Mycoplasma genitalium: Key Information for the Primary Care Clinician

Mycoplasma genitalium (MG) is an emerging sexually transmitted infection, which appears to be a cause of urethritis and cervicitis and has been associated with pelvic inflammatory disease (PID), epididymitis, proctitis, infertility, complications during pregnancy, and human immunodeficiency virus (HIV) transmission. Three Food and Drug Administration (FDA) approved tests are available. Testing should be focused to avoid inappropriate antibiotic use. The Center of Disease Control and Prevention (CDC) guidelines recommend testing for persistent male urethritis, cervicitis, and proctitis and state that testing should be considered in cases of PID. Testing is also recommended for sexual contacts of patients with MG. Testing is not recommended in asymptomatic patients, including pregnant patients, who do not have a history of MG exposure. Although resistance-guided therapy is recommended, there are currently no FDA approved tests for MG macrolide resistance, and tests are not widely available in the United States. The CDC recommends 2-step treatment with doxycycline followed by azithromycin or moxifloxacin. Moxifloxacin is recommended if resistance testing is unavailable or testing demonstrates macrolide resistance..

Tofacitinib for Patients with Anti-TNF Refractory Ulcerative Proctitis: A Multicentre Cohort Study from the GETAID

BACKGROUND

Although ulcerative proctitis [UP] can dramatically impair quality of life, treatment efficacy has been poorly investigated in UP as it was historically excluded from phase 2/3 randomised controlled trials in ulcerative colitis. Our aim was to assess the effectiveness and safety of tofacitinib for the treatment of UP.

METHODS

We conducted a retrospective, multicentre study in 17 GETAID centres, including consecutive patients with UP treated with tofacitinib. The primary endpoint was steroid-free remission between Week 8 and Week 14, defined as a partial Mayo score of 2 [and no individual subscore above 1]. Secondary outcomes included clinical response and steroid-free remission after induction and at 1 year.

RESULTS

All the 35 enrolled patients previously received anti-tumour necrosis factor [TNF] therapy and 88.6% were exposed to at least two lines of biologics. At baseline, the median partial Mayo score was 7 (intequartile range [IQR] [5.5-7]). After induction [W8-W14], 42.9% and 60.0% of patients achieved steroid-free remission and clinical response, respectively. At 1 year, the steroid-free clinical remission and clinical response rates were 39.4% and 45.5%, respectively, and 51.2% [17/33] were still receiving tofacitinib treatment. Survival without tofacitinib withdrawal was estimated at 50.4% (95% confidence interval [CI] [35.5-71.6]) at 1 year. Only a lower partial Mayo at baseline was independently associated with remission at induction (0dds ratio [OR] = 0.56 for an increase of 1, (95% CI [0.33-0.95], p = 0.03). Five [14.3%] adverse events were reported, with one leading to treatment withdrawal [septic shock secondary to cholecystitis].

CONCLUSION

Tofacitinib may offer a therapeutic option for patients with refractory UP.

Proctitis: An Approach to the Symptomatic Patient

Proctitis is an inflammatory condition of the distal rectum that can be associated with common sexually transmitted infections (STIs), such as gonorrhea, chlamydia, and syphilis. For persons presenting with ulcerative findings on examination, in addition to syphilis, Mpox, lymphogranuloma venereum, and herpes simplex virus should be in the differential. Providers should also be aware that there are evolving data to support a role for Mycoplasma genitalium in proctitis. Performing a comprehensive history, clinical evaluation including anoscopy, and rectal nucleic amplification STI testing may be useful in identifying the cause of proctitis and targeting treatment.

Anal Monkeypox Disease: Description of 65 Cases

BACKGROUND

Monkeypox is a zoonosis endemic in Africa caused by 3 orthopoxvirus clades. Knowledge of the disease is limited, but a worldwide outbreak involving a new route of transmission was declared in April 2022.

OBJECTIVE

This study aimed to describe anal symptoms and outcomes in patients infected with Monkeypox virus presenting to an emergency proctology unit in Paris.

DESIGN

This was an observational study.

SETTING

We reported anal symptoms of all consecutive patients with monkeypox anal infection in a single proctology center between June 16, 2022, and July 26, 2022. Association with sexually transmitted infections and outcomes were also recorded.

PATIENTS

Sixty-five men with a mean age of 39.6 (19.9-64.6) years with confirmed monkeypox anal infection were included in the study.

MAIN OUTCOME MEASURES

Anal symptoms and their severity were clinically assessed. A favorable outcome consisted of a complete resolution of clinical manifestation.

RESULTS

Sexual transmission was reported in 51 patients (78.4%), among whom 63 (97%) were men who have sex with men. Twenty-eight (43%) were living with HIV, and 24 (36.9%) were taking tenofovir/emtricitabine for HIV preexposure prophylaxis. Anal symptoms appeared first in 36 patients (55.4%) and skin rash or other general symptoms in 22 patients (33.8%). Incubation time was 6.9 (1-26) days. Symptoms included painful perianal (n = 42 patients; 64.6%), anal (n = 28, 43%), and rectal (n = 25; 38.4%) ulcerations and perianal vesicles (n = 24; 36.9%). Proctitis was observed in 49 patients (75.4%). It was mild in 20 (40.8%) and intense in 29 (59.2%), and severe proctitis mimicking high intersphincteric suppuration was found in 4 (8.2%). Fifteen patients (23.1%) had concurrent sexually transmitted infection and 3 were hospitalized. Complete symptom resolution occurred within 12 days.

LIMITATIONS

We performed a single-center study during a short period of time.

CONCLUSIONS

Proctological symptoms are frequent in the current outbreak of monkeypox disease, probably linked to the route of transmission. Rectal ulcerations mimicking high intersphincteric suppuration should be recognized to avoid unnecessary surgery. See Video Abstract .

