Radiation enteritis is a condition that arises as a side effect of radiotherapy during the treatment of cancer. It may cause gastrointestinal symptoms such as a change in bowel habits and abdominal pain, which may be acute or chronic.
Presentation
Radiation enteritis (RE) is an iatrogenic ailment that involves injury to the small intestine, resulting from radiation therapy employed in the treatment of malignancies. RE affects the majority of patients undergoing radiation in the abdomen or pelvis [1]. Factors that predispose patients to RE entail high dose radiotherapy, cardiovascular disease, and those simultaneously receiving chemotherapy.
RE may be acute or chronic in nature. Acute disease may present with abdominal pain, in addition to a variety of nonspecific gastrointestinal (GI) symptoms such as nausea, vomiting, anorexia, and change in bowel habits. These occur and peak with 2 to 5 weeks of initiation of therapy [2]. Acute RE often resolves spontaneously, after 3 months of treatment [3].
Chronic RE has a much slower onset and may transpire years after exposure to radiotherapy [4]. It occurs due to repeated injury of the gut, leading to inflammation and atrophy of mucosal cells, fibrosis, and impaired healing [5]. The nature and severity of symptoms correspond with the associated damage [6]. Furthermore, radiotherapy affects local blood vessels, causing arterial occlusion by surrounding tissues, that is, endarteritis obliterans, leading to chronic ischemia. Chronic RE manifests as nonspecific GI symptoms, bowel obstruction, fat malabsorption and abdominal pain associated with food intake [7]. Micronutrient deficiencies, such as vitamin B12 and calcium, are also known findings.
Entire Body System
- Severe Pain
While in the ER experienced severe pain in the abdomen. They gave me heavy duty pain killers, nothing helped. Finally put a tube in my nose and down my throat. I began throwing up and it continued for a long time. [cancercompass.com]
(anal/perianal/rectal): typical proctalgia fugax (A sudden, severe pain in the anorectal region lasting less than 20 min, resolving spontaneously) ⇓ Pain (anal/perianal/rectal): related to defecation ⇓ Steatorrhoea (the presence of excess fat in the [doi.org]
He now suffers from severe radiation proctitis and is experiencing severe pains. We understand that very high doses of Vit. [healingcancernaturally.com]
Gastrointestinal
- Diarrhea
During irradiation, diarrhea occurred in 69% and 66% of the 5-ASA and placebo groups, respectively (chi2, P = 0.22). Curves of survival without diarrhea did not differ between groups (logrank P = 0.09). [ncbi.nlm.nih.gov]
NOS ( R19.7 ) functional diarrhea ( K59.1 ) infectious gastroenteritis and colitis NOS ( A09 ) neonatal diarrhea (noninfective) ( P78.3 ) psychogenic diarrhea ( F45.8 ) due to radiation K52.0 Enteritis (acute) (diarrheal) (hemorrhagic) (noninfective) [icd10data.com]
Spicy foods trigger diarrhea for many. (Image: Philhillphotography/iStock/Getty Images) Each individual has different types of foods that trigger diarrhea, and for many the offending source is spicy foods. [livestrong.com]
When the abdomen receives radiation, there is always some nausea, vomiting, and diarrhea. In most cases, the symptoms get better within 2 to 3 months after treatment ends. [medlineplus.gov]
- Steatorrhea
The clinical presentation is nonspecific with abdominal pain, vomiting, bloody diarrhea and steatorrhea. Patients with chronic radiation enteritis may develop deficiencies of calcium, iron and vitamin B12 deficiency. [radiopaedia.org]
These include: rectal bleeding diarrhea and steatorrhea other defecation disorders including fecal urgency and incontinence. nutritional deficiencies and weight loss abdominal pain and bloating nausea, vomiting and fatigueGastrointestinal symptoms are [en.wikipedia.org]
Steatorrhea. Weight loss. Nausea and vomiting. Less common are bowel obstruction, fistulas, bowel perforation, and massive rectal bleeding.[ 9 ] The initial signs and symptoms occur 6 to 18 months after radiation therapy. [cancer.gov]
- Chronic Diarrhea
Answer: Chronic radiation enteritis is the technical term for the long-term damage that can result after radiation therapy for rectal cancer. It can lead to chronic diarrhea, incontinence, and bowel urgency. [oncologynutrition.org]
