. Treatment with nonsteroidal anti-inflammatory agents, (aspirin, indomethacin, piroxicam), misoprostol (a prostaglandin E1 analogue), or sucralfate (an anti-ulcer agent) did not ameliorate nor exacerbate radiation proctitis in rats exposed to 22.5 Gy. We conclude from these data that the female Wistar rat is a good model for studying radiation proctitis because endoscopic, histologic, and clinical changes seen post-exposure closely resemble those found in man.

Animals↗
PubMed1989

Oral administration of cyclosporin does not prevent expansion of antigen-specific, gut-associated, and spleen lymphocyte populations during Chlamydia trachomatis proctitis in nonhuman primates.

To study the effects of oral cyclosporin (CsA) administration on immune responses in the gastrointestinal tract, humoral and cellular immune responses were studied in CsA-treated nonhuman primates having Chlamydia trachomatis proctitis (lymphogranuloma venereum, LGV). There was no apparent effect of CsA treatment on the gross or microscopic appearance of LGV proctitis, but CsA-treated animals, with or without LGV infection, had lymphoid hyperplasia of spleen and mesenteric lymph nodes. CsA treatment inhibited the primary antibody response to LGV, inhibited peripheral blood lymphocyte mitogen-induced proliferation and IL-2 production, and inhibited LGV-specific proliferation of peripheral blood lymphocytes. In contrast, mitogen-stimulated proliferation of spleen, mesenteric lymph node, and lamina propria lymphocytes was not significantly inhibited in CsA-treated animals. In addition, LGV-specific proliferation of spleen and mesenteric lymph node lymphocytes was not inhibited. High mitogen-stimulated IL-2 production of lamina propria lymphocytes was only partially inhibited in CsA-treated animals. In vitro CsA treatment had the expected inhibitory effects on mitogen- and antigen-induced proliferation of spleen and mesenteric lymph node lymphocytes. Thus, although oral cyclosporin inhibits the antibody and proliferative responses of peripheral blood lymphocytes to antigens and mitogens in animals having Chlamydia trachomatis proctitis, it does not prevent the expansion of antigen-specific, gut-associated, and spleen lymphocyte populations.

Administration, Oral↗
PubMed1989

Failure of 5-aminosalicylic acid enemas to improve chronic radiation proctitis.

Radiation proctitis is a well-known complication of abdominal and pelvic radiation. Conventional medical and surgical treatment often is disappointing. 5-Aminosalicylic acid (5-ASA) is the active component in sulfasalazine and is effective in the treatment of distal ulcerative colitis. Four patients with radiation proctitis were treated with 4 g 5-ASA by enema nightly for two to six months. Patients were seen monthly, interviewed, and a sigmoidoscopic exam performed. No change was seen in the degree of mucosal inflammation on follow-up sigmoidoscopic exams. Three patients noted no change in their symptoms of bleeding, pain, or tenesmus. One patient noted initial improvement, but this was not sustained. 5-ASA enemas do not appear to be effective in the treatment of radiation proctitis.

Aminosalicylic Acids↗
PubMed1994

Intermittent therapy with high-dose 5-aminosalicylic acid enemas maintains remission in ulcerative proctitis and proctosigmoiditis.

