eMedicine Specialties > Emergency Medicine > Gastrointestinal

Proctitis

Lisandro Irizarry, MD, MPH, FAAEM, Chair, Department of Emergency Medicine, Brooklyn Hospital Center; Assistant Professor, Department of Emergency Medicine, Weill Cornell School of Medicine
Ibis Yarde, MD, Staff Physician, Department of Emergency Medicine, Brooklyn Hospital Center

Updated: Apr 27, 2009

Introduction

Background

Proctitis is inflammation of the lining of the rectum, called the rectal mucosa. Proctitis can be short term (acute) or long term (chronic). Proctitis has many causes. It may be a side effect of medical treatments like radiation therapy or antibiotics. Proctitis involves an inflammatory change of the rectum (within 15 cm of the dentate line). Proctitis is similar to proctosigmoiditis but is not necessarily associated with proximal extension of disease into the colon and usually does not evolve into ulcerative colitis. If proximal extension does occur, it usually does so within the first 2 years of initial diagnosis.

Proctitis caused by sexually transmitted diseases (STDs) is transmitted through receptive anal intercourse and is most commonly due to gonorrhea and chlamydia, or less commonly lymphogranuloma venereum or herpes virus. Nonsexually transmitted causes include autoimmune disease of the colon, such as Crohn disease and ulcerative colitis, chemicals, rectal instrumentation, and trauma to the anorectal area. It may also occur as idiopathic proctitis. Other causes include radiation therapy or celiac disease.

For more information on Crohn disease and ulcerative colitis, see Medscape’s Inflammatory Bowel Disease Resource Center.

Pathophysiology

Proctitis involves mucosal cell loss, acute inflammation of the lamina propria, eosinophilic crypt abscess, and endothelial edema of the arterioles. These may improve or progress with subsequent fibrosis of connective tissue and endarteritis of the arterioles, resulting in rectal tissue ischemia and leading to mucosal friability, bleeding, ulcers, strictures, and fistula formation.

Frequency

United States

Frequencies of proctitis are associated with their individual etiologies. With radiation therapy, 5-20% of patients display proctitis, usually within 3-24 months after completion of therapy with a total dose greater than 50 Gy.

Race

Incidence is higher in Jewish persons.

Sex

Males are affected more often than females.

Age

Proctitis occurs predominantly in adults.

Clinical

History

• General symptoms
  • A feeling of rectal fullness
  • Anal and rectal pain
  • Diarrhea, usually frequent, small amounts
  • Frequent or continuous urge to have a bowel movement
  • Pain in the lower left abdomen
  • Passing mucus through the rectum
  • Rectal bleeding
• Idiopathic proctitis
  • Passage of blood and mucus per rectum
  • Tenesmus
  • Occasionally, passage of loose stool, with or without lower abdominal pain or rectal cramping
• Infectious proctitis
  • Pruritus
  • Rectal and anal pain (may become severe)
  • Avoidance of defecation
  • Most common causes - Neisseria gonorrhoeae, Chlamydia trachomatis, herpes simplex virus (HSV) types 1 and 2
• Indolent and extensive HSV types 1 and 2 infections
  • Tenesmus
  • Rectal pain
  • Discharge
  • Hematochezia
  • The disease may run its natural course of exacerbations and remissions but is usually more prolonged and severe in patients with immunodeficiency disorders.
  • Presentations may resemble dermatitis or decubitus ulcers in debilitated, bedridden patients.
  • A secondary bacterial infection may be present.
• Radiation-induced proctitis
  • Early symptoms include tenesmus and diarrhea that resolve shortly after the treatment period.
  • Later symptoms of proctitis (occurring months to years after the completion of radiation therapy) include tenesmus, bleeding, low-volume diarrhea, and rectal pain.
  • Symptoms of radiation-induced proctitis are associated with low-grade obstruction or fistulous tracts into adjacent organs.

