EM@3AM: Proctitis

Author: Rachel Bridwell, MD (@rebridwell, EM Resident Physician, SAUSHEC / San Antonio, TX) Edited by: Brit Long, MD (@long_brit, EM Attending Physician, San Antonio, TX) // Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital)

Welcome to EM@3AM, an emDOCs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.


A 42-year-old male undergoing recent radiation therapy for colorectal cancer presents with pelvic and anal pain and pain with defecation. He experiences extreme pain prior to and during defecation. He has had mucous and blood in his stool. He denies a history of hemorrhoids.

Pertinent physical examination findings include tachycardia, temperature 101.2 F, and lower abdominal pain to palpation. Rectal exam reveals no fissures or hemorrhoids, but digital exam reveals tenderness.

What’s the next step in your evaluation and treatment?


Answer: Proctitis

Epidemiology:

    • Proctitis: Inflammation of distal 10-12 cm of the anal canal occurring secondary to inflammation, infection, free radicals, cellular damage
    • Half of all patients with pelvic malignancies will receive radiation
      • Acute radiation proctitis occurs in up to 20% of patients, necessitating interruption of radiation treatment
      • Chronic radiation proctitis occurs with an incidence of 5-11%
        • Occurs 8-12 months after treatment despite radiation cessation
      • Radiation proctitis can be associated with fistulous tracts and low grade obstructions

 

Differential:

    • Radiation
    • Caustic cleaning agents
    • Ischemic proctitis
    • Inflammatory: Ulcerative Colitis, Crohn’s disease
    • NSAIDs
    • Infectious
      • Bacteria: Shigellosis, Campylobacter, Yersinia
      • STIs: Gonoccocus, Chlamydia trachomatis, HSV, T. pallidum, LGV
      • Protozoa: Amebiasis
        • Especially in men who have sex with men (MSM)
    • Diversion proctitis: prior surgery leading to diversion of fecal flow away from rectum (e.g. colostomy)

 

Clinical Presentation:

    • Rectal fullness
    • Anorectal pain
    • Lower abdominal pain
    • Diarrhea
    • Tenesmus
    • Mucus or blood per rectum

 

Differential:

    • Diverticulitis
    • Trauma
    • Anal fistula
    • Perirectal abscess
    • Retained rectal foreign body
    • Typhlitis

 

Evaluation:

    • Assess ABCs and obtain VS to include temperature
      • Can present in extremis due to fluid loss and infection
    • Perform a complete physical examination.
      • Abdominal exam: tenderness in left lower quadrant may be present
      • Rectal exam: Friable mucosa
      • Anoscopy: Vesicles can be appreciated in mucosa in HSV
        • Purulence associated with C. trachomatis
      • Genital exam: Chancres, evidence of STI, discharge
      • Lymph: Inguinal lymphadenopathy
    • Imaging: CT pelvis with IV contrast to evaluate extent of involvement, abscess, fistulization
    • Laboratory evaluation:
      • CBC with differential
      • Fecal occult blood test
      • Fecal calprotectin
        • Levels correlate with proctitis severity in radiation proctitis
      • In patients with concern for infectious STI proctitis: rectal swab for gonorrhea, chlamydia, HIV, HSV, T. pallidum
        • Offer partner testing

 

Treatment:

    • Antipyretics for fever
    • IV fluids for fluid resuscitation as needed
    • Shigella may self resolve, however, it is responsive to ciprofloxacin, trimethoprim/sulfamethoxazole
    • STI related proctitis
      • Empiric ceftriaxone and
      • Observational study of 26 acute proctitis MSM patients, lymphogranuloma venereum (LGV) was identified in all patients, with 100% cure rate with 100 mg doxycycline twice per day for 3 weeks
      • Amebiasis related requires metronidazole and can occur without anal penetration
    • Early radiation proctitis: oral or rectal prednisone, sitz baths
      • Potential benefits form hyperbaric oxygen for bacterial growth inhibition, inhibits toxin production, encourages tissue perfusion
    • For late radiation proctitis, rectal sucralfate, addition of metronidazole have small benefits in reduction of late toxicity and symptom improvements

 

Pearls:

    • Assess history of IBD, radiation, rectal intercourse, trauma
    • In those with anorectal intercourse, LGV was another common identified pathogen with excellent response to 3 weeks of doxycycline
    • For those with radiation proctitis, sucralfate enema, and or/prednisone may alleviate symptoms
    • If appropriate for discharge, provide follow up for colonoscopy
    • Amebic proctitis can occur without rectal penetrations

References

  1. de Vries HJC, Zingoni A, White JA, Ross JDC, Kreuter A. 2013 European Guideline on the management of proctitis, proctocolitis and enteritis caused by sexually transmissible pathogens. Int J STD AIDS. 2014;25(7):465-474. doi:10.1177/0956462413516100
  2. Cotti G, Seid V, Araujo S, Souza AHS e., Kiss D rio R, Habr-Gama A. Conservative therapies for hemorrhagic radiation proctitis: a review. Rev Hosp Clin Fac Med Sao Paulo. 2003;58(5):284-292. doi:10.1590/S0041-87812003000500008
  3. Ballas LK, Elkin EB, Schrag D, Minsky BD, Bach PB. Radiation therapy facilities in the United States. Int J Radiat Oncol Biol Phys. 2006;66(4):1204-1211. doi:10.1016/j.ijrobp.2006.06.035
  4. Otchy DP, Nelson H. Radiation injuries of the colon and rectum. Surg Clin North Am. 1993;73(5):1017-1035. doi:10.1016/S0039-6109(16)46138-4
  5. Denton AS, Andreyev JJ, Forbes A, Maher J. Non surgical interventions for late radiation proctitis in patients who have received radical radiotherapy to the pelvis. Cochrane Database Syst Rev. 2002;(1). doi:10.1002/14651858.cd003455
  6. Úbeda AC, Roblas RF, Delgado RG, et al. Anorectal lymphogranuloma venereum in Madrid: A persistent emerging problem in men who have sex with men. Sex Transm Dis. 2016;43(7):414-419. doi:10.1097/OLQ.0000000000000459
  7. Hille A, Schmidt-Giese E, Hermann RM, et al. A prospective study of faecal calprotectin and lactoferrin in the monitoring of acute radiation proctitis in prostate cancer treatment. Scand J Gastroenterol. 2008;43(1):52-58. doi:10.1080/00365520701579985
  8. Kneebone A, Mameghan H, Bolin T, et al. Effect of oral sucralfate on late rectal injury associated with radiotherapy for prostate cancer: A double-blind, randomized trial. Int J Radiat Oncol Biol Phys. 2004;60(4):1088-1097. doi:10.1016/j.ijrobp.2004.04.033
  9. Do NL, Nagle D, Poylin VY. Radiation proctitis: current strategies in management. Gastroenterol Res Pract. 2011;2011:917941. doi:10.1155/2011/917941

 

 

 

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