Proctitis, Inflammatory & Radiation

Inflammatory Proctitis

• • A mild form of ulcerative colitis that is limited to the rectum

  • The disease course is often self-limited

Radiation Proctitis

• • Occurs in a patient with a history of radiation to the rectum

  • Disease may develop months to years after the injury

Epidemiology

Inflammatory Proctitis

• • Colonic manifestations of ulcerative colitis develop in 10% of patients

Radiation Proctitis

• • Follows radiation injury

Symptoms and Signs

Inflammatory Proctitis

• • Rectal bleeding, discharge, diarrhea, and tenesmus

Radiation Proctitis

• • Diarrhea, rectal bleeding, discharge, tenesmus, pain, and incontinence

  • Symptoms of late disease are secondary to strictures, fistulas, and telangiectasias

  • Patients with late disease present with the following:

  • -Recurrent urinary tract infections

    -Vaginal discharge

    -Fecal incontinence

    -Rectal bleeding

    -Changes in stool caliber

    -Constipation

Imaging Findings

Inflammatory Proctitis

• • Sigmoidoscopy: Rectal mucosa is inflamed and friable, but the remainder of the colon appears normal on exam

Radiation Proctitis

• • Endoscopy may reveal friable edematous mucosa, telangiectasias, or strictures and may show internal openings of fistulas

• • Infectious proctitis

  • Crohn disease

  • Malignancy

Rule Out

• • An infectious process must be ruled out before initiating corticosteroid therapy

  • Malignancy

• • History and physical exam

  • Sigmoidoscopy/colonoscopy

  • Biopsies are taken at endoscopy to rule out infectious processes and Crohn disease

When to Admit

• • Severe bleeding

  • Bowel obstruction

  • Bowel perforation

Inflammatory Proctitis

• • Corticosteroid retention enemas are given for 2 weeks

  • If there is no response, a short course of oral corticosteroids may be given

  • Mesalamine (5-aminosalicylic acid) may be given orally or rectally in an enema or suppository

Radiation Proctitis

• • Initial therapy includes bulk-forming agents, antidiarrheals, and antispasmodics

  • Topical corticosteroids, mesalamine preparations, misoprostol suppositories, and short-chain fatty acids have all been used

Surgery

Indications

• • Radiation proctitis

  • -Treat late complications of radiation injury: Dilatation of strictures and laser coagulation of telangiectasias

    -Surgical success in treating fistulas to the bladder or vagina is interposition or transposition of healthy nonirradiated tissue into the field

    -Infrequently is the rectum so badly damaged that it must be removed

Medications

• • Corticosteroid enema

  • Oral steroids

  • Mesalamine, oral or rectal

Treatment Monitoring

• • Lack of response to appropriate therapy calls for reassessment of the patient

  ...