Physical

• Mucosal erythema
• Mucosal friability
• Groups of vesicles eroding into circular superficial ulcers enlarged
• Tender inguinal lymph nodes (HSV)
• Painless chancres
• Hemoccult positive stools

Causes

• N gonorrhoeae
• C trachomatis
• HSV 1 (10%) and HSV 2 (90%)
• Radiation therapy
• Immunodeficiency disorders
• Crohn disease
• Syphilis (usually secondary)
• Papillomavirus
• Amebiasis
• Lymphogranuloma venereum
• Ischemia
• Toxins (eg, hydrogen peroxide enemas)
• Vasculitis
• Cytomegalovirus (CMV)
• Clostridium difficile
• Campylobacter species

Differential Diagnoses

Other Problems to Be Considered

Traumatic proctitis
Infections (eg, shigellosis, amebiasis)

Workup

Laboratory Studies

• A complete blood count (CBC) is performed to evaluate for chronic or severe blood loss.
• A sequential multiple analysis of 7 serum tests (SMA 7) is performed to evaluate for severe electrolyte/fluid losses or to look for evidence of renal insufficiency prior to initiation of medical therapy.
• C-reactive protein level is elevated in patients with extensive pancolitis but is always normal in patients with only distal disease.
• Cultures of rectal swabs help diagnose gonorrhea or chlamydia.
• Cultures of vesicular fluid or cytologic scrapings aid in the diagnosis of HSV.
• Serum Venereal Disease Research Laboratory (VDRL) test and dark field examination of scrapings from the base of the chancre reveals spirochetes and confirms the diagnosis of syphilis.
• Stool specimen for C difficile toxin.

Procedures

• Proctosigmoidoscopy reveals the following:
  • Pallor or erythema
  • Loss of usual vascularity of mucosa
  • Prominent telangiectasia
  • Friability
  • Bleeding
  • Ulcerations
  • Edema
  • Scattered areas of scarring
  • Vesicles/pustules
  • Strictures
• Biopsy for histology, culture, viral studies, and Chlamydia studies
• Colonoscopy to exclude more proximal involvement

Treatment

Emergency Department Care

• After life-threatening conditions have been excluded or controlled, aim for providing patient comfort during the examination.
• Treatment depends upon the etiology.  
  • Sitz baths, antispasmodic medications, stool softeners, low residue diet (may provide relief)
  • Steroid enemas or suppositories for ulcerative proctitis
  • Ceftriaxone and doxycycline for gonorrheal proctitis
  • Acyclovir for herpetic proctitis
  • Tetracycline or doxycycline for chlamydial proctitis
  • Shigella proctitis is usually self-limiting but may require prolonged (2-4 wk) antibiotic treatment with ampicillin, tetracycline, ciprofloxacin, or trimethoprim and sulfamethoxazole (TMP-SMZ).
  • Yersinia proctitis is usually self-limiting, but, if systemic bacteremia occurs, treat with intravenous antibiotics such as tetracycline or ceftriaxone.
  • Campylobacter proctitis is a self-limiting disease; treatment is aimed at symptomatic relief.
  • Metronidazole (Flagyl) or iodoquinol for amebiasis proctitis
  • Metronidazole (Flagyl) or oral vancomycin for C difficile proctitis
  • Formalin retention enemas (2-4%), argon plasma coagulation via endoscopy, hyperbaric oxygen for hemorrhagic radiation proctitis

Consultations

• Consult a colorectal surgeon or a gastroenterologist for further evaluation of the lower gastrointestinal (GI) tract by sigmoidoscopy, if indicated (to rule out more proximal disease), after anoscopy.
• A colorectal surgical consultation may also be considered for management/evaluation of deep tissue infection that is not amenable to incision and drainage in the ED.

Medication

Drug therapy consists of antibiotics, antivirals, corticosteroids, and GI agents.

Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Metronidazole (Flagyl)

Active against various anaerobic bacteria and protozoa. Appears to be absorbed into cells. Intermediate metabolized compounds are formed and bind DNA and inhibit protein synthesis, causing cell death. Antimicrobial effect may be due to production of free radicals.
Indicated for invasive E histolytic infections.

Dosing

Adult

500-750 mg PO tid for 10 d

Pediatric

35-50 mg/kg PO divided tid for 10 d

Interactions

May increase toxicity of anticoagulants, cyclosporine, lithium, phenytoin, tacrolimus, and carbamazepine; cimetidine may increase toxicity of metronidazole; disulfiram reaction may occur with orally ingested ethanol; coadministration increases amiodarone toxicity (QT prolongation); increases disulfiram toxicity (psychotic symptoms) with concurrent use; phenobarbital and rifampin may increase metabolism of metronidazole

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution with liver impairment, blood dyscrasias, CNS disease; reduce dosage with severe hepatic disease; monitor for seizures and development of peripheral neuropathy

Vancomycin (Vancocin)

Has excellent in vitro activity against C difficile. Kills organism by inhibiting cell wall synthesis. Significant luminal levels after PO vancomycin can be obtained because it is poorly absorbed from the GI tract. Major disadvantage is cost. PO vancomycin is relatively expensive, with a wholesale cost of approximately $150 for a 10-d supply. Because of the cost and the concern over the emergence of vancomycin-resistant enterococci strains, its use should be reserved for patients who cannot tolerate metronidazole, patients who do not respond to metronidazole, pregnant patients, and patients <10 y. Also preferred for severe cases and in patients who are high risk. Unlike IV metronidazole, IV vancomycin is not excreted into the GI lumen; therefore, delivering effective doses by this route is difficult.

Dosing

Adult

125 mg PO qid for 10-14 d

Pediatric

40 mg/kg/d PO divided tid/qid for 7-10 d; not to exceed 2 g/d

Interactions

Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in renal failure, neutropenia; red man syndrome is caused by too rapid IV infusion (dose given over a few min) but rarely happens when dose given IV over 2 h administration or as PO or IP administration; red man syndrome is not an allergic reaction

Ciprofloxacin (Cipro)

Fluoroquinolone that inhibits bacterial DNA synthesis and, consequently, growth, by inhibiting DNA gyrase and topoisomerases, which are required for replication, transcription, and translation of genetic material. Quinolones have broad activity against gram-positive and gram-negative aerobic organisms. Has no activity against anaerobes. Continue treatment for at least 2 d (7-14 d typical) after signs and symptoms have disappeared.
Usually administered on empiric basis in patients with severe colitis in addition to steroids. Also used for the treatment of pouchitis after colectomy and ileo-anal anastomosis.

Dosing

Adult

500 mg PO bid
400 mg IV bid

Pediatric

<18 years: Not recommended
>18 years: Administer as in adults

Interactions

Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations
May increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Dosage adjustments (adult adjustments)
CrCl (mL/min) <10: 50% of PO or IV dose q12h
HD: 0.25-0.5 g PO or 0.2-0.4 g IV q12h
During peritoneal dialysis: 0.25-0.5 g PO or 0.2-0.4 g IV q8h
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
Not drug of first choice in pediatrics because of increased incidence of adverse events compared with controls, including arthropathy; no data exist for dose for pediatric patients with renal impairment (ie, CrCl <50 mL/min)

Ceftriaxone (Rocephin)

Used because of an increasing prevalence of penicillinase producing N gonorrhoeae. It inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins, causing bacterial growth inhibition.

Dosing

Adult

250 mg IM once

Pediatric

Neonates >7 days: 25-50 mg/kg IM once; not to exceed 125 mg
Infant or child: 125 mg IM once plus doxycycline

Interactions

Aminoglycosides increase nephrotoxic potential; probenecid increases effects by decreasing clearance

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in renal impairment

Doxycycline (Doryx, Bio-Tab, Vibramycin)

Required with ceftriaxone for the treatment of gonorrheal proctitis. Inhibits protein synthesis and, thus, bacterial growth by binding with the 30S and possibly the 50S ribosomal subunits of susceptible bacteria.

