You are in: eMedicine Specialties > Emergency Medicine > GASTROINTESTINAL ProctitisArticle Last Updated: Mar 27, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 9
  Author: Lisandro Irizarry, MD, MPH, FAAEM, Chair, Department of Emergency Medicine, Brooklyn Hospital Center; Assistant Professor, Department of Emergency Medicine, Weill Cornell School of Medicine Lisandro Irizarry is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine Coauthor(s): Ibis Yarde, MD, Staff Physician, Department of Emergency Medicine, Brooklyn Hospital Center Editors: Michael S Beeson, MD, MBA, FACEP, Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine; Program Director, Emergency Medicine Residency, Summa Health System; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Eugene Hardin, MD, FACEP, FAAEM, Chair and Associate Professor, Department of Emergency Medicine, Charles R Drew University of Medicine and Science; Chair, Department of Emergency Medicine, Martin Luther King, Jr/Drew Medical Center; John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center; Robert E O'Connor, MD, MPH, Professor and Chair, Department of Emergency Medicine, University of Virginia Health System Author and Editor Disclosure Synonyms and related keywords: inflammation of the rectum, rectal mucosa, proctosigmoiditis, rectal tissue ischemia, rectal pain, rectal bleeding, proctitis, mucosal cell loss, acute inflammation of the lamina propria, eosinophilic crypt abscess, endothelial edema of the arterioles, mucosal friability, ulcers, strictures, fistula formation, colitis, Crohn disease, Crohn's disease, ulcerative colitis INTRODUCTIONSection 2 of 9
  BackgroundProctitis is inflammation of the lining of the rectum, called the rectal mucosa. Proctitis can be short term (acute) or long term (chronic). Proctitis has many causes. It may be a side effect of medical treatments like radiation therapy or antibiotics. Proctitis involves an inflammatory change of the rectum (within 15 cm of the dentate line). Proctitis is similar to proctosigmoiditis but is not necessarily associated with proximal extension of disease into the colon and usually does not evolve into ulcerative colitis. If proximal extension does occur, it usually does so within the first 2 years of initial diagnosis. For more information on Crohn disease and ulcerative colitis, see Medscape’s Inflammatory Bowel Disease Resource Center. For a related CME activity, see CME – The Role of Endoscopy in Ulcerative Colitis: Old Facts and New Advances and Nonbiologic Therapy for IBD Revisited. PathophysiologyProctitis involves mucosal cell loss, acute inflammation of the lamina propria, eosinophilic crypt abscess, and endothelial edema of the arterioles. These may improve or progress with subsequent fibrosis of connective tissue and endarteritis of the arterioles, resulting in rectal tissue ischemia and leading to mucosal friability, bleeding, ulcers, strictures, and fistula formation. FrequencyUnited StatesFrequencies of proctitis are associated with their individual etiologies. With radiation therapy, 5-20% of patients display proctitis, usually within 3-24 months after completion of therapy with a total dose greater than 50 Gy. RaceIncidence is higher in Jewish persons. SexMales are affected more often than females. AgeProctitis occurs predominantly in adults. CLINICALSection 3 of 9
History
Physical
Causes
DIFFERENTIALSSection 4 of 9
Anal Fistulas and Fissures Chancroid Clostridium difficile colitis/proctitis Diverticular Disease Foreign Bodies, Rectum Gonorrhea Herpes Simplex HIV Infection and AIDS Inflammatory Bowel Disease Lymphogranuloma Venereum Syphilis Vulvovaginitis
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| Drug Name | Metronidazole (Flagyl) |
|---|---|
| Description | Active against various anaerobic bacteria and protozoa. Appears to be absorbed into cells. Intermediate metabolized compounds are formed and bind DNA and inhibit protein synthesis, causing cell death. Antimicrobial effect may be due to production of free radicals. Indicated for invasive E histolytic infections. |
| Adult Dose | 500-750 mg PO tid for 10 d |
| Pediatric Dose | 35-50 mg/kg PO divided tid for 10 d |
| Contraindications | Documented hypersensitivity |
| Interactions | May increase toxicity of anticoagulants, cyclosporine, lithium, phenytoin, tacrolimus, and carbamazepine; cimetidine may increase toxicity of metronidazole; disulfiram reaction may occur with orally ingested ethanol; coadministration increases amiodarone toxicity (QT prolongation); increases disulfiram toxicity (psychotic symptoms) with concurrent use; phenobarbital and rifampin may increase metabolism of metronidazole |
| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals |
| Precautions | Caution with liver impairment, blood dyscrasias, CNS disease; reduce dosage with severe hepatic disease; monitor for seizures and development of peripheral neuropathy |
| Drug Name | Vancomycin (Vancocin) |
|---|---|
| Description | Has excellent in vitro activity against C difficile. Kills organism by inhibiting cell wall synthesis. Significant luminal levels after PO vancomycin can be obtained because it is poorly absorbed from the GI tract. Major disadvantage is cost. PO vancomycin is relatively expensive, with a wholesale cost of approximately $150 for a 10-d supply. Because of the cost and the concern over the emergence of vancomycin-resistant enterococci strains, its use should be reserved for patients who cannot tolerate metronidazole, patients who do not respond to metronidazole, pregnant patients, and patients <10 y. Also preferred for severe cases and in patients who are high risk. Unlike IV metronidazole, IV vancomycin is not excreted into the GI lumen; therefore, delivering effective doses by this route is difficult. |
| Adult Dose | 125 mg PO qid for 10-14 d |
| Pediatric Dose | 40 mg/kg/d PO divided tid/qid for 7-10 d; not to exceed 2 g/d |
| Contraindications | Documented hypersensitivity |
| Interactions | Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants |
| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus |
| Precautions | Caution in renal failure, neutropenia; red man syndrome is caused by too rapid IV infusion (dose given over a few min) but rarely happens when dose given IV over 2 h administration or as PO or IP administration; red man syndrome is not an allergic reaction |
| Drug Name | Ciprofloxacin (Cipro) |
|---|---|
| Description | Fluoroquinolone that inhibits bacterial DNA synthesis and, consequently, growth, by inhibiting DNA gyrase and topoisomerases, which are required for replication, transcription, and translation of genetic material. Quinolones have broad activity against gram-positive and gram-negative aerobic organisms. Has no activity against anaerobes. Continue treatment for at least 2 d (7-14 d typical) after signs and symptoms have disappeared. Usually administered on empiric basis in patients with severe colitis in addition to steroids. Also used for the treatment of pouchitis after colectomy and ileo-anal anastomosis. |
| Adult Dose | 500 mg PO bid 400 mg IV bid |
| Pediatric Dose | <18 years: Not recommended >18 years: Administer as in adults |
| Contraindications | Documented hypersensitivity |
| Interactions | Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations May increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT) |
| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus |
| Precautions | Dosage adjustments (adult adjustments) CrCl (mL/min) <10: 50% of PO or IV dose q12h HD: 0.25-0.5 g PO or 0.2-0.4 g IV q12h During peritoneal dialysis: 0.25-0.5 g PO or 0.2-0.4 g IV q8h In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy Not drug of first choice in pediatrics because of increased incidence of adverse events compared with controls, including arthropathy; no data exist for dose for pediatric patients with renal impairment (ie, CrCl <50 mL/min) |
| Drug Name | Ceftriaxone (Rocephin) |
|---|---|
| Description | Used because of an increasing prevalence of penicillinase producing N gonorrhoeae. It inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins, causing bacterial growth inhibition. |
| Adult Dose | 250 mg IM once |
| Pediatric Dose | Neonates >7 days: 25-50 mg/kg IM once; not to exceed 125 mg Infant or child: 125 mg IM once plus doxycycline |
| Contraindications | Documented hypersensitivity |
| Interactions | Aminoglycosides increase nephrotoxic potential; probenecid increases effects by decreasing clearance |
| Pregnancy | D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus |
| Precautions | Caution in renal impairment |
| Drug Name | Doxycycline (Doryx, Bio-Tab, Vibramycin) |
|---|---|
| Description | Required with ceftriaxone for the treatment of gonorrheal proctitis. Inhibits protein synthesis and, thus, bacterial growth by binding with the 30S and possibly the 50S ribosomal subunits of susceptible bacteria. |
| Adult Dose | Acute infections: 200 mg PO immediately, then 100 mg PO hs on d 1, followed by 100 mg PO bid for 3 d; or 300 mg PO stat followed by 300 mg PO in 1 h; alternatively, use 100 mg PO bid for 7 d |
| Pediatric Dose | <8 years: Not recommended >8 years: 2-5 mg/kg/d PO qd or divided bid; not to exceed 200 mg/d |
