Idiopathic Proctitis Research Articles

An Unusual Rectal Mass

Question: A 54-year-old man presented with a 4-day history of severe anal pain. Relevant medical history included an appendectomy, correction of an umbilical hernia, and an idiopathic proctitis in 2009 that responded to treatment with mesalazine enemas. Initially, the anal pain was related to bowel movements, but later it was continuously present especially when seated. Bowel habits had altered and the patient complained about constipation; there was no rectal blood loss or fever. The patient had a homosexual relationship and denied unsafe sexual intercourse during the past year. He tested negative for HIV. Rectal examination was painful and revealed a palpable anal and distal rectal mass. In addition, inguinal lymphadenopathy was noted. Laboratory tests showed a normal leukocyte count but an elevated C-reactive protein level (52 mg/L). Colonoscopy under sedation revealed a circular rectal mass with superficial ulceration and pus (Figure A; endoscopic retrograde view). In addition, aphthoid erosions were noted in the transverse and descending colon. Because there was a high suspicion of malignancy, a workup for rectal cancer was initiated, which included magnetic resonance imaging (MRI) showing the rectal mass with infiltration in the surrounding fat tissue (Figure B, T2 weighted, arrowhead) and locoregional (Figure C, T1 weighted, arrowhead) and inguinal (Figure B, C, arrows) lymphadenopathy. Histologic examination of the biopsies from the rectal mass showed diffuse infiltration of the lamina propria by plasma cells, lymphocytes, and occasional multinucleated giant cells. The surface epithelium was eroded and there was ulceration and focal cryptitis with infiltration of neutrophils, but no malignancy (Figure D). Additional deep incisional biopsies did also not show malignancy. What is the diagnosis of this distal rectal mass causing the severe anal pain? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. At the time the incisional biopsies were taken, serologic tests for Treponema pallidum were positive. In addition, immunohistochemical staining for spirochetes showed numerous spirochetes in the rectal biopsies (Figure E). Biopsies taken in 2009 during the episode of proctitis were immunostained and showed spirochetes in retrospect. The diagnosis was therefore late syphilis (latens tarda) presenting with severe anal pain and a rectal mass mimicking rectal cancer. After treatment with 3 injections with benzylpenicillin on days 1, 8, and 15 (after excluding neurosyphilis), the pain and serologic tests normalized completely. Within 3 months the rectal mass had disappeared, as shown by rectal examination and MRI. The patient's partner tested negative for syphilis serology. Sexually transmitted diseases (STDs) are found in 55%–86% of men who have sex with men (MSM) presenting with proctitis, with gonorrhea and chlamydia infection being the most common causes, followed by herpes and syphilis.1Klausner J.D. Kohn R. Kent C. Etiology of clinical proctitis among men who have sex with men.Clin Infect Dis. 2004; 38: 300-302Crossref PubMed Scopus (85) Google Scholar, 2Davis T.W. Goldstone S.E. Sexually transmitted infections as a cause of proctitis in men who have sex with men.Dis Colon Rectum. 2009; 52: 507-512Crossref PubMed Scopus (33) Google Scholar Rectal syphilis has many different presentations, varying from asymptomatic infection to proctitis and rarely presents as an ulcerating rectosigmoidal mass that can mimic anorectal cancer.3McMillan A. Lee F.D. Sigmoidoscopic and microscopic appearance of the rectal mucosa in homosexual men.Gut. 1981; 22: 1035-1041Crossref PubMed Scopus (71) Google Scholar Other micro-organisms that can cause a rectal mass include serovars of Chlamydia trachomatis (lymphogranuloma venerum), Mycobacterium tuberculosis, Actinomyces, and cytomegalovirus. This case illustrates the importance of taking a complete clinical history, including sexual preferences, in patients presenting with proctitis. STD as the cause of proctitis is a frequently missed diagnosis, resulting in delayed treatment and potential disease transmission. Serologic testing is therefore imperative to exclude STDs in MSM with proctitis.1Klausner J.D. Kohn R. Kent C. Etiology of clinical proctitis among men who have sex with men.Clin Infect Dis. 2004; 38: 300-302Crossref PubMed Scopus (85) Google Scholar, 2Davis T.W. Goldstone S.E. Sexually transmitted infections as a cause of proctitis in men who have sex with men.Dis Colon Rectum. 2009; 52: 507-512Crossref PubMed Scopus (33) Google Scholar, 3McMillan A. Lee F.D. Sigmoidoscopic and microscopic appearance of the rectal mucosa in homosexual men.Gut. 1981; 22: 1035-1041Crossref PubMed Scopus (71) Google Scholar In addition, clinical information is invaluable to the pathologist for adequate histopathologic examination of the rectal biopsies, which should include special stains for micro-organisms.

