Radiation enteropathy

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Radiation enteropathy
Other namesRadiation enteritis, pelvic radiation disease
Specialty Gastroenterology, surgery, oncology
Symptoms Diarrhea, abdominal pain, nausea, vomiting, anorexia and malaise
Complications Stricture formation, malabsorption
Usual onsetAcute: several weeks after radiation
Chronic: 8–12 months after radiation

Radiation enteropathy is a syndrome that may develop following abdominal or pelvic radiation therapy for cancer. [1] [2] Many affected people are cancer survivors who had treatment for cervical cancer or prostate cancer; it has also been termed pelvic radiation disease with radiation proctitis being one of the principal features. [3]

Contents

Signs and symptoms

People who have been treated with radiotherapy for pelvic and other abdominal cancers frequently develop gastrointestinal symptoms. [3] [1] [2]

These include:

Gastrointestinal symptoms are often found together with those in other systems including genitourinary disorders and sexual dysfunction. The burden of symptoms substantially impairs the patients' quality of life.[ citation needed ]

Nausea, vomiting, fatigue, and diarrhea may happen early during the course of radiotherapy. Radiation enteropathy represents the longer-term, chronic effects that may be found after a latent period most commonly of 6 months to 3 years after the end of treatment. In some cases, it does not become a problem for 20–30 years after successful curative therapy. [1]

Associated conditions

Causes

A large number of people receive abdominal and or pelvic radiotherapy as part of their cancer treatment with 60–80% experiencing gastrointestinal symptoms. [1] This is used in standard therapeutic regimens for cervical cancer, prostate cancer, rectal cancer, anal cancer, lymphoma and other abdominal malignancies. Symptoms can be made worse by the effects of surgery, chemotherapy or other drugs given to treat the cancer. [4] Improved methods of radiotherapy have reduced the exposure of non-involved tissues to radiation, concentrating the effects on the cancer. However, as the parts of the intestine such as the ileum and the rectum are immediately adjacent to the cancers, it is impossible to avoid some radiation effects. [1] Previous intestinal surgery, obesity, diabetes, tobacco smoking and vascular disorders increase the chances of developing enteropathy. [1]

Pathology

Acute intestinal injury

Early radiation enteropathy is very common during or immediately after the course of radiotherapy. This involves cell death, mucosal inflammation and epithelial barrier dysfunction. This injury is termed mucositis and results in symptoms of nausea, vomiting, fatigue, diarrhea and abdominal pain. [1] [5] It recovers within a few weeks or months.

Long-term effects of radiation

The delayed effects, found 3 months or more after radiation therapy, produce pathology which includes intestinal epithelial mucosal atrophy, vascular sclerosis, and progressive fibrosis of the intestinal wall, among other changes in intestinal neuroendocrine and immune cells and in the gut microbiota. [1] [5] These changes may produce dysmotility, strictures, malabsorption and bleeding. Problems in the terminal ileum and rectum predominate.[ citation needed ]

Diagnosis

Multiple disorders are found in patients with radiation enteropathy, so guidance including an algorithmic approach to their investigation has been developed. [4] [6] This includes a holistic assessment with investigations including upper endoscopy, colonoscopy, breath tests and other nutritional and gastrointestinal tests. Full investigation is important as many cancer survivors of radiation therapy develop other causes for their symptoms such as colonic polyps, diverticular disease or hemorrhoids. [7]

Prevention

Prevention of radiation injury to the small bowel is a key aim of techniques such as brachytherapy, field size, multiple field arrangements, conformal radiotherapy techniques and intensity-modulated radiotherapy. Medications including ACE inhibitors, statins and probiotics have also been studied and reviewed. [2] [8]

Treatment

In people presenting with symptoms compatible with radiation enteropathy, the initial step is to identify what is responsible for causing the symptoms. Management is best with a multidisciplinary team including gastroenterologists, nurses, dietitians, surgeons and others. [1] Medical treatments include the use of hyperbaric oxygen which has beneficial effects in radiation proctitis or anal damage. [9] Nutritional therapies include treatments directed at specific malabsorptive disorders such as low fat diets and vitamin B12 or vitamin D supplements, together with bile acid sequestrants for bile acid diarrhea and possibly antibiotics for small intestinal bacterial overgrowth. [2] Probiotics have all been suggested as another therapeutic avenue. [10]

Endoscopic therapies including argon plasma coagulation have been used for bleeding telangiectasia in radiation proctitis and at other intestinal sites, although there is a rick of perforation. [2]

Surgical treatment may be needed for intestinal obstruction, fistulae, or perforation, which can happen in more severe cases. [11] These can be fatal if patients present as an emergency, but with improved radiotherapy techniques are now less common.[ citation needed ] A systematic review has found there is some promising evidence for non-surgical interventions for late rectal damage, however due to low quality evidence no conclusions could be drawn. [12] Optimal treatment usually produces significant improvements in quality of life. [3]

