Proctitis and Anusitis Treatment & Management
- Author: David E Stein, MD; Chief Editor: John Geibel, MD, DSc, MSc, MA more...
The indications for therapy vary according to the etiology of the proctitis. For example, in patients with inflammatory bowel disease (IBD), a colonoscopy should be performed to find out the extent of the inflammation. Many patients with IBD who present with proctitis may progress to left-side colitis and possibly pancolitis. The first-line management of these patients is medical therapy (see below). Surgical treatment is indicated for failed medical therapy, any dysplasia seen on biopsy specimens, and cancer.
Surgery is rarely indicated for proctitis secondary to an infectious etiology. The goal of therapy is to treat the infection causing the inflammation. Rarely, profound sepsis may necessitate surgical resection as a life-saving maneuver.
Finally, the indication for treatment of chronic radiation proctitis is also based on the symptomatology and grade of proctitis. Persistent rectal bleeding and diarrhea initiate a workup, including a rigid proctoscopy and/or colonoscopy. The presence of intractable bleeding despite multiple medical/endoscopic modalities, perforation, strictures, or fistulas is an indication for surgical intervention.
In the course of any proctitis, antispasmodic agents may prove helpful in alleviating the abdominal complaints. In addition, the use of a low-residue diet and stool softeners is beneficial because of the friability of the rectal mucosa and its vulnerability to damage from the fecal contents.
Medical treatment of proctitis depends on the etiology (see below).
Idiopathic proctitis and inflammatory bowel disease
If proctitis is idiopathic or related to IBD, steroids, sulfasalazine, mesalamine, 5-aminosalicylic acid (5-ASA) products, and even immunosuppressive medications may be used. Many of these products are available as oral medications as well as enemas and suppositories. Combination therapy using both oral agents and topical agents, such as 5-ASA, has been shown to be more effective than therapy with either modality alone. In cases of refractory ulcerative proctitis, infliximab has been found to be effective in inducing a clinical response.[5, 6]
If the cause of proctitis is infectious, the treatment is targeted toward the pathogen responsible.
Infectious proctitis due to Salmonella species is usually self-limited, and antibiotics are not required. Maintaining adequate fluid and electrolyte balances and providing supportive care are all that is required.
Shigella proctitis is usually self-limited, but the duration may be shortened by the addition of antibiotics. Antibiotics for 1 week may include ampicillin, tetracycline, ciprofloxacin, and trimethoprim-sulfamethoxazole (preferred).
Yersinia proctitis is also self-limited and should not be treated with antibiotics unless systemic septicemia occurs; in which case, antibiotics (eg, trimethoprim-sulfamethoxazole, aminoglycosides, tetracycline, third-generation cephalosporin) should be used.
Campylobacter proctitis is usually self-limited as well.
E histolytica generally is treated with metronidazole and iodoquinol.
Sexually transmitted proctitis requires treatment similar to the corresponding treatment for a genital infection. Chlamydia trachomatis infection is treated with doxycycline; gonorrheal proctitis is treated with ceftriaxone or cefixime. Syphilitic proctitis responds to intramuscular (IM) penicillin G benzathine, and herpes simplex virus type 2 infection is treated with acyclovir.
C difficile infection generally is treated with intravenous (IV) or oral metronidazole or oral vancomycin. A more aggressive C difficile mutation has been seen and may have a rapidly progressive course toward septicemia and toxic colitis. In patients who do not appear to be responding to metronidazole and who have leukocytosis (leukocyte count >20,000/µL), therapy should be switched to oral vancomycin. Vancomycin enemas may also be used in individuals in whom oral antibiotics may not reach a part of the colon (eg Hartman pouch, ileostomy, colonic diversion). Discontinuation of any other antibiotics should be ordered if the clinical situation allows.
Patients colonized with C difficile have a likelihood of recurrence; consequently, whenever they are placed on antibiotics, they should be aware of the possibility of diarrhea. In patients with recurrent C difficile infections, physicians may consider fecal microbiota transplantation, which has been reported to achieve cure rates of 90% and higher in multiple studies.
Acute radiation proctitis is usually a self-limited condition, but supportive medical management (eg, hydration, antidiarrheals, and steroid or 5-ASA enemas) may be of benefit.