| Contraindications | Documented hypersensitivity; severe hepatic dysfunction |
| Interactions | Antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate can decrease bioavailability |
| Pregnancy | D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus |
| Precautions | Avoid prolonged exposure to sunlight or tanning equipment to prevent a photosensitivity reaction; use of tetracyclines during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth |
| Drug Name | Benzathine penicillin (Bicillin L-A) |
|---|---|
| Description | A bactericidal used in the treatment of rectal syphilis. Interferes with bacterial cell wall synthesis during active multiplication, inhibiting bacterial growth. |
| Adult Dose | 2.4 million U IM once in 2 injection sites |
| Pediatric Dose | 50,000 U/kg IM once; not to exceed 2.4 million U |
| Contraindications | Documented hypersensitivity |
| Interactions | Probenecid can increase the effects by decreasing clearance; conversely, coadministration of tetracyclines can decrease effects |
| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals |
| Precautions | Caution in impaired renal function |
| Drug Name | Tetracycline (Sumycin) |
|---|---|
| Description | Treats susceptible bacterial infections of both gram-positive and gram-negative organisms as well as infections caused by Mycoplasma, Chlamydia, and Rickettsia species. Inhibits bacterial protein synthesis and, thus, bacterial growth by binding with 30S and possibly 50S ribosomal subunit(s) of susceptible bacteria. |
| Adult Dose | 250-500 mg PO q6h |
| Pediatric Dose | 25-50 mg/kg/d PO divided q6h |
| Contraindications | Documented hypersensitivity; severe hepatic dysfunction |
| Interactions | Antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate can decrease bioavailability; can increase hypoprothrombinemic effects of anticoagulants; coadministration can decrease the pharmacologic effects of oral contraceptives, causing breakthrough bleeding and an increased risk of pregnancy |
| Pregnancy | D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus |
| Precautions | Prolonged exposure to sunlight or tanning equipment can cause a photosensitivity reaction; use lower-than-usual doses in patients with renal impairment; use of tetracyclines during tooth development (last half of pregnancy through age 8 y) can cause a permanent discoloration of teeth; never administer outdated tetracyclines, the degradation products are highly nephrotoxic and can cause a Fanconilike syndrome |
These agents decrease inflammation associated with proctitis, perhaps by inhibiting prostaglandin synthesis.
| Drug Name | Sulfasalazine (Azulfidine) |
|---|---|
| Description | Useful in the management of ulcerative colitis; acts locally in the colon to decrease the inflammatory response and systemically inhibits prostaglandin synthesis. |
| Adult Dose | Initial dose: 1 g PO tid/qid Maintenance dose: 2 g/d PO divided tid/qid |
| Pediatric Dose | <2 years: Not established >2 years: 40-60 mg/kg/d PO in 3-6 divided doses Maintenance dose: 20-30 mg/kg/d PO divided qid |
| Contraindications | Documented hypersensitivity; GI or GU obstruction |
| Interactions | Decreases the effect of iron, digoxin, and folic acid; conversely, increases effect of oral anticoagulants, oral hypoglycemic agents, and methotrexate |
| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals |
| Precautions | Renal or hepatic impairment; blood dyscrasias; urinary obstruction |
| Drug Name | Mesalamine (Rowasa, Asacol, Canasa, Pentasa) |
|---|---|
| Description | Used for treatment of mildly to moderately active ulcerative colitis. The usual course of therapy in adults is 3-6 wk. Some patients may need concurrent oral and rectal therapy. |
| Adult Dose | Oral: 1 g cap PO qid or 800 mg tab PO tid Rectal: One 500-mg supp PR bid or one 4-g susp enema PR qd (retained for 8 h) |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity to mesalamine or to suppository vehicle (saturated vegetable fatty acid esters) |
| Interactions | Decreases effects of iron, digoxin, and folic acid; conversely, it increases the effect of oral anticoagulants, methotrexate, and oral hypoglycemic agents |
| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals |
| Precautions | Elderly persons may have difficulty administering and retaining rectal suppositories; use caution in patients with renal or hepatic impairment; susp contains potassium metabisulfite, so care must be taken in individuals with documented sulfite allergy |
These agents are used for the treatment of herpes-related proctitis. They inhibit viral replication by competing with deoxyguanosine triphosphate for viral DNA polymerase.
