Introduction

Ulcerative colitis (UC) is a type of inflammatory bowel disease (IBD) that causes inflammation and ulcers in the lining of the colon and rectum. The exact cause of Ulcerative Colitis (UC) is still not fully understood. It tends to follow a chronic course, meaning it persists over time with periods of flare-ups and remissions where symptoms improve. One specific form of UC is called ulcerative proctitis (UP) and is a form of inflammatory bowel disease (IBD) characterised by inflammation and ulceration in the rectum, which is the lower part of the large intestine or colon. About 25-55% of UC patients initially present with UP.¹ Compared to other forms of UC that affect larger portions of the colon, UP typically has a milder course and responds well to treatment applied directly to the affected area. The good news is that UP is associated with a better prognosis compared to more extensive forms of UC. It tends to have fewer severe flare-ups and complications, and patients with UP are less likely to need surgery, hospitalisation, or strong medications like steroids or immunosuppressants. However, it's still important to monitor UP closely because some patients may develop complications over time.^1,3

Ulcerative proctitis in the rectum

Symptoms

• Rectal bleeding: Blood in the stool or toilet paper after bowel movements is a common symptom of UP. The blood may appear bright red/maroon-coloured
• Rectal pain or discomfort: Some individuals may experience pain or discomfort in the rectum ranging from mild to severe. This discomfort may be described as a constant ache or sharp, cramp-like pain³
• Urgent bowel movements: People with UP may feel a sudden/urgent need to have a bowel movement, regardless of whether the rectum is full or not. This urgency may lead to frequent bathroom trips
• Diarrhoea: Loose, watery stools may occur, especially during flare-ups or inflammation. 
• Tenesmus: This is a persistent feeling of needing to pass stool, even after having a bowel movement. Tenesmus is often described as a constant, uncomfortable sensation in the rectum
• Change in bowel habits: Some individuals may experience changes in their bowel habits, such as increased frequency of bowel movements or the feeling of incomplete emptying after defecation
• Fatigue: Chronic inflammation and frequent bowel movements can lead to fatigue or a general feeling of tiredness, which may impact daily activities^4,8

Treatments

General

When treating ulcerative colitis (UC), doctors consider how severe the condition is and how it affects different parts of the colon. They also look at how often the symptoms come back, how the person responded to previous treatments, and if there are any other health issues related to UC. Age and how long the person has had UC also matter. It's important to figure out if someone needs to be hospitalised for severe UC or if they can be treated as an outpatient. One way doctors determine this is by using the Truelove and Witts index, which helps identify severe UC. If a person has at least six episodes of bloody stools per day and either a fast heartbeat, a fever, low red blood cell count, or high sedimentation rate, they likely have severe UC. Just one extra symptom along with the frequent bloody stools confirms it's a severe attack.^2,3

In simpler terms, severe UC means a person has frequent bloody stools and at least one other serious symptom like a fast heartbeat, fever, low red blood cell count, or high sedimentation rate. This helps doctors decide on the best treatment plan and whether hospitalisation is needed.²

Treatment according to the site of disease and disease activity

Proctitis

When someone has proctitis, which is inflammation of the rectum, the first treatment doctors usually recommend is a medication called mesalamine, also known as 5-aminosalicylic acid or 5-ASA. This medication is often given as suppositories, which are inserted into the rectum because they target the inflammation better and are easier for patients to use.⁶

A review of many studies found that mesalamine suppositories are better than placebo at reducing symptoms, improving the appearance of the colon during examination, and healing the lining of the colon. This helps reduce inflammation and symptoms like bleeding and diarrhoea.² Mesalamine foam or enemas (liquid medication) are other options, but suppositories are usually preferred because they deliver the medication right where it's needed and are easier for most people to use. This means they help people feel better, improve the appearance of the colon, and promote healing. The review also found that using suppositories once a day is just as effective as using them multiple times a day.⁵

Using mesalamine directly in the rectum is better than using steroids because it's more effective at reducing inflammation without as many side effects. Sometimes, doctors might suggest using mesalamine suppositories along with mesalamine pills or topical steroids for even better results. This combination approach can be more effective at treating proctitis and helping people feel better.⁶

