Proctitis
Inflammation is sometimes limited to the
rectal mucosa; in others it is associated with a similar condition in the colon
(proctocolitis). The inflammation can be acute or chronic. The symptoms are
tenesmus, the passage of blood and mucus and, in severe cases, of pus also.
Although the patient has a frequent intense desire to defecate, the amount of
faeces passed at a time is small. Acute proctitis is usually accompanied by
malaise and pyrexia. On rectal examination the mucosa feels swollen and is often
exceedingly tender. Proctoscopy is seldom sufficient and sigmoidoscopy is the
more valuable method of examination. If the diagnosis is confirmed, colonoscopy
with multiple biopsies is mandatory, so as to determine the extent of the
inflammatory process. Skilled pathological assistance is required to establish
or exclude the diagnosis of specific infection by bacteriological examination
and culture of the stools, examination or scrapings or swabs from ulcers, and
serological tests. When early carcinoma cannot be excluded, biopsy is necessary.
Nonspecific proctitis is an inflammatory condition affecting the mucosa
and, to a lesser extent, the submucosa, confined to the terminal rectum and anal
canal. It is the most common variety. In 10 per cent of cases the condition
extends to involve the whole colon (total ulcerative colitis).
Clinical
features. The patient is usually middle-aged, and complains of slight loss of
blood in the motions. Often the complaint is one of diarrhoea, but on closer
questioning it transpires that usually one relatively normal action of the
bowels occurs each day, although it is accompanied by some blood. During the day
the patient attempts to defecate, with the passage of flatus and a little
blood-stained faecal matter, which is mistakenly interpreted as diarrhoea. On
rectal examination, the mucosa feels warm and smooth. Often there is some blood
on the examining finger. Proctoscopic and Sigmoidoscopic examination shows
inflamed mucous membrane of the rectum, but usually no ulceration. The
inflammation
usually extends for only 12.5—15 cm from the anus, the mucosa above this level
being quite normal.
Treatment.
Although, fortunately, the condition is usually self-limiting, much relief may
be obtained from the use of sulphasalazine (Salazopyrin) and its more active
component 5-ASA (Asacol), acetarsol suppositories or prednisolone retention
enemas. Milk should be rigidly excluded from the diet. In very severe resistant
cases, oral steroids may have to be used to obtain remission. Rarely, surgical
treatment is used as a last resort when the patient is desperate for relief of
symptoms.
Ulcerative
proctocolitis. Proctitis is present in a high percentage of cases of ulcerative
colitis, and the degree of severity of the rectal involvement may influence the
type of operative procedure (see Chapter
Proctitis
due to Crohn’s disease. Crohn’s disease can occasionally affect the rectum,
although classically it is spared. Sigmoidoscopic characteristics differ from
those in nonspecific proctitis. The inflammatory process tends to he patchy rather than
confluent and there may he fissuring, ulceration and even a cobblestone
appearance. Rectal Crohn’s disease is often associated with severe perineal
disease characterised by fistulation. Skip lesions are also often present in the
rest of the colon or small bowel, or both.
Proctitis due
to specific infections
Clostridium
difficile. An
acute form of proctocolitis by infection with C. difficile can follow broad-spectrum antibiotic administration (especially
lincomycin). A ~membrane’ can sometimes he seen on proctoscopy (‘pseudomernbranous’
enterocolitis).
Bacillary
dysentery. The appearance is that of an acute purulent proctitis with multiple
small, shallow ulcers. The examination of a swab taken from the ulcerated
mucous membrane is more certainly diagnostic than is a microscopical examination
of the stools. Proctological examination is painful; agglutination tests may
render it unnecessary.
Amoebic
dysentery. The infection is more liable to be chronic, and exacerbations after a
long period of freedom from symptoms often occur. Proctoscopy and sigmoidoscopy
are not painful. The appearance of an amoebic ulcer is described in Chapter 57.
Scrapings from the ulcer should be immersed in warm isotonic saline solution and
sent to the laboratory for immediate microscopical examination.
Amoebic
granuloma. This presents as a soft mass, usually in the rectosigmoid region.
This lesion is frequently mistaken for a carcinoma. Sigmoidoscopy shows an
ulcerated surface, hut the mass is less friable than a carcinoma. A scraping
should he taken, preferably with a small, sharp spoon on a long handle, and the
material sent for immediate microscopical examination, as detailed above. If
doubt exists, a provocative dose of emetine may cause cysts of the amoebae to
appear in the stools. A biopsy can also help. Treatment is as described in
Chapter 57.
Amoebic
granuloma of the rectum is from time to time encountered in a patient who has
never visited a country in which the disease is endemic. Persons living in old
people’s institutions ate liable to harbour this deceptive lesion.
Tuberculous
proctitis. This is nearly always associated with active pulmonary tuberculosis
ulceration of the anus. Submucous rectal abscesses burst and leave ulcers with
an undermined edge. A hypertrophic type of tuberculous proctitis occurs in
association with tuberculous peritonitis, or tuberculous proctitis occurs in
association with tuberculous peritonitis or tuberculous salpingitis. This type
of tuberculous proctitis requires biopsy for confirmation of the diagnosis.
