Radiation proctitis is a term describing rectal injury after pelvic radiation therapy. Based on the onset of symptoms, radiation proctitis can be acute or chronic, with a slightly different mechanism of injury and symptoms. A detailed patient history revealing prior pelvic radiation in the setting of lower gastrointestinal tract symptoms are highly suggestive of radiation proctitis. The diagnosis is made with invasive methods, such as colonoscopy and rectosigmoidoscopy.
Radiotherapy is still one of the most widely used treatment modalities for malignant diseases of the pelvis (including gynecological, gastrointestinal, and genitourinary). Approximately 5-20% of patients suffer from some form of rectal injury as a result of the therapy and it is known as radiation proctitis   . Depending on the onset of symptoms and the mechanism of injury, two main types are described in the literature      :
- Acute - Defined as the appearance of symptoms within three months after pelvic radiotherapy, acute radiation proctitis stems from significant inflammatory changes in the mucosa . Principal symptoms are diarrhea, tenesmus, abdominal cramping, nausea, mucus discharge, and a frequent feeling of urgency, while minor bleeding is observed in about 20% of cases, in whom radiation therapy must be stopped  . However, the majority of symptoms are mild and self-limiting .
- Chronic - When symptoms develop at least three months after initial radiotherapy, or when symptoms of acute radiation proctitis last > 90 days, the term chronic radiation proctitis is used to describe the signs and symptoms    . However, the majority of reports suggest that the symptoms appear after a median time of 8-12 months  . The progressive transmural injury of the bowel results in significant vascular injury and ischemia of the surrounding tissues, which is why a more severe clinical presentation is observed - severe bleeding, perforation, diarrhea, the formation of fistulas, and bowel obstruction   . Blood loss may be severe enough to cause iron deficiency and require blood transfusions . The degree of injury is proportionate to the dose received and the volume of irradiated tissue, whereas the presence of comorbidities that further impede blood flow (eg. diabetes mellitus, peripheral vascular disease) have shown to be an important determinant of the severity of symptoms seen in chronic radiation proctitis  .
The main symptoms are diarrhea, urgency, tenesmus, and rectal bleeding. [ncbi.nlm.nih.gov]
Principal symptoms are diarrhea, tenesmus, abdominal cramping, nausea, mucus discharge, and a frequent feeling of urgency, while minor bleeding is observed in about 20% of cases, in whom radiation therapy must be stopped. [symptoma.com]
Symptoms such as diarrhea and painful defecation need to be systematically investigated and the underlying causes each carefully treated. [en.wikipedia.org]
In addition to diarrhea and rectal pain, patients can also experience lasting complications such as bleeding. [proktis-m.ca]
- Chronic Diarrhea
Although the signs and symptoms seen in radiation proctitis can point to a number of differential diagnoses, identifying prior pelvic radiotherapy for an underlying malignant disease during history taking must raise clinical suspicion of radiation injury. For this reason, a detailed patient history is perhaps the most important step in workup   . The course and the spectrum of symptoms should be assessed in order to determine whether chronic or acute forms of injury has occurred, after which imaging studies are employed. Non-invasive radiological investigations like ultrasonography, computed tomography, and magnetic resonance imaging are not useful in the initial evaluation of radiation proctitis, and invasive procedures, such as colonoscopy and rectosigmoidoscopy, are preferred  . A pale, friable mucosa with telangiectasias are typical findings, but it must be pointed out that biopsies are avoided when radiation injury is suspected, principally because of possible aggravation of bleeding and the development of other complications that could compromise the patient   . Additionally, recto-vesicular, recto-urethral or rectovaginal fistulas, considered as late-presenting signs of this disease, may also be confirmed during colonoscopy . Thus, the diagnosis of radiation proctitis relies on the history of prior radiotherapy, typical signs and symptoms, and macroscopic findings from invasive procedures.