Chronic radiation proctitis involves more extensive medical treatment, including both oral and rectal therapies. Oral medications include 5-ASA, sulfasalazine, steroids, and metronidazole. Another therapeutic approach is the use of WF10, an IV therapy initially developed as an adjunctive AIDS treatment. Initial studies demonstrate control of bleeding within two doses of therapy and maintenance of results with once- to twice-yearly repeat therapy.
Rectal therapy for chronic radiation proctitis with sucralfate or pentosan polysulfate has been shown to result in better symptomatic relief than oral anti-inflammatory therapy. Studies demonstrate sucralfate enemas to be the most effective medical therapy for radiation proctitis when administered twice daily for 3 months. Such rectal therapies are believed to work via stimulation of epithelial healing and formation of a protective barrier.
Steroid and short-chain fatty acid enemas have also been used with moderate success. In terms of steroid enemas, hydrocortisone seems to be more effective in relieving symptoms and rectal bleeding compared with other steroids, such as betamethasone. Whereas short-chain fatty acid enemas, such as butyrate, have some proven benefit in other types of proctitis, no studies have conclusively demonstrated that they have any beneficial effect on proctitis secondary to radiation.
Research has shown hyperbaric oxygen treatment to have some efficacy in the treatment of radiation-induced proctitis.[11, 12] A large single-center study reported a 63% response rate in patients with gastrointestinal radionecrosis, supporting the findings of several previous smaller series. Hyperbaric oxygen therapy has emerged as a potential therapy for radiation proctitis because of its ability to increase the number of blood vessels in irradiated tissues by acting as a stimulant for angiogenesis; however, further studies must be performed to establish the efficacy of this treatment modality.
Other medical therapies aimed at the treatment of radiation proctitis, such as antioxidant therapy with vitamins A, C, and E, have showed efficacy in small single-institution studies, but at present, the evidence is insufficient to justify recommendation. Additionally, ozone therapy via rectal insufflation and topical ozonized oil has shown some possible efficacy, but large randomized clinical trials are lacking.
More invasive management of radiation proctitis with rectal/topical formalin is believed to work via sclerosis of neovasculature in a form of chemical cauterization. Multiple studies have demonstrated the efficacy of formalin in the resolution of hemorrhagic proctitis, with success rates in the range of 70-80%.[16, 17, 18] Of note, significant complications from treatment include stricture and skin damage to the perianal skin.
Symptomatic diversion proctitis generally improves after the ostomy is taken down and bowel continuity is restored. However, in patients who need to be out of circuit indefinitely, short-chain fatty acid enemas may be beneficial.
Many factors come into play in deciding when to operate and which operation to perform. For most cases of proctitis, medical treatment should suffice. However, for certain disease processes, surgical treatment is more likely.
Choice of procedure
For patients with ulcerative colitis requiring surgical therapy, a total proctocolectomy should be performed because of the risk of cancer in the remaining rectal stump. Ileostomy or reconstruction with an ileal pouch may be offered after total proctocolectomy. In patients with severe Crohn colitis or proctitis, options range from fecal diversion to proctectomy to total proctocolectomy, depending on the extent of the disease process.
In the infectious causes of proctitis, surgical treatment is rarely required. In cases of severe C difficile colitis, a subtotal colectomy may be warranted.
For patients with radiation proctitis complicated by refractory bleeding, endoscopic therapy seems to be more effective than medical therapy; it also results in less morbidity than surgical therapy. Specifically, argon plasma coagulation (APC)[16, 20, 21] has proved to be superior to formalin and endoscopic laser treatments. Other endoscopic therapies include endoscopic thermal methods, such as heater probes and lasers, which destroy telangiectasias to stop bleeding.
If, despite medical and endoscopic measures, significant hemorrhage still occurs, a laparoscopic fecal diversion (ileostomy or colostomy) should be performed. Although fecal diversion alleviates patients' symptoms, it rarely eliminates them entirely; it should be reserved for truly refractory cases. Fewer than 10% of patients do not respond to some form of medical management and require surgical intervention.
Rarely, radiation proctitis can be so severe that it ulcerates, potentially leading to the formation of a rectourethral fistula. In these cases, temporary fecal and urinary diversion should be performed until the inflammation subsides. Definitive therapy may then be provided. The procedure of choice is a perineal approach with repair of the defect with muscle and mucosal flaps.
