Proctitis affects approximately 30% of patients at presentation and later spreading to a more proximal extent is possible in about 40% of cases. The mainstay of treatment is topical administration of mesalazine or steroids. The topical or oral route is sometimes insufficient with the frustrating problem of a proctitis unresponsive to medical therapy. In the non-responders, rectal bismuth preparations  and arsenical suppositories  seem to be effective and safe, but about 5% of the cases need total colectomy because of impaired quality of life .
Left-sided and pan-colitis are usually well managed with the standard regimens of steroids and mesalazine, but attention has to be paid to the patients who develop resistance or dependence of steroids. The gastroenterologist and the surgeon should very carefully consider the possible options, particularly in cases of severe, unresponsive or fulminant colitis in which the lack of clinical improvement within the first week of medical therapy represents an indication for colectomy. This observation is even stronger in patients with toxic dilation of the colon-in this case colectomy is mandatory in the absence of response within 24 h .
In all these situations we should always bear in mind a comprehensive view of the life of our patients in terms of severity of symptoms, safety of the current therapy, drug toxicity, safety of surgical procedure and quality of life expectancy. As David Sachar said some years ago "we too readily accept as a criterion of success the ability to keep patients out of surgery. Somehow the internists tend to view surgery as a last resort or as indication of failure of medical therapy. In adopting such an attitude we render our patients a terrible disservice."
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