You are in: eMedicine Specialties > General Surgery > Colorectal Proctitis and AnusitisArticle Last Updated: Aug 7, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: David E Stein, MD, Assistant Professor, Drexel University College of Medicine; Chief, Division of Colorectal Surgery, Department of Surgery, Hahneman University Hospital David E Stein is a member of the following medical societies: American College of Surgeons, American Society of Colon and Rectal Surgeons, Association for Surgical Education, Crohns and Colitis Foundation of America, Pennsylvania Medical Society, and Society for Surgery of the Alimentary Tract Coauthor(s): Elisa A Stein, MD, Staff Physician, Department of Surgery, Drexel University College of Medicine, Hahnemann University Hospital; Clifford Y Ko, MD, MS, Assistant Professor, Department of Surgery, University of California at Los Angeles School of Medicine Editors: Marc D Basson, MD, PhD, MBA, Professor, Department of Surgery, Wayne State University School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Amy L Friedman, MD, Professor of Surgery, Director of Transplantation, State University of New York Upstate Medical University College of Medicine, Syracuse; Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy; John Geibel, MD, DSc, MA, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital Author and Editor Disclosure Synonyms and related keywords: inflammatory bowel disease, IBD, inflammatory bowel colitides, ulcerative colitis, Crohn disease, Salmonella, Shigella, Clostridium difficile, C difficile, radiation proctitis, diversion proctitis, hemorrhoids, ischemic proctitis INTRODUCTIONSection 2 of 10
  Inflammation of the mucosal lining of the rectum is defined as proctitis, whereas anusitis is simply inflammation of the anal canal. Inflammation in these areas can cause symptoms, such as itching, burning, rectal bleeding, pelvic pressure, and foul-smelling discharge. The distinction between proctitis and anusitis is not overly pertinent, as the etiology and the treatment of anusitis and proctitis are similar. Several different etiologies exist, including inflammatory bowel disease (IBD), infectious organisms (eg, gonorrhea, Salmonella, Shigella), noninfectious causes (eg, radiation, ischemic, diversion), and idiopathic causes. This article organizes these etiologies into 3 categories, as follows: IBD, infectious proctitis, and noninfectious proctitis. For the purpose of this article, the term proctitis will be used to include anusitis. ProblemAs mentioned above, proctitis refers to inflammation of the epithelial lining in the rectum/anus. Proctitis can occur in both the acute setting and the chronic setting and can cause significant anorectal complaints. The treatment is generally nonsurgical. However, in certain cases, surgery is indicated. FrequencyNo epidemiological studies have been performed to ascertain the prevalence of proctitis in the general population. However, one can ascertain the incidence of proctitis when analyzing specific disease states. For example, patients with ulcerative colitis may initially present with proctitis. In addition, patients treated with radiation therapy (cervical, prostate, rectal) have a 1-2% chance of developing chronic radiation proctitis. This percentage is related to the dose of radiation received. EtiologyThis article divides the etiologies into the following 3 categories:
PathophysiologyThe pathophysiology is dependent on the various etiologies and is not completely understood. In addition, some patients seem more susceptible to this inflammatory condition. The pathophysiology of proctitis in IBD is believed to be caused by an autoimmune process, though the specific antigen has not been elicited. Infectious etiologies may be related to the organism itself or to a toxin produced by the organism. Radiation proctitis may be due to cellular injury secondary to ischemia from radiation. Diversion proctitis is thought to be caused by a deficiency of short-chain fatty acids. Ischemic proctitis may be due to mesenteric venous occlusion, aortoiliac surgery, radiotherapy, vascular intervention, atherosclerotic disease, or drug use (eg, cocaine). Regardless, all 3 categories (ie, IBD, infectious, noninfectious) result in an unrestrained inflammatory response, with the inflammatory cells being products that mediate cellular-tissue injury. ClinicalA patient with proctitis may present with some of the following symptoms and/or signs:
