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 its principal features [3] and radiation-induced lumbar plexopathy (RILP) being a rare consequence. [4]

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. [5] 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] [6] 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] [6] 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. [5] [7] 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. [8]

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] [9]

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. [10] 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. [11]

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. [12] 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. [13] 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. [14] 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. [15]

Related Research Articles

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Crohn's disease is a chronic inflammatory bowel disease characterized by recurrent episodes of intestinal inflammation, primarily manifesting as diarrhea and abdominal pain. Unlike ulcerative colitis, inflammation can occur anywhere in the gastrointestinal tract, though it most frequently affects the ileum and colon, involving all layers of the intestinal wall. Symptoms may be non-specific and progress gradually, often delaying diagnosis. About one-third of patients have colonic disease, another third have ileocolic disease, and the remaining third have isolated ileal disease. Systemic symptoms such as chronic fatigue, weight loss, and low-grade fevers are common, along with extraintestinal manifestations affecting organs like the skin and joints. Complications can include bowel obstructions, fistulas, and an increased risk of intestinal cancers.

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

Ulcerative colitis (UC) is one of the two types of inflammatory bowel disease (IBD), with the other type being Crohn's disease. 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

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 or cloaca. 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> Infrequent or difficult bowel movements

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">Fecal incontinence</span> Inability to refrain from defecation

Fecal incontinence (FI), or in some forms, encopresis, is a lack of control over defecation, leading to involuntary loss of bowel contents — including flatus (gas), liquid stool elements and mucus, or solid feces. FI is a sign or a symptom, not a diagnosis. Incontinence can result from different causes and might occur with either constipation or diarrhea. Continence is maintained by several interrelated factors, including the anal sampling mechanism, and incontinence usually results from a deficiency of multiple mechanisms. The most common causes are thought to be immediate or delayed damage from childbirth, complications from prior anorectal surgery, altered bowel habits. An estimated 2.2% of community-dwelling adults are affected. However, reported prevalence figures vary. A prevalence of 8.39% among non-institutionalized U.S adults between 2005 and 2010 has been reported, and among institutionalized elders figures come close to 50%.

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

Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder 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.

<span class="mw-page-title-main">Enteritis</span> Inflammation of the small intestine

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<span class="mw-page-title-main">Gastrointestinal disease</span> Illnesses of the digestive system

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

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<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.

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

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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. ↑ Faithfull, Sara; Maher, Jane; Andreyev, Jervoise (2022). "Best Practice Pathway for Pelvic Radiation Disease" (PDF). www.prda.org.uk. Pelvic Radiation Disease Association. pp. 111–118. Retrieved 26 October 2024.
  5. 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.
  6. 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.
  7. ↑ 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.
  8. ↑ 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.
  9. ↑ 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.
  10. ↑ 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.
  11. ↑ 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.
  12. ↑ 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.
  13. ↑ 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.
  14. ↑ 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.
  15. ↑ 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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