Dosing

Adult

Acute infections: 200 mg PO immediately, then 100 mg PO hs on d 1, followed by 100 mg PO bid for 3 d; or 300 mg PO stat followed by 300 mg PO in 1 h; alternatively, use 100 mg PO bid for 7 d

Pediatric

<8 years: Not recommended
>8 years: 2-5 mg/kg/d PO qd or divided bid; not to exceed 200 mg/d

Interactions

Antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate can decrease bioavailability

Contraindications

Documented hypersensitivity; severe hepatic dysfunction

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Avoid prolonged exposure to sunlight or tanning equipment to prevent a photosensitivity reaction; use of tetracyclines during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth

Benzathine penicillin (Bicillin L-A)

A bactericidal used in the treatment of rectal syphilis. Interferes with bacterial cell wall synthesis during active multiplication, inhibiting bacterial growth.

Dosing

Adult

2.4 million U IM once in 2 injection sites

Pediatric

50,000 U/kg IM once; not to exceed 2.4 million U

Interactions

Probenecid can increase the effects by decreasing clearance; conversely, coadministration of tetracyclines can decrease effects

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in impaired renal function

Tetracycline (Sumycin)

Treats susceptible bacterial infections of both gram-positive and gram-negative organisms as well as infections caused by Mycoplasma, Chlamydia, and Rickettsia species. Inhibits bacterial protein synthesis and, thus, bacterial growth by binding with 30S and possibly 50S ribosomal subunit(s) of susceptible bacteria.

Dosing

Adult

250-500 mg PO q6h

Pediatric

25-50 mg/kg/d PO divided q6h

Interactions

Antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate can decrease bioavailability; can increase hypoprothrombinemic effects of anticoagulants; coadministration can decrease the pharmacologic effects of oral contraceptives, causing breakthrough bleeding and an increased risk of pregnancy

Contraindications

Documented hypersensitivity; severe hepatic dysfunction

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Prolonged exposure to sunlight or tanning equipment can cause a photosensitivity reaction; use lower-than-usual doses in patients with renal impairment; use of tetracyclines during tooth development (last half of pregnancy through age 8 y) can cause a permanent discoloration of teeth; never administer outdated tetracyclines, the degradation products are highly nephrotoxic and can cause a Fanconilike syndrome

Rectal anti-inflammatory agents

These agents decrease inflammation associated with proctitis, perhaps by inhibiting prostaglandin synthesis.

Sulfasalazine (Azulfidine)

Useful in the management of ulcerative colitis; acts locally in the colon to decrease the inflammatory response and systemically inhibits prostaglandin synthesis.

Dosing

Adult

Initial dose: 1 g PO tid/qid
Maintenance dose: 2 g/d PO divided tid/qid

Pediatric

<2 years: Not established
>2 years: 40-60 mg/kg/d PO in 3-6 divided doses
Maintenance dose: 20-30 mg/kg/d PO divided qid

Interactions

Decreases the effect of iron, digoxin, and folic acid; conversely, increases effect of oral anticoagulants, oral hypoglycemic agents, and methotrexate

Contraindications

Documented hypersensitivity; GI or GU obstruction

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Renal or hepatic impairment; blood dyscrasias; urinary obstruction

Mesalamine (Rowasa, Asacol, Canasa, Pentasa)

Used for treatment of mildly to moderately active ulcerative colitis. The usual course of therapy in adults is 3-6 wk. Some patients may need concurrent oral and rectal therapy.

