Proctitis Patients Research Articles

Efficacy and safety of Yunxiangjing derived from Chinese herbal medicine administered as an enema in the management of acute radiation-induced proctitis in patients with pelvic malignancy

ObjectiveTo assess the efficacy and safety of Yunxiangjing (YXJ), derived from Chinese herbal medicine, in the management of acute radiation-induced proctitis (ARIP) in patients with pelvic malignancy. MethodsForty-eight patients with grade 2 ARIP were administered YXJ as an enema (1:30 dilution) for 2 weeks and followed up for 2 years. All were assessed for response and ARIP grade. Quality of life (QOL) was assessed with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30. ResultsOf the 48 patients, six (12.5%) achieved complete remission of ARIP and 28 (58.3%) showed a decrease from grade 2 to grade 1 ARIP. No patient experienced a grade ≥3 toxicity. At the end of radiotherapy, patients showed significant improvements in QOL (P < 0.05). Two years after treatment, 46 patients showed no late toxicity, with only two experiencing grade 1 late toxicity. ConclusionYXJ can be used as an enema to manage acute radiation-induced proctitis in cancer patients undergoing radiotherapy. These findings suggest that YXJ enema may be an alternative treatment of ARIP.

Proctitis after stapled hemorrhoidopexy is an underestimated complication of a widely used surgical procedure: a retrospective observational cohort study in 129 patients

BackgroundHemorrhoidal disease is highly prevalent in the western world. Stapled hemorrhoidopexy also known as the procedure for prolapsed hemorrhoids (pph) has been shown to be superior to conventional hemorrhoidectomy with regard to postoperative pain, length of hospital stay and early return to work. Proctitis following stapled hemorrhoidopexy has not been reported previously. Herein, we report our experience with proctitis in patients following stapled hemorrhoidopexy and question if proctitis could be a complication of stapled hemorrhoidopexy.Materials and methodsA retrospective analysis of the data of patients undergoing stapled hemorrhoidopexy with the PPH03 in the coloproctology unit of the department of surgery of a primary care hospital in Germany within a 5-year period was performed. All cases were managed and followed up by a single attending surgeon with expertise in coloproctology.Results129 patients were included for analysis including 21 cases with grade 2, 103 cases of grade 3 and 5 cases of grade 4 hemorrhoids. The median duration of surgery was 20 min. 17 complications including two recurrences were recorded. Post-pph proctitis was recorded in 14 cases (10.9 %). Post-pph proctitis was not associated with gender, extent of hemorrhoidal disease, BMI and ASA (p >0.05). All cases recovered within 4 weeks following management with nonsteroidal anti-inflammatory drugs and suppositories.ConclusionProctitis could be a complication of stapled hemorrhoidopexy with a good response to conservative treatment with suppositories.

Chlamydial Proctitis in Patients with Chlamydial Cervicitis

Aims: We investigated the status of chlamydial proctitis, detected using a transcription-mediated amplification (TMA) method, in rectal mucosal swab samples from patients with chlamydial cervicitis. Methodology: Patients with chlamydial cervicitis were interviewed, and rectal mucosal swab samples were collected for TMA. If the patient agreed, colonoscopy was also conducted. Chlamydial proctitis was treated with a single dose of oral azithromycin (2000 mg). Three weeks after treatment, additional samples from the cervix and rectal mucosa were subjected to TMA, and follow-up colonoscopy was performed. Results: Among the 59 patients, 4 had diarrhea and 3 had melena; only 1 patient had practiced Original Research Article Iwasaku et al.; ISRR, 3(1): 8-13, 2015; Article no.ISRR.2015.002 9 anal sex. The rectal mucosal TMA test was positive in 43 (72.9%) cases. After treatment, TMA tests of the cervix and rectal mucosa were negative in all patients and in 26 (86.7%) of 30 patients, respectively. Conclusion: The clearance rate of chlamydial infection of the rectal mucosa was not 100% and the cervical samples became negative in all cases following treatment in this study. Further studies may be needed to determine the optimal indicator for evaluating patient treatment responses and to reliably clear the infection with an alternate drug or dosing regimen.

Difference in the rate of rectal complications following prostate brachytherapy based on the prostate-rectum distance and the prostate longitudinal length among early prostate cancer patients.

