Table 1.
Reasons for treatment refractoriness in patients with ulcerative proctitis.
| Etiology | Investigations | Approach |
|---|---|---|
| Lack of adherence to treatment | History, interview | Patient education, single vs divided doses, suppositories vs enemas, change route of administration |
| Suboptimal treatment (inadequate dose and schedule, monotherapy, increased BMI) | Dose optimization, combination therapy, supportive measures | |
| Duration of treatment | Wait at least 2–3 weeks | |
| Disease extension | Endoscopy | “Treat to target” |
| Proximal constipation | Abdominal x-ray | Νon-stimulant osmotic laxatives |
| NSAIDS | History | Use of COX-2 inhibitors, alternative regimens |
| CMV | Biopsies (inclusion bodies, IHC, PCR) | Antiviral treatment |
| Clostridioides difficle | GDH, Toxins, NAAT | Treatment according to severity - guidelines |
| Superinfections (Cambylobacter, Salmonella, Shigella, Cryptosporidium, Strongyloides, Schistosoma) | Stool cultures for bacteria and parasites | Treat accordingly |
| STDs (Neisseria gonorrhoeae, Chlamydia trachomatis, Herpes simplex virus, Syphilis, Lymphogranuloma Venereum) | Cultures, PCR | Specific treatment as indicated |
| Crohn's disease | Ileocolonoscopy (repeat biopsies), MRE | Treatment modification |
| Radiotherapy or immunotherapy (cell-cycle checkpoint inhibitors) exposure | History, endoscopy | Treat accordingly |
| Mesalazine-induced colitis | Temporal association of symptoms | Treatment cessation and re-introduction trial |
| Proctitis cystica profunda, Chemical proctitis |
BMI: body mass index, CMV: cytomegalovirus, COX-2 inhibitors: cyclo-oxygenase-2 inhibitors, GDH: glutamate dehydrogenase, IGRA: interferon gamma release assay, IHC: immunohistochemistry, MRE: magnetic resonance enterography, NAAT: nucleic acid amplification tests, NSAIDs: non-steroidal anti-inflammatory drugs, PCR: polymerase chain reaction, STD: sexually transmitted diseases.