The topical treatment of distal ulcerative colitis. Eur J Gastroenterol Hepatol 1996;8:599–602. PubMed CrossRef Google Scholar 2. Breuer RI, Soergel KH, Lashner BA, et al. [doi.org]
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]
Acute radiation colitis is mostly self-limited, and usually, only supportive management is required. [gastrointestinalatlas.com]
Radiation colitis Diagnosis in short Radiation proctitis. H&E stain. [librepathology.org]
[…] or eosinophilic colitis but the history will allow accurate diagnosis Ischemic proctitis: may be impossible to distinguish from chronic radiation proctitis without a history, although superficial hyaline perivascular changes and radiation fibroblasts [pathologyoutlines.com]
Symptom score and sigmoidoscopic grade were assessed before, and at 1 month after, treatment. RESULTS: Ninety per cent of patients in Group 1 and 74.5% of patients in Group 2 responded to treatment (P = 0.038). [ncbi.nlm.nih.gov]
To reduce rectal damage without compromising prognosis, the gap between EBRT and HDR-ICBT should exceed 5 days in cervical cancer patients undergoing CCRT. [ncbi.nlm.nih.gov]
What is the prognosis of radiation proctitis? Pelvic radiation therapy is associated with an increased rate of rectal cancer. [annapoliscolon.com]
Jahnson S, Westerborn O, Gerdin B: Prognosis of surgically treated radiation-induced damage to the intestine. Eur J Surg Oncol 1992;18:487–493. Russell CJ, Welch JP: Operative management of radiation injuries of the intestinal tract. [karger.com]
This is because it has some advantages over postoperative radiotherapy such as better prognosis, more sphincter saving, and less complication associated with radiation [ 5 ]. [pubs.sciepub.com]
In contrast, patients whose symptoms are more severe may not have such a favorable prognosis. Several approaches have been tried in these patients. [aboutcancer.com]
Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. [icd10coded.com]
In this study, the expression profiles of angiogenic factors were analyzed to clarify their role in the etiology of radiation proctitis. METHODS: Rectal biopsies were taken from 8 patients with radiation proctitis and 8 normal subjects. [ncbi.nlm.nih.gov]
More rectal bleeding in misoprostol group Conclusion: Misoprostol not helpful Chronic radiation proctitis [ edit ] Chronic Radiation Proctitis Timing: 9-14 months after RT, but sometimes after 2 years (and as late as 30 years) Etiology: obliterative endarteritis [en.wikibooks.org]
The etiology of radiation proctitis is considered to be chronic mucosal ischemia caused by tissue fibrosis and obliterative endarteritis. [ro-journal.biomedcentral.com]
Definition / general Radiation induced injury to anorectum Acute or chronic Epidemiology Over 100,000 American patients annually receive therapeutic pelvic radiation for malignancies of prostate, anus, rectum, uterine cervix, endometrium, urinary bladder [pathologyoutlines.com]
[…] other sites Acute radiation proctitis occurs in nearly all patients but is generally self limited and not biopsied Only 5 to 15% develop chronic radiation proctitis, although with improving techniques for radiation therapy the incidence is decreasing Pathophysiology [pathologyoutlines.com]
Pathophysiology, approaches to treatment and prophylaxis. Strahlenther Onkol 1998 ; 174 ( Suppl 3 ): 82-4. Google Scholar 12. Hauer-Jensen, M, Wang, J, Boerma, M, Fu, Q, Denham, JW. [journals.sagepub.com]
Radiation damage to the rectum and anus: pathophysiology, clinical features and surgical implications. Colorectal Dis, 4 (2002), pp. 2-12  R.C. Chautems, X. Delgadillo, L. Rubbia-Brandt, J.P. Deleaval, M.C.L. Marti, D. Roche. [elsevier.es]
Pathophysiology of side effects of cancer therapies Chemotherapy Cytotoxic chemotherapy agents have a direct effect on the GI mucosa causing inflammation, 11–13 oedema, ulceration and atrophy. [gut.bmj.com]
Based on the frequency of CRP, prospective controlled and larger studies are advised to increase our knowledge about both the prevention and treatment of CRP. [atlasofscience.org]
Radiation treatment (RT) techniques to prevent CRP are constantly improving thanks to image-guided RT and intensity-modulated RT. [ncbi.nlm.nih.gov]
Arm 2) pentoxifylline x6 months Outcome: No difference Conclusion: No advantage for prevention of late rectal bleeding with pentoxifylline [en.wikibooks.org]
Prevention The primary approach to the prevention of radiation proctitis is the use of contemporary conformal radiation therapy techniques (e.g. intensity-modulated radiation therapy, image-guided radiation therapy) that minimise the dose of radiation [eviq.org.au]
- Nelamangala Ramakrishnaiah VP, Krishnamachari S. Chronic haemorrhagic radiation proctitis: A review. World J Gastrointest Surg. 2016;8(7):483-491.
- Denton AS, Andreyev HJN, Forbes A, Maher EJ. Systematic review for non-surgical interventions for the management of late radiation proctitis. Br J Cancer. 2002;87(2):134-143.
- Do NL, Nagle D, Poylin VY. Radiation Proctitis: Current Strategies in Management. Gastroenterol Res Pract. 2011;2011:917941.
- Vanneste BGL, Van De Voorde L, de Ridder RJ, Van Limbergen EJ, Lambin P, van Lin EN. Chronic radiation proctitis: tricks to prevent and treat. Int J Colorectal Dis. 2015;30:1293-1303.w
- Henson C. Chronic radiation proctitis: issues surrounding delayed bowel dysfunction post-pelvic radiotherapy and an update on medical treatment. Therap Adv Gastroenterol. 2010;3(6):359-365.
- Kennedy GD, Heise CP. Radiation Colitis and Proctitis. Clin Colon Rectal Surg. 2007;20(1):64-72.