The Proctitis Paradox: Refractory Ulcerative Proctitis Associated With Development of Disease Complications in a Multicenter South Australian Cohort.

BACKGROUND: Despite limited extent, patients with ulcerative proctitis (UP) can suffer from debilitating symptoms, complications, and risk of disease extension. The aim was to provide a contemporary real-world insight into the management and outcomes of UP. METHODS: A retrospective cohort study was conducted of UP patients attending three tertiary hospitals in Adelaide, South Australia, between 2015 and 2024. Demographic, treatment, and disease-related data were captured. Treatment success was defined as clinical response at last follow up. The primary outcome was the development of disease-related complications. RESULTS: Of 185 patients with UP, 60.5% were female, mean age at diagnosis was 41.1 years (±14.2) and median duration of follow up was 4.18 years (IQR 2.0-7.3 years). Most patients (n = 114, 62.3%) achieved treatment success with 5-ASA therapy, but one third (n = 56, 30.3%) developed refractory UP. For those with refractory UP, treatment success was achieved in 45% of patients using systemic immunomodulators (n = 40) and in 59% using advanced therapies (n = 27). Topical tacrolimus was used in 10 patients, of whom three achieved treatment success. Overall, 34 patients (18.4%) developed either proximal disease extension (n = 22, 11.9%) or traditional UC related complications including hospitalization (n = 15, 8.1%) and colectomy (n = 1, 0.05%). The presence of refractory UP was associated with development of traditional UC related complications (p < 0.0001). CONCLUSION: Despite a short segment of inflammation, UP remains a clinical conundrum as many patients develop refractory disease, disease extension, and complications. Further prospective studies are required to define optimal therapeutic strategies for this under-recognized cohort.