PurposeTo investigate the difference in rectal complications rate following prostate low dose rate (LDR) brachytherapy based on prostate-rectum distance and prostate longitudinal length among early prostate cancer patients.Materials and MethodsFrom March 2008 to February 2013, 245 prostate cancer patients with a Gleason score ≤7 were treated with 125-I LDR brachytherapy. Among them, 178 patients with prostate volume 20-35 mL and a follow-up period ≥6 months were evaluated for radiation proctitis. Magnetic resonance imaging (MRI) was performed for a prebrachytherapy evaluation, and prostate-rectum distance and prostate longitudinal length were measured. The radiation proctitis was confirmed and graded via colonoscopy based on the radiation therapy oncology group (RTOG) toxicity criteria.ResultsTwenty-three patients received a colonoscopy for proctitis evaluation, and 12 were identified as grade 1 on the RTOG scale. Nine patients were diagnosed as grade 2 and 2 patients were grade 3. No patient developed grade 4 proctitis. The rectal-complication group had a mean prostate-rectum distance of 2.51±0.16 mm, while non-rectal-complication control group had 3.32±0.31 mm. The grade 1 proctitis patients had a mean prostate-rectum distance of 2.80±0.15 mm, which was significantly longer than 2.12±0.31 mm of grades 2 and 3 patient groups (p=0.045). All 11 patients of grades 2 and 3 had a prostate longitudinal length of 35.22±2.50 mm, which was longer than group 1, but the difference was not statistically significant (p=0.214).ConclusionsAs the prostate-rectum distance increased, fewer postimplantation rectal symptoms were observed. Patients with a shorter prostate-rectum distance in MRI should receive modified implantation techniques or radical prostatectomy.

PWE-077 Access To A Faecal Calprotectin Service Provides Clinicians With The Confidence To Diagnose And Treat Concomitant Functional Bowel Symptoms In Known Ibd Patients

IntroductionAn accurate clinical assessment of disease activity in inflammatory bowel disease (IBD) is essential to provide appropriate management strategies. The concurrent presence of functional symptoms in IBD patients is common...

Analysis of Late Radiation Proctitis Among Patients Treated for Cervical Cancer: A Comparative Study Between Linear Accelerator and Cobalt Teletherapy

BackgroundConcerns have been raised over adequate target volume coverage with conventional 2-dimensional planning owing to wide variations in pelvic anatomy between individual patients. To improve tumor volume coverage, increasing numbers of patients are being treated with 3-dimensional conformal radiotherapy (3DCRT), resulting in increased treatment volume as opposed to conventional planning. This study compares the occurrence of late radiation proctitis among patients with carcinoma of the cervix treated with 3DCRT using a linear accelerator (LINAC) versus conventional therapy using a telecobalt unit. Patients and MethodsA total of 66 patients with carcinoma of the cervix treated with curative intent between August 2006 and August 2012, having a minimum of 6 months of posttreatment follow-up, were reviewed retrospectively. Whole-pelvis irradiation was administered in cobalt teletherapy using the box-field technique (33 patients) or using 3DCRT on a 6-MV LINAC (33 patients), followed by low-dose-rate intracavitary brachytherapy to a dose of 30 Gy. ResultsThe median ages of patients treated on cobalt teletherapy and LINAC were 50 and 52 years, respectively, and the median follow-up durations were 24 and 18 months, respectively. Seven patients (21%) developed radiation proctitis in the cobalt teletherapy arm, compared with 12 patients (36%) in the LINAC arm (P = .03; χ2 test). ConclusionThere is a significant increase in the incidence of late radiation proctitis in patients treated with the 3DCRT technique compared with the conventional technique. The effect of associated factors such as rectal dose during brachytherapy needs to be studied before a definitive conclusion can be drawn.

Repeated Autologous Bone Marrow-Derived Mesenchymal Stem Cell Injections Improve Radiation-Induced Proctitis in Pigs