Open access follow up for inflammatory bowel disease: pragmatic randomised trial and cost effectiveness study

Objective: To evaluate whether follow up of patients with inflammatory bowel disease is better through open access than by routine booked appointments.Design: Pragmatic randomised controlled trial.Setting: Two district general hospitals...

Idiopathic proctitis: A follow-up study on predictive factors for diffusion

Idiopathic proctitis: A follow-up study on predictive factors for diffusion

Idiopathic ulcerative proctitis may be the initial manifestation of Crohn's disease.

Of 213 patients with proctitis of all etiologies seen between 1977 and 1987, we studied an original cohort of 96 patients with idiopathic ulcerative proctitis (mean follow-up of 62 months). The diagnosis was made according to strict inclusion criteria, and all cases with any initial feature suggestive of Crohn's disease were excluded. Follow-up showed that 13 patients (13.6%) eventually progressed to Crohn's disease, usually within the first 3 years of the initial diagnosis of idiopathic ulcerative proctitis. Their clinical, endoscopic and histological features at initial presentation were indistinguishable from those in whom the diagnosis remained that of idiopathic ulcerative proctitis. In nine of 13 of these patients (70.0%), the clinical course was characterized by a more protracted course and a poorer response to standard treatment. Such features were not found in those in whom the diagnosis of idiopathic ulcerative proctitis was maintained. Clinicians should be aware that Crohn's disease may present initially as apparent idiopathic ulcerative proctitis.

Medical management of severe inflammatory disease of the rectum and distal colon: Non-nutritional aspects

Rectal bleeding is the cardinal symptom in patients with inflammation of the rectum, and initial management must be directed at establishing an underlying diagnosis. In many patients in the Western World this will be idiopathic inflammatory bowel disease, although in all cases other causes such as infection must be excluded. Idiopathic proctitis is usually due to either ulcerative colitis or Crohn's disease, and in both conditions corticosteroids, either systemic or topical, provide the mainstay of treatment. The 5-aminosalicylic acid drugs are helpful in both acute and maintenance treatment, again given either systemically or topically, while metronidazole is of value in patients with Crohn's disease. In those with refractory proctitis alternative agents such as azathioprine, immunomodulating drugs and barrier agents may be useful. Severe inflammation of the rectum secondary to pelvic irradiation will also usually respond to topical steroid therapy, although sucralfate enemas may be equally successful; in resistant cases other treatments may be needed. Infective proctitis, when diagnosed, may require treatment with specific antimicrobial agents.

Isolation and characterization of colonic tissue-bound antibodies from patients with idiopathic ulcerative colitis

To determine if specific anticolon antibodies bound to colonic mucosa occur in ulcerative colitis, we obtained surgical specimens of colon from five patients with ulcerative colitis, one patient with diverticulitis, and three control subjects with carcinoma. Two specimens of ileum and cecum were also obtained from patients with Crohn ileocolitis. Tissue was homogenized and washed and bound Ig was eluted by citrate buffer, pH 3.2. Concentrated eluates of all specimens from patients with ulcerative colitis reacted with antisera to kappa and gamma and not with antisera to alpha and mu chains. Corresponding eluates from all other specimens did not react with these antisera, but did react with antialbumin. The presence of IgG in ulcerative colitis eluates was also determined by immunoelectrophoresis, immunocoprecipitation, and affinity chromatography with antisera against human IgG. Indirect immunofluorescence and uptake of radiolabeled antibody demonstrated antigenic sites in diseased colonic epithelium of biopsy specimens obtained from six additional patients with ulcerative colitis and three patients with idiopathic proctitis, but not in patients with Crohn disease, nonspecific diarrhea, and bacillary dysentery and control subjects. Although the role of colitis colon-bound antibody in the pathogenesis of ulcerative colitis is unclear, local antibody-antigen complexes may initiate colonic epithelial cytolysis by various immunologically mediated mechanisms.

