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IDIOPATHIC GRANULAR PROCTITIS
1253
IDIOPATHIC GRANULAR PROCTITIS C. F. J. CROPPER O.B.E., B.A. Oxfd, F.R.C.P.E. PHYSICIAN, RONKSWOOD HOSPITAL, WORCESTER
PUBLISHED reports surprisingly few, and differential diagnosis
on
idiopathic granular proctitis are
textbooks usually omit it from the of rectal bleeding : Price’s (1947) index does not mention it. Brooke’s (1954) description cannot be excelled : "... non-specific procto.-sigmoiditis, an insidious and indolent condition of the distal end of the large bowel, has been observed by many but recorded by few.... A mild, chronic and intractable inflammation is to be seen in the lowermost part of the rectum, often limited to the last two or three inches with a sharply defined upper limit ; less frequently its distribution throughout the rectal ampulla is patchy. On proctoscopy the rectal mucosa in the area involved is granular and bleeds to the touch. Over the course of years the inflammation may spread upwards to involve the sigmoid and at this stage the sigmoidoscopic appearance is not dissimilar from that found in ulcerative colitis ... the onset is insidious and slow and there is no constitutional upset when secondary anaemia results from constant blood except loss.""
between percentage oxygen saturation as determined with the oximeter and by the manometric method of
Fig. 4-Linear relationship Van
Slyke.
Accuracy When
a
series of estimations
are
carried out and
compared with the results obtained with the manometric method of Van Slyke and Neil (1924) the relationship is found to be linear (fig. 4) ; but there is a systematic error which in the above example is z- 14% at 0% saturation. This error depends on the quantity of sodium hydrosulphite added to the samples in order to obtain the readings recorded in fig. 2. The values plotted in the uncorrected line in by reducing them by 14%. OXIMETER
READINGS
OF
(CORRECTED VALUES)
fig
3
PERCENTAGE ON
OBTAINED ON THE SAME METHOD OF VAN SLYKE
therefore corrected
are
OXYGEN
SATURATION
25 SAMPLES, SAMPLES
WITH THE RESULTS BY THE MANOMETRIC
The condition is, however, distressing to the patient and a social handicap, since the presence of blood in the rectum is apt to precipitate diarrhoea. Sigmoidoscopic recognition is easy : there is complete loss of the normal satiny sheen of the mucosa (Cropper 1945), whose place is taken by a coarse roughening of the surface due to the exposure of the deeper layers of the membrane. The inflammation fluctuates unpredictably, and no treatment can be regarded as specific. Since idiopathic granular proctitis has been so seldom described, I review here my own series of 26 cases (see table). This series excludes all cases of secondary granular proctitis, which fall into two groups : those in which the granularity is a forerunner or concomitant of true ulcerative colitis ; and those due to recurrent amoebic dysentery. In both these groups the appearances are identical with those of idiopathic granular proctitis, but in ulcerative colitis actual ulceration of the mucosa can often be seen, with or without blood and pus flowing Such evidence of actual down from higher levels. ulceration rules out, by definition, the diagnosis of
idiopathic proctitis. Similarly, granulation occurring as a stage in recurrent amcebic dysentery must almost invariably be regarded as a sequel of acute amcebiasis. Evidence of its amoebic origin will be forthcoming from the history or from serial sigmoidoscopies at which scrapings from ulcers contain entamoebae. In many cases the metamorphosis, over months, of ulcers into pin-point craters (Cropper 1945) and perhaps of craters into granularity, eliminates benign proctitis from the diagnosis. accompanying table shows the analyses ; fig. 4 was constructed from the The
but with the oximeter values corrected. deviation of the method is 4- 4%. ,
Material and
results of 25 same
readings,
The standard
Summary
A
simple optical cuvette, consisting of a spiral of polythene tubing, is described for use in any photoelectric colorimeter for the oximetry of whole blood. The method is reliable and rapid, and requires only 0-5 ml. blood. REFERENCES Handforth, C. P. (1953) J. Physiol. 120, 43P. Millikan, A. (1942) Rev. sci. Instr. 13, 434. Van Slyke, D. D., Neil, J. M. (1924) J. biol. Chem. 61, 523. Wood, E. H. (1950) In Medical Physics. Editor: O. Glasser. Chicago; vol. 2.