The management of proctitis in patients who have undergone very-high-dose conformal radiotherapy is extremely challenging. The fibrosis-necrosis, fistulae, and hemorrhage induced by pelvic overirradiation have an impact on morbidity. Augmenting tissue repair by the use of mesenchymal stem cells (MSCs) may be an important advance in treating radiation-induced toxicity. Using a preclinical pig model, we investigated the effect of autologous bone marrow-derived MSCs on high-dose radiation-induced proctitis. Irradiated pigs received repeated intravenous administrations of autologous bone marrow-derived MSCs. Immunostaining and real-time polymerase chain reaction analysis were used to assess the MSCs' effect on inflammation, extracellular matrix remodeling, and angiogenesis, in radiation-induced anorectal and colon damages. In humans, as in pigs, rectal overexposure induces mucosal damage (crypt depletion, macrophage infiltration, and fibrosis). In a pig model, repeated administrations of MSCs controlled systemic inflammation, reduced in situ both expression of inflammatory cytokines and macrophage recruitment, and augmented interleukin-10 expression in rectal mucosa. MSC injections limited radiation-induced fibrosis by reducing collagen deposition and expression of col1a2/col3a1 and transforming growth factor-β/connective tissue growth factor, and by modifying the matrix metalloproteinase/TIMP balance. In a pig model of proctitis, repeated injections of MSCs effectively reduced inflammation and fibrosis. This treatment represents a promising therapy for radiation-induced severe rectal damage.

Use of Anticoagulants Predict Late Rectal Bleeding Following Definitive External Beam Radiation Therapy for Prostate Cancer

To determine the relationship between hematologic modifying drugs and the risk of acute and late radiation proctitis in patients undergoing definitive external beam radiation therapy for prostate cancer.

Topical therapy is underused in patients with ulcerative colitis

AbstractThe availability of new topical preparations for the treatment of left sided ulcerative colitis offers a therapy optimization for many patients. Rectal application of steroids and 5-aminosalicylic acid (5-ASA) is associated with fewer side effects and has a higher therapeutic efficacy in left-sided colitis as compared to a systemic therapy. Therefore, we were interested in the use of topical therapy in patients with ulcerative colitis. The key question was whether topical treatment is more frequently used than oral therapy in patients with proctitis and left sided colitis. Data of 800 patients of the Swiss IBD cohort study were analyzed.Sixteen percent of patients of the cohort had proctitis, 21% proctosigmoiditis and 41% pancolitis. Topical therapy with 5-ASA or corticosteroids was given in 26% of patients with proctitis, a combined systemic and topical treatment was given in 13%, whereas systemic treatment with 5-ASA without topical treatment was given in 29%. Proportion of topical drug use decreased with respect to disease extension from 39% for proctitis to 13.1% for pancolitis (P=0.001). Patients with severe colitis received a significantly higher dose of topical 5-ASA than patients in remission.Side effects of topical or systemic 5-ASA or budesonide treatment were less frequently seen compared to other medications. Topical treatment was frequently stopped over time. The quality of life was the same in patients with limited disease compared to patients with pancolitis.Topical treatment in proctitis patients was underused in Switzerland. Since topical treatment is safe and effective it should be used to a larger extend.

Placebo controlled evaluation of Xilei San, a herbal preparation in patients with intractable ulcerative proctitis

Topical mesalamine or corticosteroid has shown efficacy in patients with ulcerative proctitis, but patients often become refractory to these interventions. Xilei San is a herbal preparation with evidence of anti-inflammatory effects. We evaluated the efficacy of topical Xilei San in ulcerative proctitis patients. In a double blind setting, 30 patients with intractable ulcerative proctitis despite ≥ 4 weeks of topical mesalamine or corticosteroid were randomly assigned to True (n = 15) and placebo (n = 15). Patients in True received suppository Xilei San (0.1 g/dose per day of Xilei San), the other 15 received placebo suppository. The initial efficacy was evaluated on day 14. Primary endpoint of the trial was avoiding relapse during 180 days, relapse meant recurrence of active disease. Riley's index was applied for endoscopic and histological evaluations, while patients' quality of life was evaluated by an inflammatory bowel disease questionnaire. On day 14, the number of patients who achieved remission, clinical activity index ≤ 4 in True was significantly higher versus placebo (P < 0.04). Likewise, at day 180, an 81.8% of patients in True were without relapse versus 16.7% in placebo (P < 0.001). Further, significant endoscopic (P < 0.01), histological (P < 0.02) and inflammatory bowel disease questionnaire (P < 0.04) improvements were observed in True, but not in placebo. This is the first controlled investigation showing significant clinical and endoscopic efficacy for Xilei San in patients with intractable ulcerative proctitis. Topical Xilei San was well tolerated, and was without safety concerns.

Management of oral and gastrointestinal mucositis: ESMO Clinical Practice Guidelines

Management of oral and gastrointestinal mucositis: ESMO Clinical Practice Guidelines

Ulcerative proctitis patients' preference for topical formulations of mesalamine.

