Proctitis

Proctitis

  • If not already performed, plan index colonoscopy once disease in remission to classify disease

  • Define schedule for surveillance

  • Ensure vaccines updated

  • Provide patient education

  • Provide contact details in case of disease flare

Joint treatment plan

  • Assess activity using Truelove and Witts or the Mayo scale

  • Upgrade to more active category if symptoms have been refractory to appropriate treatment

Assess disease activity

ECCO statement 3G (UC 2017)

Microbial testing is recommended in patients with colitis relapse. This includes testing for C. difficile and Cytomegalovirus infection [EL3]

Further information

  • Colitis-like symptoms commonly caused by infective or ischaemic colitis; rectal mucosal prolapse; Crohn’s disease; malignancy; IBS with haemorrhoidal bleeding

  • Ensure investigations have included sigmoidoscopy / colonoscopy & biopsy , stool culture, C. difficile assay (and parasites if travel history). Screen colonic biopsies for CMV infection in treatment refractory disease

Exclude alternative diagnoses

Quiescent

Mild

Moderate

Severe

ECCO statement 12A (UC 2017)

The goal of maintenance therapy in ulcerative colitis is to maintain steroid-free remission, defined clinically [EL1] and endoscopically [EL2]

ECCO statement 12B (UC 2017)

Long-term maintenance treatment is recommended for almost all patients [EL1]. Intermittent therapy is acceptable insome patients with proctitis [EL3]

Further information

  • Treatment depends on disease duration and activity; previous disease course including extra-intestinal manifestations ; and response and side-effects of medication

  • Maintenance therapy usually daily or alternate daily mesalazine 1g PR suppository

  • Determine follow-up schedule (e.g. on demand or in 6 months; sooner if recent moderate/severe disease)

Mesalazine suppository or no treatment

ECCO statement 11A (UC 2017)

A mesalamine 1-g suppository once daily is the preferred initial treatment for mild or moderately active proctitis [EL1]. Mesalamine foam or enemas are an alternative [EL1], but suppositories deliver the drug more effectively to the rectum and are better tolerated [EL3]. Topical mesalamine is more effective than topical steroids [EL1]. Combining topical mesalamine with oral mesalamine or topical steroids is more effective [EL2]

Further information

  • Treatment depends on disease duration and activity; previous disease course including extra-intestinal manifestations; and response and side-effects of medication

  • 1g mesalazine suppository nocte. Generally, treatment escalated if relapse occurs, or continues (e.g. > 1 month) on treatment, as follows: nil->mesalazine suppository->add topical steroid->add oral 5-ASA->add oral steroids

  • Determine follow-up schedule (e.g. 3 months)

Mesalazine suppository

ECCO statement 11A (UC 2017)

A mesalamine 1-g suppository once daily is the preferred initial treatment for mild or moderately active proctitis [EL1]. Mesalamine foam or enemas are an alternative [EL1], but suppositories deliver the drug more effectively to the rectum and are better tolerated [EL3]. Topical mesalamine is more effective than topical steroids [EL1]. Combining topical mesalamine with oral mesalamine or topical steroids is more effective [EL2]

Further information

  • Treatment depends on disease duration and activity; previous disease course including extra-intestinal manifestations; and response and side-effects of medication

  • 1g mesalazine suppository nocte +/- at least 2 g oral mesalazine. Generally, treatment escalated if relapse occurs, or continues (e.g. > 1 month) on treatment, as follows: nil->mesalazine suppository->add topical steroid->add oral 5-ASA->add oral steroids

  • Plan maintenance therapy

  • Determine follow-up schedule (e.g. 6 weeks)

Mesalazine suppository +/- oral therapy

ECCO statement 11A (UC 2017)

A mesalamine 1-g suppository once daily is the preferred initial treatment for mild or moderately active proctitis [EL1]. Mesalamine foam or enemas are an alternative [EL1], but suppositories deliver the drug more effectively to the rectum and are better tolerated [EL3]. Topical mesalamine is more effective than topical steroids [EL1]. Combining topical mesalamine with oral mesalamine or topical steroids is more effective [EL2]

Further information

  • 1g mesalazine suppository nocte and at least 2 g oral mesalazine; and topical +/- oral steroids

  • Some patients can delay starting oral steroids for 7-14 days at onset of relapse

  • Clinical response should occur within 2 weeks of starting oral steroids

  • Plan maintenance therapy

  • Determine follow-up schedule (e.g. 2 weeks)

Mesalazine suppository + oral therapy; & oral/topical steroids & consider admission to hospital

  • Confirm relapse with rigid or flexible sigmoidoscopy (some patients can be treated empirically with dose escalation, depending on disease duration and activity, previous disease course including response and side-effects of medication)

  • Check stool culture, C. difficile assay (and parasites if travel history)

  • Restart topical therapy if investigation delayed

Reassess disease

Assess response

Assess response

ECCO statement 3G (UC 2017)

Microbial testing is recommended in patients with colitis relapse. This includes testing for C. difficile and Cytomegalovirus infection [EL3]

ECCO statement 11A (UC 2017)

