Radiation proctitis

Radiation proctitis (and the related radiation colitis) is inflammation and damage to the lower parts of the colon after exposure to x-rays or other ionizing radiation as a part of radiation therapy.[1] Radiation proctitis most commonly occurs after treatment for cancers such as cervical cancer, prostate cancer, and colon cancer. Radiation proctitis involves the lower intestine, primarily the sigmoid colon and the rectum, and is part of the conditions known as pelvic radiation disease and radiation enteropathy.[2]

Radiation proctitis
Endoscopic image of radiation proctitis before and after therapy with argon plasma coagulation.
SpecialtyGastroenterology 

Classification

Radiation proctitis can occur a few weeks after treatment, or after several months or years:

  • Acute radiation proctitis — symptoms occur in the first few weeks after therapy. These symptoms include diarrhea and the urgent need to defecate, often with pain while doing so (tenesmus). Acute radiation proctitis usually resolves without treatment after several months, but symptoms may improve with butyrate enemas.[3][4] This acute phase is due to direct damage of the lining (epithelium) of the colon.[1]
  • Chronic radiation proctitis — is a widely used term, but is not correct as in long term after radiotherapy, inflammation in the bowel is minimal. The inappropriate name can lead to inappropriate treatment choices. The terms chronic radiation proctopathy—or better, Pelvic Radiation Disease—have been suggested as more accurate alternatives.[2] In the chronic setting the pathological changes are characterised by ischemia and fibrosis. Symptoms may begin as early as several months after therapy but occasionally not until several years later. Symptoms that may manifest include diarrhea, rectal bleeding, painful defecation, incontinence, excess flatulence and intestinal blockage. Intestinal blockage is a result of narrowing of the bowel which blocks the flow of feces. Connections (fistulae) may also develop between the colon and other parts of the body such as the skin or urinary system. Chronic radiation proctopathy occurs in part because of damage to the blood vessels which supply the colon. The colon is therefore deprived of oxygen and necessary nutrients.[1]

Diagnosis

Gastrointestinal symptoms occurring in a person who has had exposure to radiation need appropriate investigations to diagnose the nature and the extent of involvement. Symptoms such as diarrhea and painful defecation need to be systematically investigated and the underlying causes each carefully treated.[5] Proctitis is usually recognized by the macroscopic appearances on endoscopy (sigmoidoscopy or colonoscopy) and mucosal biopsy is not needed. Telangiectasia are characteristic and prone to bleeding.[2]

Treatment

Complications such as obstruction and fistulae may require surgery. Several other methods have been studied in attempts to lessen the effects of radiation proctitis. These include sucralfate, hyperbaric oxygen therapy, corticosteroids, metronidazole, argon plasma coagulation, radiofrequency ablation and formalin irrigation.[1][2][6]

See also

References
  1. Babb RR (1996). "Radiation proctitis: a review". Am. J. Gastroenterol. 91 (7): 1309–11. PMID 8677984.
  2. Fuccio L, Guido A, Andreyev HJ (2012). "Management of intestinal complications in patients with pelvic radiation disease". Clin. Gastroenterol. Hepatol. 10 (12): 1326–1334.e4. doi:10.1016/j.cgh.2012.07.017. PMID 22858731.
  3. Vernia P, Fracasso PL, Casale V, et al. (October 2000). "Topical butyrate for acute radiation proctitis: randomised, crossover trial". Lancet. 356 (9237): 1232–1235. doi:10.1016/S0140-6736(00)02787-2. PMID 11072942.
  4. Hille A, Herrmann MK, Kertesz T, et al. (December 2008). "Sodium butyrate enemas in the treatment of acute radiation-induced proctitis in patients with prostate cancer and the impact on late proctitis. A prospective evaluation". Strahlenther Onkol. 184 (12): 686–692. doi:10.1007/s00066-008-1896-1. PMID 19107351.
  5. Andreyev, HJ; Muls, AC; Norton, C; Ralph, C; Watson, L; Shaw, C; Lindsay, JO (January 2015). "Guidance: The practical management of the gastrointestinal symptoms of pelvic radiation disease". Frontline Gastroenterology. 6 (1): 53–72. doi:10.1136/flgastro-2014-100468. PMC 4283714. PMID 25580207.
  6. Ma TH, Yuan ZX, Zhong QH, Wang HM, Qin QY, Chen XX, Wang JP, Wang L (2015). "Formalin irrigation for hemorrhagic chronic radiation proctitis". World J. Gastroenterol. 21 (12): 3593–8. doi:10.3748/wjg.v21.i12.3593. PMC 4375582. PMID 25834325.
Classification
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