Ulcerative proctitis patients' preference for topical formulations of mesalamine.

The role of endoscopy in patients with anorectal disorders

The role of endoscopy in patients with anorectal disorders

Local Immune Regulation of Mucosal Inflammation by Tacrolimus

PurposeTacrolimus is a potent immunomodulator that is effective in the treatment of inflammatory bowel disease (IBD). However, potential toxicity and systemic effects with oral intake limit its use. Local tacrolimus treatment is effective in a subgroup of proctitis patients. This study aimed to evaluate whether colonic mucosal immune cells are susceptible to locally applied tacrolimus in vitro. Our in vivo studies aimed at evaluating whether local tacrolimus treatment in mice would bring about local immune suppression and to compare colonic and systemic tacrolimus levels after locally and systemically applied tacrolimus.ResultsIn vitro tacrolimus inhibited the activation of multiple cell types present in colonic tissue; lamina propria T cells, NKT cells, and both classical- and non- classical antigen presenting cells. However, the cytokine production of epithelial cells was not inhibited by tacrolimus at these concentrations. After rectal administration in mice, tacrolimus blood levels were comparable to those obtained by oral intake. However, rectally treated mice exhibited a 14-fold higher concentration of tacrolimus within their colonic tissue than orally treated mice. Moreover, rectally applied tacrolimus resulted in a local but not a systemic immune suppression in mice.ConclusionsTacrolimus inhibits activation of several pivotal immune cells of the intestinal mucosa. Murine studies indicate that colonic application of tacrolimus induces local rather than systemic immune suppression.

Assessing Grade 2-4 Proctitis in Patients Undergoing Combined Modality Therapy for Prostate Cancer: An Innovative Approach to Determine BED Dose Volume Toxicity

Assessing Grade 2-4 Proctitis in Patients Undergoing Combined Modality Therapy for Prostate Cancer: An Innovative Approach to Determine BED Dose Volume Toxicity

Sodium butyrate enemas in the treatment of acute radiation-induced proctitis in patients with prostate cancer and the impact on late proctitis

To evaluate prospectively the effect of sodium butyrate enemas on the treatment of acute and the potential influence on late radiation-induced proctitis. 31 patients had been treated with sodium butyrate enemas for radiation-induced acute grade II proctitis which had developed after 40 Gy in median. During irradiation the toxicity was evaluated weekly by the Common Toxicity Criteria (CTC) and subsequently yearly by the RTOG (Radiation Therapy Oncology Group) and LENT-SOMA scale. 23 of 31 patients (74%) experienced a decrease of CTC grade within 8 days on median. A statistical significant difference between the incidence and the severity of proctitis before start of treatment with sodium butyrate enemas compared to 14 days later and compared to the end of irradiation treatment course, respectively, was found. The median follow-up was 50 months. Twenty patients were recorded as suffering from no late proctitis symptom. Eleven patients suffered from grade I and 2 of these patients from grade II toxicity, too. No correlation was seen between the efficacy of butyrate enemas on acute proctitis and prevention or development of late toxicity, respectively. Sodium butyrate enemas are effective in the treatment of acute radiation-induced proctitis in patients with prostate cancer but have no impact on the incidence and severity of late proctitis.

Clinical guidelines for the medical management of left-sided ulcerative colitis and ulcerative proctitis: Summary statement

There are few published guidelines for the treatment of inflammatory bowel disease. Physicians choose therapy based on evidence-based data, peer and expert opinion, and personal experience. This article provides treatment guidelines for the induction and maintenance of ulcerative proctitis and left-sided colitis and the management of disease refractory to 5-aminosalicylic acid (5-ASA) compounds and corticosteroids The guidelines are derived from evidence-based data and, when lacking, expert opinion or the authors' experience. The comprehensive review of the literature is presented in the accompanying article, "The Medical Management of Left-Sided Ulcerative Colitis and Ulcerative Proctitis: Critical Evaluation of Therapeutic Trials". Rectally administered 5-ASA and corticosteroid suppositories are effective treatment for most ulcerative proctitis patients. Corticosteroid and 5-ASA enemas, which reach the splenic flexure of the colon, are recommended for patients with left-sided ulcerative colitis. The combination of rectally administered 5-ASA enemas and oral 5-ASA agents may afford better treatment of left-sided colitis and possibly prevent proximal extension of disease. Patients refractory to 5-ASAs and corticosteroids may require an immunomodulator or biological response modifier therapy. Those who have ongoing signs and symptoms of ulcerative proctitis and left-sided ulcerative colitis despite maximal medical therapy require a proctocolectomy.