Overall, mesalamine suppositories are often the first choice for treating proctitis because they are effective and well-tolerated by most people. If they don't work, or if someone can't use them, there are other options available to help manage symptoms and promote healing of the rectum.⁷

Sulfasalazine

Sulfasalazine is an oral medication used for certain types of ulcerative proctitis, but it's not commonly used in the United States due to the lack of rectal preparations. While it's affordable, some people don't tolerate it well. It's usually considered when other treatments like topical medications and steroids haven't worked or for long-term maintenance after symptoms have improved.³

Side effects of sulfasalazine can be divided into two groups. The first group includes dose-related side effects like headaches, nausea, vomiting, and stomach discomfort. The second group, which isn't related to the dose, can be more serious and includes symptoms like fever, anaemia, pancreatitis, kidney problems, liver issues, low white blood cell count, and changes in sperm count.³

Refractory proctitis

When proctitis doesn't respond well to initial treatments like mesalamine suppositories or enemas, it's called refractory proctitis. In these cases, more powerful medications may be needed to control inflammation and symptoms.

• Systemic Steroids: These are medications taken by mouth or through a vein (intravenously) that help reduce inflammation throughout the body. They can be effective for treating severe or refractory proctitis, but they also come with potential side effects, especially when used for long periods²
• Immunosuppressants: These medications work by suppressing the immune system's response, which helps reduce inflammation. They are often used in cases of refractory proctitis to control symptoms and prevent flare-ups. Examples include azathioprine, 6-mercaptopurine, and methotrexate¹²
• Biologics: Biologic therapies are a type of medication that targets specific molecules involved in the inflammatory process. They are often used when other treatments haven't worked well enough. Biologics are usually given by injection or infusion and may include drugs like infliximab, adalimumab, vedolizumab, or ustekinumab²

Left-sided ulcerative colitis

For people with mild to moderately active left-sided colitis, the first treatment doctors usually recommend is a combination of mesalamine taken by mouth and mesalamine applied directly to the rectum. This combination therapy is more effective at achieving remission and results in a shorter time to remission compared to taking mesalamine by mouth alone. However, both oral and topical mesalamine are better than doing nothing at all. When mesalamine is applied directly to the rectum, it leads to higher concentrations of the medication in the rectal area compared to taking it by mouth.² Low-volume enemas are just as effective as high-volume ones and may be easier for some people to tolerate.¹⁰

While mesalamine is generally better than steroid medications for treating left-sided colitis, one type of steroid called beclomethasone dipropionate seems to work about the same as rectal mesalamine. Budesonide rectal foam alone can also help induce remission for mild to moderate left-sided colitis.⁹

Oral mesalamine is about as effective as another medication called sulfasalazine, but it tends to cause fewer side effects. Taking mesalamine once a day is just as good as taking it multiple times a day, and different forms of mesalamine all seem to work equally well.⁹

Extensive ulcerative colitis

For individuals with mild to moderately active extensive ulcerative colitis, which involves inflammation throughout a large portion of the colon, initial treatment typically involves a combination of therapies. This includes using an aminosalicylate enema at a dose of 1 gram per day, along with oral mesalamine at a dose of at least 2.4 grams per day.

For individuals with more severe symptoms or those who do not respond adequately to mesalamine therapy, systemic corticosteroids may be necessary. These are medications that are taken orally or through injection and work throughout the body to reduce inflammation.³

Severe extensive ulcerative -Colitis

In cases of severe extensive colitis, where symptoms are particularly severe or complications are present, hospital admission may be necessary for intensive treatment and monitoring. This allows for closer medical supervision and access to additional therapies if needed to manage the condition effectively.

When severe active ulcerative colitis is diagnosed, the initial recommended treatment involves intravenous steroids. However, in cases where patients experience serious adverse events due to steroids or do not respond well to them, an alternative treatment option is monotherapy with intravenous ciclosporin. Ciclosporin can be particularly beneficial in these cases

In addition to medication, it's important for patients with severe active ulcerative colitis to receive supportive care. This includes ensuring that patients receive adequate volumes of intravenous fluids to maintain hydration and providing low-molecular-weight heparin for thromboprophylaxis to prevent blood clots. If patients experience electrolyte abnormalities or anaemia, these should be promptly corrected as needed.

