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chancres,3symptoms of discharge, bleeding, significant pain, and itching are also other
possible symptoms.
1
Untreated syphilis can evolve to secondary syphilis, where mucous
membrane lesions of the anus and rectum, proctitis, and anorectal condylomata lata can
appear.
1,2
Condyloma lata are warty, mucoid, plaque-like perianal lesions.
17
The Venereal Disease Research Laboratory (VDRL) test and the Rapid Plasma Reagin
(RPR) test (nontreponemal tests) are often used for screening and monitoring response to
therapy. If reactive, the patient should undergo a treponemal test, like the Fluorescent
Treponemal Antibody Absorption (FTA-ABS) test, to confirm the diagnosis. This test
remains positive in most patients after the first infection, so it is not appropriate for disease treatment monitoring. There are several situations that can lead to a false-positive
results in a nontreponemal test, namely infections (e.g., HIV), autoimmune conditions,
immunizations, pregnancy, injection-drug use, and older age, therefore this test needs
to be confirmed.
9
A decline of nontreponemal test titers is usually seen after treatment
(in some cases it can persist for a long period of time) and might become nonreactive with
time.
9
T. pallidum-specific NAATs of the ulcer exudate, condylomata lata, and rectal biop-
sies might allow direct pathogen detection.
12
The CDC guidelines9and the 2014 European guidelines for treatment of adults with
early syphilis
16
recommended as first-line therapy benzathine penicillin G 2.4 million
FIG. 10.2 Perianal syphilis in a man who have sex with men.
Chapter 10 • Infectious Proctitis 129
units IM in a single dose (both HIV-positive and HIV-negative patients). In early stages,
syphilis has a good response to curative treatment.
2
Follow-up and test-of-cure should
be done with nontreponemal tests at 6 and 12 months after treatment, according to the
CDC
9
; and at 1 month, 3 months, 6 months, and 12 months after treatment, according to
the European guidelines.
16
Failure of nontreponemal test titers to decline fourfold at
6–12 months might be indicative of treatment failure. For re-treatment, weekly injections
of benzathine penicillin G 2.4 million units IM for 3 weeks is recommended.
9,16
Sexual partners should be identified: 46%–60% of traced sexual contacts of patients with early syphilis
are likely to be infected and need to be tested at the first visit and repeated at 6 weeks and
3 months.
16
Syphilis increases the risk of HIV transmission (by two to five times) and
patients should also be tested for HIV and other STDs,
2,16
hepatitis C included.
16
10.5 Non-LGV Chlamydia
Infections caused by C. trachomatis are the most commonly reported bacterial STDs in
Europe
12
and in North America.
1,3
The frequent transmission routes are anal sexual inter-
course and cervico/vaginal dissemination in women.
C. trachomatis serovars D-K can cause proctitis. The latency period is around 7–10 days
after infection and most of patients are asymptomatic. Pain, discharge, and rectal bleeding
can be reported with several endoscopic patterns, like friability, ulceration, and mild
erythema.
3
The 2015 European guidelines on the management of C. trachomatis infections recommended using a NAAT for the diagnosis of rectal infection, although the sensitivity and
specificity in rectal specimens are lower compared to urogenital specimens.
18
The recommended first-line therapy is azithromycin 1 g orally once a day or doxycycline 100mg orally twice a day for 7 days (similar for HIV-positive and negative
patients).
9,18
There are some studies s uggesting a lower efficacy of azithromycin in rectal
infection,
19–21
but more data are needed. The CDC9and the 2015 European gui delines
18
recommend both drugs as first-line therapy,
9,18
although the European guidelines recommended a test-of-cure if azithromycin is used. A NAATshould be performed 4 weeks after
completion of therapy.
18
A test-of-cure is not recommended according to the CDC.
9
Patients should be instructed to abstain from sexual intercourse for 7days after singledose therapy or until completion of a 7-day regimen and until all of their sex partners
are treated.
9
Testing for HIV, gonorrhea, and syphilis is also needed. Sexual partners
should be referred for evaluation, testing, and presumptive treatment.
9,18
10.6 Lymphogranuloma Venereum
LGV is a STD caused by C. trachomatis serovars L1, L2, or L3. Since 2003 there has been a
rising incidence in MSM, most of whom are HIV-positive, with several outbreaks reported
in different developed countries presenting as a severe proctitis.