Dosing

Adult

Oral: 1 g cap PO qid or 800 mg tab PO tid
Rectal: One 500-mg supp PR bid or one 4-g susp enema PR qd (retained for 8 h)

Pediatric

Not established

Interactions

Decreases effects of iron, digoxin, and folic acid; conversely, it increases the effect of oral anticoagulants, methotrexate, and oral hypoglycemic agents

Contraindications

Documented hypersensitivity to mesalamine or to suppository vehicle (saturated vegetable fatty acid esters)

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Elderly persons may have difficulty administering and retaining rectal suppositories; use caution in patients with renal or hepatic impairment; susp contains potassium metabisulfite, so care must be taken in individuals with documented sulfite allergy

Antivirals

These agents are used for the treatment of herpes-related proctitis. They inhibit viral replication by competing with deoxyguanosine triphosphate for viral DNA polymerase.

Acyclovir (Zovirax)

Reduces duration of symptomatic lesions. Indicated for patients who present within 48 h of experiencing rash. Patients taking acyclovir experience less pain and faster resolution of cutaneous lesions.

Dosing

Adult

Initial episode: 200 mg PO q4h (while awake) 5 times/d for 10 d
Recurrence: 200 mg PO q4h (while awake) 5 times/d for 10 d

Pediatric

Not established
Suggested dose: 10-20 mg/kg/dose PO (up to 800 mg) qid for 5 d; start treatments within 24 h of rash onset

Interactions

Concomitant use of probenecid or zidovudine prolongs half-life and thus increases CNS toxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Renal failure; coadministration of other nephrotoxic drugs

Corticosteroids

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immunity to diverse stimuli.

Dexamethasone (AK-Dex, Alba-Dex, Baldex, Decadron, Dexone)

Has many pharmacologic benefits but significant adverse effects. Stabilizes cell and lysosomal membranes, increases surfactant synthesis, increases serum vitamin A concentration, and inhibits prostaglandin and proinflammatory cytokines (eg, TNF-alpha, IL-6, IL-2, and IFN-gamma). The inhibition of chemotactic factors and factors that increase capillary permeability inhibits recruitment of inflammatory cells into affected areas. Suppresses lymphocyte proliferation through direct cytolysis and inhibits mitosis. Breaks down granulocyte aggregates, and improves pulmonary microcirculation. Adverse effects are hyperglycemia, hypertension, weight loss, GI bleeding or perforation synthesis, cerebral palsy, adrenal suppression, and death. Most of the adverse effects of corticosteroids are dose-dependent or duration-dependent.
Readily absorbed via the GI tract and metabolized in the liver. Inactive metabolites are excreted via the kidneys. Lacks salt-retaining property of hydrocortisone.
Patients can be switched from an IV regimen to a PO regimen in a 1:1 ratio.

Dosing

Adult

0.75-9 mg/d PO in divided doses q6-12h

Pediatric

0.08-0.3 mg/kg/d or 2.5-10 mg/m²/d divided PO q6-12h

Interactions

Effects decrease with coadministration of barbiturates, phenytoin, and rifampin; dexamethasone decreases effect of salicylates and vaccines used for immunization

Contraindications

Documented hypersensitivity; active bacterial or fungal infection

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Increases risk of multiple complications, including severe infections; monitor adrenal insufficiency when tapering drug; abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications of glucocorticoid use

Prednisolone (Articulose-50, Delta-Cortef, PediaPred)

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.

Dosing

Adult

5-60 mg/d PO/IV/IM

Pediatric

Not established

Interactions

Decreases effects of salicylates and toxoids (for immunizations); phenytoin, carbamazepine, barbiturates, and rifampin decrease effects of corticosteroids

Contraindications

Documented hypersensitivity; fungal, tubercular skin, connective tissue, or viral infections; peptic ulcer disease; hepatic dysfunction; GI bleeding or ulceration

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hyperthyroidism, osteoporosis, cirrhosis, nonspecific ulcerative colitis, peptic ulcer, diabetes, and myasthenia gravis

Prednisone (Orasone, Deltasone, Sterapred)

May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity.

