From the Guidelines
Long-term ulcerative proctitis carries a risk of colorectal cancer similar to the general population, but patients with left-sided colitis or extensive colitis have a higher risk, and thus, require regular surveillance colonoscopies 1. The primary risks associated with long-term ulcerative proctitis include:
- Progression to more extensive ulcerative colitis, with inflammation spreading beyond the rectum to involve the sigmoid colon and potentially the entire colon
- Complications such as rectal bleeding, anemia, perianal disease, and stricture formation that can lead to obstructive symptoms
- Extraintestinal manifestations affecting joints, skin, eyes, and liver due to chronic inflammation
- Significant impairment of quality of life due to persistent symptoms like urgency, tenesmus, and rectal pain Treatment typically involves:
- Topical 5-ASA medications (mesalamine suppositories or enemas) as first-line therapy
- Topical corticosteroids (hydrocortisone foam or budesonide enemas) added for flares
- Systemic therapy with oral mesalamine may be needed for more extensive or refractory disease
- Immunomodulators or biologics considered for steroid-dependent or resistant cases According to the most recent evidence, patients with proctitis alone do not need surveillance colonoscopy, whereas patients with left-sided and extensive colitis are generally advised to have surveillance colonoscopy 1. Regular follow-up with a gastroenterologist is essential to monitor disease activity, adjust treatment, and implement cancer surveillance protocols.
From the Research
Risks of Long-Term Ulcerative Proctitis
- Disease extension occurs in many patients with ulcerative proctitis, as noted in the study by 2
- Approximately 50% of cases may progress into left-sided or extensive colitis upon long-term follow-up, according to 3
- Patients with ulcerative proctitis are at risk of developing complications such as colorectal cancer, as mentioned in 4
Treatment and Management
- Mesalazine suppository is the first-line therapy for patients with ulcerative proctitis due to its high effectiveness and safety, as stated in 2
- Topical treatment of ulcerative proctitis, particularly using mesalazine suppository, has been underused in clinical practice, according to 2
- The combination of topical and oral 5-ASA and steroids should be considered for escalation of treatment, as recommended in 3
Long-Term Outcomes
- Good clinical outcomes were recorded in ulcerative proctitis, with treatment success in 87% of patients, as reported in 5
- However, 28% of patients needed escalation to biologicals, and long-term outcome in patients on biologicals was superior to azathioprine, according to 5
- 5-ASA maintenance treatment is indicated in all ulcerative colitis cases to prevent relapse and disease progression, as noted in 3