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A 12-year-old girl is described who developed rectal bleeding 5 months after being diagnosed as having a Coombs-positive hemolytic anemia. Colonoscopy showed that the rectal bleeding was due to ulcerative proctitis. This is the first case report of Coombs-positive hemolytic anemia preceding the onset of ulcerative proctitis in a child.
Two men sought treatment at an emergency room with apparent gonococcal proctitis. Further evaluation after failure of antibiotic therapy in both patients revealed that rectal damage resulting from the patients' sexual habits had resulted in a severe traumatic proctitis. The discovery of several organisms, including Neisseria gonorrhoeae and two nonpathogenic amebas, was probably only incidental. Two points are emphasized: the importance of obtaining a complete sexual history for every patient treated for venereal disease, and the inherent complications associated with anorectal manipulation.
Argon plasma coagulation (APC) has been used extensively for a wide range of indications in gastrointestinal endoscopy. We describe a case of haemorrhagic radiation proctitis treated successfully with APC. A 54-year-old Japanese woman presented with daily rectal bleeding 4 months after cessation of radiotherapy for uterine cancer. Colonoscopic examination showed friable bleeding teleangiectasias in the rectum. Her haemoglobin level was decreased to 5.4 g/dl, requiring frequent blood transfusions. Endoscopic APC set at 1.2 l/min and 45 W was applied. After four treatment sessions without any complications, the patient showed complete resolution of haematochezia and subsequent haematological improvement. Standard and magnifying endoscopic follow-up revealed complete eradication of the vascular lesions and cicatrization of the treated areas, and mucosal covering with normal crypt lining. Endoscopic APC is an effective and well-tolerated treatment modality for the management of haemorrhagic proctitis.
OBJECTIVE: To evaluate the efficacy of hyperbaric oxygen therapy in treatment of severe refractory radiation-induced hemorrhagic proctitis. METHODS: Nine patients with median age 75 (range, 66-83) treated with hyperbaric oxygen (HBO) at University of Cincinnati were reviewed. Pre- and post-therapy bleeding was graded on a 5-point scale. Five patients had previous hospitalizations for anemia and required transfusions. Three patients had undergone electrocautery or argon plasma coagulation before hyperbaric oxygen therapy (HBOT). The remainder had medical therapy before HBO. No patients experienced resolution of symptoms before HBO. The median follow-up after HBO was 17 months (range, 1-77). RESULTS: Seven patients had complete resolution of rectal bleeding. Two patients exhibited a partial response, but continued to experience intermittent bleeding. The Wilcoxon signed rank test determined that HBOT significantly reduced rectal bleeding. CONCLUSIONS: HBOT is a very effective treatment of hemorrhagic radiation-induced proctitis.
BACKGROUND: The goal of this work was to critically evaluate the published studies on the treatment of ulcerative proctitis (UP) and left-sided ulcerative colitis (L-UC). The results of this review provided the content for the accompanying treatment guidelines, Clinical Guidelines for the Medical Management of Left-sided Ulcerative Colitis and Ulcerative Proctitis: Summary Statement. METHODS: All English language articles published between 1995 and September 2005 were identified through a comprehensive literature search using OVID and PubMed. The quality of the data supporting or rejecting the use of specific therapies was categorized by a data quality grading scale. An "A+" grade was assigned to treatment supported by multiple high-quality randomized controlled trials with consistent results, whereas a "D" grade was given to therapy supported only by expert opinion. The therapeutic efficacy of a treatment was defined by its success in treating UP and L-UC compared with placebo. A medication was ranked as "excellent" if it was specifically studied for UP and L-UC and had consistently positive results compared with placebo or another agent. Quality and efficacy scores were agreed on by author consensus. RESULTS: For the acute treatment of UP or L-UC, the rectally administered corticosteroids and mesalazine (5-ASA), either alone or in combination with oral 5-ASAs, are the most effective therapy: evidence quality, A+; efficacy, excellent. Only rectally administered 5-ASA received an A+/excellent rating for maintenance of remission. Infliximab received an A+ grade for induction and maintenance of remission but only a "good" rating because the studies were performed in all UC, not specifically UP or L-UC. CONCLUSIONS: This critical evaluation of treatment provides a "report card" on medications available for the management of patients with UP and L-UC. The guidelines should provide a useful reference and supplement for physicians treating UC patients.
BACKGROUND: The aim was to compare budesonide enema, 2 mg/100 mL (Entocort) and hydrocortisone acetate foam enema, 125 mg (Colifoam) in patients with active haemorrhagic proctitis. METHODS: The trial was a controlled, randomized, investigator-blind study with two parallel groups. Endoscopy, histology and diary cards were used to assess the response to therapy. Safety was assessed by laboratory tests and adverse event recording. RESULTS: Seventy-two patients were included. Investigations were made before treatment and after 2 and 4 weeks. Both treatment groups showed statistically significant improvement in endoscopic scores but significant differences between the groups were not found. In the hydrocortisone group, plasma cortisol was significantly lowered after 4 weeks compared with budesonide. Bowel habits and quality of life variables did not differ between the treatments. The recorded adverse events were mild or moderate and may have been due to the proctitis. CONCLUSIONS: These results suggest that budesonide enema is as effective as hydrocortisone foam enema, but without the potential for side-effects associated with suppression of plasma cortisol.