ENFERMEDAD ANAL DE LA VIRUELA DEL MONO DESCRIPCIN DE CASOS

ANTECEDENTES:La viruela del simio mono es una zoonosis endémica en África causada por tres clados de orthopoxvirus. El conocimiento de la enfermedad es limitado, pero en abril de 2022 se declaró un brote mundial que implica una nueva vía de transmisión.OBJETIVO:Describir los síntomas anales y los resultados en pacientes que sufren de infección por Monkeypox que asistieron a una unidad de proctología de emergencia en París.DISEÑO:Un estudio observacional.ESCENARIO:Informamos los síntomas anales de todos los pacientes consecutivos con infección anal por viruela del mono en un solo centro de proctología entre el 16/6/2022 y el 26/7/2022. También se registró la asociación con infecciones de transmisión sexual (ITS) y el resultado.PACIENTES:Sesenta y cinco hombres de 39,6 [19,9-64,6] años con infección anal confirmada.PRINCIPALES MEDIDAS DE RESULTADO:Los síntomas anales y su gravedad se evaluaron clínicamente. Un resultado favorable consistió en una resolución completa de la manifestación clínica.RESULTADOS:La transmisión sexual se informó en 51 (78,4%) pacientes, de los cuales 63 (97%) eran hombres que tuvieron sexo con hombres. Veintiocho (43%) vivían con el VIH y 24 (36,9%) tomaban Emtricitabina/Tenofovir para profilaxis previa por exposición al VIH. Los síntomas anales aparecieron primero en 36 (55,4%) pacientes y la erupción cutánea u otros síntomas generales en 22 (33,8%). El tiempo de incubación fue de 6,9 [1-26] días. Los síntomas incluyeron ulceraciones perianales dolorosas (n = 42 pacientes, 64,6%), anales (n = 28, 43%), rectales (n = 25, 38,4%) y vesículas perianales (n = 24, 36,9%). Se observó proctitis en 49 (75,4%) pacientes. Fue leve en 20 (40,8%) e intensa en 29 (59,2%) y proctitis severa simulando supuración interesfinteriana alta en 4 (8,2%). Quince (23,1%) pacientes presentaban ITS concurrentes y 3 fueron hospitalizados. La resolución completa de los síntomas ocurrió dentro de los 12 días.LIMITACIONES:Estudio de un solo centro y durante corto período de tiempo.CONCLUSIÓN:Los síntomas proctológicos son frecuentes en el brote actual de la enfermedad de la viruela del mono, probablemente relacionados con la vía de transmisión. Las ulceraciones rectales que simulan una supuración interesfinteriana alta deben reconocerse para evitar una cirugía innecesaria. (Traducción-Dr. Fidel Ruiz Healy ).

Qingchang suppositry induced remission in patients with mild-to-moderate ulcerative proctitis: a multicenter, prospective, randomized, parallel-controlled clinical trial

OBJECTIVE

To evaluate the efficacy and safety of Qingchang suppository (, QCS), a preparation of Chinese herbal medicine, in the induction of remission in patients with mild-to-moderate ulcerative proctitis (UP).

METHODS

We performed a multicenter, prospective, randomized, parallel-controlled trial to evaluate the efficacy of QCS induction therapy in 140 adult patients with mild-to-moderate UP and TCM syndrome of dampness-heat in large intestine. The patients were randomized to receive QCS (study group) or Salicylazosulfapyridine (SASP) suppository (control group) one piece each time, twice a day, per anum for 12 weeks. Mayo score and main symptoms score were evaluated at weeks 0, 2, 4, 8 and 12, rectosigmoidscopy was taken at weeks 0, 4, 8 and 12, Geboes score, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and safety indexes were assessed at weeks 0 and 12. The primary efficacy endpoint is clinical remission rate, the secondary efficacy endpoints are clinical response rate, mucosa healing rate, Geboes score, the remission rates of the main symptoms, the median day to the remission of the symptom, etc. RESULTS: There were no statistical difference in the clinical remission rates, the clinical response rates, the mucosa healing rates, Geboes score, ESR and CRP between the two groups. The remission rates of tenesmus and anal burning sensation of the study group were significantly higher than those of the control group (76.5% vs 25.0%, P = 0.009; 74.51% vs 29.63%, P = 0.003). The median day to the remission of purulent bloody stool of the study group was significantly less than that of control group [11 (1, 64) vs 19 (2, 67), P = 0.007]. The patients receiving QCS had a significantly higher mucosa healing rate at week 4 than the patients receiving SASP suppository (71.42% vs 52.85%, P = 0.023). No adverse event occurred in the study group while the adverse events incidence of the control group was 5.7% (P = 0.049).

CONCLUSIONS

QCS could induce the remission of UP as effectively and safely as SASP suppository, and was superior to SASP suppository in relieving the symptoms of tenesmus, anal burning sensation and purulent bloody stool and the time to reach mucosa healing.

Anorectal Manifestations of Treatment-Refractory Monkeypox Requiring Surgical Intervention

Anorectal manifestations of monkeypox are increasingly being recognized as a potentially serious complication. We present the case of an HIV-positive, tecovirimat-treated male presenting with monkeypox virus-associated severe proctitis with associated perianal pathology. Despite the use of antiviral agents and intravenous vaccinia immune globulin, the monkeypox-associated perianal lesions evolved into abscesses, requiring incision and drainage. This report highlights a multidisciplinary approach involving surgery for anorectal complications of monkeypox virus-associated proctitis and perianal lesions. Surgery may offer immediate relief and reduce the potential long-term morbidity associated with severe monkeypox virus-associated rectal and perianal manifestations refractory to available medical countermeasures.

Acute cytomegalovirus proctitis and epididymitis acquired via sexual transmission in an immunocompetent patient: a case report

BACKGROUND

We present a case report of an immunocompetent host with presumed sexually transmitted cytomegalovirus proctitis and epididymitis, where there currently is a sparsity of published data.

CASE PRESENTATION

A 21-year-old previously healthy Caucasian individual was admitted for severe rectal and testicular pain in the setting of proctitis and epididymitis. Serology and rectal pathology confirmed acute primary cytomegalovirus infection.