PURPOSE: The aim of this study was to compare the efficacy of intermittent therapy with mesalazine enemas and continuous oral mesalazine to maintain remission of distal ulcerative colitis or proctitis. METHODS: Thirty-eight patients with distal ulcerative colitis (n = 17) or ulcerative proctitis (n = 21) in clinical, endoscopic, and histologic remission were randomly assigned to receive either oral mesalazine (0.5 g three times/day, Eudragit L coating, n = 19) or intermittent therapy with mesalazine enemas (4 g of 5-aminosalicylic acid enema every third night, n = 19). Both groups were comparable in regard to sex, age, age at disease onset, extent and duration of disease, number and mode of treatment of previous attacks, and time in remission. Patients were reviewed at the beginning of the study and, subsequently, at two-month intervals for 24 months or until a relapse occurred. At each visit, diaries were reviewed and clinical and laboratory assessments were performed. Sigmoidoscopy was carried out and biopsies were obtained by a blinded observer. Histology was assessed without knowledge of the patient's clinical state or treatment category. RESULTS: At the end of the study, 6 of 19 patients on oral mesalazine (32 percent) and 14 of 19 patients on mesalazine enemas (74 percent) were still in full remission (log rank test: 15.28, P < 0.001). Differences in relapse rates between groups were significant even when data were stratified by extent of disease (P < 0.01). In the oral group, six and seven patients relapsed at 12 and 24 months, respectively. In the enema group, three and two relapses occurred in the first and second year of the study, respectively. All patients complied with the treatment satisfactorily and there were no dropouts. CONCLUSION: These results suggest that intermittent therapy with mesalazine enemas is more effective than continuous oral mesalazine in maintaining remission in patients with distal ulcerative colitis and proctitis.

Administration, Oral↗
PubMed1992

Acute ischemic proctitis. Report of six cases.

Acute ischemic proctitis is a rare clinical entity caused by vascular insufficiency of the major or collateral circulation to the rectum. It usually occurs following aortic or aortoiliac operations. Six patients with acute ischemic proctitis are presented; four cases occurred after direct arterial interruption, one after accidental embolization of the blood supply to the rectum, and one from tumor edema. Bloody diarrhea was the most common symptom. Loss of anal sphincter tone was also an early sign in three patients. The diagnosis of ischemia was made by mucosal appearance on proctosigmoidoscopy and is differentiated from infectious proctitis by stool culture. Superficial mucosal ischemia was treated without surgery, but deeper levels of necrosis required laparotomy and Hartmann's resection. Rectal excision was not necessary. Four patients survived the ischemic event.

Acute Disease↗
PubMed1997

Short-chain fatty acids in the treatment of radiation proctitis: a randomized, double-blind, placebo-controlled, cross-over pilot trial.

PURPOSE: Treatment of chronic radiation proctitis remains unsatisfactory. Short-chain fatty acids are the preferred energy source for the colonic epithelium. We aimed to determine for the first time whether topical butyric acid enemas relieve symptoms and improve the macroscopic and microscopic findings in chronic radiation proctitis. METHODS: A randomized, double-blind, placebo-controlled, cross-over pilot trial compared patients given two weeks of butyric acid enemas (40 mmol) twice per day with those given placebo, with a one-week washout period; 15 patients were randomized and 12 completed both arms of the trial. A total symptom score combined six symptom items per week (rectal pain, episodes of rectal bleeding, amount of blood passed, days with diarrhea, number of stools, and urgency). Symptom, endoscopic, and histologic scores were obtained at the beginning of the study and again at the last week of each treatment arm. RESULTS: Total symptom score at baseline (median, 5.5) improved for those patients receiving active treatment (median, 3.5), but compared with placebo (median, 4.5), the change was not significant. Endoscopic appearances were largely unaltered by active treatment. Histology was abnormal in 82 percent of patients receiving placebo compared with 55 percent of those given butyric acid enemas (P = not significant). CONCLUSION: Butyric acid enemas do not appear to be superior to placebo in the treatment of chronic radiation proctitis.

Administration, Topical↗
PubMed1996

Formalin instillation for refractory radiation-induced hemorrhagic proctitis. Report of 16 patients.

