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Acute or chronic inflammation of the rectal mucosa
- Predominant age: adults
- Predominant sex: male > female
- Ulcerative colitis (UC): 2 to 19 per 100,000 person-years
- Gonococcal proctitis is most common in individuals <25 years of age.
- People of Jewish descent are 3 to 5 times more likely to have UC.
- Acute radiation proctitis; arises in almost all patients, self-limited, lasts up to 3 months after treatment
- Prevalence of rectal chlamydia and rectal gonorrhea among men who have sex with men (MSM) is 9% and 5%, respectively.
- In children diagnosed with UC:
- 25% will only have ulcerative proctitis (UP).
- Girls are twice as likely to have UP than boys.
- >30% of patients with UC have isolated rectal involvement.
- Proximal extension of UP increases from 20% at 5 years to 84% at 20 years.
- Chronic radiation proctopathy (CRP):
- Onset ranges from 8 to 13 months but can occur many years after radiation exposure.
- Prevalence is 2–20%.
- Diversion proctitis (DP): Onset is usually from 3 to 36 months after fecal diversion. <50% of patients are symptomatic.
Etiology and Pathophysiology
- Chronic radiation proctitis secondary to ischemic and fibrotic changes
- DP: Proximal fecal diversion causes increased nitrate-reducing bacteria and decreased obligate anaerobes resulting in short-chain fatty acids (SCFAs) deficiency.
- Rectal intercourse in women or MSM can result in proctocolitis.
- Infectious causes:
- Gonorrhea; chlamydia; syphilis
- Herpes simplex virus (HSV; 90% HSV-2)
- Lymphogranuloma venereum (LGV); chancroid
- Cytomegalovirus (CMV)
- Human papillomavirus (HPV)
- Clostridium difficile
- Enteric infections, including Campylobacter, Shigella, Escherichia coli, Salmonella, and amebiasis
- Inflammatory causes:
- Crohn disease
- Other causes:
- Radiation injury
- Occurs with doses 8 Gy or higher
- Damage to intestinal cell DNA with helical breaks, inability to replicate and undergo normal cellular repair
- Acute radiation injury usually occurs within 6 weeks of treatment.
- Toxins (e.g., hydrogen peroxide enemas)
- Side effects of medications
- Radiation injury
“Chronic radiation proctopathy” has replaced the term “radiation proctitis.”
- Higher incidence of UC among certain ethnicities
- In genetically predisposed individuals with dysregulated immune responses, GI infections may increase the risk of UP.
- STD-related proctitis: HIV-positive MSM with receptive anal intercourse
- UP: protective factors: smoking and appendectomy
- Risk factors: family history of inflammatory bowel disease (IBD), Jewish ancestry, NSAIDs, bisulfate, estrogen, gastroenteritis, GI dysbiosis, angiogenesis, lymphogenesis, impaired immune responses
- CRP: pelvic radiation, chemotherapy, abdominal surgery, vascular disease, GI angioectasia, AV malformation, smoking, GI dysbiosis, patient comorbidities
- DP; rectal injury; rectal medication use
Safe sex practices; condom use with anal intercourse
Commonly Associated Conditions
- Malignancy in patients treated with pelvic radiotherapy