Factors Associated With Proximal Disease Extension in Ulcerative Proctitis: Experience From an IBD Tertiary Center in Southeastern Brazil

BACKGROUND: Ulcerative proctitis (UP) accounts for a significant proportion of cases of ulcerative colitis (UC) and implies limited involvement of the rectum. Some patients presenting initially with UP may progress to more extensive colitis (inflammation found distally to the rectum-sigmoid junction). Although several predictive factors for this progression have been described, none has been established as definitive. We aimed at determining risk factors predictive of proximal disease extension in UP. METHODS: Retrospective analysis of data from 97 patients (67% female) with UP (Montreal Classification: E1) with at least 12 months of follow-up at the local University Hospital from January 2001 up to December 2018. Proximal extension was evaluated endoscopically during follow-up and was defined as E1 progressing to E2/E3. Factors examined comprised age, gender, race, presence of extraintestinal manifestations, Mayo endoscopic score, disease relapse, use of corticosteroids, immunosuppressive and biological agents and colectomy. We used univariate analysis (Chi-square test) to assess the association of individual factors to proximal disease extension. RESULTS: A total of 29 (29.9%) patients experienced proximal disease extension during a mean follow-up of 137.36 ± 86.63 months. The following factors were significantly associated with proximal disease extension: higher initial Mayo score ( P = 0.035) and higher initial disease severity ( P = 0.0024). Use of corticosteroids initially (86.2% vs 41.2%, P < 0.0001), increased disease relapse rate (86.2% vs 20.6%, P < 0.0001) and the need for immunosuppressive agents (57.1% vs 13.6%, P < 0.0001) or biological agents (42.9% vs 10.3%, P < 0.0001) were all significantly higher among UP patients with disease proximal extension, when compared to non-extensors. Colectomy was also associated with proximal disease extension ( P = 0.0002). No significant association was found between UP proximal extension and gender, race, age at diagnosis and extraintestinal manifestations. CONCLUSION(S): UP is a dynamic disease that may progress over time. UP patients with increased clinical and endoscopic severity at the diagnosis are likely to evolve with proximal extension and should be more carefully followed up.