Radiation proctitis

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Radiation proctitis
Other namesRadiation proctopathy, Radiation associated vascular ectasias (RAVE)
Radiation proctitis APC.jpg
Endoscopic image of radiation associated vascular ectasias (RAVE) before and after therapy with argon plasma coagulation.
Specialty Gastroenterology   OOjs UI icon edit-ltr-progressive.svg
Symptoms Pelvic pain, tenesmus, diarrhea, urgency, hematochezia
Complications Anemia, perforation, fistulae
TypesAcute (<3 months after radiation) and Chronic (>3 months after radiation)
CausesPelvic radiation for cancer
Diagnostic method Colonoscopy or flexible sigmoidoscopy
Differential diagnosis Infectious proctitis, inflammatory bowel disease
TreatmentEndoscopy with argon plasma coagulation, bipolar electrocautery, radiofrequency ablation

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. [1] Radiation proctopathy may occur as acute inflammation called "acute radiation proctitis" (and the related radiation colitis) or with chronic changes characterized by radiation associated vascular ectasiae (RAVE) and chronic radiation proctopathy. [2] [1] 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. [3]

Contents

Signs and symptoms

Acute radiation proctopathy often causes pelvic pain, diarrhea, urgency, and the urge to defecate despite having an empty colon (tenesmus). [4] Hematochezia and fecal incontinence may occur, but are less common. [4] Chronic radiation damage to the rectum (>3 months) may cause rectal bleeding, incontinence, or a change in bowel habits secondary. Severe cases may lead to with strictures or fistulae formation. [5] [4] Chronic radiation proctopathy can present at a median time of 8-12 months following radiation therapy. [4]

Histopathology

Acute radiation proctopathy occurs due to direct damage of the lining (epithelium) of the colon. [1] Rectal biopsies of acute radiation proctopathy show superficial depletion of epithelial cells and acute inflammatory cells located in the lamina propria. [4] By contrast, rectal biopsies of RAVE and chronic radiation proctopathy demonstrates ischemic endarteritis of the submucosal arterioles, submucosal fibrosis, and neovascularization. [4]

Diagnosis

Where chronic radiation proctopathy or RAVE is suspected, a thorough evaluation of symptoms is essential. Evaluation should include an assessment of risk factors for alternate causes of proctitis, such as C. difficile colitis, NSAID use, and travel history. [6] Symptoms such as diarrhea and painful defecation need to be systematically investigated and the underlying causes each carefully treated. [7] Testing for parasitic infections (amebiasis, giardiasis) and sexually transmitted infections (Neisseria gonorrhoeae and herpes simplex virus) should be considered. [6] The location of radiation treatment is important, as radiation directed at regions of the body other than the pelvis (eg brain, chest, etc) should not prompt consideration of radiation proctopathy. [6]

Endoscopy is the mainstay of diagnosis for radiation damage to the rectum, with either colonoscopy or flexible sigmoidoscopy. RAVE is usually recognized by the macroscopic appearances on endoscopy characterized by vascular ectasias. [8] Mucosal biopsy may aid in ruling out alternate causes of proctitis, but is not routinely necessary and may increase the risk of fistulae development. [6] Telangiectasias are characteristic and prone to bleeding. [3] Additional endoscopic findings may include pallor (pale appearance), edema, and friability of the mucosa.

Classification

Radiation proctitis can occur a few weeks after treatment, or after several months or years:

Treatment

Several methods have been studied in attempts to lessen the effects of radiation proctitis. Acute radiation proctitis usually resolves without treatment after several months. When treatment is necessary, symptoms often improve with hydration, anti-diarrheal agents, and discontinuation of radiation. [4] Butyrate enemas may also be effective. [9] [10]

In contrast, RAVE and chronic radiation proctopathy usually is not self-limited and often requires additional therapies. [4] These include sucralfate, hyperbaric oxygen therapy, corticosteroids, metronidazole, argon plasma coagulation, radiofrequency ablation and formalin irrigation. [1] [3] [11] The average number of treatment sessions with argon plasma coagulation to achieve control of bleeding ranges from 1 to 2.7 sessions. [4]

In rare cases that do not respond to medical therapy and endoscopic treatment, surgery may be required. Overall, less than 10 percent of individuals with radiation proctopathy require surgery. [4] In addition, complications such as obstruction and fistulae may require surgery.

Epidemiology

Up to 30 percent of individuals who receive pelvic radiation therapy for cancer may develop radiation proctopathy. [4]

See also

Related Research Articles

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Ulcerative colitis (UC) 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">Fecal incontinence</span> Inability to refrain from defecation

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<span class="mw-page-title-main">Rectal prolapse</span> Medical condition

A rectal prolapse occurs when walls of the rectum have prolapsed to such a degree that they protrude out of the anus and are visible outside the body. However, most researchers agree that there are 3 to 5 different types of rectal prolapse, depending on whether the prolapsed section is visible externally, and whether the full or only partial thickness of the rectal wall is involved.

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

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<span class="mw-page-title-main">Dieulafoy's lesion</span> Medical condition

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

Gastrointestinal bleeding, also called gastrointestinal hemorrhage (GIB), is all forms of bleeding in the gastrointestinal tract, from the mouth to the rectum. When there is significant blood loss over a short time, symptoms may include vomiting red blood, vomiting black blood, bloody stool, or black stool. Small amounts of bleeding over a long time may cause iron-deficiency anemia resulting in feeling tired or heart-related chest pain. Other symptoms may include abdominal pain, shortness of breath, pale skin, or passing out. Sometimes in those with small amounts of bleeding no symptoms may be present.

<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.

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">Blood in stool</span> Medical condition

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<span class="mw-page-title-main">Ischemic colitis</span> Medical condition

Ischemic colitis is a medical condition in which inflammation and injury of the large intestine result from inadequate blood supply. Although uncommon in the general population, ischemic colitis occurs with greater frequency in the elderly, and is the most common form of bowel ischemia. Causes of the reduced blood flow can include changes in the systemic circulation or local factors such as constriction of blood vessels or a blood clot. In most cases, no specific cause can be identified.

<span class="mw-page-title-main">Argon plasma coagulation</span> Medical procedure

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Radiation enteropathy is a syndrome that may develop following abdominal or pelvic radiation therapy for cancer. 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.

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References

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