Prevalence

An increasing number of people are now surviving cancer, with improved treatments producing cure of the malignancy (cancer survivors). There are now over 14 million such people in the US, and this figure is expected to increase to 18 million by 2022. [13] More than half are survivors of abdominal or pelvic cancers, with about 300,000 people receiving abdominal and pelvic radiation each year. It has been estimated there are 1.6 million people in the US with post-radiation intestinal dysfunction, a greater number than those with inflammatory bowel disease such as Crohn's disease or ulcerative colitis. [1]

Research

New agents have been identified in animal studies that may have effects on intestinal radiation injury. [1] The research approach in humans has been reviewed. [14]

Related Research Articles

<span class="mw-page-title-main">Radiation therapy</span> Therapy using ionizing radiation, usually to treat cancer

Radiation therapy or radiotherapy, often abbreviated RT, RTx, or XRT, is a treatment using ionizing radiation, generally provided as part of cancer therapy to either kill or control the growth of malignant cells. It is normally delivered by a linear particle accelerator. Radiation therapy may be curative in a number of types of cancer if they are localized to one area of the body, and have not spread to other parts. It may also be used as part of adjuvant therapy, to prevent tumor recurrence after surgery to remove a primary malignant tumor. Radiation therapy is synergistic with chemotherapy, and has been used before, during, and after chemotherapy in susceptible cancers. The subspecialty of oncology concerned with radiotherapy is called radiation oncology. A physician who practices in this subspecialty is a radiation oncologist.

<span class="mw-page-title-main">Ulcerative colitis</span> Inflammatory bowel disease that causes ulcers in the colon

Ulcerative colitis (UC) is a type of inflammatory bowel disease (IBD). It is a long-term condition that results in inflammation and ulcers of the colon and rectum. The primary symptoms of active disease are abdominal pain and diarrhea mixed with blood (hematochezia). Weight loss, fever, and anemia may also occur. Often, symptoms come on slowly and can range from mild to severe. Symptoms typically occur intermittently with periods of no symptoms between flares. Complications may include abnormal dilation of the colon (megacolon), inflammation of the eye, joints, or liver, and colon cancer.

<span class="mw-page-title-main">Defecation</span> Expulsion of feces from the digestive tract via the anus

Defecation follows digestion, and is a necessary process by which organisms eliminate a solid, semisolid, or liquid waste material known as feces from the digestive tract via the anus. The act has a variety of names ranging from the common, like pooping or crapping, to the technical, e.g. bowel movement, to the obscene (shitting), to the euphemistic, to the juvenile. The topic, usually avoided in polite company, can become the basis for some potty humor.

<span class="mw-page-title-main">Constipation</span> Bowel dysfunction

Constipation is a bowel dysfunction that makes bowel movements infrequent or hard to pass. The stool is often hard and dry. Other symptoms may include abdominal pain, bloating, and feeling as if one has not completely passed the bowel movement. Complications from constipation may include hemorrhoids, anal fissure or fecal impaction. The normal frequency of bowel movements in adults is between three per day and three per week. Babies often have three to four bowel movements per day while young children typically have two to three per day.

<span class="mw-page-title-main">Irritable bowel syndrome</span> Functional gastrointestinal disorder

Irritable bowel syndrome (IBS) is a "disorder of gut-brain interaction" characterized by a group of symptoms that commonly include abdominal pain, abdominal bloating and changes in the consistency of bowel movements. These symptoms may occur over a long time, sometimes for years. IBS can negatively affect quality of life and may result in missed school or work or reduced productivity at work. Disorders such as anxiety, major depression, and chronic fatigue syndrome are common among people with IBS.

Enteritis is inflammation of the small intestine. It is most commonly caused by food or drink contaminated with pathogenic microbes, such as Serratia, but may have other causes such as NSAIDs, radiation therapy as well as autoimmune conditions like Crohn's disease and celiac disease. Symptoms include abdominal pain, cramping, diarrhea, dehydration, and fever. Related diseases of the gastrointestinal system include inflammation of the stomach and large intestine.

<span class="mw-page-title-main">Inflammatory bowel disease</span> Medical condition

Inflammatory bowel disease (IBD) is a group of inflammatory conditions of the colon and small intestine, with Crohn's disease and ulcerative colitis (UC) being the principal types. Crohn's disease affects the small intestine and large intestine, as well as the mouth, esophagus, stomach and the anus, whereas ulcerative colitis primarily affects the colon and the rectum.

<span class="mw-page-title-main">Gastrointestinal disease</span> Medical condition

Gastrointestinal diseases refer to diseases involving the gastrointestinal tract, namely the esophagus, stomach, small intestine, large intestine and rectum, and the accessory organs of digestion, the liver, gallbladder, and pancreas.