CONCLUSIONS

This report details his diagnostic workup and highlights cytomegalovirus as a rare cause of sexually transmitted disease among immunocompetent persons.

Infective anoproctitis in men having sex with men: Don't forget Mycoplasma genitalium

OBJECTIVES

The aim was to describe the clinical characteristics of symptomatic anoproctitis and the occurrence of Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Mycoplasma genitalium (MG) infections in a prospective cohort of MSM patients.

METHODS

From February 2018 to January 2020, all consecutive patients presenting at the Leopold Bellan Proctology Institute of Saint-Joseph Hospital, Paris, France with symptoms of anoproctitis were tested on rectal samples for C. trachomatis (CT), N. gonorrhoeae (NG), M. genitalium (MG). Clinical, microbiological, biological data, STI risk factors, medical history and treatments were collected.

RESULTS

Three hundred and sixty-five patients were included for suspected infective anoproctitis. CT was detected in 84/365 (23%) patients, NG in 45/365 (12%) and MG in 46/315 patients (15%), associated with macrolide resistance in 28/46 MG strains (61%). The most frequent symptoms were rectal pains, rectal bleeding, purulent discharge in 253 (79%), 191 (60%), and 164 (51%) of cases respectively. In comparison with MG infections, ulcerations, erythematous proctitis, rectorragia and false needs were more frequently described in CT infections, while purulent proctitis, functional pain and purulent discharge were more often observed in NG and CT anoproctitis.

CONCLUSION

We found a high prevalence rate of STIs due to CT, NG, while MG detection was associated with a high rate of macrolide resistance in a cohort of MSM patients. Our results confirm that in cases of symptomatic anoproctitis, MG should be tested in association with other STI pathogens.

Systematic review with meta-analysis: Medical therapies for treatment of ulcerative proctitis

BACKGROUND

Ulcerative proctitis (UP) is a common highly symptomatic form of ulcerative colitis that can be difficult to treat.

AIM

To assess the efficacy of medical treatments for UP.

METHODS

We searched MEDLINE, EMBASE, and CENTRAL on 23 November 2022 for randomised controlled trials (RCTs) of medical therapy for adults with UP. Primary outcomes included induction and maintenance of clinical remission. Pooled risk ratios (RRs) and 95% confidence intervals (CIs) were calculated for each outcome.

RESULTS

We included 53 RCTs (n = 4096) including 46 induction studies (n = 3731) and seven maintenance studies (n = 365). First-line therapies included topical 5-aminosalicylic acid (5-ASA), conventional corticosteroids, budesonide, and oral 5-ASA. Therapy for refractory UP included topical tacrolimus and small molecules. Topical 5-ASA was superior to placebo for induction (RR 2.72, 95% CI 1.94-3.82) and maintenance of remission (RR 2.09, 95% CI 1.26-3.46). Topical corticosteroids were superior to placebo for induction of remission (RR 2.83, 95% CI 1.62-4.92). Topical budesonide was superior to placebo for induction of remission (RR 2.34, 95% CI 1.44-3.81). Combination therapy with topical 5-ASA and topical corticosteroids was superior to topical monotherapy with either agent. Topical tacrolimus was superior to placebo. Etrasimod was superior to placebo for induction (RR 4.71, 95% CI 1.2-18.49) and maintenance of remission (RR 2.08, 95% CI 1.31-3.32).

CONCLUSIONS

Topical 5-ASA and corticosteroids are effective for active UP. Topical 5-ASA may be effective for maintenance of remission. Tacrolimus may be effective for induction of remission. Etrasimod may be effective for induction and for maintenance of remission. Trials should include UP to expand the evidence base for this under-represented population.

A 40-Year-Old Man with Anemia, Proctitis, Rectal Bleeding, and a Perianal Rash Due to Mpox (Monkeypox) Infection

BACKGROUND A recently described zoonotic viral infection, mpox (monkeypox), is an Orthopoxvirus transmitted by close contact, which causes symptoms similar to smallpox, although less severe. This report presents the case of a 40-year-old man with anemia, proctitis, rectal bleeding, and a perianal rash due to mpox infection. CASE REPORT A 40-year-old man with a medical history of human immunodeficiency virus (HIV) and syphilis presented multiple times with progressive and painful perianal lesions. On initial presentation, swabbing of the lesions and polymerase chain reaction (PCR) testing confirmed a diagnosis of mpox infection, and treatment with a 14-day course of Tecovirimat was started. Nine days after initiating Tecovirimat, the patient presented again with worsening perianal pain and associated hematochezia resulting in acute symptomatic anemia. Despite a blood transfusion to treat his anemia, the patient's status declined as his viral symptoms progressed. Computed tomography (CT) investigation demonstrated significant proctitis with interval development of small perianal abscesses. A multidisciplinary approach for medical management and treatment was instituted. The resolution of the patient's anemia and mpox proctitis was confirmed on follow-up. CONCLUSIONS Despite treatment with antiviral agents, mpox infection can progress quickly; thus, swift management with a multidisciplinary approach and close follow-up is needed to treat and prevent secondary complications such as anemia and proctitis. Further data collection regarding the sexual practices of those with diagnoses of mpox as well as seminal, anorectal, and genital swabbing would be valuable to confirm the mode of transmission and cause of mpox proctitis.

Comparative efficacy of oral drugs for chronic radiation proctitis - a systematic review

BACKGROUND

Chronic radiation proctitis (CRP) is a long-term complication of pelvic radiotherapy that manifests as rectal bleeding, diarrhoea, fistula formation and obstruction. Treatments such as endoscopic argon plasma coagulation, hyperbaric oxygen therapy and rectal topical formalin have imposed a significant medical burden on CRP patients. In contrast, oral therapies offer a more accessible and acceptable option for managing CRP. Here, we conducted a systematic review of the efficacy of oral treatments for CRP to assess their potential as an effective and convenient treatment option for this condition.