Findings
I have
kept detailed records of about 2300 patients, chiefly ex-Servicemen, involving about 2800 endoscopies between November, 1946, and July, 1954 : 11 of these presented with granular proctitis associated with ulcerative colitis, 7 with granular proctitis following amoebic dysentery, and 26 with the idiopathic granular proctitis. Although 21 of these 26 patients had served in the" tropics, and most of them had been labelled " dysentery at some time in their service, careful study of their
and repeated sigmoidoscopies and stool examinaprovided convincing evidence of a non-dysenteric picture.
history tions
This work was initiated when I was appointed to the then Ministry of Pensions. Therefore most of the material
1254 ANALYSIS OF CASES OF IDIOPATHIC GRANULAR PROCTITIS
selected group. Temporary residence in is tropics not, however, to be regarded as an aetiological factor ; nor is the fact that all the patients were male more than fortuitous. Among general hospital patients idiopathic granular proctitis affects both sexes in roughly equal proportions (B. N. Brooke, personal
represents
I
would be saved from ill-advised, and often harmful therapy.
a
the
and the microscope could be used within sound of the guns. Such a unit would be of incalculable value in promoting immediate treatment of the true dysenteries, and the immediate return to the front line of patients with -granular proctitis.
sigmoidoscope
Note
on
Treatment
It is my impression that phthalylsulphathiazole suppositories (Cluer 1947) have a place, albeit small, in controlling idiopathic granular proctitis. It is true that, since no infective agent has been incriminated, the Plain cocouse of an antibacterial drug is empyrical. butter suppositories are probably just as effective, and it is worth prescribing these, particularly in periods of quiescence. Although severe secondary anaemia was not observed in this series it can develop (B. N. Brooke, personal communication) and would indicate iron therapy. Probably the most valuable part of the
in all 4 cases was about four years. The follow-up letters show that in no case was the patient obliged to lose more than an occasional week’s work : thus even in cases with a six-year history no gross deterioration has taken place. In case 21 the disease has lasted more than thirty years without causing much inconvenience to the patient. It is important that this syndrome should be clearly defined and kept in mind whenever rectal bleeding is If it can be diagnosed with under consideration. precision, the patient can be assured that his disease is comparatively harmless ; this is of great importance because rectal bleeding usually fills the patient with alarm and apprehension, and he is likely to torture himself with possibilities which he hardly dares to mention. There c-,n be no doubt whatever that a very large number of patients with idiopathic granular proctitis were hastily and uncritically diagnosed as having some form of tropical dysentery and treated as such. Indeed tracing back the history of such cases leads one into a tangle of vague diagnoses which in retrospect is impossible to unravel. The upshot of this is that, if the syndrome were widely recognised, the evacuation of personnel from forward areas would be minimised, and many an innocent victim
unnecessary,
I have often thought that the Forward Malaria Treatment Unit evolved in the late war might well be paralleled -by a Forward Dysentery Treatment Unit, where the
communication). The patients marked P.o.w. in the table were in Japanese hands and therefore virtually deprived of diagnostic or therapeutic facilities for the first few years of their " dysentery " : in these cases the past history of the disease was particularly obscure. The length of observation shown in the table is the period from when the patient was first seen by me until the date of the follow-up letter. In 4 cases sigmoidoscopy was done at the end of the period of observation, which
Discussion
expensive,
treatment is
reassurance.
,
Summary 26 cases of idiopathic granular proctitis are reviewed. The recognition of this syndrome is important, so that it can be clearly distinguished from the more serious conditions of which it may be a forerunner, a concomitant, or a
sequel.
I wish to thank Mr. B. N. Brooke for his advice during the preparation of this article. Seeing that war pensioners’ medical documents have been used, it is fitting that acknowledgment should be made to the Ministry of Pensions and National Insurance for permission to use these records. REFERENCES
Brooke, B. N. (1954) Ulcerative Colitis and its Surgical Treatment. Edinburgh ; p. 18. Cluer, E. H. (1947) Lancet, ii, 168. Cropper, C. F. J. (1945) Ibid, ii, 460. Price, F. W. (1947) Textbook of the Practice of Medicine. 7th ed., London.