6
Some sexual behavi ors,
like anal enemas, sex with a HIV-positive partner, and sex in sex parties were associated
130 ANORECTAL DISORDERS
with LGV proctitis.22Anorectal manifestations normally occur after inoculation via the
rectum. A systematic review and meta-analysis showed that the prevalence of HIV among
LGV cases was 67% to 100%.
23
LGV normally corresponds to an invasive infection affecting the submucosa and with
lymphatic dissemination to loco regional lymph nodes; serovars D-K infections are confined to the mucosal layer with more mild to asymptomatic clinical presentations.
22
The
classical presentation with tender inguinal and/or femoral lymphadenopathy is now
uncommon.
24
Proctitis and proctocolitis are currently the most frequently reported clin-
ical manifestations of LGV, especially in MSM.
24
This disease can be misdiagnosed as
inflammatory bowel disease (IBD),
25,26
due to the similarities in clinical manifestations,
complications, and endoscopic and histologic appearance. Symptoms of pain, rectal
bleeding, fever, and tenesmus can occur. There are several endoscopic patterns described,
from normal or mild erythematous and friable mucosa to deep ulcers or granulomas with
mucopurulent exudates.
25
Complications might arise, like strictures, fistulas, and
abscesses, similar to Crohn’s disease.
The recommended tests for rectal specimens are NAATs (which are positive in both
LGV and non-LGV chlamydial infections).
9,18
Positive rectal specimens for C. trachomatis
should be characterized further (genotyping for LGV), to differentiate LGV from nonLGV,
13
because this has implications for the recommended treatment duration.
Empiric treatment for LGV should start when compatible symptoms are present.
9
The
CDC
9
and the 2013 European Guideline on the Management of Lymphogranuloma Vener-
eum
27
recommended doxycycline 100 mg orally twice daily for 21 days (simi lar for HIVpositive and HIV-negative patients). The duration of treatment is different from other
chlamydia infections (serovars D-K), where treatment is only 7 days. An alternative regimen is erythromycin 500 mg orally four times a day for 21 days. Screening for HIV and
other STDs should be done, including hepatitis B and C.
27
There should be no sexual contact until therapy is complete, and sexual partners should be tested and presumptively
treated.
27
10.7 Cytomegalovirus
The rectum is an area less frequently affected by CMV, compared with the colon, which is
the most commonly affected area of the gastrointestinal tract.
28
This infection can be a
reactivation or a primary infection, and cases were described in both immunosuppressed
(transplant patients, HIV-positive, chemotherapy)
29
and immunocompetent patients.
30,31
There were cases associated with nonprotected anal sex in MSM and women32; however,
there were situations where this associatio n was not found, especially in the elder ly and/or
patients with comorbidities (e.g., diabetes mellitus and IBD).
30,31
In immunocompetent patients, CMV infection is normally asymptomatic, and clini-
cally significant disease is most often seen in the immunosuppressed.
33
Mononucleosis-like illness with rectal bleeding, after unprotected anal intercourse, is suggestive of sexually transmitted CMV proctitis.
32
Endoscopy can reveal mucositis, ulcera-
tion, polypoid, and mass lesions.
32
Chapter 10 • Infectious Proctitis 131
CMV sero logy is of limited value for diagnosis due to the high seroprevalence of CMV in
the adult population, although a recent infection can be suggested by a positive CMV
IgM.
34
DNA detection by polymerase chain reaction (PCR) in the blood and mucosa allows
rapid quantitative and qualitative results with high sensitivity.
33
Histopathological findings including ulcerations, enlarged cells with intracytoplasmic and intranuclear inclusion bodies, and a positive CMV histochemistry can be helpful for diagnosis.
32
This infectious proctitis generally resolves spontaneously and does not require anti-
viral therapy,
32
but in severe cases, normally in immunosuppressed patients, therapy
needs to be considered.
29
Intravenous (IV) ganciclovir 5 mg/kg twice daily for 2–3 weeks
is the first-line therapy for gastrointestinal infect ion. Foscarnet 90 mg/kg IV twice daily c an
be used as a first option or an alternative in cases of intolerance or ganciclovir failure.