PURPOSE: Our goal was to evaluate use of topical (4 percent) formalin in management of radiation-induced hemorrhagic proctitis, refractory to other methods of treatment. Specifically, we wished to determine its safety, ability to stop bleeding, and complications associated with therapy. METHODS: Sixteen patients with radiation-induced hemorrhagic proctitis were treated with topical (4 percent) formalin. All had been previously treated with conservative regimens such as cautery, topical steroids, or laser, but these had failed. Five-hundred milliliters (ml) of a 4 percent formalin solution was instilled into the rectum in 50-ml aliquots. Each aliquot was kept in contact with rectal mucosa for approximately 30 seconds. Treatments were performed under local anesthesia in nine patients, sedation only in four, spinal in two, and general in one patient. RESULTS: In 12 patients, bleeding stopped after a single formalin instillation; in 3, bleeding was considerably reduced but continued sporadically. One patient required three treatments before bleeding stopped. Four patients developed postoperative anal pain, of which one also had significant tenesmus and reduced capacity. Of these four patients, only two had significant anal pain and fissures that lasted longer than one month. CONCLUSIONS: Topical (4 percent) formalin is safe and effective in treatment of radiation-induced hemorrhagic proctitis. A single treatment will stop bleeding in 75 percent of patients.

Administration, Rectal↗
PubMed1998

Comparison of oral with rectal mesalazine in the treatment of ulcerative proctitis.

PURPOSE: The aim of our study was to compare the efficacy and safety of oral mesalazine with mesalazine suppositories in patients with active ulcerative proctitis. PATIENTS AND METHODS: A four-week, randomized, single-blind trial was performed in 58 patients with active, histologically confirmed ulcerative proctitis (< or = 15 cm) to evaluate the efficacy and safety of oral 800-mg mesalazine tablets taken three times per day (n = 29) compared with 400 mg of mesalazine suppositories administered three times per day (n = 29). Patients were evaluated at study entry and after two and four weeks. Efficacy evaluations included a disease activity index, which represents a score with four variables: stools frequency, rectal bleeding, mucosal appearance, and physician's assessment of disease severity. Histologic activity was also assessed at study entry and after two and four weeks in accordance with the criteria by Truelove and Richard. Safety assessment included clinical laboratory parameters and adverse event reports. RESULTS: There were no significant differences with regard to baseline comparisons of demographics and severity between the two treatment groups. Improvement in mean disease activity index score was significantly greater with suppositories compared with oral mesalazine, both at two-week and four-week visits (mean disease activity index scores at baseline, two, and four weeks: suppositories = 7.7, 2.59, and 1.48; tablets = 7.42, 5.72, and 3.48, respectively (P < 0.001)). The rate of histologic remission was significantly greater with suppositories compared with tablets both at two and four weeks (P < 0.01). There were no significant differences in adverse events or clinical laboratory results between treatment groups. CONCLUSIONS: Results of this study indicate that treatment with mesalazine suppositories produces earlier and significantly better results than oral mesalazine in the treatment of active ulcerative proctitis.

Administration, Oral↗
PubMed1984

Proctitis cystica profunda. Incidence, etiology, and treatment.

Proctitis cystica profunda is an uncommon benign rectal condition with a range of appearances that has led to confusion in nomenclature. In a personal series of 28 patients with histologically proven proctitis cystica profunda, over 50 per cent had associated rectal prolapse. Cure of the prolapse cured the proctitis cystica profunda in 80 per cent of the patients only. Direct surgical excision (local or segmental) has not been successful and two patients have required a stoma for relief of pain.

Adolescent↗
PubMed2002

Pharmacotherapy for chronic hemorrhagic radiation proctitis.

Endoscopic thermal therapy and formalin are being increasingly recommended for the treatment of chronic hemorrhagic radiation proctitis. It may be too early, however, to discard pharmacologic agents from the management process, especially in medical institutions where specialized equipment is unavailable. We prospectively assessed the effectiveness of medical therapy in 14 consecutive patients with chronic hemorrhagic radiation proctitis from July 1999 to June 2001. All 14 subjects were women (mean age 56 years), 13 of whom had had radiotherapy for cancer of the cervix. The median time to onset of symptoms following irradiation was 16 months. Six patients had a hemoglobin level of < 8 g/dl, and blood transfusion was required in 11 patients. In five patients (36%) initially treated with hydrocortisone enemas prior to referral, this treatment continued; and the remaining nine patients were commenced on sucralfate enemas. Two patients given rectal hydrocortisone continued to bleed and were treated with sucralfate enemas and topical formalin, respectively. Rectal sucralfate suspension effectively procured symptomatic alleviation in all 11 patients. Rectal bleeding recurred in two patients who had been managed exclusively with hydrocortisone and sucralfate enemas, respectively, over a mean follow-up of 6 months. Both patients were managed with topical formalin, which controlled their symptoms. Even though the number of subjects in this study is small, sucralfate enema can be recommended as an effective first-line agent for managing patients with chronic hemorrhagic radiation proctitis. The use of more specialized therapy can therefore be reserved for cases where primary treatment failure occurs with sucralfate therapy.