<span class="mw-page-title-main">Small intestinal bacterial overgrowth</span> Medical condition

Small intestinal bacterial overgrowth (SIBO), also termed bacterial overgrowth, or small bowel bacterial overgrowth syndrome (SBBOS), is a disorder of excessive bacterial growth in the small intestine. Unlike the colon, which is rich with bacteria, the small bowel usually has fewer than 100,000 organisms per millilitre. Patients with bacterial overgrowth typically develop symptoms which may include nausea, bloating, vomiting, diarrhea, malnutrition, weight loss and malabsorption, which is caused by a number of mechanisms.

Rectal tenesmus is a feeling of incomplete defecation. It is the sensation of inability or difficulty to empty the bowel at defecation, even if the bowel contents have already been evacuated. Tenesmus indicates the feeling of a residue, and is not always correlated with the actual presence of residual fecal matter in the rectum. It is frequently painful and may be accompanied by involuntary straining and other gastrointestinal symptoms. Tenesmus has both a nociceptive and a neuropathic component.

Proctitis is an inflammation of the anus and the lining of the rectum, affecting only the last 6 inches of the rectum.

<span class="mw-page-title-main">Radiation proctitis</span> Medical condition

Radiation proctitis or radiation proctopathy is a condition characterized by damage to the rectum after exposure to x-rays or other ionizing radiation as a part of radiation therapy. Radiation proctopathy may occur as acute inflammation called "acute radiation proctitis" or with chronic changes characterized by radiation associated vascular ectasiae (RAVE) and chronic radiation proctopathy. Radiation proctitis most commonly occurs after pelvic radiation treatment for cancers such as cervical cancer, prostate cancer, bladder cancer, and rectal cancer. RAVE and chronic radiation proctopathy involves the lower intestine, primarily the sigmoid colon and the rectum, and was previously called chronic radiation proctitis, pelvic radiation disease and radiation enteropathy.

Radiation colitis is injury to the colon caused by radiation therapy. It is usually associated with treatment for prostate cancer or cervical cancer. Common symptoms are diarrhea, a feeling of being unable to empty the bowel, gastrointestinal bleeding, and abdominal pain.

Management of ulcerative colitis involves first treating the acute symptoms of the disease, then maintaining remission. Ulcerative colitis is a form of colitis, a disease of the intestine, specifically the large intestine or colon, that includes characteristic ulcers, or open sores, in the colon. The main symptom of active disease is usually diarrhea mixed with blood, of gradual onset which often leads to anaemia. Ulcerative colitis is, however, a systemic disease that affects many parts of the body outside the intestine.

Dysbiosis is characterized by a disruption to the microbiome resulting in an imbalance in the microbiota, changes in their functional composition and metabolic activities, or a shift in their local distribution. For example, a part of the human microbiota such as the skin flora, gut flora, or vaginal flora, can become deranged, with normally dominating species underrepresented and normally outcompeted or contained species increasing to fill the void. Dysbiosis is most commonly reported as a condition in the gastrointestinal tract.

Total mesorectal excision (TME) is a standard surgical technique for treatment of rectal cancer, first described in 1982 by Professor Bill Heald at the UK's Basingstoke District Hospital. It is a precise dissection of the mesorectal envelope comprising rectum containing the tumour together with all the surrounding fatty tissue and the sheet of tissue that contains lymph nodes and blood vessels. Dissection is along the avascular alveolar plane between the presacral and mesorectal fascia, described as holy plane. Dissection along this plane facilitates a straightforward dissection and preserves the sacral vessels and hypogastric nerves and is a sphincter-sparing resection and decreases permanent stoma rates. It is possible to rejoin the two ends of the colon; however, most patients require a temporary ileostomy pouch to bypass the colon, allowing it to heal with less risk of infection, perforation or leakage.

Bile acid malabsorption (BAM), known also as bile acid diarrhea, is a cause of several gut-related problems, the main one being chronic diarrhea. It has also been called bile acid-induced diarrhea, cholerheic or choleretic enteropathy, bile salt diarrhea or bile salt malabsorption. It can result from malabsorption secondary to gastrointestinal disease, or be a primary disorder, associated with excessive bile acid production. Treatment with bile acid sequestrants is often effective. It is recognised as a disability in the United Kingdom under the Equality Act 2010

Rectal discharge is intermittent or continuous expression of liquid from the anus. Normal rectal mucus is needed for proper excretion of waste. Otherwise, this is closely related to types of fecal incontinence but the term rectal discharge does not necessarily imply degrees of incontinence. Types of fecal incontinence that produce a liquid leakage could be thought of as a type of rectal discharge.