METHODS

We searched the Cochrane Central Register of Controlled Trials, PubMed, Web of Science, China National Knowledge Infrastructure and Chinese VIP in February 2021. We included post-radiotherapy participants with CRP that compared oral medicine alone or in combination with other treatments versus control treatments. The primary outcomes were bleeding, diarrhoea and symptom score. Heterogeneity between studies was checked using Cochrane Q test statistics and I2 test statistics. The Cochrane risk-of-bias tool was used to assess the quality of the included studies.

RESULTS

We included 10 randomised controlled trials (RCTs) and 1 retrospective study with 898 participants. Three placebo-controlled trials evaluated the effects of oral sucralfate on CRP, with meta-analysis showing no significant different with placebo arm. Four trials on TCM demonstrated significant improvement of symptoms, especially for the 3 trials on oral TCM drinks. Retinyl palmitate and high-fibre diet were found to reduce rectal bleeding. The combination of oral pentoxifylline and tocopherol did not significantly change the process of CRP.

CONCLUSIONS

Our study implies that oral TCM drinks, retinyl palmitate and a high-fiber diet showed significant improvement in CRP symptoms, but not with the combination of oral pentoxifylline and tocopherol. Further multicentre, larger-scale RCTs are needed to confirm the efficacy and safety of these treatments and optimize treatment strategies, ultimately improving the quality of life for patients with CRP.

Monkeypox-induced proctitis: a case report of an emerging complication

PURPOSE

At the outset of the 2022 human monkeypox virus outbreak, the World Health Organization described the self-limited disease as a rash illness associated with nonspecific symptoms such as fever, myalgias, and lymphadenopathy. Historically, the infection caused by this zoonotic virus has presented with rashes primarily on the face, palms, and soles of feet. However, emerging case report literature from the 2022 recent outbreak highlighted more atypical presentations ranging from ocular manifestations to myocarditis.

CASE DESCRIPTION

We present a case of a 32-year-old African American male with a past medical history of poorly controlled acquired immunodeficiency syndrome and external hemorrhoids that presented for worsening rectal pain. The patient was afflicted with diffuse skin lesions even present on his hemorrhoids. Initial imaging significant circumferential rectal thickening consistent with proctitis. Subsequent polymerase chain reaction testing confirmed active monkeypox infection, and a 14-day course of twice daily tecovirimat 600 mg was initiated to treat disseminated monkeypox infection. After improved pain control and starting antiviral treatment, the patient was discharged two days later.

CONCLUSION

As more cases of monkeypox-associated proctitis emerge, clinicians should keep this disease in their differential due to the growing atypical presentations that have diverged from previous patterns to avoid the risk of misdiagnosing another sexually transmitted infection. Additionally, appropriate medical management is still not definitive and requires further development of evidence-based protocols to treat such patients.

Argon plasma coagulation therapy in hemorrhagic radiation proctitis following pelvic radiation in gynecological malignancies

Introduction

Chronic radiation proctitis is a common chronic complication of malignant pelvic diseases after pelvic radiation therapy. Although, the incidence has decreased after advent of intensity-modulated radiotherapy due to better control of radiation dose to rectum. In the era of conventional two-field radiotherapy to pelvis, this was a common complication usually presenting after 1-2 years of treatment completion. Rectal bleeding caused by radiation proctitis is difficult to manage. Argon plasma coagulation (APC) is an electrocoagulation technique that appears to be an effective and low-cost alternative to the use of lasers in gastrointestinal endoscopy. The aim of this study was to evaluate the efficacy of APC, as well as patients' tolerance of the procedure, in the treatment of bleeding radiation-induced proctitis.

Materials and Methods

Between January 2015 and August 2017, 29 patients of cancer cervix treated with definite radiotherapy both external and brachytherapy who suffered from rectal bleeding due to radiation proctitis were included for treatment with argon plasma laser (APC). Twenty-three patients suffered from anemia, 16 of whom required blood transfusion. APC was performed, applying the no-touch spotting technique at an electrical power of 40 Watt and an argon gas flow of 1.5-2.0 l/min. Pulse duration was <0.5 s. Treatment sessions were carried out at intervals of 3 weeks. Subjects received 2-4 treatment sessions.

Results

Twenty-eight out of 29 patients were accessible for effects and results. APC led to persistent clinical and endoscopic remission of rectal bleeding after a median of three sessions. No adverse effects were encountered after initial treatment. All the patients were in complete remission.

Conclusions

APC is an effective, safe, and well-tolerated treatment for rectal bleeding caused by chronic radiation proctitis. It should be considered as a first-line therapy for radiation proctitis.

Ginsenoside Rg3 treats acute radiation proctitis through the TLR4/MyD88/NF-κB pathway and regulation of intestinal flora

Objectives

This study aimed to investigate the protective effect of ginsenoside Rg3 (GRg3) against acute radiation proctitis (ARP) in rats.

Methods

Wistar rats were randomly divided into control, model, dexamethasone-positive, GRg3 low-dose, GRg3 medium-dose, and GRg3 high-dose groups. The ARP rat model was established by a single 22-Gy irradiation of 6 MV) X-rays. The distribution and function of intestinal flora were detected using 16S rRNA high-throughput sequencing, rectal tissue was observed by hematoxylin and eosin (H&E) staining, the expression of interleukin 1β (IL-1β) and IL-10 inflammatory factors was detected by ELISA, and mRNA and protein expression of toll-like receptor 4 (TLR4), myeloid differentiation primary response 88 (MyD88), and nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) were detected by RT-qPCR and Western blotting, respectively.