The prognosis of idiopathic proctitis.

Follow-up studies of 2 groups of patients with idiopathic proctitis show that the survival rate is little affected by the disease. The cumulative probability of extension of the inflammation to the descending colon above the left iliac crest was about 5% at 5 years and 12% at 10 years. Corresponding figures for extension to the hepatic flexure were about 4% at 5 years and 6% at 10 years. The probability of radical surgical treatment was 3--5%.

Idiopathic proctitis

A group of 31 patients with idiopathic proctitis were colonoscoped while they were symptomatic. Multiple mucosal biopsies were taken from the transverse, descending, and sigmoid colon and from the rectum. While visualization by colonoscopy revealed abnormalities limited to the most distal 18-20 cm of the colon, microscopic abnormalities were frequently seen in more proximal locations. Analysis of clinicopathological data indicates that there is good correlation between the extent of microscopic mucosal abnormalities and the clinical course. Patients with abnormalities limited to the rectum generally responded well to conventional treatment while patients with more proximal involvement were refractory to such therapy.

Immunohistochemical changes in morphologically involved and uninvolved colonic mucosa of patients with idiopathic proctitis.

Alterations in secretory component, IgA, IgG, and IgM were studied by immunofluorescent techniques in mucosal biopsy specimens obtained at colonoscopy from inflamed and grossly uninvolved colonic mucosa from 12 patients with idiopathic proctitis. Parotid-salivary secretory component and IgA and serum immunoglobulins were also investigated. Decreased secretory IgA was observed in the epithelium of all grossly involved rectal mucosa and in 40% of proximal normal mucosa. Salivary secretory IgA was not diminished. These observations suggest that a local immune defect may be pathogenetically related to idiopathic proctitis.

The Clinical Experience of Steroid Suppositories in the Treatment of Idiopathic Proctitis

The clinical experience of both hydrococtisone and prednisolone suppositories in 30 patients with idiopathic proctitis was presented. The main values of steroid suppositories were 1) quick effect, 2) lack of side effect in spite of long-term use and a large amount of dose, and 3) easy management for the patient. They were also useful for controlling recurrent inflammation of the rectal stump after ileo-rectal anastomosis for total ulcerative colitis. From our clinico-pathological study idiopathic proctitis was confirmed to be a type of ulcerative colitis, only difference being a different extent of the disease, as has been already suggested. Early diagnosis and correct treatment with steroid suppositories seemed to be the best way for controlling idiopathic proctitis.

The Autonomy of Idiopathic Erosive Proctitis

HIGH ON the list of badly underpublicized diseases of the gastrointestinal tract stands idiopathic erosive proctitis. Its poor press is explained by the usual habit of lumping it with common ulcerative colitis. The fact: it is an entirely different disease, no more like ulcerative colitis than amebic colitis. The Subjective Picture Idiopathic erosive proctitis usually begins during the third or fourth decade. Most patients are women, although I am unable to suggest in what proportion. To the patient, the onset seems sudden. The patient feels well but all at once sees red blood on stool or toilet tissue. Rectal bleeding is the main manifestation at the beginning and throughout the course of the illness. It tends to persist daily for many weeks or months, sometimes with brief periods of spontaneous improvement, but in most patients it shows a doggedness that leads to chronic discouragement among all concerned. The blood is

A double blind controlled trial of prednisolone-21-phosphate suppositories in the treatment of idiopathic proctitis.

A double blind trial of prednisolone suppositories in out-patients with idiopathic proctitis is reported. Significant improvement was noted. When prednisolone suppositories were given after the patient had already used suppositories of base alone for three weeks the active treatment was no longer so effective.

Observations on idiopathic proctitis

This paper presents the natural history of idiopathic proctitis and concludes that this disease and idiopathic procto-colitis are two manifestations of one disease differing only in the extent of the colon involved.