Dosing

Adult

5-60 mg/d PO qd or divided bid/qid; taper over 2 wk, as symptoms resolve

Pediatric

4-5 mg/m²/d PO; alternatively, 0.05-2 mg/kg PO divided bid/qid; taper over 2 wk, as symptoms resolve

Interactions

Coadministration with estrogens may decrease clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics

Contraindications

Documented hypersensitivity; fungal, tubercular skin, connective tissue, or viral infections; peptic ulcer disease; hepatic dysfunction; GI bleeding or ulceration

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use

Chemoprotective agent

These agents reduce the cumulative renal toxicity associated with the repeated administration of chemotherapy agents like cisplatin.

Amifostine (Ethyol)

Prodrug that is dephosphorylated by alkaline phosphatase in tissues to a pharmacologically-active free thiol metabolite. The free thiol is available to bind to, and detoxify, reactive metabolites of cisplatin; and can also act as a scavenger of free radicals that may be generated (by cisplatin or radiation therapy) in tissues.

Dosing

Adult

Prevention of radiation proctitis in rectal cancer (unlabeled use): 340 mg/m² IV qd prior to radiation therapy

Pediatric

Not established

Interactions

May potentiate hypotensive effects of antihypertensive medications (withhold antihypertensive medications for 24 h prior to amifostine administration; if antihypertensive therapy can not be withheld, do not administer amifostine)

Contraindications

Documented hypersensitivity to aminothiol compounds or any component of the formulation

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Serious cutaneous reactions, including erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis, toxoderma, and exfoliative dermatitis reported (discontinue treatment for severe/serious cutaneous reaction, or with fever; withhold treatment and obtain dermatologic consultation for rash involving lips or mucosa (of unknown etiology outside of radiation port) and for bullous, edematous or erythematous lesions on hands, feet, or trunk; reinitiate only after careful evaluation)
Rare hypersensitivity reactions, including anaphylaxis and allergic reaction, reported; discontinue if allergic reaction occurs; do not rechallenge; medications for treatment of hypersensitivity reactions should be available
Monitor serum calcium levels in patients at risk of hypocalcemia, such as those with nephrotic syndrome, or patients receiving multiple amifostine doses (may require calcium supplementation)
Hypotension may occur during or shortly after infusion (hypotensive or dehydrated should not receive amifostine)
Adequately hydrate prior to treatment and keep in supine position during infusion (monitor blood pressure every 5 min during infusion; if hypotension requiring interruption of therapy occurs, patients should be placed in Trendelenburg position and given infusion of normal saline using a separate IV line; subsequent infusions may require a dose reduction)
Infusions >15 min are associated with higher incidence of adverse effects
Incidence of nausea and vomiting is higher in patients receiving amifostine compared to chemotherapy alone
Antiemetic medications, including dexamethasone 20 mg IV and serotonin 5-HT3 receptor antagonist, should be administered prior to and in conjunction with amifostine
Use with caution in patients whom adverse effects of nausea/vomiting may have serious adverse events
Caution in patients with cardiovascular disease or whom adverse effects of hypotension may have serious adverse events
Use with caution in patients with cerebrovascular disease; not for use (in patients receiving chemotherapy for malignancies other than ovarian cancer) where chemotherapy is expected to provide significant survival benefit or in patients receiving definitive radiotherapy, unless within the context of a clinical trial

Follow-up

Further Outpatient Care

• Discharge if no life-threatening condition exists and the patient is able to comply with the therapeutic regimen.
• Discharge should include follow-up with a colorectal surgeon or gastroenterologist who will monitor the patient's progress clinically and endoscopically, in addition to following results of cultures, labs, and biopsies.

Inpatient & Outpatient Medications

• Maintenance medical therapy is not used routinely in idiopathic proctitis unless the patient’s condition is slow to respond, difficult to control, or has frequent flare-ups.
• In radiation proctitis, no evidence indicates that corticosteroids, and/or the various aminosalicylic acid derivations given as an enema or orally, are beneficial in preventing the progression of the disease.