Serum-derived bovine immunoglobulin/protein isolate (SBI) is a medical food product derived from bovine serum obtained from adult cows in the United States. It is sold under the name EnteraGam.

<span class="mw-page-title-main">Colonic ulcer</span> Medical condition

Colonic ulcer can occur at any age, in children however they are rare. Most common symptoms are abdominal pain and hematochezia.

References

  1. 1 2 3 4 5 6 7 8 9 10 11 Hauer-Jensen M, Denham JW, Andreyev HJ (August 2014). "Radiation enteropathy—pathogenesis, treatment and prevention". Nature Reviews. Gastroenterology & Hepatology. 11 (8): 470–479. doi:10.1038/nrgastro.2014.46. PMC   4346191 . PMID   24686268.
  2. 1 2 3 4 5 Stacey R, Green JT (January 2014). "Radiation-induced small bowel disease: latest developments and clinical guidance". Therapeutic Advances in Chronic Disease. 5 (1): 15–29. doi:10.1177/2040622313510730. PMC   3871275 . PMID   24381725.
  3. 1 2 3 Fuccio L, Guido A, Andreyev HJ (December 2012). "Management of intestinal complications in patients with pelvic radiation disease". Clinical Gastroenterology and Hepatology. 10 (12): 1326–1334.e4. doi: 10.1016/j.cgh.2012.07.017 . PMID   22858731.
  4. 1 2 3 Andreyev HJ, Davidson SE, Gillespie C, Allum WH, Swarbrick E (February 2012). "Practice guidance on the management of acute and chronic gastrointestinal problems arising as a result of treatment for cancer". Gut. 61 (2): 179–192. doi:10.1136/gutjnl-2011-300563. PMC   3245898 . PMID   22057051.
  5. 1 2 Carr KE (2001). "Effects of radiation damage on intestinal morphology". International Review of Cytology. 208: 1–119. doi:10.1016/s0074-7696(01)08002-0. ISBN   9780123646125. PMID   11510566.
  6. ↑ 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.
  7. ↑ Min M, Chua B, Guttner Y, Abraham N, Aherne NJ, Hoffmann M, et al. (February 2014). "Is "pelvic radiation disease" always the cause of bowel symptoms following prostate cancer intensity-modulated radiotherapy?". Radiotherapy and Oncology. 110 (2): 278–283. doi:10.1016/j.radonc.2013.11.012. PMID   24412017.
  8. ↑ Gibson RJ, Keefe DM, Lalla RV, Bateman E, Blijlevens N, Fijlstra M, et al. (January 2013). "Systematic review of agents for the management of gastrointestinal mucositis in cancer patients". Supportive Care in Cancer. 21 (1): 313–326. doi: 10.1007/s00520-012-1644-z . PMID   23142924.
  9. ↑ Lin ZC, Bennett MH, Hawkins GC, Azzopardi CP, Feldmeier J, Smee R, Milross C (August 2023). "Hyperbaric oxygen therapy for late radiation tissue injury". The Cochrane Database of Systematic Reviews. 2023 (8): CD005005. doi:10.1002/14651858.CD005005.pub5. PMC  10426260. PMID   37585677.
  10. ↑ Hamad A, Fragkos KC, Forbes A (June 2013). "A systematic review and meta-analysis of probiotics for the management of radiation induced bowel disease". Clinical Nutrition. 32 (3): 353–360. doi:10.1016/j.clnu.2013.02.004. PMID   23453637.
  11. ↑ Regimbeau JM, Panis Y, Gouzi JL, Fagniez PL (September 2001). "Operative and long term results after surgery for chronic radiation enteritis". American Journal of Surgery. 182 (3): 237–242. doi:10.1016/s0002-9610(01)00705-x. PMID   11587684.
  12. ↑ van de Wetering FT, Verleye L, Andreyev HJ, Maher J, Vlayen J, Pieters BR, et al. (April 2016). "Non-surgical interventions for late rectal problems (proctopathy) of radiotherapy in people who have received radiotherapy to the pelvis". The Cochrane Database of Systematic Reviews. 2016 (4): CD003455. doi:10.1002/14651858.cd003455.pub2. PMC   7173735 . PMID   27111831.
  13. ↑ Siegel R, DeSantis C, Virgo K, Stein K, Mariotto A, Smith T, et al. (2012). "Cancer treatment and survivorship statistics, 2012". CA. 62 (4): 220–241. doi: 10.3322/caac.21149 . PMID   22700443.
  14. ↑ Movsas B, Vikram B, Hauer-Jensen M, Moulder JE, Basch E, Brown SL, et al. (January 2011). "Decreasing the adverse effects of cancer therapy: National Cancer Institute guidance for the clinical development of radiation injury mitigators". Clinical Cancer Research. 17 (2): 222–228. doi: 10.1158/1078-0432.CCR-10-1402 . PMID   21047979.
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