Counseling from a Registered Dietitian and adherence to a strict gluten-free diet completely eliminated the chronic diarrhea. 24) Some RDs are reporting that a few patients have had successful resolution of long-standing diarrhea by the use of either [cancerrd.com]
- Hematochezia
Most often, the patient presents with abdominal pain, diarrhea, hematochezia, and signs of malnutrition. Others may present, initially, with intestinal obstruction, perforation, or fistulization. [ncbi.nlm.nih.gov]
Candidates for endoscopic therapy include, but are not limited to, patients with chronic hematochezia associated with transfusion dependency. Video Endoscopic Sequence 10 of 13. The procedures described above are considered to be safe. [gastrointestinalatlas.com]
- Abdominal Bloating
GI mucositis is associated with many symptoms of which significant pain, ulceration, abdominal bloating, nausea and vomiting, diarrhea, and constipation are a few [ 5 ]. [doi.org]
Workup
RE is a significant problem, as it negatively impacts the quality of life. Furthermore, the condition may not receive adequate attention and treatment due to patients being less forthcoming about GI complaints, as well as clinicians failing to recognize and refer the former to specialists [1] [8]. It is thus important to educate patients about the possible gastrointestinal side effects of radiotherapy and encourage a preventative health-seeking behavior. In radiation enteritis, the medical history is of significant importance, as it may reveal radiotherapy exposure, possibly many years prior to presentation. Clinical examination further aids in diagnosis.
Biochemically, chronic RE may be evidenced by anemia and malnutrition [9]. Sepsis and raised inflammatory markers may be observed if there is an intestinal obstruction. There may also be a concurrent electrolyte imbalance, abnormal liver function tests, and coagulopathy.
Radiological techniques are useful, as there are a number of changes that are detectable. Computed tomography (CT) and magnetic resonance imaging (MRI) scans may show signs of intestinal wall inflammation such as thickening of the bowel walls, edema, and features of intestinal obstruction. Fistula formation, between the bowel and adjacent pelvic structures, may also be visualized in this way. The small bowel, as inspected via fluoroscopic enteroclysis, may exhibit signs of edema and fibrosis, stenosis and ulcers. There may be segments that appear similar to a stack of coins. Other radiological exams carried out include barium studies. Invasive techniques include endoscopy.
Several gastrointestinal disorders may be considered as differential diagnoses, such as Crohn's disease, malignant metastases, ischemia and enteritis due to alternative agents.
Colonoscopy
- Colitis
Convert to ICD-10-CM : 558.1 converts directly to: 2015/16 ICD-10-CM K52.0 Gastroenteritis and colitis due to radiation Approximate Synonyms Colitis due to radiation Enteritis due to radiation Radiation enteritis Radiation enterocolitis Radiation gastroenteritis [icd9data.com]
[…] and colitis K52.2 Allergic and dietetic gastroenteritis and colitis K52.21 Food protein-induced enterocolitis syndrome K52.22 Food protein-induced enteropathy K52.29 Other allergic and dietetic gastroenteritis and colitis K52.3 Indeterminate colitis [icd10data.com]
[…] often resolves spontaneously within weeks 80-90% of these will have permanent alteration of bowel habits Moderate to severe chronic radiation enteritis/colitis develops in 5-15% • Diagnosis is usually suggested by clinical and imaging features Confirmed [radiologykey.com]
Treatment
Acute RE often resolves spontaneously, after 3 months of treatment. Chronic RE has a much slower onset and may transpire years after exposure to radiotherapy. [symptoma.com]
Abstract Acute radiation enteritis is almost inevitable in the curative treatment of malignant tumors of the abdomen and pelvic area. [ncbi.nlm.nih.gov]
Prognosis
Cox survival analysis taking into account the stage of the cancer and the age at diagnosis showed that rectal bleeding is a factor with a prognosis significantly poorer than the mild symptoms (p = 0.05), equivalent to that of the severe complications. [ncbi.nlm.nih.gov]