Results

GRg3 improved the symptoms of ARP in rats in a dose-dependent manner. The species distribution of intestinal flora in GRg3 rats was significantly different from that in ARP rats. These differences were more significant in the high-dose group, where the numbers of Ruminococcus, Lactobacillus, and other beneficial bacteria were significantly increased, whereas those of Escherichia, Alloprevotella, and other harmful bacteria were decreased. In addition, GRg3 was closely related to amino acid metabolism. After GRg3 treatment, the mRNA and protein expression of TLR4, MyD88, and NF-κB in rectal tissue was significantly down-regulated, and the level of downstream inflammatory factor IL-1β decreased, whereas that of IL-10 increased.

Conclusion

Our study indicated GRg3 as a new compound for the treatment of ARP by inhibiting the TLR4/MyD88/NF-κB pathway, down-regulating the expression of proinflammatory factors, thus effectively regulating intestinal flora and reducing inflammatory reactions.

Tacrolimus (FK506) for induction of remission in corticosteroid-refractory ulcerative colitis

BACKGROUND

There are a limited number of treatment options for people with corticosteroid-refractory ulcerative colitis. Animal models of inflammatory bowel disease and uncontrolled studies in humans suggest that tacrolimus may be an effective treatment for ulcerative colitis.

OBJECTIVES

To evaluate the efficacy and safety of tacrolimus for induction of remission in people with corticosteroid-refractory ulcerative colitis.

SEARCH METHODS

We searched the Cochrane Gut group specialised register, CENTRAL, MEDLINE (PubMed), Embase, Clinicaltrials.gov and WHO ICTRP from inception to October 2021 to identify relevant randomised controlled trials (RCT).

SELECTION CRITERIA

Two review authors independently selected potentially relevant studies to determine eligibility based on the prespecified criteria.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and analysed them using Review Manager Web. The primary outcomes were induction of remission and clinical improvement, as defined by the studies and expressed as a percentage of the participants randomised (intention-to-treat analysis).

MAIN RESULTS

This review included five RCTs with 347 participants who had active ulcerative colitis or ulcerative proctitis. The duration of intervention varied between two weeks and eight weeks. Tacrolimus versus placebo Tacrolimus (oral and rectal) may be superior in achieving clinical remission compared to placebo (oral and rectal) (14/87 participants with tacrolimus versus 1/61 participants with placebo; risk ratio (RR) 3.76, 95% confidence interval (CI) 1.03 to 13.73; 3 studies). These results are of low certainty due to imprecision and risk of bias. Tacrolimus (oral and rectal) may be superior for clinical improvement compared to placebo (oral and rectal) (45/87 participants with tacrolimus versus 7/61 participants with placebo; RR 4.47, 95% CI 2.15 to 9.29; 3 studies). These results are of low certainty due to imprecision and risk of bias. The evidence is very uncertain about the effects of tacrolimus (oral and rectal) on serious adverse events compared to placebo (oral and rectal) (2/87 participants with tacrolimus versus 0/61 participants with placebo; RR 2.44, 95% CI 0.12 to 48.77; 3 studies). These results are of very low certainty due to high imprecision and risk of bias. Tacrolimus versus ciclosporin One study compared oral tacrolimus to intravenous ciclosporin, with an intervention lasting two weeks and 113 randomised participants. The evidence is very uncertain about the effect of tacrolimus on achievement of clinical remission compared to ciclosporin (15/33 participants with tacrolimus versus 24/80 participants with ciclosporin; RR 1.52, 95% CI 0.92 to 2.50). The results are of very low certainty due to risk of bias and high imprecision. The evidence is very uncertain about the effect of tacrolimus on clinical improvement compared to intravenous ciclosporin (23/33 participants with tacrolimus versus 62/80 participants with ciclosporin; RR 0.90, 95% CI 0.70 to 1.16). The results are of very low certainty due to risk of bias and imprecision. Tacrolimus versus beclometasone One study compared tacrolimus suppositories with beclometasone suppositories in an intervention lasting four weeks with 88 randomised participants. There may be little to no difference in achievement of clinical remission (16/44 participants with tacrolimus versus 15/44 participants with beclometasone; RR 1.07, 95% CI 0.60 to 1.88). The results are of low certainty due to high imprecision. There may be little to no difference in clinical improvement when comparing tacrolimus suppositories to beclometasone suppositories (22/44 participants with tacrolimus versus 22/44 with beclometasone; RR 1.00, 95% CI 0.66 to 1.52). The results are of low certainty due to high imprecision. There may be little to no difference in serious adverse events when comparing tacrolimus suppositories to beclometasone suppositories (1/44 participants with tacrolimus versus 0/44 with beclometasone; RR 3.00, 95% CI 0.13 to 71.70). These results are of low certainty due to high imprecision. There may be little to no difference in total adverse events when comparing tacrolimus suppositories to beclometasone suppositories (21/44 participants with tacrolimus versus 14/44 participants with beclometasone; RR 1.50, 95% CI 0.88 to 2.55). These results are of low certainty due to high imprecision. No secondary outcomes were reported for people requiring rescue medication or to undergo surgery.

AUTHORS' CONCLUSIONS

There is low-certainty evidence that tacrolimus may be superior to placebo for achievement of clinical remission and clinical improvement in corticosteroid-refractory colitis or corticosteroid-refractory proctitis. The evidence is very uncertain about the effect of tacrolimus compared to ciclosporin for achievement of clinical remission or clinical improvement. There may be no difference between tacrolimus and beclometasone for inducing clinical remission or clinical improvement. The cohorts studied to date were small, with missing data sets, offered short follow-up and the clinical endpoints used were not in line with those suggested by regulatory bodies. Therefore, no clinical practice conclusions can be made. This review highlights the need for further research that targets the relevant clinical questions, uses appropriate trial methodology and reports key findings in a systematic manner that facilitates future integration of findings with current evidence to better inform clinicians and patients. Future studies need to be adequately powered and of pertinent duration so as to capture the efficacy and effectiveness of tacrolimus in the medium to long term. Well-structured efficacy studies need to be followed up by long-term phase 4 extensions to provide key outputs and inform in a real-world setting.