28,34
The presence of sexually transmitted CMV proctitis should raise the suspicion of other
STDs, including HIV, which should be excluded.
32
Regarding IBD, subclinical reactivation of CMV during immunomodulator or biologi-
cal therapy is common but is normally self-limited.
34
The prevalence of CMV is 21%–34%
in acute severe colitis and, in the steroid refractory group, around 33%–36%.
35
The Second
European evidence-based consensus on the prevention, diagnosis, and management of
opportunistic infections in IBD recommended that in cases of acute steroid-resistant colitis/proctitis, CMV should be excluded, and when identified during immunomodulator
therapy, antiviral therapy should be initiated and the discontinuation of immunomodulators considered.
34
CMV diagnoses should be done preferably by PCR in blood and
mucosa or immunohistochemistry of the mucosa.
34
10.8 Amebiasis
Amebiasis is caused by E. histolytica, a protozoan parasite. Other Entamoeba species have
been identified, but E. histolytica is the only one that can cause human disease.
36
Infection
occurs primarily through fecal-contaminated food or water containing cysts, but also by
sexual transmission (oral-anal sex).
37,38
Invasive infections have an increasing prevalence
in developed coun tries in MSM who engage in oral-anal sex.
37
In developing countries the
risk in MSM is less studied.
37
Most E. histolytica infections are asymptomatic (80%– 90%)36and 4%–10% of asymp-
tomatic subjects will develop disease over a year.
38
Colitis and liver abscess are the most
common complications of invasive infections, and bloody diarrhea, fever and abdominal
pain
39
are often reported symptoms. Pregnancy, immunosuppression, and corticosteroids
intake are risk factors associated with more severe disease.
38
Different patterns of endoscopic appear ance for right-side colitis (more commonly
affected) and proctosigmoiditis were described.
39
Aphthae, erosions, ulcers, exudates,
or edematous swollen mucosa in the cecum are normally present in a right-sided colitis.
An edematous swollen mucosa with bloody exudate is the most frequently seen pattern in
proctosigmoiditis, although ulcers and aphthae can also occur, mimicking ulcerative colitis.
39
Amebiasis and ulcerative colitis have different therapeutic approaches (corticoste-
roids are contraindicated in amebiasis); therefore differential diagnosis is important.
132 ANORECTAL DISORDERS
The sensitivity and specificity for detection of E. histolytica in stool are low and microscopy cannot differentiate between the several types of Entamoeba. Antigen assays and
PCR
40
can be used with better sensitivity and specificity.37Antibodies (serology) can be
negative in the acute phase or persist for a long period.
37
In a pilot study including five
patients with suspected amoebic colitis, in vivo visualization of trophozoites by using
an endocytoscope was described (all cases had rectum involvement).
40
These findings
need to be confirmed in a larger study; therefore this method is not currently recommended for diagnosis.
There are no specific recommendations for proctitis therapy due to this pathogen, but
the first-line treatment for invasive amoebiasis are nitroimidazole derivatives (e.g., metronidazole and tinidazole), followed by a luminal agent to eradicate colonization.
37,38
Metronidazole given in an oral dose of 750mg three times daily for 5–10 days is the drug
of choice. For a luminal agent, paromomycin 10mg/kg/day three times daily for 5–10 days
or diloxanide furoate 500 mg three times daily for 10 days
13
orally can be used. Asymptomatic carriers of (only) E. histolytica should receive treatment with luminal agents, to prevent development of invasive disease and the spread of the infection.
37,38
10.9 Conclusions
It is important to recognize infection as a cause of proctitis, the high-risk groups for the
disease and the most commonly involved pathogens (N. gonorrhoeae, C. trachomatis, T.
pallidum, and HSV). A higher index of suspicion should exist in MSM and patients with
IBD that do not respond to therapy. Endosc opy/anoscopy, serology, culture, and, in most
cases, NAATs are important for diagnosis. Diligent and appropriate treatment is necessary
to control the symptoms and disease transmission; most infections have a high cure rate
with therapy. The presence of HIV and other STDs need to be excluded. An increased risk
of HIV transmission is norma lly present in patients with infectious proctitis. In several
countries, the reporting of many of these infections (e.g., syphilis, gonorrhea, and chlamydia) to a health authority is required and should not be neglected.