Preparation for operation
As always, general surgical preparation includes optimizing medical status and providing deep vein thrombosis (DVT) prophylaxis, bowel preparation, and preoperative antibiotic prophylaxis. A Foley catheter will be placed after induction of anesthesia.
Preoperative nutritional status may be the most significant predictor of outcomes. Every effort should be given to assess the patient's nutritional status and improve it if necessary. The author's current practice is to obtain a prealbumin level on all patients scheduled to undergo laparotomy. If it is low, the author will delay the surgery and place them on nutritional supplementation.
If the patient is going to have a stoma, preoperative counseling with a trained enterostomal nurse is essential. The nurse will educate the patient about life with a stoma and also mark the patient preoperatively to ensure optimal stoma placement.
For patients requiring a subtotal colectomy, an assessment of their sphincter complex is helpful in determining postoperative fecal continence. This is also true for patients undergoing a total proctocolectomy with an ileal pouch.
In addition, for patients undergoing a proctectomy, it is important to discuss their sexual and urinary function before performing the procedure; there is a small but real possibility of diminished sexual function and bladder continence after pelvic surgery.
Good surgical technique is imperative. In the performance of a pelvic dissection, knowing the anatomic planes and adjacent structures is important for avoiding injury.
The presacral nerves are on the anterior aspect of the sacrum. These nerves usually can be identified at the sacral promontory, approximately 1 cm lateral to the midline.
Be aware of the parasympathetic innervation to the urinary and genital organs and the rectum at the lateral edges of the rectum, near the lateral stalks. The parasympathetic nerve supply in this area is from the nervi erigentes. Dissection that is too lateral will likely affect this nerve supply.
Maintain the correct plane of dissection along the posterior rectum. Along the same principles of total mesorectal excision, the plane outside the mesorectum but above the presacral fascia is the correct plane to dissect. Dissection that is too anterior results in entry into the mesorectum. Dissection that is too deep through the presacral fascia risks presacral bleeding.
Maintain the correct plane of dissection along the anterior rectum. Clearly, important structures exist in both females (vagina) and males (prostate, seminal vesicles).
Remain cognizant of the course of the ureters along the lateral rectum when dissection enters into the pelvis.
As with any major surgical procedure, close monitoring of fluid status, cardiac status, pulmonary status, and return of gastrointestinal (GI) function is important. For patients who require a hospital stay, DVT prophylaxis is essential. Many centers have different protocols for removing a Foley catheter. The author tends to remove the Foley catheter on the third postoperative day.
One of the more important concerns includes those patients with a perineal wound. Often, tension on the wound may be significant, depending on whether the sphincter mechanism is resected or not. Because patients often are in the supine position, overlooking examination of the perineal wound is easy. Close observation of this area is important; problems with wound healing in this area are significant. The risk of wound complications increases in those patients who have undergone irradiation of the pelvis.
Wound infection may develop with a proctectomy. It is not uncommon for the perineal wound to separate slightly during the immediate postoperative period. If any discharge or erythema is noted around the wound, especially if there was some tension upon closure, opening the wound earlier rather than later is prudent. Addressing the open wound with wet-to-dry dressing changes routinely allows the wound to close without incident.
Sexual dysfunction can occur when the pelvic nerves are injured. The best way to deal with this complication is to be cognizant of the possibility prior to surgery and avoid it. Once it occurs, very little can be done to help the nerves. The role of medications such as sildenafil remains unclear, though sildenafil has been reported to help.
As with sexual dysfunction, every effort should be made to avoid urinary dysfunction in the operating room.
Avoiding ureteral injury by remaining cognizant of the ureteral anatomy is a paramount consideration. Once the injury occurs, recognizing this at the time of operation clearly is best. The repair is dictated by where the injury occurs in the ureter. Consultation with a urologist is prudent.
In a few cases, presacral bleeding has been reported to progress to death. Clearly, avoidance is the best way to deal with this complication. If it does occur in the midst of the procedure, cautery or pressure generally does not stop true presacral bleeding from the pelvic veins. The usual method of stopping the bleeding is to use a thumbtack. A muscle pledget is also a clever way to cauterize the bleeding. Take a piece of rectus muscle, apply it to the bleeding site, and cauterize the muscle on a high coagulation setting.
Follow-up care with regard to the surgical wounds (both perineal and abdominal) and the colostomy is important. In addition, postoperative sexual and urinary function should be discussed and a further workup initiated if required.
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