Pravastatin Alleviates Radiation Proctitis by Regulating Thrombomodulin in Irradiated Endothelial Cells

Although radiotherapy plays a crucial in the management of pelvic tumors, its toxicity on surrounding healthy tissues such as the small intestine, colon, and rectum is one of the major limitations associated with its use. In particular, proctitis is a major clinical complication of pelvic radiotherapy. Recent evidence suggests that endothelial injury significantly affects the initiation of radiation-induced inflammation. The damaged endothelial cells accelerate immune cell recruitment by activating the expression of endothelial adhesive molecules, which participate in the development of tissue damage. Pravastatin, a cholesterol lowering drug, exerts persistent anti-inflammatory and anti-thrombotic effects on irradiated endothelial cells and inhibits the interaction of leukocytes and damaged endothelial cells. Here, we aimed to investigate the effects of pravastatin on radiation-induced endothelial damage in human umbilical vein endothelial cell and a murine proctitis model. Pravastatin attenuated epithelial damage and inflammatory response in irradiated colorectal lesions. In particular, pravastatin improved radiation-induced endothelial damage by regulating thrombomodulin (TM) expression. In addition, exogenous TM inhibited leukocyte adhesion to the irradiated endothelial cells. Thus, pravastatin can inhibit endothelial damage by inducing TM, thereby alleviating radiation proctitis. Therefore, we suggest that pharmacological modulation of endothelial TM may limit intestinal inflammation after irradiation.

Recommendations of the Crohn's Disease and Ulcerative Colitis Spanish Working Group (GETECCU) for the treatment of perianal fistulas of Crohn's disease

Recommendations are advice that is given and considered to be beneficial; however, they are still suggestions and are therefore open to different interpretations. In this sense, the final objective of the review has been to try to homogenize, with the evidence available, the approach to the diagnosis and medical/surgical treatment of one of the most complex manifestations of Crohn's disease, such as simple and complex perianal fistulas.

Rectal Lymphoid Follicle Aphthous Lesions Frequently Progress to Ulcerative Colitis with Proximal Extension

Objective Rectal lymphoid follicular aphthous (LFA) lesions are related to ulcerative colitis (UC) and can be initial lesions of UC. We investigated the clinical course and prognosis of rectal LFA lesions. Methods This is a retrospective analysis of the clinical records at a single center. Patients Thirteen consecutive cases with LFA lesions treated at Hiroshima University Hospital between 1998 and 2015 were evaluated. Another 49 consecutive cases with ulcerative proctitis treated in the same period were enrolled as the control group. The clinical course and prognosis of both groups were evaluated. Results The group with LFA lesions included 9 women and 4 men with a median age of 39.9 years (range, 21-70 years). A total of 11 cases progressed to typical UC at 5-51 months. Proximal extension of these typical UC lesions was observed in 7 (53.8%) cases, which was significantly higher than in the control group (10 cases, 20.8%). Three cases (5-year accumulation incidence rate, 27.3%) progressed to steroid-intractable UC, a significantly higher incidence than that of the control group (3 cases; 5-year accumulation incidence rate, 6.9%). Conclusion Rectal LFA lesions frequently progress to typical UC with proximal extension, some of which become intractable to corticosteroid treatment.

Optimized Management of Ulcerative Proctitis: When and How to Use Mesalazine Suppository

BACKGROUND

Ulcerative proctitis, one of the disease types of ulcerative colitis, is considered one of the initial manifestations of ulcerative colitis. Prevention of aggravation of ulcerative proctitis is important for improving the prognosis of ulcerative colitis. Here we reviewed the epidemiology, diagnosis, and management of ulcerative proctitis.

SUMMARY

The number of patients with ulcerative proctitis is increasing. Disease extension occurs in many patients with ulcerative proctitis. Differential diagnosis from other chronic proctitis is important and should be performed based on the clinical history and endoscopical and histological features. Mesalazine suppository has been the first-line therapy for patients with ulcerative proctitis because of its high effectiveness and safety. Topical treatment of ulcerative proctitis, particularly using mesalazine suppository has been underused in clinical practice. Key Messages: Mesalazine suppositories are more effective than dose intensification of oral mesalazine for relapsed patients with maintenance dose of oral mesalazine. However, low adherence to rectal mesalazine has hindered remission in patients with ulcerative proctitis.

Linear IgA bullous dermatosis associated with ulcerative proctitis: treatment challenge

Linear IgA bullous dermatosis is a rare bullous disease in children and adults that can be associated with autoimmune conditions, malignancies, infections, or medication exposure. The definitive diagnosis relies on the biopsy. A 58-year-old man presented to our clinic with a pruritic vesicular and bullous eruption. Histology showed the classic findings of a subepidermal blister with neutrophilic infiltrate and linear IgA deposition along the dermal-epidermal junction. Upon further evaluation, he was diagnosed with ulcerative proctitis. His therapy was complicated owing to side effects and lack of response to the standard treatment options. Dapsone, a first-line therapy, caused symptomatic methemoglobinemia whereas niacinamide with doxycycline were not effective. He required intravenous and oral steroids to reach improvement followed by transitioning to methotrexate.

Primary syphilitic proctitis : case report and literature review

Rectal ulcerations are an uncommon presentation of a primary syphilis infection. Anorectal syphilis is difficult to diagnose because of its often asymptomatic or atypical clinical presentation. It is important to consider sexually transmitted diseases (STD) in all patients presenting with rectal symptoms. A history of anal sexual intercourse should be made, especially in men having sex with men (MSM). Moreover, the possibility of a primary syphilis infection of the rectum should be considered. Endoscopic findings might be diverse, whereas a typical chancre can present as an anorectal ulcer associated with regional lymphadenopathy. It is important to consider other causes of anorectal ulcers, like other STD, inflammatory bowel disease (IBD) or even malignant causes. The diagnosis of anorectal syphilis is based on the combination of the clinical presentation, serology tests, endoscopic findings and biopsies. The cornerstone of the treatment is based on an intramuscularly administration of a long-acting preparation of penicillin (benzathine penicillin G).

