Thursday, 5 December 2013

Proctitis – Ischemic proctitis Treatments In conventional medicine perspective

Proctitis is is defined as a condition of inflammation of the anus and the lining of the rectum (i.e., the distal 10–12 cm) of that can lead to bowl discomfort, bleeding, a discharge of mucus or pus, etc.
VI. Treatments
A. In conventional medicine perspective
Medical treatment of proctitis depends on the etiology
A.2. Ischemic proctitis
A.2.1. Acute ischemic proctitis
1. Non surgical interventions, include
a. Superficial mucosal ischemia
Superficial mucosal ischemia was treated without surgery, but deeper levels of necrosis required laparotomy and Hartmann’s resection. Rectal excision was not necessary. Four patients survived the ischemic event(67).
b. Formalin instillation
Topical (4 percent) formalin is safe and effective in treatment of radiation-induced hemorrhagic proctitis. A single treatment will stop bleeding in 75 percent of patients(68). Other study also indicated that there is a case of an elderly male with multiple medical problems and hemorrhagic, ischemic proctitis is presented. The proctitis was refractory to all other medical options but responded to topical instillation of 4 percent formalin(69).
2. Surgical interventions include
a. Proctectomy
There is a report of four cases of acute ischemic proctitis that required complete proctectomy. All patients had large vessel atherosclerosis with rectal bleeding and sepsis as the presenting signs and symptoms. Three of four patients underwent complete proctectomy as the initial procedure. The fourth patient underwent complete proctectomy five days after the initial intervention. Two of four patients survived and were ultimately discharged from the hospital. A third patient recovered from surgery but ultimately died of respiratory complications. Only the patient who was initially treated by subtotal proctectomy died as the result of the disease. Although ischemic necrosis of the rectum is rare, complete proctectomy may be necessary to save the patient’s life(70).
b. Transcatheter embolization
In the study of treatment of lower gastrointestinal bleeding was attempted in 13 patients by selective embolization of branches of the mesenteric arteries with Gelfoam, showed that One patient improved after embolization but bleeding recurred within 24 hours and in another patient the catheterization was unsuccessful. Five patients with diverticular hemorrhage were embolized in the right colic artery four times, and once in the middle colic artery. Three patients had embolization of the ileocolic artery because of hemorrhage from cecal angiodysplasia, post appendectomy, and leukemia infiltration. Three patients had the superior hemorrhoidal artery embolized because of bleeding from unspecific proctitis, infiltration of the rectum from a carcinoma of the bladder, and transendoscopic polypectomy(71).
A.2.2. Chronic ischemic proctitis
1. Non surgical treatments
In the study to identify the various non-surgical treatment options for the management of late chronic radiation proctitis and evaluate the evidence for their efficacy, showed that Sixty-three studies met the inclusion criteria, including six randomised controlled trials that described the effects of anti-inflammatory agents in combination, rectal steroids alone, rectal sucralfate, short chain fatty acid enemas and different types of thermal therapy(72).
2. Surgical interventions include
1. Laparoscopic colorectal surgery
In the study to assess the outcome of laparoscopic colorectal surgery in patients >60 years of age and compare it to a younger group of patients who underwent similar procedures, indicated that here were no statistically significant differences between the younger and older groups relative to the incidence of complications (11 vs 14%, respectively) and conversion (8 vs 11%, respectively) or the length of ileus (2.8 vs 4.2 days, respectively) or hospitalization (5.2 vs 6.5 days, respectively) (P = NS for all). There was no mortality in either group. The outcome of laparoscopic colorectal surgery in older patients is similar to that noted in younger patients. Advanced age should not be a contraindication to laparoscopic colorectal surgery(73).
2. Laparoscopic or laparoscopic-assisted colorectal operations
There were 140 laparoscopic and laparoscopic-assisted procedures performed between May 1991 and January 1995. The mean patient age was 48 (range 12-88) years; there were 78 males and 62 females. Indications for surgery included inflammatory bowel disease in 47, colorectal carcinoma in 19, diverticular disease in 17, polyps in 16, familial polyposis in 7, colonic inertia in 7, fecal incontinence in 11, sigmoidocele in 3, irradiation proctitis in 3, rectal prolapse in 2, intestinal lymphoma in 2, and miscellaneous conditions in 6. The procedures included 38 total abdominal colectomies (TAC) (ileoanal reservoir 28, ileorectal anastomosis 8 and end ileostomy 2); 70 segmental resections of the colon, small bowel, and rectum(74)
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