Ulcerative proctitis is a non-specific inflammatory condition of a diffuse nature involving the mucosa of the rectum. It commences at the dentate line and extends proximally for a variable distance. By definition, the upper extent of the disease must be able to be seen at sigmoidoscopy. This is usually at a distance of 5 to 15 cm from the anal verge. The natural history of the condition is one of spontaneous remission after varying periods. This makes scientific assessment of therapy very difficult if not impossible. In a small proportion of patients (10% or less) the disease will extend to involve the colon. It is difficult to be certain whether this is true progression or inaccurate assessment of extent at the time of presentation. The treatment of the condition is non-specific. Reassurance of the patient with emphasis on the excellent prognosis is essential. Response to drug therapy is unpredictable and in many instances disappointing. Dietary manipulation is usually not required. Operative treatment is never indicated for proctitis. If extension of the disease occurs, operation may be required.
OBJECTIVES: A multicenter double-blind placebo-controlled clinical study was conducted to evaluate the efficacy and tolerability of two different therapeutic schedules of mesalazine suppositories in patients with ulcerative proctitis. METHODS: From 1990 to 1993, 111 patients with ulcerative proctisis in remission, limited to the rectum (< or = 15 cm from anus), were enrolled. After obtaining informed consent, patients were randomized to three treatment groups: 500 mg mesalazine b.i.d. (36 patients), 500 mg mesalazine u.i.d. (40 patients), and placebo (35 patients). The treatment lasted 1 yr. Follow-up consisted of periodic clinical, endoscopic, and histological assessments. An endoscopic score > 1 according to the Baron scale defined relapse occurrence. The three groups were homogeneous as regards main demographic, diagnostic, and prognostic features. RESULTS: The cumulative relapse rates at 12 months were 10% (95% confidence interval [CI]: 0-21) in the mesalazine b.i.d. group, 32% (95% CI: 16-49) in the mesalazine u.i.d. group, and 47% (95% CI: 29-65) in the placebo group. The comparison between the mesalazine b.i.d. group and the mesalazine u.i.d. group cumulative relapse rates gave a p value of 0.0334, whereas the corresponding comparison between the mesalazine b.i.d. group and the placebo group gave a p value of 0.007 (log-rank test). The dose-response relationship was statistically significant (p = 0.008 by Cox analysis). Two patients in the mesalazine b.i.d. group, two patients in the mesalazine u.i.d. group, and one patient in the placebo group withdrew from the study due to nonserious adverse events; four, three, and four patients per group, respectively, dropped out because of poor compliance. Two patients in the mesalazine u.i.d. group and two in the placebo group were lost to follow-up. CONCLUSIONS: The results of this study confirm the therapeutic efficacy of mesalazine suppositories in the maintenance treatment of ulcerative proctitis. According to our experience the most effective therapeutic schedule is 500 mg mesalazine b.i.d.
OBJECTIVES: Therapeutic trials in left-sided ulcerative colitis (L-UC) and ulcerative proctitis (UP) have lacked control for medication type, dose, delivery, and duration of therapy. METHODS: All published therapeutic articles and abstracts in L-UC or UP from 1958-1997 were reviewed. Improvement, remission rates, and adverse events were recorded for all (ALL), placebo-controlled (PC) studies, and for PC studies passing quality assessment (QA) scoring. Meta-analysis was used where appropriate. RESULTS: Left-sided UC: For active disease, 67 studies (17 PC; 10 QA) were identified. Mesalamine enemas achieved remission in a duration but not a dose response (QA), with higher remission rates than steroid enemas (ALL) and clinical improvement rates superior to oral therapies (QA, ALL). Remission maintenance: 17 (six PC, six QA) studies were identified. Mesalamine therapies had comparable remission rates at 6 months, with a possible dose but not delivery effect. Mesalamine enema dosing intervals between QHS to Q3 days maintained efficacy. Reported adverse events were most common with oral sulfasalazine and dose-independent for mesalamine. Withdrawals from therapy were less than placebo, or < or =3%. Ulcerative proctitis: For active disease, 18 (nine PC, three QA) studies were identified. Mesalamine suppositories achieved clinical improvement and remission in a duration but not dose response, with higher rates of remission than topical steroids (ALL). Remission maintenance: three (three PC, two QA) studies were identified. Remission ranged from 75% to 90% (6 months) and 61-90% (12 months) for mesalamine agents. Reported adverse events were most common for mesalamine foam (8%). Withdrawals from therapy were <2%. CONCLUSIONS: In L-UC and UP, the efficacy and side-effect profile of topical mesalamine are dose independent and superior to oral therapies and topical steroids. Economic analysis suggests that use of these agents will also result in an overall decrease in patient costs.