Clinical and microbiological aspects of the use of Lactobacillus rhamnosus PL1 strains in proctological patients with symptoms of chronic proctitis

Recurrent proctitis and the symptoms associated therewith pose significant clinical problem in proctological patients. The objective of this study was to assess the impact of the probiotic Lactobacillus rhamnosus PL1 strain on the clinical presentation and composition of intestinal microbiota in patients with symptoms of proctitis in the course of hemorrhoidal disease and diverticulosis. Material consisted of 24 patients in whom no complete clinical improvement could be obtained after the treatment of the underlying disease. Subject to the assessment was the presence and the intensity of clinical symptoms as well as qualitative and quantitative changes in the composition of bacterial flora detected in the stool before, during and after a 9-week supplementation with the probiotic Lactobacillus rhamnosus PL1 strain.

RESULTS

In the entire study group, the intensity of pain after 12 weeks was significantly lower (p=0,.011) compared to baseline; the intensity of flatulence and abdominal discomfort was reduced significantly as early as after 3 weeks, with the difference reaching a highly significant level after 12 weeks (pP&lt;0,.0001). No significant difference was observed in the frequency of the reported episodes of diarrhea, constipation, as well as itching and burning in the anal region. As early as after 3 weeks of supplementation with the probiotic L. rhamnosus PL1 strain, significant qualitative and quantitative changes were observed in the composition of intestinal microbiota; the changes differed depending on the underlying disease. An increase in the total counts of the bacteria of Lactobacillus genus, particularly L. rhamnosus PL1 strain was observed regardless of the underlying disease.

CONCLUSION

Tthe probiotic Lactobacillus rhamnosus PL1 strain appears to be useful in restoring appropriate ratios of bacterial populations in patients presenting with symptoms of proctitis in the course of the treatment of certain diseases of the lower gastrointestinal tract.

Lymphogranuloma venereum: an emerging cause of proctitis in men who have sex with men

Before 2003, lymphogranuloma venereum (LGV) was rare in developed nations. Several large clusters of LGV in men who have sex with men have been reported across Europe and in the United States of America (USA) since 2003. LGV is caused by L1, L2 and L3 serovars of Chlamydia trachomatis and is a sexually transmitted infection. LGV causes genital ulcers, infected inguinal lymph nodes (buboes) and proctitis/proctocolitis. Treatment with a three-week course of doxycycline prevents rectal strictures, bowel obstruction, bowel perforation and possibly death. Clinicians seeing men who have sex with men with inguinal lymphadenopathy and bowel symptoms should be aware of this current epidemic.

Sexually transmitted diseases syndromic approach: proctitis

Proctitis is a common problem and is most frequently associated with inflammatory bowel diseases (IBD). However, in the last ten years the incidence of infectious proctitis appears to be rising, especially in men who have sex with men. This may be due to the rise of people participating in receptive anal sex as well as the increase in sexually transmitted infections, such as those from Chlamydia trachomatis, Neisseria gonorrhoeae, Herpes simplex virus and Treponema pallidum. Recent outbreaks of lymphogranuloma venereum among homosexual men throughout Europe highlight the need to consider sexually transmitted infections in the differential diagnosis of proctitis. Symptoms of infectious proctitis can include rectal blood and mucous discharge, anorectal pain, aphtous ulcers and, sometimes, generalized lymphadenopathy and fever. A careful history and physical examination are crucial in establishing a diagnosis, eventually supported by endoscopy, histology, serology, culture and PCR. Treatment with antibiotics or antivirals is usually initiated, either empirically or after establishing a diagnosis. Coinfections, HIV testing, and treatment of sexual partners should always be considered.

Gastrointestinal mucositis: focus on the treatment of the effects of chemotherapy and radiotherapy on the rectum

In an article published in the January/February 2012 issue of the International Journal of Pharmaceutical Compounding, damage to the oral mucosa, commonly referred to as oral mucositis, as a result of chemotherapy, radiotherapy, or a combination of both therapies was discussed. his article continues that discussion but in respect to the injury that these rapies cause to the gastrointestinal tract. Like oral mucositis, gastrointestinal mucositis is a significant problem in oncology, as it causes very serious pathologies along the alimentary tract, damaging the quality of life of the oncologic patient, and sometimes the damages are life-threatening. The most vulnerable organs of the gastrointestinal tract to radiation and chemotherapy toxicities are the small intestine, colon, and rectum. This article concentrates on the chronic rectum and anus toxicities of radiotherapy and escribes two compounding preparations to treat chronic radiation induced proctitis with rectal bleeding. As in oral mucositis, although substantial scientific progress has been made in learning more about this pathology, current treatments to manage gastrointestinal mucositis is inadequate.

[Application of antiseptic decasan in purulent infections of pararectal region]

The results of studying of antiseptic preparation Decasan for the treatment of patients, suffering purulent infections of pararectal region, are adduced. Efficacy of Decasan was analyzed in 102 patients. The results of investigation obtained are trusting hig antiseptic efficacy of preparation, witnessing possibility of its application as a preparation of choice for the treatment of patients, suffering purulent infections of pararectal region.

Efficacy and safety of mesalamine suppositories for treatment of ulcerative proctitis in children and adolescents

BACKGROUND

Treatment of ulcerative proctitis has not been well studied in pediatric populations. We conducted an open-label trial to evaluate the clinical efficacy of a mesalamine suppository (500 mg) to treat pediatric patients with mild to moderate ulcerative proctitis.

METHODS

Pediatric patients (5-17 years of age) with ulcerative proctitis were enrolled for baseline evaluations, including a flexible sigmoidoscopic (or colonoscopic) assessment with biopsies performed at study entry. Eligible patients were started on mesalamine suppositories (500 mg) at bedtime. Two follow-up visits were scheduled after 3 and 6 weeks of treatment. The dose could be increased to 500 mg twice daily at the week 3 follow-up visit if deemed appropriate by the investigator based on the Disease Activity Index (DAI) assessment. The primary outcome measure was a DAI derived from a composite score of stool frequency, urgency of defecation, rectal bleeding, and general well-being.

