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Radiation Proctitis

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.


Presentation

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 [1] [2] [3]. Depending on the onset of symptoms and the mechanism of injury, two main types are described in the literature [1] [2] [3] [4] [5] [6]:

  • Acute - Defined as the appearance of symptoms within three months after pelvic radiotherapy, acute radiation proctitis stems from significant inflammatory changes in the mucosa [3]. 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 [3] [4]. However, the majority of symptoms are mild and self-limiting [6].
  • 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 [1] [2] [3] [5]. However, the majority of reports suggest that the symptoms appear after a median time of 8-12 months [1] [2]. 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 [1] [4] [5]. Blood loss may be severe enough to cause iron deficiency and require blood transfusions [3]. 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 [2] [5].
Diarrhea
  • The main symptoms are diarrhea, urgency, tenesmus, and rectal bleeding.[ncbi.nlm.nih.gov]
  • Diarrhea remitted completely in one of five patients and improved in three others. Of the 10 patients treated, only two did not respond to HBOT.[ncbi.nlm.nih.gov]
  • These symptoms include diarrhea and the urgent need to defecate, often with pain while doing so ( tenesmus ).[en.wikipedia.org]
  • 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]
Chronic Diarrhea
  • diarrhea or loose stools In most cases, your doctor will listen to your symptoms and record your medical history.[marcusgi.com]
  • Chronic diarrhea or poor absorption of food is one of the common late side effects of radiation.[mdanderson.org]

Workup

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 [1] [3] [4]. 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 [3] [4]. 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 [1] [3] [4]. Additionally, recto-vesicular, recto-urethral or rectovaginal fistulas, considered as late-presenting signs of this disease, may also be confirmed during colonoscopy [1]. Thus, the diagnosis of radiation proctitis relies on the history of prior radiotherapy, typical signs and symptoms, and macroscopic findings from invasive procedures.

Colitis
  • 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]
  • One patient (25%) in the IR group developed acute colitis consistent with formalin instillation, which was managed by intravenous antibiotics. The patients were followed for a mean of 10 months (range, 1 to 38 months).[ncbi.nlm.nih.gov]
  • […] 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]
  • 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[en.wikipedia.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]

Treatment

  • No criterion standard of treatment has been established, although argon plasma coagulation (APC) has increasingly become the treatment of choice.[ncbi.nlm.nih.gov]
  • Depending on physician's decision nine patients received symptomatic treatment only. RESULTS: With pentoxifylline/tocopherol treatment 15/21 patients (71%) experienced a relief of their symptoms.[ncbi.nlm.nih.gov]
  • 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]
  • AIM: Our objective was to investigate the effectiveness of hyperbaric oxygenation (HBO) in the treatment of radiation proctitis. The current literature was reviewed with regard to the necessary number of HBO treatments.[ncbi.nlm.nih.gov]
  • A total of 60 patients with ARP was equally and randomly distributed into the control group (conventional treatment) and the combination group (conventional treatment plus QBD).[ncbi.nlm.nih.gov]

Prognosis

  • 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]
  • 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]
  • 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]

Etiology

  • 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]
  • […] effects Mast Cells/enzymology Mast Cells/pathology* Mice Mice, Inbred C57BL Myocytes, Smooth Muscle/drug effects Myocytes, Smooth Muscle/metabolism Myocytes, Smooth Muscle/pathology Neutrophils/drug effects Neutrophils/metabolism Phenotype Proctitis/etiology[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]

Epidemiology

  • 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]
Sex distribution
Age distribution

Pathophysiology

  • […] 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]
  • Radiation damage to the rectum and anus: pathophysiology, clinical features and surgical implications. Colorectal Dis, 4 (2002), pp. 2-12 [2] R.C. Chautems, X. Delgadillo, L. Rubbia-Brandt, J.P. Deleaval, M.C.L. Marti, D. Roche.[elsevier.es]
  • 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]

Prevention

  • Radiation treatment (RT) techniques to prevent CRP are constantly improving thanks to image-guided RT and intensity-modulated RT.[ncbi.nlm.nih.gov]
  • However, neither bosentan nor atrasentan prevented radiation damage to the rectum when given long term. The only effect seen for atrasentan was an increased number of sclerotic vessel sections in injured tissues.[ncbi.nlm.nih.gov]
  • 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]
  • Considering the negative impact of acute proctitis symptoms on patients' daily activities and the potential relationship between the severity of acute radiation injury and late damage, misoprostol was tested in the prevention of acute radiation-induced[ncbi.nlm.nih.gov]
  • No correlation was seen between the efficacy of butyrate enemas on acute proctitis and prevention or development of late toxicity, respectively.[ncbi.nlm.nih.gov]

References

Article

  1. Nelamangala Ramakrishnaiah VP, Krishnamachari S. Chronic haemorrhagic radiation proctitis: A review. World J Gastrointest Surg. 2016;8(7):483-491.
  2. 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.
  3. Do NL, Nagle D, Poylin VY. Radiation Proctitis: Current Strategies in Management. Gastroenterol Res Pract. 2011;2011:917941.
  4. 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
  5. 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.
  6. Kennedy GD, Heise CP. Radiation Colitis and Proctitis. Clin Colon Rectal Surg. 2007;20(1):64-72.

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Last updated: 2017-08-09 15:06