From the Guidelines
Acute proctitis, an inflammatory condition of the rectum, is best managed with mesalamine 1-g suppositories once daily as the preferred initial treatment for mild or moderately active cases. This approach is supported by the most recent and highest quality evidence from the AGA clinical practice guidelines on the management of mild-to-moderate ulcerative colitis, published in 2019 1. The guidelines strongly recommend using mesalamine suppositories for patients with mild-moderate ulcerative proctitis who choose rectal therapy over oral therapy, based on moderate quality evidence.
Causes of Acute Proctitis
The exact causes of acute proctitis can vary, but it often results from immune system dysregulation and potential infectious triggers, leading to mucosal damage and symptoms like bloody diarrhea, urgency, and tenesmus.
Treatment Options
For mild to moderate cases of acute proctitis, the following treatment options are considered effective:
- Mesalamine suppositories (1g daily) as the first-line treatment, due to their effectiveness in delivering the drug directly to the rectum and being better tolerated compared to other forms like foam or enemas 1.
- Mesalamine foam or enemas as alternative options, although they are less effective than suppositories 1.
- Combining topical mesalamine with oral mesalamine or topical steroids for more extensive disease or refractory cases, as this combination has been shown to be more effective than topical mesalamine alone 1.
Management of Refractory Cases
For refractory proctitis, treatment with systemic steroids, immunosuppressants, and/or biologics may be necessary, as suggested by the ECCO statement 11B 1. It's crucial to monitor the patient's response to treatment and adjust the therapy as needed to achieve the best outcomes in terms of morbidity, mortality, and quality of life.
Additional Considerations
Patients with acute proctitis should be advised to avoid trigger foods, maintain adequate fluid intake, and seek immediate medical attention if they experience severe pain, high fever, or significant rectal bleeding. Follow-up evaluation is essential to monitor treatment response and adjust therapy accordingly. The use of probiotics, curcumin, or fecal microbiota transplantation is not recommended outside of a clinical trial setting due to the current knowledge gap and lack of strong evidence supporting their effectiveness in treating mild-moderate ulcerative colitis 1.
From the Research
Causes of Acute Proctitis
- Acute proctitis can be caused by infectious agents, such as bacteria, viruses, or parasites 2
- Inflammatory bowel disease, including ulcerative colitis, can also cause acute proctitis 3, 4, 5, 6
- Other causes of acute colitis include neutropenic colitis, drug-induced colitis, and infectious colitis 2
Treatment Options for Acute Proctitis
- For infectious colitis, antimicrobials are often used as treatment 2
- For acute severe ulcerative colitis, intravenous corticosteroids are the primary initial therapy, although approximately 30-40% of patients do not respond to treatment 3, 4, 5, 6
- Rescue medical therapy with ciclosporin or infliximab can be used for patients who do not respond to corticosteroids 3, 4, 5, 6
- Surgery, including colectomy, may be necessary for patients who do not respond to medical therapy 3, 4, 5, 6
- Multidisciplinary teams, including inflammatory bowel disease experts, colorectal surgeons, and other medical staff, can contribute to better management of patients with acute severe ulcerative colitis 4, 5, 6