Ulcerative Proctitis

Ulcerative proctitis is an idiopathic mucosal inflammatory disease involving only the rectum and is therefore an anatomically limited form of ulcerative colitis. Diagnosis is made based on clinical presentation, endoscopic appearance, and histopathology. Additionally, other etiologies of proctitis are excluded. The course of the disease is variable ranging from complete resolution to easily maintained remission to frequent relapses or refractory disease. Extension of inflammatory changes involving the proximal colon occurs in some cases. Rectal 5-aminosalicylic acid (5-ASA) or steroids are the initial treatments of choice with oral 5-ASA, sulfasalazine, or steroids used for treatment failures or patients unable to tolerate rectally administered drugs. Immunomodulators like azathioprine and 6-mercaptopurine have been used successfully in small groups of patients who have not responded to 5-ASA or steroids. Oral or rectal 5-ASA products maintain remission but long-term steroid use should be avoided. Rare cases may require surgical therapy.

KEYWORDS

Proctitis - ulcerative proctitis - 5-ASA - hydrocortisone

REFERENCES

• 1 Farmer R G. Evolution of the concept of proctosigmoiditis.  Med Clin North Am. 1990;  74 91-102
• 2 Langholz E, Munkholm P, Davidsen M, Nielson O H, Binder V. Changes in extent of ulcerative colitis: a study on the course and prognostic factors.  Scand J Gastroenterol. 1996;  31 260-266
• 3 Meucci G, Vecchi M, Astegiano M et al.. The natural history of ulcerative proctitis: a multicenter, retrospective study.  Am J Gastroenterol. 2000;  95 469-473
• 4 Russell M G, Dorant E, Volovics A et al.. High incidence of inflammatory bowel disease in The Netherlands: results of a prospective study. The South Limbourg IBD Study Group.  Dis Colon Rectum. 1998;  41 33-40
• 5 Stewenius J, Adnerhill I, Ekelund G et al.. Ulcerative colitis and indeterminate colitis in the city of Malmo, Sweden. A 25-year incidence study.  Scand J Gastroenterol. 1995;  30 38-43
• 6 Campieri M, Gionchetti P, Belluzzi A et al.. 5-aminosalicylic acid as enemas or suppositories in distal ulcerative colitis?.  J Clin Gastroenterol. 1988;  10 406-409
• 7 Campieri M, De Franchis R, Bianchi Porro G et al.. Mesalazine (5-aminosalicylic acid) suppositories in the treatment of ulcerative proctitis or distal proctosigmoiditis. A randomized controlled trial.  Scand J Gastroenterol. 1990;  25 663-668
• 8 Sutherland L R, Martin F, Greer S et al.. 5-aminosalicylic acid enema in the treatment of distal ulcerative colitis, proctosigmoiditis, and proctitis.  Gastroenterology. 1987;  92 1894-1898
• 9 Marshall J B, Butt J H. Proctitis: approach to diagnosis, causes, and treatment.  J Clin Gastroenterol. 1982;  4 431-444
• 10 Langevin S, Menard D B, Haddad H et al.. Idiopathic ulcerative proctitis may be the initial manifestation of Crohn's disease.  J Clin Gastroenterol. 1992;  15 199-204
• 11 Quinton J F, Sendid B, Reumaux D et al.. Anti-Saccharomyces cerevisiae mannan antibodies combined with antineutrophil cytoplasmic autoantibodies in inflammatory bowel disease: prevalence and diagnostic role.  Gut. 1998;  42 788-791
• 12 Peeters M, Joossens S, Vermeire S et al.. Diagnostic value of anti-Saccharomyces cerevisiae and antineutrophil cytoplasmic autoantibodies in inflammatory bowel disease.  Am J Gastroenterol. 2001;  96 730-734
• 13 Rampalo A M. Diagnosis and treatment of sexually acquired proctitis and proctocolitis: an update.  Clin Infect Dis. 1999;  28(suppl 1) S84-S90
• 14 Tagkalidis P P, Tjandra J J. Chronic radiation proctitis.  ANZ J Surg. 2001;  71 230-237
• 15 Haboubi N Y, Schofield P F, Rowland P L. The light and electron microscopic features of early and late phase radiation-induced proctitis.  Am J Gastroenterol. 1988;  83 1140-1144
• 16 Nelson R L, Briley S, Schuler J J, Abcarian H. Acute ischemic proctitis. Report of six cases.  Dis Colon Rectum. 1992;  35 375-380
• 17 Dawson M A, Schaefer J W. The clinical course of reversible ischemic colitis. Observations on the progression of sigmoidoscopic and histological changes.  Gastroenterology. 1971;  60 577-580
• 18 Hurley B W, Nguyen C C. The spectrum of pseudomembranous enterocolitis and antibiotic-associated diarrhea.  Arch Intern Med. 2002;  162 2177-2184
• 19 Kyne L, Farrell R J, Kelly C P. Clostridium difficile .  Gastroenterol Clin North Am. 2001;  30 753-777
• 20 Williams C N, Haber G, Aquino J A. Double-blind placebo-controlled evaluation of 5-ASA suppositories in active distal proctitis and measurement of extent of spread using 99-m-Tc-labeled 5-ASA suppositories.  Dig Dis Sci. 1987;  32 71S-75S
• 21 Jay M, Beihn R M, Digenis G A et al.. Disposition of radiolabeled suppositories in humans.  J Pharm Pharmacol. 1985;  37 266-268
• 22 Brown J, Haines S, Wilding I R. Colonic spread of three rectally administered mesalazine (Pentasa) dosage forms in healthy volunteers as assessed by gamma scintigraphy.  Aliment Pharmacol Ther. 1997;  11 685-691