IDIOPATHIC GRANULAR PROCTITIS C. F. J. CROPPER O.B.E., B.A. Oxfd, F.R.C.P.E. PHYSICIAN, RONKSWOOD HOSPITAL, WORCESTER
PUBLISHED reports surprisingly few, and differential diagnosis
on
idiopathic granular proctitis are
textbooks usually omit it from the of rectal bleeding : Price’s (1947) index does not mention it. Brooke’s (1954) description cannot be excelled : "... non-specific procto.-sigmoiditis, an insidious and indolent condition of the distal end of the large bowel, has been observed by many but recorded by few.... A mild, chronic and intractable inflammation is to be seen in the lowermost part of the rectum, often limited to the last two or three inches with a sharply defined upper limit ; less frequently its distribution throughout the rectal ampulla is patchy. On proctoscopy the rectal mucosa in the area involved is granular and bleeds to the touch. Over the course of years the inflammation may spread upwards to involve the sigmoid and at this stage the sigmoidoscopic appearance is not dissimilar from that found in ulcerative colitis ... the onset is insidious and slow and there is no constitutional upset when secondary anaemia results from constant blood except loss.""
between percentage oxygen saturation as determined with the oximeter and by the manometric method of
Fig. 4-Linear relationship Van
Slyke.
Accuracy When
a
series of estimations
are
carried out and
compared with the results obtained with the manometric method of Van Slyke and Neil (1924) the relationship is found to be linear (fig. 4) ; but there is a systematic error which in the above example is z- 14% at 0% saturation. This error depends on the quantity of sodium hydrosulphite added to the samples in order to obtain the readings recorded in fig. 2. The values plotted in the uncorrected line in by reducing them by 14%. OXIMETER
READINGS
OF
(CORRECTED VALUES)
fig
3
PERCENTAGE ON
OBTAINED ON THE SAME METHOD OF VAN SLYKE
therefore corrected
are
OXYGEN
SATURATION
25 SAMPLES, SAMPLES
WITH THE RESULTS BY THE MANOMETRIC
The condition is, however, distressing to the patient and a social handicap, since the presence of blood in the rectum is apt to precipitate diarrhoea. Sigmoidoscopic recognition is easy : there is complete loss of the normal satiny sheen of the mucosa (Cropper 1945), whose place is taken by a coarse roughening of the surface due to the exposure of the deeper layers of the membrane. The inflammation fluctuates unpredictably, and no treatment can be regarded as specific. Since idiopathic granular proctitis has been so seldom described, I review here my own series of 26 cases (see table). This series excludes all cases of secondary granular proctitis, which fall into two groups : those in which the granularity is a forerunner or concomitant of true ulcerative colitis ; and those due to recurrent amoebic dysentery. In both these groups the appearances are identical with those of idiopathic granular proctitis, but in ulcerative colitis actual ulceration of the mucosa can often be seen, with or without blood and pus flowing Such evidence of actual down from higher levels. ulceration rules out, by definition, the diagnosis of
idiopathic proctitis. Similarly, granulation occurring as a stage in recurrent amcebic dysentery must almost invariably be regarded as a sequel of acute amcebiasis. Evidence of its amoebic origin will be forthcoming from the history or from serial sigmoidoscopies at which scrapings from ulcers contain entamoebae. In many cases the metamorphosis, over months, of ulcers into pin-point craters (Cropper 1945) and perhaps of craters into granularity, eliminates benign proctitis from the diagnosis. accompanying table shows the analyses ; fig. 4 was constructed from the The
but with the oximeter values corrected. deviation of the method is 4- 4%. ,
Material and
results of 25 same
readings,
The standard
Summary
A
simple optical cuvette, consisting of a spiral of polythene tubing, is described for use in any photoelectric colorimeter for the oximetry of whole blood. The method is reliable and rapid, and requires only 0-5 ml. blood. REFERENCES Handforth, C. P. (1953) J. Physiol. 120, 43P. Millikan, A. (1942) Rev. sci. Instr. 13, 434. Van Slyke, D. D., Neil, J. M. (1924) J. biol. Chem. 61, 523. Wood, E. H. (1950) In Medical Physics. Editor: O. Glasser. Chicago; vol. 2.