Given the severity of the condition and the complexity of treatment, patients with severe active ulcerative colitis are best managed by a multidisciplinary team. This typically involves collaboration between a gastroenterologist (a specialist in digestive disorders) and a colorectal surgeon (a specialist in surgical procedures involving the colon and rectum). This joint approach ensures that patients receive comprehensive care addressing both medical and surgical aspects of their condition, and it's supported by evidence.³

The goal of maintenance therapy

The main goal of maintenance therapy in ulcerative colitis is to achieve and sustain remission without the need for steroid medications. Remission is defined both clinically and endoscopically.

Clinical remission refers to the absence of symptoms such as increased stool frequency and rectal bleeding. Endoscopic remission, on the other hand, is confirmed by visual examination of the colon and rectum, showing no signs of inflammation or ulceration.

Long-term studies have demonstrated that achieving and maintaining remission is crucial for improving the outcomes of UC. Patients who remain in remission for extended periods experience better long-term prognosis. Continuous treatment with medications such as 5-ASA (5-aminosalicylic acid), thiopurines, or biologics has been shown to increase the likelihood of achieving and sustaining remission over time.¹¹

Risk factors for relapse

The choice of maintenance treatment for ulcerative colitis depends on several factors:

• Disease Extent: The extent of the disease throughout the colon helps determine the appropriate maintenance therapy
• Disease Course: This includes how often flare-ups occur and their severity. Understanding the pattern of the disease helps in selecting the most suitable long-term treatment
• Response and Side Effects of Previous Treatments: If previous maintenance treatments have been ineffective or caused adverse effects, alternative options may be considered
• Severity of the Most Recent Flare: The severity of the most recent flare-up can influence the choice of maintenance therapy. More severe flares may require more aggressive maintenance treatment
• Treatment Used for Inducing Remission: The medication or therapy that was successful in inducing remission during the most recent flare may influence the choice of maintenance treatment
• Safety of Maintenance Treatment: The safety profile of the maintenance therapy is crucial, as long-term use may be necessary to manage the chronic condition
• Cancer Prevention: Some maintenance treatments may offer additional benefits in terms of reducing the risk of developing colon cancer, which is a concern in ulcerative colitis²

Taking all these factors into account, healthcare providers work with patients to choose the most appropriate maintenance treatment plan to effectively manage their ulcerative colitis and minimise the risk of future flare-ups and complications.

Surgical options for refractory proctitis

Surgery is not often needed for proctitis. But if treatments like medications don't work, especially for those with inflammation spreading further up the colon, surgery might be necessary. Surgery options include procedures like restorative proctocolectomy or proctocolectomy with an ileostomy. In some cases, a diverting colostomy might be the best choice. These surgeries aim to remove the affected parts of the colon and rectum to improve symptoms and quality of life.³

Summary

Ulcerative proctitis (UP) is a milder form of UC affecting the rectum. UP is inflammation in the rectum without a known cause. Doctors diagnose it by considering symptoms, examining the rectum with a scope and checking tissue samples. The disease can affect people differently. Some may quickly improve and have a few issues afterwards, while others may need ongoing treatment for frequent flare-ups. The extent of inflammation also varies, with some only having rectal involvement and others experiencing inflammation farther up the colon. Symptoms include rectal bleeding, pain, urgency, diarrhoea, tenesmus, changes in bowel habits, and fatigue. Treatment often begins with mesalamine suppositories and may progress to systemic steroids, immunosuppressants, or biologics for refractory cases. Severe cases may require hospitalisation and intravenous steroids or ciclosporin. Maintenance therapy aims to achieve and sustain remission without steroids, considering disease extent, course, previous treatments, severity, and safety. Collaboration between gastroenterologists and colorectal surgeons is essential to ensure comprehensive care.^4,8