• 23 Campieri M, Gionchetti P, Belluzzi A et al.. Topical treatment with 5-aminosalicylic in distal ulcerative colitis by using a new suppository preparation. A double-blind placebo-controlled trial.  Int J Colorectal Dis. 1990;  5 79-81
• 24 Gionchetti P, Rizzello F, Venturi A et al.. Comparison of oral with rectal mesalazine in the treatment of ulcerative proctitis.  Dis Colon Rectum. 1998;  41 93-97
• 25 Malchow H, Gertz B. A new mesalazine foam enema (Claversol Foam) compared with a standard liquid enema in patients with active distal ulcerative colitis.  Aliment Pharmacol Ther. 2002;  16 415-423
• 26 Ardiazzone S, Doldo P, Ranzi T et al.. Mesalazine foam (Salofalk foam) in the treatment of active distal ulcerative colitis. A comparative trial versus Salofalk enema. The SAF-3 study group.  Ital J Gastroenterol Hepatol. 1999;  31 677-684
• 27 Farup P G, Hovde O, Halvorsen F A et al.. Mesalazine suppositories versus hydrocortisone foam in patients with distal ulcerative colitis. A comparison of the efficacy and practicality of two topical treatment regimens.  Scand J Gastroenterol. 1995;  30 164-170
• 28 Lucidarme D, Marteau P, Foucault M, Vautrin B, Filoche B. Efficacy and tolerance of mesalazine suppositories versus hydrocortisone foam in proctitis.  Aliment Pharmacol Ther. 1997;  11 335-340
• 29 Marteau P, Florent C. Comparative, open, randomized trial of the efficacy and tolerance of slow-release 5-ASA suppositories once daily versus conventional 5-ASA suppositories twice daily in the treatment of active cryptogenic proctitis.  Am J Gastroenterol. 2000;  95 166-170
• 30 Das K M, Eastwood M A, McManus J P, Sircus W. Adverse reactions during salicylazosulfapyridine therapy and the relation with drug metabolism and acetylator phenotype.  N Engl J Med. 1973;  289 491-495
• 31 Allgayer H. Sulfasalazine and 5-ASA compounds.  Gastroenterol Cl North Am. 1992;  21 643-658
• 32 Hanauar S B, Robinson M, Pruitt R et al.. Budesonide enema for the treatment of active, distal ulcerative colitis and proctitis: a dose-ranging study. U.S. Budesonide Enema Study Group.  Gastroenterology. 1998;  115 525-532
• 33 Bar-Meir S, Fidder H H, Fasczyk M et al.. Budesonide foam vs. hydrocortisone acetate foam in the treatment of active ulcerative proctosigmoiditis.  Dis Colon Rectum. 2003;  46 929-936
• 34 van der Heide H, van den Brandt-Gradel V, Tytgat G N et al.. Comparison of beclomethasone diproprionate and prednisolone 21-phosphate enemas in the treatment of ulcerative proctitis.  J Clin Gastroenterol. 1988;  10 169-172
• 35 Mulder C J, Fockens P, Meijer J W et al.. Beclomethasone diproprionate (3 mg) versus 5-aminosalicylic acid (2 g) versus the combination of both (3 mg/2 g) as retention enemas in active ulcerative procitis.  Eur J Gastroenterol Hepatol. 1996;  8 549-553
• 36 Safdi M, DeMicco M, Sninsky C et al.. A double-blind comparison of oral versus rectal mesalamine versus combination therapy in the treatment of distal ulcerative colitis.  Am J Gastroenterol. 1997;  92 1867-1871
• 37 Bitton A. Medical management of ulcerative proctitis, proctosigmoiditis, and left-sided colitis.  Semin Gastrointest Dis. 2001;  12 263-274
• 38 Sandborn W J, Tremaine W J, Schroeder K W et al.. A placebo-controlled trial of cylcosporine enemas for mildly to moderately active left-sided ulcerative colitis.  Gastroenterology. 1994;  106 1429-1435
• 39 Ardizzone S, Petrillo M, Antonacci C M, Bianchi Porro G. Sucralfate and hydrocortisone enemas in the treatment of active ulcerative proctitis-a randomized single-blind comparative study.  Aliment Pharmacol Ther. 1996;  10 957-960
• 40 Love M A, Rubin P H, Chapman M L, Present D H. 6-mercaptopurine is effective in intractable proctosigmoiditis.  Gastroenterology. 1995;  100 A832
• 41 George J, Present D H, Pou R, Godian C, Rubin P H. The long-term outcome of ulcerative colitis treated with 6-mercaptopurine.  Am J Gastroenterol. 1996;  91 1711-1714
• 42 Gornet J M, Couve S, Hassani Z et al.. Infliximab for refractory ulcerative colitis or indeterminate colitis: an open-label multicentre study.  Aliment Pharmacol Ther. 2003;  18 175-181
• 43 Probert C S, Hearing S D, Schreiber S et al.. Infliximab in moderately severe glucocorticoid-resistant ulcerative colitis: a randomized controlled trial.  Gut. 2003;  52 998-1002
• 44 d'Albasio G, Paoluzi P, Campieri M et al.. Maintenance treatment of ulcerative proctitis with mesalazine suppositories: a double-blind placebo-controlled trial. The Italian IBD Study Group.  Am J Gastroenterol. 1998;  93 799-803
• 45 Marteau P, Crand J, Foucault M, Rambaud J-C. Use of mesalazine slow-release suppositories 1 g three times per week to maintain remission of ulcerative proctitis: a randomized double-blind placebo-controlled multicentre study.  Gut. 1998;  42 195-199
• 46 D'Albasio G, Pacini F, Camarri E et al.. Combined therapy with 5-aminosalicylic acid tablets and enemas for maintaining remission in ulcerative colitis: a randomized double-blind study.  Am J Gastroenterol. 1997;  92 1143-1147