Focal intramural nodules were palpated in the rectal wall of a 12-year-old pony mare presented for rectal prolapse. Eosinophilic proctitis was diagnosed by examination of fine needle aspirates and biopsy of the largest rectal nodule. After treatment with a course of corticosteroids, the rectal nodule and accompanying peripheral eosinophilia resolved. There was no recurrence of the condition during the follow-up period of 20 months. Focal eosinophilic proctitis appeared to be an unusual cause of tenesmus and rectal prolapse in this case.
The effect of topical disodium cromoglycate (DSCG) has been examined in 30 patients with chronic active proctitis using a double-blind crossover trial. Each treatment period was four weeks and patients were given DSCG 200 mg by enema twice daily and 100 mg orally three times each day. Twenty-six patients completed the trial successfully, 14 responded to DSCG treatment, two improved with placebo, and 10 responded to neither. Patients who responded to DSCG had significantly more eosinophils in their rectal biopsies than those who failed to respond and in some instances the counts were very high. The findings support the hypothesis than an allergic reaction is important in the pathogenesis of proctitis.
In patients with Crohn's disease involving the rectum (n=25), there was an inverse relationship between rectal capacity and the degree of proctitis. However, in patients with Crohn's disease not involving the rectum (n=22) the rectal capacity was similar to that of normal controls (n=20). The frequency of defaecation was not related to the degree of proctitis or to the pressure of a colectomy and ileorectal anastomosis. Control subjects had a significantly lower frequency of defaecation than patients with Crohn's disease irrespective of involvement of the rectum.
Over a four-year period 21 cases of solitary ulcer syndrome (SUS) were studied for their clinical, histological, and mucus secretion patterns and compared with histological and mucus secretion patterns of 78 cases of non-specific proctitis collected over the same period. Normal mucus composition was found in non-specific proctitis while abnormalities of mucins with predominance of sialomucins were associated with SUS. Although histology remains the most important investigation in the diagnosis of SUS, mucin changes provide valuable additional evidence.
Sexually transmitted infections such as chlamydia, gonorrhoea, herpes simplex virus and syphilis commonly present with rectal symptoms. Recent outbreaks of lymphogranuloma venereum among homosexual men throughout Europe highlight the need to consider sexually transmitted infections in the differential diagnosis of proctitis. This article examines the causative organisms, clinical features, diagnosis and treatment of sexually transmitted proctitis.
AIM: The aim of this study was to evaluate the efficacy of local instillation of 4% formalin in the management of uncontrolled radiation-induced and ischemic hemorrhagic proctitis. PATIENTS AND METHODS: Eight patients were reviewed. Operation characteristics, morbidity and long-term results were analyzed. RESULTS: All patients were followed for a median of 18 months. In 5 patients the bleeding stopped after a single treatment and in 3 after a second one. During follow-up no recurrent rectal bleeding occurred, no further medical treatment was needed and in all patients the complaints had disappeared. CONCLUSION: Local instillation of 4% formalin is an effective treatment for uncontrolled radiation-induced and ischemic hemorrhagic proctitis.
Alterations in secretory component, IgA, IgG, and IgM were studied by immunofluorescent techniques in mucosal biopsy specimens obtained at colonoscopy from inflamed and grossly uninvolved colonic mucosa from 12 patients with idiopathic proctitis. Parotid-salivary secretory component and IgA and serum immunoglobulins were also investigated. Decreased secretory IgA was observed in the epithelium of all grossly involved rectal mucosa and in 40% of proximal normal mucosa. Salivary secretory IgA was not diminished. These observations suggest that a local immune defect may be pathogenetically related to idiopathic proctitis.
Homosexual men are known to have an increased incidence of sexually transmitted proctitis. A knowledge of the pathogenesis and the radiographic appearance of these processes has resulted in earlier diagnosis and more rapid institution of appropriate therapy. While gonococcus (Neisseria gonorrhoeae) and lymphogranuloma venereum (usually Chlamydia) have long been considered the common etiologies of proctitis in this population, other organisms, such as herpes, Mycoplasma, and Entamoeba have been implicated and could give an identical radiographic and clinical pattern. Diffuse narrowing and ulceration limited to the rectum was seen in five affected homosexual men recently studied at Northwestern Memorial Hospital, Chicago.
Whole-gut transit time was measured by the time taken for an orally administered dose of brilliant blue dye to disappear from the stool in 20 patients with ulcerative proctitis and in 20 age- and sex-matched controls. Ten of the patients had active, and 10 inactive disease. The dye usually appeared in the stool with the next bowel movement after ingestion in both patients and controls; however, the time at which the dye disappeared from the stool (transit time) was prolonged to 76.1 h in the patients, compared with 50.2 h in the controls (p less than 0.01). This delay occurred both in patients with active disease at 70.5 h (p less than 0.05) and in those with inactive disease at 81.8 h (p less than 0.05). This prolongation of transit time may be relevant to both the pathogenesis and treatment of ulcerative proctitis.