When taking the patient's history, pertinent questions should include a personal history of IBD, pelvic radiation, travel history, and sexual history (including questions regarding anal intercourse). The patient's HIV status is important to note as well. Obtaining a list of medications used (eg, NSAIDs, antibiotics) is clearly important. A family history of IBD or other gastrointestinal diseases is extremely important. A review of systems is needed to review any systemic symptoms that can be related to the proctitis, such as IBD and collagen vascular disorders. In addition, identifying patients who are immunocompromised is important, because some infections (eg, cytomegalovirus, cryptosporidiosis) that may cause proctitis affect only this subset of patients. The physical examination findings may be unremarkable. Abdominal tenderness may be seen in IBD, infectious colitides, and ischemic proctitis. A digital rectal examination may not be possible to perform because of tenderness. If this is the case, an evaluation under anesthesia is required. INDICATIONSSection 3 of 10
The indications for therapy vary according to the etiology of the proctitis. For example, in patients with IBD, a colonoscopy should be performed to find out the extent of the inflammation. Many patients with IBD who present with proctitis may progress to left-sided colitis and possibly pancolitis. The first-line management of these patients is medical therapy, which will be discussed below. Surgical treatment is indicated for failed medical therapy, any dysplasia seen on biopsy specimens, and cancer. Surgery is rarely indicated for proctitis secondary to an infectious etiology. The goal of therapy is to treat the infection causing the inflammation. Rarely, profound sepsis may require a surgical resection as a life-saving maneuver. Finally, the indication for treatment of radiation or diversion proctitis is also based on the symptomology. Persistent rectal bleeding and diarrhea initiate a workup, including a rigid proctoscopy and/or colonoscopy. The presence of symptoms is the indication for evaluation. RELEVANT ANATOMYSection 4 of 10
Recognizing that most inflammatory processes of the rectum also involve the adjacent colon and the anus is important. Controversy remains regarding the anatomy of the rectum and the anus. Some authorities say that the rectum starts at the level of the third sacral vertebra, whereas others consider the start of the rectum to be at the sacral promontory. Where the rectum ends also is debated. While some say it ends when it passes through the levator ani muscles, most agree that the rectum transitions to the anus where the epithelial cells change from columnar cells to squamous cells. The World Health Organization (WHO) and the American Joint Cancer Committee define the anal canal as the distal portion of the gastrointestinal tract that corresponds to the internal anal sphincter. In proctitis and anusitis, the anatomy does not change therapy, as a significant overlap between anorectal inflammation and rectosigmoid inflammation exists. WORKUPSection 5 of 10
Lab Studies
Imaging Studies
Diagnostic Procedures
Histologic FindingsHistologic findings are usually consistent with inflammation. However, detailed histology leading to the etiology is often not possible. Severe inflammation destroys the specific histopathologic findings of other diseases, such as IBD or C difficile. Regarding infectious etiologies, diversion colitis, or radiation proctitis, the inflammatory histology is not pathognomonic. The one exception is CMV colitis in patients who are immunocompromised, as inclusion bodies may be seen. TREATMENTSection 6 of 10
Medical therapyMedical treatment of proctitis depends on the etiology. If it is idiopathic or related to IBD, steroids, sulfasalazine, 5-aminosalicylic acid (5-ASA) products, and even immunosuppressive medications may be used. Many of these products are available as enemas and suppositories. If the cause is infectious, the treatment is targeted toward the pathogen responsible. Infectious proctitis due to Salmonella species is usually self-limited, and antibiotics are not required. Maintaining adequate fluid and electrolyte balances and providing supportive care are all that is required. Shigella proctitis is usually self-limited, but the duration may be shortened by the addition of antibiotics. Antibiotics for 1 week may include ampicillin, tetracycline, ciprofloxacin, and trimethoprim-sulfa (preferred). Yersinia proctitis is also self-limited and should not be treated with antibiotics unless systemic septicemia occurs; in which case, antibiotics (trimethoprim-sulfa, aminoglycosides, tetracycline, or a third-generation cephalosporin) should be used. Campylobacter species is usually self-limited as well. E histolytica generally is treated with metronidazole and iodoquinol. C difficile generally is treated with intravenous or oral metronidazole or oral vancomycin. More recently, a more aggressive C difficile