A mesalamine 1-g suppository once daily is the preferred initial treatment for mild or moderately active proctitis [EL1]. Mesalamine foam or enemas are an alternative [EL1], but suppositories deliver the drug more effectively to the rectum and are better tolerated [EL3]. Topical mesalamine is more effective than topical steroids [EL1]. Combining topical mesalamine with oral mesalamine or topical steroids is more effective [EL2]

Further information

  • Treat based on disease activity and extent

  • Exclude C. difficile infection in those hospitalised or who have received antibiotics recently

Treatment based on activity / extent

ECCO statement 3G (UC 2017)

Microbial testing is recommended in patients with colitis relapse. This includes testing for C. difficile and Cytomegalovirus infection [EL3]

ECCO statement 11A (UC 2017)

A mesalamine 1-g suppository once daily is the preferred initial treatment for mild or moderately active proctitis [EL1]. Mesalamine foam or enemas are an alternative [EL1], but suppositories deliver the drug more effectively to the rectum and are better tolerated [EL3]. Topical mesalamine is more effective than topical steroids [EL1]. Combining topical mesalamine with oral mesalamine or topical steroids is more effective [EL2]

Further information

  • Consider need to reassess disease activity ± extent with rigid or flexible sigmoidoscopy (some patients can be treated empirically with dose escalation, depends on disease duration and activity, previous disease course including response and side-effects of medication)

  • Screen colonic biopsies for CMV infection in treatment refractory disease

  • Exclude C. difficile infection if treatment refractory or following recent antibiotic use

  • Generally, treatment escalated if relapse occurs, or continues (e.g. > 1 month) on treatment, as follows: mesalazine suppository->add topical steroid->add oral 5-ASA->add oral steroids

Consider sigmoidoscopy; escalate treatment

ECCO statement 3G (UC 2017)

Microbial testing is recommended in patients with colitis relapse. This includes testing for C. difficile and Cytomegalovirus infection [EL3]

Further information

  • Rigid or flexible sigmoidoscopy and biopsy to assess response and exclude other diagnoses

  • Screen colonic biopsies for CMV infection in treatment refractory disease

  • Exclude C. difficile infection if treatment refractory or following recent antibiotic use

Sigmoidoscopy

Assess response

  • Reassess disease activity and extent if continued relapse despite treatment escalation, and treat accordingly

Continue treatment & reassess response

ECCO statement 11A (UC 2017)

A mesalamine 1-g suppository once daily is the preferred initial treatment for mild or moderately active proctitis [EL1]. Mesalamine foam or enemas are an alternative [EL1], but suppositories deliver the drug more effectively to the rectum and are better tolerated [EL3]. Topical mesalamine is more effective than topical steroids [EL1]. Combining topical mesalamine with oral mesalamine or topical steroids is more effective [EL2]

ECCO statement 11B (UC 2017))

Refractory proctitis may require treatment with systemic steroids, immunosuppressants, and/or biologics [EL4]

Further information

  • Refractory proctitis / distal colitis (failed oral / PR ASA and PO steroids)

    • Check adherence to therapy

    • Ensure dose and route administration optimal

    • Consider investigation to exclude IBS, Crohn’s disease, cancer

    • Abdominal X-ray (AXR) to exclude proximal constipation (consider laxative)

    • Consider admission to hospital for IV steroids or salvage Rx with CYA or anti-TNF

  • Admission mandated if severe colitis based on the Truelove and Witts scale

  • Consider thiopurines in patients with steroid dependency

Escalate treatment

  • Reassess disease activity and extent if continued relapse despite treatment escalation, and treat accordingly

Reassess activity and extent

Consider need for admission to hospital

Maintenance of remission

Maintenance of remission

ECCO statement 12A (UC 2017)

The goal of maintenance therapy in ulcerative colitis is to maintain steroid-free remission, defined clinically [EL1] and endoscopically [EL2]

ECCO statement 12B (UC 2017)

Long-term maintenance treatment is recommended for almost all patients [EL1]. Intermittent therapy is acceptable insome patients with proctitis [EL3]

Further information

  • Treatment depends on disease duration and activity; previous disease course including extra-intestinal manifestations ; and response and side-effects of medication

  • Maintenance therapy usually daily or alternate daily mesalazine 1g PR suppository

  • Determine follow-up schedule (e.g. on demand or in 6 months; sooner if recent moderate/severe disease)

Mesalazine suppository

  • Confirm relapse with rigid or flexible sigmoidoscopy (some patients can be treated empirically with dose escalation, depending on disease duration and activity, previous disease course including response and side-effects of medication)

  • Check stool culture, C. difficile assay (and parasites if travel history)

  • Restart topical therapy if investigation delayed

Reassess disease

ECCO statement 3G (UC 2017)

Microbial testing is recommended in patients with colitis relapse. This includes testing for C. difficile and Cytomegalovirus infection [EL3]

ECCO statement 11A (UC 2017)

A mesalamine 1-g suppository once daily is the preferred initial treatment for mild or moderately active proctitis [EL1]. Mesalamine foam or enemas are an alternative [EL1], but suppositories deliver the drug more effectively to the rectum and are better tolerated [EL3]. Topical mesalamine is more effective than topical steroids [EL1]. Combining topical mesalamine with oral mesalamine or topical steroids is more effective [EL2]

Further information

  • Treat based on disease activity and extent

  • Exclude C. difficile infection in those hospitalised or who have received antibiotics recently

Treatment based on activity / extent

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