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.