Findings
I have
kept detailed records of about 2300 patients, chiefly ex-Servicemen, involving about 2800 endoscopies between November, 1946, and July, 1954 : 11 of these presented with granular proctitis associated with ulcerative colitis, 7 with granular proctitis following amoebic dysentery, and 26 with the idiopathic granular proctitis. Although 21 of these 26 patients had served in the" tropics, and most of them had been labelled " dysentery at some time in their service, careful study of their
and repeated sigmoidoscopies and stool examinaprovided convincing evidence of a non-dysenteric picture.
history tions
This work was initiated when I was appointed to the then Ministry of Pensions. Therefore most of the material
1254 ANALYSIS OF CASES OF IDIOPATHIC GRANULAR PROCTITIS
selected group. Temporary residence in is tropics not, however, to be regarded as an aetiological factor ; nor is the fact that all the patients were male more than fortuitous. Among general hospital patients idiopathic granular proctitis affects both sexes in roughly equal proportions (B. N. Brooke, personal
represents
I
would be saved from ill-advised, and often harmful therapy.
a
the
and the microscope could be used within sound of the guns. Such a unit would be of incalculable value in promoting immediate treatment of the true dysenteries, and the immediate return to the front line of patients with -granular proctitis.
sigmoidoscope
Note
on
Treatment
It is my impression that phthalylsulphathiazole suppositories (Cluer 1947) have a place, albeit small, in controlling idiopathic granular proctitis. It is true that, since no infective agent has been incriminated, the Plain cocouse of an antibacterial drug is empyrical. butter suppositories are probably just as effective, and it is worth prescribing these, particularly in periods of quiescence. Although severe secondary anaemia was not observed in this series it can develop (B. N. Brooke, personal communication) and would indicate iron therapy. Probably the most valuable part of the
in all 4 cases was about four years. The follow-up letters show that in no case was the patient obliged to lose more than an occasional week’s work : thus even in cases with a six-year history no gross deterioration has taken place. In case 21 the disease has lasted more than thirty years without causing much inconvenience to the patient. It is important that this syndrome should be clearly defined and kept in mind whenever rectal bleeding is If it can be diagnosed with under consideration. precision, the patient can be assured that his disease is comparatively harmless ; this is of great importance because rectal bleeding usually fills the patient with alarm and apprehension, and he is likely to torture himself with possibilities which he hardly dares to mention. There c-,n be no doubt whatever that a very large number of patients with idiopathic granular proctitis were hastily and uncritically diagnosed as having some form of tropical dysentery and treated as such. Indeed tracing back the history of such cases leads one into a tangle of vague diagnoses which in retrospect is impossible to unravel. The upshot of this is that, if the syndrome were widely recognised, the evacuation of personnel from forward areas would be minimised, and many an innocent victim
unnecessary,
I have often thought that the Forward Malaria Treatment Unit evolved in the late war might well be paralleled -by a Forward Dysentery Treatment Unit, where the
communication). The patients marked P.o.w. in the table were in Japanese hands and therefore virtually deprived of diagnostic or therapeutic facilities for the first few years of their " dysentery " : in these cases the past history of the disease was particularly obscure. The length of observation shown in the table is the period from when the patient was first seen by me until the date of the follow-up letter. In 4 cases sigmoidoscopy was done at the end of the period of observation, which
Discussion
expensive,
treatment is
reassurance.
,
Summary 26 cases of idiopathic granular proctitis are reviewed. The recognition of this syndrome is important, so that it can be clearly distinguished from the more serious conditions of which it may be a forerunner, a concomitant, or a
sequel.
I wish to thank Mr. B. N. Brooke for his advice during the preparation of this article. Seeing that war pensioners’ medical documents have been used, it is fitting that acknowledgment should be made to the Ministry of Pensions and National Insurance for permission to use these records. REFERENCES
Brooke, B. N. (1954) Ulcerative Colitis and its Surgical Treatment. Edinburgh ; p. 18. Cluer, E. H. (1947) Lancet, ii, 168. Cropper, C. F. J. (1945) Ibid, ii, 460. Price, F. W. (1947) Textbook of the Practice of Medicine. 7th ed., London.