Management of endoscopic rectal activity in ulcerative colitis: real-world adherence to guidelines and clinical...

Rectal disease activity in ulcerative colitis is associated with a high symptom burden. The British Society of Gastroenterology (BSG) provides evidence-based recommendations for the management of ulcerative proctitis, which are relevant to patients with rectal disease activity; however, real-world adherence and outcomes remains unclear. This study aimed to evaluate adherence to BSG guideline-recommended management and its relationship with treatment timing and clinical outcomes.

We conducted a retrospective observational cohort study at a single tertiary center (2022-2024). Adults with endoscopically confirmed rectal disease activity in ulcerative colitis were included. Guideline adherence was assessed using predefined criteria derived from the BSG algorithm. Clinical, biochemical, endoscopic, and histological remission were evaluated at 12 months.

Of 119 patients, 63 (52.9%) received guideline-adherent management. Adherence was significantly higher when treatment decisions were made at endoscopy compared with deferral to clinic (73 vs. 22%, RR: 0.30, 95% CI: 0.16-0.51; P < 0.001). At 12 months, clinical remission was achieved in 97/119 (81.5%), biochemical remission in 80/96 (83.3%), endoscopic remission in 36/68 (52.9%), and histological remission in 30/68 (44.1%). Guideline-adherent management showed numerically higher clinical remission rates, though not statistically significant. Deferral of treatment decisions was associated with a lower rate of clinical remission (72 vs. 86%), although not statistically significant (P = 0.06).

Guideline adherence is suboptimal in real-world practice. Endoscopy-led decision-making were strongly associated with guideline adherence and represents a modifiable system-level factor in care delivery. High overall remission rates suggest that guideline adherence alone may be an incomplete surrogate for care quality.