Administration, Rectal↗
PubMed1996

Application of formaldehyde for treatment of hemorrhagic radiation-induced proctitis.

Radiation-induced proctitis with hemorrhage is not a common complication of radiotherapy to the pelvis for carcinoma. In the most severe forms, massive hemorrhage may necessitate repeated transfusions and inpatient treatment. In severe cases medical treatment has not been proved effective. Surgery may lead to serious complications and is technically difficult. Six patients who showed a hemorrhagic radiation-induced proctitis have been treated as outpatients with application of formaldehyde 4%. In four cases the bleeding ceased after the first formaldehyde application; two patients continued to bleed, but another application of formaldehyde 3 weeks later definitively controlled the hemorrhage. Follow-up evaluation at 12 months showed in each case that the hemorrhage was controlled and treated. There were no complications, such as burns or late stenoses of the deep layers of the rectum. This inexpensive technique is well tolerated by the patient, gives good long-term results, and is available at every hospital. Local application of formaldehyde 4% to the rectum may be the treatment of choice for hemorrhagic radiation-induced proctitis.

Administration, Topical↗
PubMed2000

Complications following formalin installation in the treatment of radiation induced proctitis.

Formalin installation has been safely and effectively used to treat refractory bleeding caused by radiation proctitis. This study evaluated the results of such treatment in terms of outcome and complications. All four patients who underwent formalin irrigation for transfusion-dependent radiation proctitis over a 15-month period were evaluated retrospectively. The procedure was performed under sedation in the operating room, with patients in the prone jack-knife position. A solution of 4% formalin was introduced in aliquots of 50 ml kept in contact with the mucosa for 30 s and then cleared away using saline irrigation; five to six aliquots were used in each session. In a fifth patient formalin-soaked gauze pads were applied directly to the injured mucosa. At a mean follow-up of 18 months (range 6-26) two patients had repeat episodes of bleeding, one underwent successful repeat irrigation, and the other refused further treatment. One patient suffered from severe anococcygeal pain and worsening of incontinence after the procedure. The pain was treated with lidocaine ointment and sitz baths with partial success. Another patient developed severe formalin-induced colitis 5 days after the procedure, which required intravenous antibiotics and hydration. Formalin installation may be effective in controlling refractory bleeding due to radiation induced proctitis. The procedure, however, is not risk free and may induce major complications such as acute colitis.

Aged↗
PubMed2001

Endoscopic therapy for radiation proctitis-induced hemorrhage in patients with prostatic carcinoma using argon plasma coagulator application.

BACKGROUND: Recurrent hemorrhage in patients with severe radiation proctitis is very common. It is often refractory to medical therapy. Endoscopic and surgical treatment may be required when conservative medical therapy fails. The aim of this study was to assess the therapeutic results of the Argon Plasma Coagulator (APC) (ERBE USA, Inc., Marietta, GA, USA) application in patients with radiation proctitis-induced hemorrhage. METHODS: Forty patients with radiation-induced proctitis causing severe bleeding, who had failed conservative medical management were treated endoscopically. Twenty-one patients in this group required blood transfusions. RESULTS: APC application was used in 40 patients with only one failure. The failed patient underwent formalin application using 4% formalin solution with resolution of the bleeding. CONCLUSION: Argon plasma coagulation application is a safe, well-tolerated treatment option and, historically, has been superior to Nd:YAG laser ablation.

Administration, Oral↗