Introduction

Ulcerative proctitis (also called isolated proctitis) affects approximately 30% of patients with ulcerative colitis , yet achieving disease control remains challenging. Controlling the disease is essential to preventing disability and disease progression. Backbone therapy includes topical and oral 5-aminosalicylic acid (5-ASA) and steroids. One third of patients with ulcerative proctitis are refractory to conventional therapy with 5-ASA and steroids.

Aims & Methods

The aim of this study was to investigate current practice on isolated proctitis management across the globe.
Physicians with experience in treating inflammatory bowel diseases (IBD) were invited to participate in an anonymous, multiple-choice survey between January and February 2025. The survey addressed various aspects of patient care including clinical practice and attitudes towards isolated proctitis identification, disease activity measurement attitudes, and current treatment of isolated proctitis, including the use of advanced therapies.

Results

The survey included 460 physicians from 66 countries. Gastroenterologists were the most represented specialists (89.0%), followed by surgeons (6.3%), and internal medicine doctors (3.5%). Three quarters of participants (74.6%) had > 10 years of experience in IBD.
The majority of participants (87.9%) assessed clinical activity of isolated proctitis within 3 months of treatment initiation, 75.9% used fecal calprotectin, and 67.1% used C-reactive protein (CRP) to measure disease activity. Endoscopic assessment was performed 3 to 6 months (34.2%) or 6 to 12 months (48.4%) after treatment induction. For patients in clinical remission, the participants assessed clinical and biological disease activity every 6 months (54% and 59% respectively), and endoscopic evaluation every 5+ years (rectosigmoidoscopy: 27% and colonoscopy: 31%).
In this survey, 49% of participants were more reluctant to begin an advanced therapy in patients with isolated proctitis compared to pancolitis or left sided colitis. Infliximab (mean 6.55/10; SD: 2.64), vedolizumab (mean 5.64/10; SD: 2.98), upadacitinib (mean 4.88/10; SD: 2.91), and ustekinumab (mean 4.81/10; SD: 2.90) were preferred in refractory proctitis. Two thirds of participants (61.0%) were less likely to use biologics in combination with immunosuppressants in isolated proctitis compared to left sided or pancolitis. Anti-TNF (tumor necrosis factor) (48.4%) was the preferred choice in first line advanced therapy after failing conventional treatment.

Conclusion

This study highlighted differences in management of isolated proctitis compared to left sided colitis or pancolitis. This is likely explained by the fact that isolated proctitis patients were historically excluded from clinical trials, therefore management relied on extrapolation of data from studies on more extensive disease. To date, a single advanced therapy (etrasimod) has demonstrated efficacy in isolated proctitis patients through a double blinded, randomized clinical trial . Future clinical trials on advanced therapies for this frequent and disabling condition are eagerly awaited.

References

1. Fumery M, Singh S, Dulai PS, Gower-Rousseau C, Peyrin-Biroulet L, Sandborn WJ.. Natural history of adult ulcerative colitis in population-based cohorts: a systematic review. Clin Gastroenterol Hepatol 2018;16:343–356.e3.
2. Dubois E, Moens A, Geelen R, Sabino J, Ferrante M, Vermeire S.. Long-term outcomes of patients with ulcerative proctitis: analysis from a large referral centre cohort. United European Gastroenterol J 2020;8:933–41.
3. Peyrin-Biroulet, L., Dubinsky, M. C., Sands, B. E., Panés, J., Schreiber, S., Reinisch, W., Feagan, B. G., Danese, S., Yarur, A. J., D'Haens, G. R., Goetsch, M., Wosik, K., Keating, M., Lazin, K., Wu, J., Modesto, I., McDonnell, A., Bartolome, L., & Vermeire, S. (2024). Efficacy and Safety of Etrasimod in Patients with Moderately to Severely Active Isolated Proctitis: Results From the Phase 3 ELEVATE UC Clinical Programme. Journal of Crohn's & colitis, 18(8), 1270–1282. https://doi.org/10.1093/ecco-jcc/jjae038

Disclosure

This study was conducted as a collaboration between Materia Prima and Pfizer. Materia Prima is the study sponsor.

Introduction

Precut techniques provide an alternative approach for biliary cannulation during ERCP. While traditionally considered high-risk and typically reserved for high-volume centers, recent evidence supports the safety and efficacy of early precut techniques when performed by experienced endoscopists. However, data on the safety of precut techniques in the outpatient setting remain limited, particularly in comparison to standard sphincterotomy.

Aims & Methods

We conducted a retrospective analysis of all outpatient ERCP procedures performed at our institution between 2020 and 2024. A total of 304 cases were reviewed. Patients were divided into two groups: Group A, who underwent standard sphincterotomy, and Group B, who required precut techniques following failed standard cannulation attempts.

Results

A total of 159 outpatient ERCPs involving naïve papillae were included: 122 in Group A and 37 in Group B. There was no significant difference in baseline characteristics and indications for ERCP between the 2 groups. Overall cannulation success rate was 97.5% (n=155/159), reaching 89.2% (n=33/37) in the pre-cut group. There was an overall post-procedure complication rate of 6.9% (n=11/159): 7.4% (n=9/122) of patients in Group A and 5.4% (2/37) in Group B, with no significant difference between groups (p= 0.860).

Conclusion

In our outpatient ERCP cohort, precut techniques demonstrated a favorable safety profile and comparable outcomes to standard sphincterotomy. These findings support the selective use of precut methods in the outpatient setting.

References

1) Moreira M, Tarrio I, Andrade AJ, Araújo T, Fernandes JSS, Canena J, Lopes L. Standard Cannulation versus Fistulotomy for Biliary Access in Endoscopic Retrograde Cholangiopancreatography: Should We Expect the Same Success when Treating Choledocholithiasis? GE Port J Gastroenterol. 2024 Feb 14;31(6):401-407. doi: 10.1159/000536398. PMID: 39633909; PMCID: PMC11614427.
2) Jeurnink SM, Poley JW, Steyerberg EW, Kuipers EJ, Siersema PD. ERCP as an outpatient treatment: a review. Gastrointest Endosc. 2008 Jul;68(1):118-23. doi: 10.1016/j.gie.2007.11.035. Epub 2008 Mar 4. PMID: 18308308.