Complications

• Chronic ulcerative colitis
• Fistula formation
• Abscess
• Treatment failure
• Perforation

Prognosis

• Failure rates as high as 35% have been reported following treatment of rectal gonorrhea; symptoms frequently recur.
• Most surgeons favor a diverting colostomy for medically intractable proctitis.

Patient Education

• For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles, Anal Abscess, Rectal Pain, and Rectal Bleeding.

References

1. Babb RR. Radiation proctitis: a review. Am J Gastroenterol. Jul 1996;91(7):1309-11. [Medline].

2. Bassford T. Treatment of common anorectal disorders. Am Fam Physician. Apr 1992;45(4):1787-94. [Medline].

3. Bitton A. Medical Management of Ulcerative Proctitis, Proctosigmoiditis, and left-sided colitis. Semin Gastrointest Dis. 2001;12(4):263-274. [Medline].

4. Denton AS, Andreyev HJ, Forbes A, Maher EJ. Systematic review for non-surgical interventions for the management of late radiation proctitis. Br J Cancer. Jul 15 2002;87(2):134-43. [Medline].

5. Rafal RB, Nichols JN, Cennerazzo WJ, et al. MRI for evaluation of perianal inflammation. Abdom Imaging. May-Jun 1995;20(3):248-52. [Medline].

6. Regueiro MD. Diagnosis and treatment of ulcerative proctitis. J Clin Gastroenterol. Oct 2004;38(9):733-40. [Medline].

7. Spencer CM, McTavish D. Budesonide. A review of its pharmacological properties and therapeutic efficacy in inflammatory bowel disease. Drugs. Nov 1995;50(5):854-72. [Medline].

8. MacDermott RP. Management of ulcerative proctitis, proctosigmoiditis and left sided colitis. Available at www.uptodate.com. Accessed March 31, 2009.

9. Nostrant TT. Diagnosis and treatment of chronic radiation proctitis. Up to Date. Available at www.uptodate.com. Accessed March 31, 2009.

10. Kornbluth A, Sachar DB. Ulcerative colitis practice guidelines in adults (update): American College of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol. Jul 2004;99(7):1371-85. [Medline].

Keywords

inflammation of the rectum, rectal mucosa, proctosigmoiditis, rectal tissue ischemia, rectal pain, rectal bleeding, proctitis, mucosal cell loss, acute inflammation of the lamina propria, eosinophilic crypt abscess, endothelial edema of the arterioles, mucosal friability, ulcers, strictures, fistula formation, colitis, Crohn disease, Crohn's disease, ulcerative colitis

Contributor Information and Disclosures

Author

Lisandro Irizarry, MD, MPH, FAAEM, Chair, Department of Emergency Medicine, Brooklyn Hospital Center; Assistant Professor, Department of Emergency Medicine, Weill Cornell School of Medicine
Lisandro Irizarry, MD, MPH, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Ibis Yarde, MD, Staff Physician, Department of Emergency Medicine, Brooklyn Hospital Center
Disclosure: Nothing to disclose.

Medical Editor

Michael S Beeson, MD, MBA, FACEP, Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine; Program Director, Emergency Medicine Residency, Summa Health System
Michael S Beeson, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Eugene Hardin, MD, FAAEM, FACEP, Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Robert E O'Connor, MD, MPH, Professor and Chair, Department of Emergency Medicine, University of Virginia Health System
Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Clinical guidelines

Proctitis, proctocolitis, and enteritis. Sexually transmitted diseases treatment guidelines 2006. Centers for Disease Control and Prevention, Workowski KA, Berman SM. Proctitis, proctocolitis, and enteritis. Sexually transmitted diseases treatment guidelines 2006. MMWR Morb Mortal Wkly Rep 2006 Aug 4;55(RR-11):78.

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