RESULTS

Forty-nine patients were included in the intent-to-treat analysis. The mean DAI value decreased from 5.5 at baseline to 1.6 and 1.5 at weeks 3 and 6, respectively (P < 0.0001). Only 4 patients had their dose increased to 500 mg twice daily at week 3. Forty-one patients experienced at least one adverse event, most of which were deemed mild and unrelated to study therapy. The most common treatment-emergent adverse events were gastrointestinal (n = 30, 61.2%).

CONCLUSIONS

This study showed that a daily bedtime dose of a 500 mg mesalamine suppository is safe and efficacious in children with ulcerative proctitis.

Formalin instillation for uncontrolled radiation induced haemorrhagic proctitis

BACKGROUND

Radiation induced haemorrhagic proctitis is a well recognized complication of pelvic radiotherapy and its treatment is quite challenging.

AIM

To evaluate the efficacy of local instillation of 4% formalin in the management of uncontrolled radiation induced haemorrhagic proctitis.

METHODS

This prospective study included twenty-three patients who underwent formalin instillation. We documented the control of the symptoms, assessed the outcome of the treatment, presence of complications & long term results.

RESULTS

All patients were followed for a median of 13 months. In 15 patients, the bleeding stopped after a single treatment and in 6 after a second session. Only two patients required formalin instillation for the third time. During the follow-up period all patients were reviewed systemically with reference to the pretreatment complaints. No recurrent rectal bleeding occurred, bowel frequency was decreased and no further blood transfusion was required.

CONCLUSION

Local instillation of 4% formalin is an effective treatment for uncontrolled radiation induced haemorrhagic proctitis.

Intrarectal application of formalin for chronic radiation proctitis: a simple, cheap and effective treatment

BACKGROUND

Chronic radiation proctitis is known to be a difficult to treat condition. Argon Plasma Coagulation (APC) though being effective requires prolonged sessions and has limited availability. Formalin, by virtue of its chemical cauterizing effects, has been found to be effective in patients with bleeding radiation cystitis and hemorrhagic proctitis. Our goal was to study the effectiveness of 4% formalin instillation in resistant patients of chronic hemorrhagic radiation proctitis.

METHODS

13 patients with chronic radiation proctitis were treated with instillation of 50 mi 4% formalin into the rectum (3 minutes for 3 times). The total mucosal contact time was approximately 10 minutes. Their clinical response, tolerance to treatment and complications were assessed. Patients who did not have complete response were given another session(s) a week later.

RESULTS

The mean (SD) age of patients was 48.62 +/- 11.66 years. Twelve patients (92%) were female who received radiotherapy for carcinoma cervix and 1(08%) was male with carcinoma prostate. The overall clinical response rate was 100%; eight patients (61.5%) had complete cessation of bleeding while 5 patients (38.5%) had significant cessation of bleeding. Eight patients needed only one session, four needed 2 sessions and one patient needed 3 sessions for the clinical response. Serious complications were not observed. No recurrence of symptoms was seen during follow-up.

CONCLUSION

The treatment of hemorrhagic radiation proctitis with local formalin instillation is effective, well tolerated, inexpensive, technically simple and safe procedure.

[Active and refractory ulcerative proctitis: an update]

Ulcerative colitis (UC) is a chronic inflammatory disease of unknown etiology that affects a variable length of the colon, starting from the rectum. When the disease is confined to the rectum is called ulcerative proctitis (UP). Several studies have unsuccessfully attempted to determine the factors that determine the extent of involvement. The goals of therapy in UP are to induce and maintain remission of symptoms and disease. Topical treatment with 5-aminosalicylates (5-ASA) is the treatment of choice to induce remission. In the maintenance phase, long-term follow up studies suggest that treatment with 5-ASA is better than placebo, to maintain the disease inactive. For those patients that do not respond to treatment with topical 5-ASA or have a moderate to severe disease, there are additional therapies such as oral 5-ASA, topical or systemic corticosteroids, immunomodulators, biological therapies (Infliximab) and cyclosporine. Surgery is seldom needed.

[The treatment of an acute paraproctitis]

The results of surgical treatment of an acute paraproctitis in 708 patients, in 9 (1.27%) of whom gangrenous -- putrificated form of paraproctitis was diagnosed, are adduced. In 187 (42.6%) patients the abscess disclosure with intraintestinal purulent fistula, going into intestinal lumen, excision was performed, together with cryptectomy -- in 182 (41.4%), the ligature method was applied in 18 (4.1%) with subsequent fistula excision and its internal orifice plasty using mucosal-submucosal flap. For extrasphincteric or transsphincteric purulent tunnel the abscess was opened and drained, its internal orifice sutured, using 'distant" removable suture. It internal orifice was not revealed there was accomplished procedure of disclosure and draining of purulent cavity, the wound sanation with insufflation of ozone-oxygen mixture. In anaerobic paraproctitis the procedure consisted of disclosure and draining of purulent cavities with necrectomy was performed. To all the patients antibacterial therapy was conducted. In 20 (4.5%) patients an acute paraproctitis recurrence had occurred, in 9 (2%) -- pararectal fistula, and in 5 (1.1%) -- the anal sphincter stage I insufficiency.

[Perianal erythema in a child--group A streptococci?!]

Perianal streptococcal dermatitis is a common disease. The typical clinical picture includes perianal erythema, pruritus, painful defaecation and bloody stools. The diagnosis is made by a swab taken from the affected skin with bacterial culture. Therapy consists of penicillin for 10 days. Screening for affected persons in contact with the patient is indicated because perianal streptococcal dermatitis is known to be highly contagious. Relapse is common and therefore follow-up visits are recommended. In case of relapse, a first or second generation cephalosporin may be considered.