What is the Prognosis of Radiation Enteritis? (Outcomes/Resolutions) The prognosis for Radiation Enteritis is very good when the symptoms are acute. [dovemed.com]
Outlook (Prognosis) When the abdomen receives radiation, there is always some nausea, vomiting, and diarrhea. In most cases, the symptoms get better within 2 - 3 months after treatment ends. [nicklauschildrens.org]
Etiology
We reviewed the etiology, prevalence, symptoms, diagnosis and management of CRE and CRE with malnutrition in this article. Functional short bowel syndrome as a cause of malnutrition in CRE is also considered. [ncbi.nlm.nih.gov]
Etiology and Pathophysiology Radiation injury activates intracellular mechanisms which alter cell division, leading to inflammation or cell death. Injury likely mediated indirectly by free-radical release, affecting DNA repair. [unboundmedicine.com]
(Etiology) Radiation therapy is commonly used to treat cancer and it employs the use of high-energy particles or waves, such as x-rays, gamma rays, electron or proton beams, to destroy cancer cells by damaging their DNA Intestinal lining cells, which [dovemed.com]
Epidemiology
CMCR and oncology clinical trial group leaders were joined by experts in epidemiology and quality of life issues, representatives from the pharmaceutical industry, patient advocates, and U.S. Food and Drug Administration (FDA) officials. [doi.org]
Pathophysiology
A hypodeiodination condition and a potential pituitary-thyrotroph dysfunction might play a role in the pathophysiology of LT3S in RE. Worse nutritional status and clinical outcomes were confirmed in RE patients with LT3S. [ncbi.nlm.nih.gov]
Etiology and Pathophysiology Radiation injury activates intracellular mechanisms which alter cell division, leading to inflammation or cell death. Injury likely mediated indirectly by free-radical release, affecting DNA repair. [unboundmedicine.com]
Pathophysiology Ionising radiation generates free radicals from intracellular water, which in turn affect DNA synthesis. Cells with a high proliferation rate tend to be more susceptible to radiation injury. [surgwiki.com]
Clinical, pathophysiologic and radiobiologic aspects. A review. Acta Oncol. 1990;29(4):401-415. http://doi.org/10.3109/02841869009090022 Rogler G, Gelbmann CM, Vogl D, Brunner M, Schölmerich J, Falk W, Andus T, Brand K. [revistagastrocol.com]
Ann Gastroenterol Hepatol (Paris) 24:7–12 CAS Google Scholar Marx RE (1983) Osteoradionecrosis: a new concept of its pathophysiology. [link.springer.com]
Prevention
An increased understanding of the tissue response and the clinical features of radiation enteritis has led to advances in the prevention and management of this condition. [ncbi.nlm.nih.gov]
References
- Andreyev J. Gastrointestinal symptoms after pelvic radiotherapy: a new understanding to improve management of symptomatic patients. Lancet Oncol. 2007;8(11):1007-1017.
- Khalid U, McGough C, Hackett C, et al. A modified inflammatory bowel disease questionnaire and the Vaizey Incontinence questionnaire are more sensitive measures of acute gastrointestinal toxicity during pelvic radiotherapy than RTOG grading. Int J Radiat Oncol Biol Phys. 2006;64(5):1432-1441.
- Do N, Nagle D, Poylin V. Radiation proctitis: current strategies in management. Gastroenterol Res Pract. 2011;2011:917941.
- Kountouras J, Zavos C. Recent advances in the management of radiation colitis. World J Gastroenterol. 2008;4(48):7289–7301.
- Denham J, Hauer-Jensen M. The radiotherapeutic injury–a complex ‘wound’. Radiother Oncol. 2002;63(2):29-145.
- Lange M, Marijnen C, Maas C, et al. Risk factors for sexual dysfunction after rectal cancer treatment. Eur J Cancer. 2009;45(9):1578–1588.
- Theis VS, Sripadam R, Ramani V, Lal S. Chronic radiation enteritis. Clin Oncol (R Coll Radiol). 2010;22(1):70-83.
- Andreyev H, Davidson S, Gillespie C, et al. Practice guidance on the management of acute and chronic gastrointestinal problems arising as a result of treatment for cancer. Gut. 2012;61(2):179-192.
- Webb GJ, Brooke R, De Silva AN. Chronic radiation enteritis and malnutrition. J Dig Dis. 2013;14(7):350-357.