References
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3. Voth ML, Akbari RP. Sexually transmitted proctitides. Clin Colon Rectal Surg. 2007;20:58–63.
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18. Lanjouw E, Ouburg S, de Vries HJ, Stary A, Radcliffe K, Unemo M. 2015 European guideline on the
management of Chlamydia trachomatis infections. Int J STD AIDS. 2016;27:333–348.
19. Hathorn E, Opie C, Goold P. What is the appropriate treatment for the management of rectal Chla-
mydia trachomatis in men and women? Sex Transm Infect. 2012;88:352–354.
20. Steedman NM, McMillan A. Treatment of asymptomatic rectal Chlamydia trachomatis: is single-dose
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21. Khosropour CM, Dombrowski JC, Barbee L A, Manhart LE, Golden MR. Comparing azithromycin and
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30. Alam I, Shanoon D, Alhamdani A, Boyd A, Griffiths AP, Baxter JN. Severe proctitis, perforation, and fatal
rectal bleeding secondary to cytomegalovirus in an immunocompetent patient: report of a case. Surg
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33. Galiatsatos P, Shrier I, Lamoureux E, Szilagyi A. Meta-analysis of outcome of cytomegalovirus colitis in
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34. Rahier JF, Magro F, Abreu C, et al. European Crohn’s and Colitis Organisation (ECCO). Second Euro-
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35. Kandiel A, Lashner B. Cytomegalovirus colitis complicating inflammatory bowel disease. Am J Gastro-
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Chapter 10 • Infectious Proctitis 135
11
Anorectal Disorders in Inflammatory
Bowel Disease
Jesu´s K. Yamamoto-Furusho, Katya E. Bozada-Guti!errez
IN F L A M M AT O R Y B O W E L DI S E A S E C L I N I C , D E PA R T M E N T O F G A S T R O E NT E R O L OG Y , N A T I ON A L
IN S T I T UT E O F MED I C A L SCI E N C E S A N D N UT R I T I ON S A L V A D O R ZU B I R A´N, M E X IC O C I TY ,
ME X I C O
11.1 Introduction
Inflammatory bowel disease (IBD) comprises two conditions, Crohn’s disease (CD) and
ulcerative colitis (UC). CD can affect the whol e gastrointestinal tract from the oral cavity
to the anus, whereas UC involves the rectum and colon. The etiology is still unknown;
however, it is considered to be a multifactorial disease due to the interaction of genetic,
immunological, and environmental factors.
1
The anorectum is commonly invo lved in patients with IBD, where inflammation and
disease activity can produce anorectal manifestations that affect quality of life. These
complications include fistulas, perianal abscesses, and fissures, which can be associated
with disease acitivity.
2
The aim of this chapter is to describe the most common anorectal disorders in patients
with IBD.
11.2 Anorectal Manifestations in Inflammatory Bowel Disease
In some patients with CD, the anorectal complications are the major cause of symptoms
and morbidity and these are estimated to occur in 25%–35% of cases.
3
Symptoms of perianal CD include pain, bleeding, drainage, and incontinence. The perianal lesions include
abscesses, fistula, hemorrhoids, skin tags (STs), fissures, ulcers, strictures, and
malignancy.
11.3 Epidemiology
The incidence of perianal involvement in CD has been reported to be between 3.8% and
80%.
4
There is a trend toward a higher rate of perianal disease in patients with colorectal
involvement (52% vs 14%), mostly in those who had 99% rectal involvement. This trend
was reported by Wiese et al. where perianal fistulas in CD patients were located in the
small bowel (12%), ileocolonic region, colon (41%), and rectum (92%).
5
Anorectal Disorders. https://doi.org/10.1016/B978-0-12-815346-8.00011-4
© 2019 Elsevier Inc. All rights reserved.
137
The cumulative incidence of perianal CD increases with disease duration. In a
population-based study, the cumulative probability of developing any type of perianal
CD was 29.5% and 42.7% at 10 and 20 years after diagnosis, respectively, and for the development of perianal fistulas was 16.9% and 28.3% at 10 and 20years after diagnosis, respectively.
