Should I consult a Gastroenterologist (GI) for proctitis?

From the Guidelines

You should consult a gastroenterologist (GI specialist) for proctitis, especially if symptoms persist despite initial treatment or if the cause is unclear. Initial management typically includes topical anti-inflammatory medications such as mesalamine suppositories (1g daily) or hydrocortisone foam (90mg daily) for 2-4 weeks, as recommended by the AGA guidelines 1. Oral medications may be added for more extensive disease, including oral mesalamine (2.4-4.8g daily) or prednisone (40mg daily with taper) for severe cases.

• The AGA recommends using mesalamine suppositories for patients with mild-moderate ulcerative proctitis who choose rectal therapy over oral therapy, with a strong recommendation and moderate quality evidence 1.
• For patients with mild-moderate ulcerative proctosigmoiditis or proctitis being treated with rectal therapy who are intolerant of or refractory to mesalamine suppositories, the AGA suggests using rectal corticosteroid therapy rather than no therapy for induction of remission, with a conditional recommendation and low quality evidence 1.
• While primary care physicians can initiate treatment for mild cases, GI consultation is important because proctitis can result from various causes including inflammatory bowel disease, infections (like sexually transmitted infections), radiation therapy, or ischemia.
• A gastroenterologist can perform specialized diagnostic procedures such as sigmoidoscopy or colonoscopy with biopsies to determine the exact cause and guide appropriate treatment, as supported by the AGA guidelines 1.
• They can also help manage complications and provide long-term care plans for chronic conditions like ulcerative proctitis.
• The use of probiotics or curcumin is not recommended due to a lack of evidence, as stated in the AGA guidelines 1.
• Fecal microbiota transplantation may be considered in the context of a clinical trial for patients with mild-moderate ulcerative colitis without Clostridium difficile infection, as recommended by the AGA guidelines 1.

From the Research

Diagnosis and Treatment of Proctitis

• Proctitis is an inflammatory condition of the distal rectum that can be associated with various causes, including sexually transmitted infections (STIs) and ulcerative colitis 2, 3.
• A comprehensive history, clinical evaluation, and laboratory tests, such as rectal nucleic amplification STI testing, may be useful in identifying the cause of proctitis and targeting treatment 2, 3.
• The symptoms of proctitis include anorectal itching, pain, tenesmus, bleeding, constipation, and discharge in and around the anal canal 3.

Role of a Gastroenterologist

• A gastroenterologist (GI) may be consulted for the diagnosis and treatment of proctitis, particularly for cases related to ulcerative colitis or other gastrointestinal conditions 4, 5, 6.
• Gastroenterologists can provide guidance on the management of ulcerative proctitis, including the use of mesalazine suppositories, which are considered first-line therapy for patients with ulcerative proctitis 4.
• In cases of refractory ulcerative proctitis, a gastroenterologist may consider advancing to more potent therapies, such as systemic corticosteroids, thiopurines, calcineurin inhibitors, biologic agents, and small molecules 5.

Importance of Early Consultation

• Early consultation with a gastroenterologist is important for preventing the aggravation of ulcerative proctitis and improving the prognosis of ulcerative colitis 4.
• Identifying early prognostic factors that herald a disabling disease progression can help in optimizing treatment and avoiding surgery 5.