Ulcerative Proctitis

Ulcerative colitis (UC) is a chronic inflammatory disease of digestive tract of unknown cause. This disease is characterized by a chronic course with alternating periods of activity and clinical remission. The incidence of UC in America has a range extending from 2.2 to 14.3 per 100,000 population per year [1]. The continuous involvement from the rectum to proximal presents an extension that is variable among patients and in the course of the disease [2]. The extension of the compromise determines its clinical presentation, the treatment and prognosis of UC [2]. Depending on the size, it is classified as proctitis or ulcerative proctitis (UP) when it affects the rectum; left or distal colitis when inflammation is distal to the splenic flexure and extended colitis when the inflammation reaches the transverse colon, right or has an involvement the entire colon [2]. Several studies have attempted to establish the factors that determine the extension of the involvement. Among the factors associated with rectal compromise are middle age patients, absence of serious bleeding and absence of extraintestinal manifestations [3]. However, these factors have not been replicated, so even today there are no factors strongly related to PU [1,4]. The mayority of the new cases are diagnosed in adults as a PU or distal colitis [1,5]. Although initial reports indicated that PU had a low frequency [6], recent studies reported that incidence has been increasing up to 48% and 60% [4,7], whereas the incidence of colitis has been decreasing in most geographic areas [8]. Some authors have suggested that PU represents a completely different clinical entity from the CU [8-9]. However, most authors agree that the PU is an initial form of CU with the potential to extend into the proximal segments of the colon [10-12]. Ulcerative proctitis, unlike other forms of more extensive presentation of CU, is clinically characterized by bleeding and or rectal pushing, without systemic symptoms or abnormal physical examination or laboratory tests and can be treated solely with topical rectal therapies [7]. The 5-aminosalicylates (5-ASA) and corticosteroids are available for topical use as a local anti-inflammatory agents [7]. These drugs can get straight to the site of inflammation, which decreases systemic absorption and minimize potential side effects [7,13]. The oral 5-ASA is also an alternative prior to the use of corticosteroids, as these have a number of risks and limitations in short and long term use, reserving for very severe active PU [14]. When refractory to previous treatment, drugs that can be used to induce and maintain remission are immunomodulators such as azathioprine [15], 6-mercaptopurine [16] and/or Infliximab therapy [17-18].