How is noninfectious proctitis treated?

Updated: Mar 27, 2020
  • Author: David E Stein, MD; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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Answer

Acute radiation proctitis is usually a self-limited condition, but supportive medical management (eg, hydration, antidiarrheals, and steroid or 5-ASA enemas) may be of benefit. [8]

Chronic radiation proctitis involves more extensive medical treatment, including both oral and rectal therapies. Oral medications include 5-ASA, sulfasalazine, steroids, and metronidazole. Another therapeutic approach is the use of WF10, an IV therapy initially developed as an adjunctive AIDS treatment. Initial studies demonstrate control of bleeding within two doses of therapy and maintenance of results with once- to twice-yearly repeat therapy. [9]

Rectal therapy for chronic radiation proctitis with sucralfate or pentosan polysulfate has been shown to result in better symptomatic relief than oral anti-inflammatory therapy. Studies demonstrate sucralfate enemas to be the most effective medical therapy for radiation proctitis when administered twice daily for 3 months. Such rectal therapies are believed to work via stimulation of epithelial healing and formation of a protective barrier.

Steroid and short-chain fatty acid enemas have also been used with moderate success. [10] In terms of steroid enemas, hydrocortisone seems to be more effective in relieving symptoms and rectal bleeding compared with other steroids, such as betamethasone. Whereas short-chain fatty acid enemas, such as butyrate, have some proven benefit in other types of proctitis, no studies have conclusively demonstrated that they have any beneficial effect on proctitis secondary to radiation.

Research has shown hyperbaric oxygen treatment to have some efficacy in the treatment of radiation-induced proctitis. [11, 12] A large single-center study reported a 63% response rate in patients with gastrointestinal radionecrosis, supporting the findings of several previous smaller series. [13] Hyperbaric oxygen therapy has emerged as a potential therapy for radiation proctitis because of its ability to increase the number of blood vessels in irradiated tissues by acting as a stimulant for angiogenesis; however, further studies must be performed to establish the efficacy of this treatment modality. [14]

Other medical therapies aimed at the treatment of radiation proctitis, such as antioxidant therapy with vitamins A, C, and E, have showed efficacy in small single-institution studies, [15] but at present, the evidence is insufficient to justify recommendation. Additionally, ozone therapy via rectal insufflation and topical ozonized oil has shown some possible efficacy, but large randomized clinical trials are lacking.

More invasive management of radiation proctitis with rectal/topical formalin is believed to work via sclerosis of neovasculature in a form of chemical cauterization. Multiple studies have demonstrated the efficacy of formalin in the resolution of hemorrhagic proctitis, with success rates in the range of 70-80%. [16, 17, 18] Of note, significant complications from treatment include stricture and skin damage to the perianal skin.

Symptomatic diversion proctitis generally improves after the ostomy is taken down and bowel continuity is restored. However, in patients who need to be out of circuit indefinitely, short-chain fatty acid enemas may be beneficial.


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