mutation has been seen and may have a rapidly progressive course toward septicemia and toxic colitis. In patients who do not appear to be responding to metronidazole and have leukocytosis (leukocyte count of greater than 20,000 WBCs/mL), therapy should be switched to oral vancomycin. Medical treatment of radiation proctitis includes steroid or 5-ASA enemas. In addition, sucralfate enemas have been reported to be helpful when administered twice a day for 3 months. Anecdotal reports also show some efficacy for hyperbaric oxygen treatment, although no adequate studies have been done evaluating this modality of therapy. Symptomatic diversion proctitis generally improves after the ostomy is taken down and bowel continuity is restored. However, in patients who need to be out of circuit indefinitely, short-chain fatty acid enemas may be beneficial. In the course of any proctitis, antispasmodic agents may prove helpful in alleviating the abdominal complaints. In addition, the use of a low-residue diet and stool softeners is beneficial because of the friability of the rectal mucosa and its vulnerability to damage from the fecal contents. Surgical therapyMany factors come into play when deciding when to operate and which operation to perform. For most cases of proctitis, medical treatment should suffice. However, for certain disease processes, surgical treatment is more likely. For patients with ulcerative colitis requiring surgical therapy, a total proctocolectomy should be performed and reconstruction with an ileal pouch may be offered. In patients with severe Crohn colitis or proctitis, options range from fecal diversion, proctectomy, and total proctocolectomy based on the extent of the disease process. In the infectious causes of proctitis, surgical treatment is rarely required. In cases of severe C difficile colitis, a subtotal colectomy may be warranted. For patients with radiation proctitis complicated by refractory bleeding, endoscopic APC coagulation may be attempted. If this fails, application of formalin (4%) to the inflamed mucosa fixes the tissue and decreases the bleeding. This procedure may be repeated if needed. If, despite these measures, significant hemorrhage still occurs, a laparoscopic fecal diversion should be performed. Rarely, radiation proctitis can be so severe that it ulcerates and a rectourethral fistula can form. In these cases, temporary fecal and urinary diversion should be performed until the inflammation subsides. Definitive therapy may then be performed. The procedure of choice is a perineal approach with repair of the defect with muscle and mucosal flaps. Preoperative detailsThe preoperative details concerning proctitis concern the specific indication for surgery and the etiology of the proctitis. As always, general surgical preparation includes optimizing medical status and giving deep vein thrombosis (DVT) prophylaxis, a bowel preparation, and preoperative antibiotic prophylaxis. A Foley catheter will be placed after induction of anesthesia. Preoperative nutritional status may be the most significant predictor of outcomes. Every effort should be given to assess the patient's nutritional status and improve it if needed. The author's current practice is to obtain a prealbumin on all patients scheduled to undergo laparotomy. If it is low, the author will delay the surgery and place them on nutritional supplementation. If the patient is going to have a stoma, preoperative counseling with a trained enterostomal nurse is essential. They will educate the patient about life with a stoma and also mark the patient preoperatively to ensure optimal stoma placement. For patients requiring a subtotal colectomy, an assessment of their sphincter complex is helpful in determining postoperative fecal continence. This is also true for patients undergoing a total proctocolectomy with an ileal pouch. In addition, for patients undergoing a proctectomy, there is a need to discuss their sexual and urinary function prior to performing the procedure, as there is a small but real possibility of diminished sexual function and bladder continence after pelvic surgery. Intraoperative detailsGood surgical technique is imperative. When performing a pelvic dissection, knowing the anatomical planes and adjacent structures is important in avoiding injury. The presacral nerves are on the anterior aspect of the sacrum. These nerves usually can be identified at the sacral promontory, approximately 1 cm lateral to the midline. Be aware of the parasympathetic innervation to the urinary and genital organs and the rectum at the lateral edges of the rectum, near the lateral stalks. The parasympathetic nerve supply in this area is from the nervi erigentes. Dissection too