| Drug Name | Acyclovir (Zovirax) |
|---|---|
| Description | Reduces duration of symptomatic lesions. Indicated for patients who present within 48 h of experiencing rash. Patients taking acyclovir experience less pain and faster resolution of cutaneous lesions. |
| Adult Dose | Initial episode: 200 mg PO q4h (while awake) 5 times/d for 10 d Recurrence: 200 mg PO q4h (while awake) 5 times/d for 10 d |
| Pediatric Dose | Not established Suggested dose: 10-20 mg/kg/dose PO (up to 800 mg) qid for 5 d; start treatments within 24 h of rash onset |
| Contraindications | Documented hypersensitivity |
| Interactions | Concomitant use of probenecid or zidovudine prolongs half-life and thus increases CNS toxicity |
| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals |
| Precautions | Renal failure; coadministration of other nephrotoxic drugs |
| Drug Name | Dexamethasone |
|---|---|
| Description | Has many pharmacologic benefits but significant adverse effects. Stabilizes cell and lysosomal membranes, increases surfactant synthesis, increases serum vitamin A concentration, and inhibits prostaglandin and proinflammatory cytokines (eg, TNF-alpha, IL-6, IL-2, and IFN-gamma). The inhibition of chemotactic factors and factors that increase capillary permeability inhibits recruitment of inflammatory cells into affected areas. Suppresses lymphocyte proliferation through direct cytolysis and inhibits mitosis. Breaks down granulocyte aggregates, and improves pulmonary microcirculation. Adverse effects are hyperglycemia, hypertension, weight loss, GI bleeding or perforation synthesis, cerebral palsy, adrenal suppression, and death. Most of the adverse effects of corticosteroids are dose-dependent or duration-dependent. Readily absorbed via the GI tract and metabolized in the liver. Inactive metabolites are excreted via the kidneys. Lacks salt-retaining property of hydrocortisone. Patients can be switched from an IV regimen to a PO regimen in a 1:1 ratio. |
| Adult Dose | 0.75-9 mg/d PO in divided doses q6-12h |
| Pediatric Dose | 0.08-0.3 mg/kg/d or 2.5-10 mg/m2/d divided PO q6-12h |
| Contraindications | Documented hypersensitivity; active bacterial or fungal infection |
| Interactions | Effects decrease with coadministration of barbiturates, phenytoin, and rifampin; dexamethasone decreases effect of salicylates and vaccines used for immunization |
| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus |
| Precautions | Increases risk of multiple complications, including severe infections; monitor adrenal insufficiency when tapering drug; abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications of glucocorticoid use |
| Drug Name | Prednisolone |
|---|---|
| Description | Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability. |
| Adult Dose | 5-60 mg/d PO/IV/IM |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity; fungal, tubercular skin, connective tissue, or viral infections; peptic ulcer disease; hepatic dysfunction; GI bleeding or ulceration |
| Interactions | Decreases effects of salicylates and toxoids (for immunizations); phenytoin, carbamazepine, barbiturates, and rifampin decrease effects of corticosteroids |
| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus |
| Precautions | Caution in hyperthyroidism, osteoporosis, cirrhosis, nonspecific ulcerative colitis, peptic ulcer, diabetes, and myasthenia gravis |
| Drug Name | Prednisone |
|---|---|
| Description | May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. |
| Adult Dose | 5-60 mg/d PO qd or divided bid/qid; taper over 2 wk, as symptoms resolve |
| Pediatric Dose | 4-5 mg/m2/d PO; alternatively, 0.05-2 mg/kg PO divided bid/qid; taper over 2 wk, as symptoms resolve |
| Contraindications | Documented hypersensitivity; fungal, tubercular skin, connective tissue, or viral infections; peptic ulcer disease; hepatic dysfunction; GI bleeding or ulceration |
| Interactions | Coadministration with estrogens may decrease clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics |
| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals |
| Precautions | Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use |
Article Last Updated: Mar 27, 2008