Gonococcal
proctitis. Gonococcal proctitis occurs in both sexes as the result of rectal
coitus, and in the female from direct spread from the vulva. In the acute stage,
the mucous membrane is hyperaemic and thick pus can he expressed as the
proctoscope is withdrawn. In the early stages, the diagnosis can be readily
established by bacteriological examination, hut later, when the infection is
mixed, it is mote difficult to recognise. Specific treatment is so effective
that local treatment is unnecessary.
Lymphogranuloma
inguinale. The modes of infection are similar to those of gonoccocal proctitis,
hut in the female infection spreading from the cervix uteri via lymphatics to
the pararectal lymph nodes is common. The proctological findings are similar to
those of gonococcal proctitis. The diagnosis of lymphogranuloma in inguinale
should he suspected when the inguinal lymph nodes are greatly enlarged, although
the enlargement may be subsiding by the time proctitis commences (Chapter
Acquired immunodeficiency syndrome (AIDS).
AIDS may present with a particularly florid
type of proctitis. In such patients unusual organisms such as cytomegalovirus (CMV)
are often found on culture.
‘Strawberry’
lesion of the rectosigmoid. This is due to an infection by Spirochaeta vincenti and Bacillus
fusiform is. The leading symptom is diarrhoea, often scantily blood stained.
Occasionally the diagnosis can he made by the demonstration of the specific
organisms in the stools. More often sigmoidoscopy is required. The
characteristic lesion is thickened, somewhat raised mucosa with superficial
ulceration in the region of the rectosigmoid. The inflamed mucous membrane oozes
blood at numerous pin-points, giving the appearance of an over-ripe strawberry.
A swab should be taken from the lesion and examined for Vincent’s and fusiform
organisms. Swabs from the gums and the throat are also advisable.
Treatment. Acetarsol suppositories together with vitamin C ate almost specific.
Rectal
bilharziasis. Rectal bilharziasis is caused by Schistosoma mansoni, which is endemic in many tropical and subtropical countries, and
particularly in the delta of the Nile.
Stage 1.
A cutaneous lesion develops at the site of entrance of the cercairae (parasites
of freshwater snails).
Stage 2
is characterised by pyrexia, urticaria and a high eosinophilia. Both of these
stages ate frequently overlooked.
Stage 3
is due to deposition of the ova in the rectum (much more rarely in the
bladder, Chapter 65) and is manifested
by bilharzial dysentery. On examination in the later stages, papillomas are
frequently present. The papillomas, which are sessile or pedunculated, contain
the ova of the trematode, the life-cycle of which resembles that of Sehistosoma
haematobium.
Untreated,
the rectum becomes festooned, and prolapse of the diseased mucous membrane is
usual. Multiple fistulae-in-ano are prone to develop.
General treatment of bilharziasis mansomi. Compounds not containing
antimony include
niridazole (Ambilhar) in cases of infestation with S. haematobium or S. mansomi (not
S. japonicum or in those with heart,
mental or liver disease). Dose is 25 mg/kg body weight daily in two divided
doses for 5—7 days. Hycanthone,
lucanthone and oxamniquine are other compounds with weight-related single doses
given by deep intramuscular (i.m.). injection, and all have toxic side effects.
Metriphonate is an organophosphorous compound, effective against S.
haematobium only and must he handled with care. Praziquantel (Biltricide)
has proved a major advance in drug therapy, and is highly effective against all
schistosome species. It is generally given as a single oral dose of 40 mg/kg for
S. haematobium and S. mansomi,
and for S. japonicum a higher dose
of 60 mg/kg is given as two or three divided doses throughout 1 day.
Compounds containing antimony, either as the salts, tartar emetic (antimony potassium tartrate) and sodium salt given
intravenously (iv.)., or antimony lithium thiomalate, sodium antimonygluconate,
stibogluconate and stibocaptate (Astiban) may still be required.
Local treatment. When the papillomas persist in spite of general treatment, they must be
treated in the same manner as other papillomas by local destruction.
Proctitis
due to herbal enemas. This is a well-known clinical entity to those practising
in tropical Africa. Following an enema consisting of a concoction of ginger,
pepper and bark, administered by a witch doctor, a most virulent proctitis sets
in. Pelvic peritonitis frequently supervenes.
Not infrequently, a complete gelatinous cast
of the mucous membrane of the rectum is extruded. Very large doses of morphine,
together with streptomycin, often prevent a fatal issue if commenced early (Bowesman).
Temporary colostomy is often advisable.
Treatment
General treatments should include bed rest in
extreme cases. The stools should be kept soft with Isogel. Suppositories of
5-ASA are often beneficial. The specific treatments for the dysenteries,
tuberculosis, gonorrhea, lymphogranuloma inguinale and syphilis are described
in the appropriate sections of this book.