lateral will likely affect this nerve supply. Maintain the correct plane of dissection along the posterior rectum. Along the same principles of total mesorectal excision, the plane outside the mesorectum but above the presacral fascia is the correct plane to dissect. Dissection too anterior results in entering into the mesorectum. Dissection too deep through the presacral fascia risks presacral bleeding. Maintain the correct plane of dissection along the anterior rectum. Clearly, important structures exist in both females (vagina) and males (prostate, seminal vesicles). Remain cognizant of the course of the ureters along the lateral rectum when dissection enters into the pelvis. Postoperative detailsAs with any major surgical procedure, close monitoring of fluid status, cardiac status, pulmonary status, and return of gastrointestinal function is important. For patients who require a hospital stay, DVT prophylaxis is essential. Many centers have different protocols for removing a Foley catheter. The author tends to remove the Foley catheter on the third postoperative day. One of the more important concerns includes those patients with a perineal wound. Often, tension on the wound may be significant, depending on whether the sphincter mechanism is resected or not. Because patients often are in the supine position, overlooking examination of the perineal wound is easy. Close observation of this area is important, as problems with wound healing in this area are significant. The risk of wound complications increases in those patients who have had radiation to the pelvis. Follow-upFollow-up care with regard to the surgical wounds (both perineal and abdominal) and the colostomy is important. In addition, postoperative sexual and urinary function should be discussed and a further workup initiated if required. COMPLICATIONSSection 7 of 10
The complications associated with a proctectomy include the following: Wound infection: It is not uncommon for the perineal wound to separate slightly during the immediate postoperative period. If any discharge or erythema is noted around the wound, especially if there was some tension upon closure, opening the wound earlier rather than later is prudent. Addressing the open wound with wet-to-dry dressing changes routinely allows the wound to close without incident. Sexual dysfunction: This occurs when the pelvic nerves are injured. The best way to deal with this complication is to be cognizant of the possibility prior to surgery and avoid it. Once it occurs, very little can be done to help the nerves. The role of medications such as sildenafil (Viagra) remains unclear, although sildenafil has been reported to help. Urinary dysfunction: Similar to sexual dysfunction, avoid urinary dysfunction in the operating room. Ureteral injury: Avoiding this complication by remaining cognizant of the ureteral anatomy is paramount. Once the injury occurs, recognizing this at the time of operation clearly is best. Where the injury occurs in the ureter dictates the repair. Consultation with a urologist is prudent. Presacral bleeding: In a few cases, presacral bleeding has been reported to progress to death. Clearly, avoiding this occurrence is the best way to deal with this complication. If it does occur in the midst of the procedure, cautery or pressure generally does not stop true presacral bleeding from the pelvic veins. The usual method of stopping the bleeding is by thumbtack. A muscle pledget is also a clever way to cauterize the bleeding. Take a piece of rectus muscle, apply it to the bleeding site, and cauterize the muscle on a high coagulation setting. OUTCOME AND PROGNOSISSection 8 of 10
In the acute setting, most bouts of proctitis have a good outcome and prognosis. More specifically, once appropriately treated, infectious proctitises tend not to recur. For the more chronic diseases, such as IBD, outcomes and prognoses vary. Clearly, in medically treated ulcerative colitis and proctitis, approximately 40-70% of cases do not require operation. If proctocolectomy surgery is performed, the patient is cured of the disease. Crohn disease is another story. Because it can occur in all portions of the GI tract even after a proctectomy, recurrence of Crohn disease ranges from 45-90%. Diversion proctitis generally has a good outcome and prognosis once the diversion is reversed. The outcome and prognosis of radiation proctitis varies with the severity of proctitis. Outcomes range from requiring a few medical treatments in the form of enemas to surgery. Complication rates for surgical treatment have been reported as high as 75%. MULTIMEDIASection 9 of 10
REFERENCESSection 10 of 10
Proctitis and Anusitis excerpt Article Last Updated: Aug 7, 2006 | |||||||
