What is the initial management approach for a patient with proctitis, constipation, and a single episode of perirectal (PR) bleeding?

Initial Management of Proctitis with Constipation and Single Episode of PR Bleeding

For patients with proctitis presenting with constipation and a single episode of perirectal bleeding, the initial management should include diagnostic evaluation to identify the underlying cause while addressing symptoms, with urgent colonoscopy indicated for patients with high-risk features or ongoing bleeding.

Diagnostic Approach

Initial Assessment

• Perform ano-proctoscopy or flexible sigmoidoscopy as first-line diagnostic tool to evaluate the rectum and identify the source of bleeding 1
• Exclude infectious causes of proctitis including sexually transmitted infections (STIs) such as Chlamydia trachomatis and Neisseria gonorrhoeae, which can mimic inflammatory bowel disease 2, 3
• Evaluate for other causes of proctitis including inflammatory bowel disease, radiation-induced, ischemic, or prolapse-induced proctitis 4

When to Consider Urgent Endoscopy

• Urgent colonoscopy (within 24 hours) is indicated for patients with high-risk features or evidence of ongoing bleeding 1, 5
• Full colonoscopy should be performed if the patient has risk factors for colorectal cancer or suspicion of a concomitant more proximal source of bleeding 1
• Upper endoscopy should be considered when a clear diagnosis of bleeding source is not possible, as up to 15% of patients presenting with serious hematochezia have an upper gastrointestinal source 5

Warning Signs Requiring Immediate Attention

• Persistent hemodynamic instability despite resuscitation efforts 5
• Continuous active bleeding or significant recurrent bleeding 5
• Constipation lasting more than 7 days 6
• Failure to have a bowel movement 6

Management Approach

For Mild Bleeding with Constipation

• Provide intravenous fluid replacement if necessary 5, 1
• Correct any coagulopathy (if present) 5, 1
• For constipation associated with proctitis, relief of constipation should be addressed as part of the treatment plan 5
• Consider that stool frequency assessment in patients with proctitis requires special consideration, as constipation is a prominent symptom in many patients with ulcerative proctitis 5

For Inflammatory Causes

• If ulcerative proctitis is diagnosed, topical aminosalicylates are effective first-line agents and act more effectively and rapidly to induce and maintain remission compared with oral counterparts or topical steroids 7
• For severe cases not responding to topical therapy, systemic corticosteroids, antibiotics, or immunomodulators may be required 7

For Infectious Causes

• If infectious proctitis is suspected, particularly in patients with risk factors such as anal intercourse, appropriate antibiotics or antivirals should be initiated based on the identified pathogen 3, 8
• Sexual partners should be treated accordingly if sexually transmitted infections are identified 3

Special Considerations

Distinguishing Between Inflammatory and Infectious Causes

• There is significant overlap in clinical presentation, endoscopic and histological features between inflammatory bowel disease and infectious proctitis 8
• A detailed sexual history is crucial to identify risk factors for sexually transmitted infections 2, 3
• Histopathological examination is important to differentiate between inflammatory and infectious causes 5, 8

Safety Netting Recommendations

• Patients should be advised to seek immediate medical attention if:
  • Bleeding recurs or worsens 6
  • Constipation persists despite treatment 6
  • New symptoms develop such as fever, severe pain, or significant change in bowel habits 5
• Follow-up evaluation should be scheduled to assess response to treatment and consider additional diagnostic testing if symptoms persist 5

Pitfalls to Avoid

• Failing to consider infectious causes of proctitis, particularly sexually transmitted infections, which may lead to unnecessary endoscopic evaluation and inappropriate treatment 2, 8
• Overlooking the possibility of colorectal cancer in patients with rectal bleeding, as the estimated risk ranges from 2.4% to 11% 5
• Focusing solely on the rectum without considering more proximal sources of bleeding, as up to 8% of bleeding in patients with diverticulosis and hematochezia have an upper source 5
• Misinterpreting constipation as a sign of functional bowel disorder rather than a symptom of proctitis 5