Factors associated with disease evolution in Greek patients with inflammatory bowel disease

BackgroundThe majority of Crohn's disease patients with B1 phenotype at diagnosis (i.e. non-stricturing non-penetrating disease) will develop over time a stricturing or a penetrating pattern. Conflicting data exist on the rate of proximal disease extension in ulcerative colitis patients with proctitis or left-sided colitis at diagnosis. We aimed to study disease evolution in Crohn's disease B1 patients and ulcerative colitis patients with proctitis and left-sided colitis at diagnosis.Methods116 Crohn's disease and 256 ulcerative colitis patients were followed-up for at least 5 years after diagnosis. Crohn's disease patients were classified according to the Vienna criteria. Data were analysed actuarially.ResultsB1 phenotype accounted for 68.9% of Crohn's disease patients at diagnosis. The cumulative probability of change in disease behaviour in B1 patients was 43.6% at 10 years after diagnosis. Active smoking (Hazard Ratio: 3.01) and non-colonic disease (non-L2) (Hazard Ratio: 3.01) were associated with behavioural change in B1 patients. Proctitis and left-sided colitis accounted for 24.2%, and 48.4% of ulcerative colitis patients at diagnosis. The 10 year cumulative probability of proximal disease extension in patients with proctitis and left-sided colitis was 36.8%, and 17.1%, respectively (p: 0.003). Among proctitis patients, proximal extension was more common in non-smokers (Hazard Ratio: 4.39).ConclusionClassification of Crohn's disease patients in B1 phenotype should be considered as temporary. Smoking and non-colonic disease are risk factors for behavioural change in B1 Crohn's disease patients. Proximal extension is more common in ulcerative colitis patients with proctitis than in those with left-sided colitis. Among proctitis patients, proximal extension is more common in non-smokers.

Chromoendoscopy: A new vision for colonoscopic surveillance in IBD

Chromoendoscopy: A new vision for colonoscopic surveillance in IBD

Hyperbaric Oxygen Therapy for Radiation Induced Proctopathy in Men Treated for Prostate Cancer

Radiation proctitis is a common complication following external beam radiation therapy and brachytherapy for prostate cancer. While 95% percent of radiation induced proctitis is temporary and self-limiting, up to 5% of patients experience toxicities that are refractory to conservative management. Hyperbaric oxygen has a well-defined role in treating chronic wounds, osteomyelitis, hemorrhagic cystitis and necrotizing fasciitis. We reviewed our experience with hyperbaric oxygen therapy for radiation induced proctitis in patients undergoing radiation treatment for prostate cancer. From October 1998 to December 2003, 27 patients with radiation induced proctitis secondary to brachytherapy (4), external beam radiation therapy (16) or combined modality (7) for prostate cancer were treated with hyperbaric oxygen therapy at Virginia Mason Medical Center in Seattle, Washington. In all patients primary medical or endoscopic management had failed. Patients received 100% oxygen in a multiplace hyperbaric chamber at a pressure of 2.4 atmospheres absolute for 90 minutes 5 to 7 days weekly for an average of 36 sessions (range 29 to 60). Data were collected from a retrospective review of medical records following approval by the Institutional Review Board at Virginia Mason Medical Center. All 27 men completed the planned course of therapy. Of patients with bleeding 48% showed complete resolution after therapy, while 28% reported significantly fewer bleeding episodes. Of patients 50% noted complete resolution of fecal urgency. Six of the 8 patients (75%) with pain noticed some improvement after therapy, although no patients reported complete resolution of rectal pain. Of patients with rectal ulceration 21% showed complete resolution of the ulcer on posttreatment endoscopy, while 29% showed evidence of improvement. Six patients (43%) had no change or worsening of rectal ulcers. Overall 67% of patients had a partial to good response, while 33% showed no response or disease progression. This series of patients showed a good overall response rate to hyperbaric oxygen for radiation induced proctopathy after other attempts at management had failed. Hyperbaric oxygen is generally well tolerated and it remains an important treatment option for managing this common and difficult disease.