6
Children and adolescents with CD can suffer from perianal manifestations at rates
of between 13% and 62%; however, a young age at diagnosis increases the risk of developing perianal disease over the time. A study from 1126 patients with CD found that proximal disease is more common in whites (RR ¼ 1.8) than Hispanics, and African Americans
more commonly demonstrate perianal manifestations.
7
11.4 Complications of Perianal Disease
Perianal CD is a clinical manifestation of aggressive disease as well as extra-intestinal
manifestations and steroid resistance that impacts negatively on an individual’s quality
of life. Regarding the need for surgical treatment, more than 80% of patients may require
intestinal resection including proctectomy.
8
Large studies have failed to find a significantly higher incidence of rectal cancer, but
have shown an increased risk for squamous cell carcinoma of the anus in patients with
anorectal involvement in CD.
9
11.5 Diagnosis
The anorectal examination is very important in the assessment of patients with IBD. A
careful evaluation should include a comprehensive history, inquiring about anorectal
pain, purulent discharge or persistent drainage from the anoperineal region, rectal bleeding, recurrent urinary tract infections, and fecal incontinence (FI). It is important to evaluate the presence of abscess, perianal and rectovaginal fistulas, and anorectal strictures,
which may be difficult to distinguish from STs and hemorrhoids. Other modalities used in
the diagnosis and classification of perianal CD include examination under anesthesia
(EUA), anorectal endoscopic ultrasound (EUS), and pelvic magnetic resonance imaging
(MRI), all of which are helpful tests to identify the location of anorectal complications.
10
11.6 Classification
Anorectal disorders can be divided into two groups in relation to the disease activity:
1. Primary lesions involving inflammatory pseudo STs, fissures, ulcerations, and
granulomatous cutaneous lesions; and
2. Secondary lesions including abscess, anal fistula, and anorectal strictures associated
with flares in CD.
In 1978, Hughes et al.
11
proposed an anatomic and pathologic classification for perianal
CD (the Cardiff classification), which is described in
Table 11.1. Conceptually, the
138 ANORECTAL DISORDERS
classification is analogous to the TNM system for cancer. The main classification defines
the presence of ulceration, fistula/abscess, and strict ure, qualified by numeric values
reflecting severity (0 ¼ not present, 1¼ limited clinical impact, and 2 ¼ severe). A subclassification defines associated conditions, proximal intestinal involvement, and disease
activity. In addition, the classification may be used in a detailed form for research or comparative purposes or in a simple form defining only the dominant lesions for routine
clinical use.
11.6.1 Skin Tags
STs are present in 37% of patients with CD.
11
They are usually asymptomatic, soft, and
mobile, but can become inflamed, hard, and painful during a CD flare.
11.6.1.1 Classification
STs have been classified into two types. One is raised, broad, or narrow; single or multiple;
soft or firm; and painless, and the tags are often referred to as “elephant ears.” The second
one is characterized as edematous, hard, oft en cyanotic, tender or not, and typically
Table 11.1 Cardiff Classification
U: Ulceration F: Fistula or Abscess S: Stricture
0 Not present
1 Superficial fissures
(a) posterior and/or anterior
(b) lateral
(c) with gross skin tags
0 Not present
1 Low or superficial
(a) perianal
(b) ano-vulval/
anoscrotal
(c) intersphincteric
(d) ano-vaginal
0 Not present
1 Reversible stricture
(a) anal canal-spasm
(b) low rectum-membranous
(c) spasm with severe pain (no
sepsis)
2 Cavitating ulcers
(a) anal canal
(b) lower rectum
(c) With extension to perineal skin (aggressive
ulceration)
2 High
(a) blind supralevator
(b) high direct
(anorectal)
(c) high complex
(d) rectovaginal
(e) ileoperineal
2 Irreversible stricture
(a) anal stenosis
(b) extrarectal stricture
Subsidiary classification
A Associated anal conditions
0 None
1 Hemorrhoids
2 Malignancy
3 Other specify
P Proximal intestinal
disease
0 No proximal disease
1 Contiguous rectal
disease
2 Colon (rectum spared)
3 Small intestine
4 Investigation
incomplete
D Disease activity (in anal lesions)
1 Active
2 Inactive
3 Inconclusive
Chapter 11 • Anorectal Disorders in Inflammatory Bowel Disease 139
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