Short-chain fatty acids in the treatment of radiation proctitis: a randomized, double-blind, placebo-controlled, cross-over pilot trial

Chronic radiation proctitis: issues surrounding delayed bowel dysfunction post-pelvic radiotherapy and an update on medical treatment

Late onset bowel dysfunction post-pelvic radiotherapy is an increasingly common clinical scenario which is related to improved oncological treatments and cancer survival. 50% of patients develop bowel symptoms after pelvic radiotherapy which affects quality of life. Historically, bowel symptoms post-pelvic radiotherapy have been labelled 'chronic radiation proctitis', although it is increasingly recognised that these symptoms are due to dysfunction of the gastrointestinal (GI) tract at numerous points. The evidence-base is poor and comprises often small, heterogenous, single centre unblinded studies. This article critically reviews the evidence for the medical treatment options for 'chronic radiation proctitis', which include anti-inflammatory drugs, antibiotics, sucralfate, formalin and hyperbaric oxygen. The difficulties in extrapolation from the literature to clinical practise are also explored. From the available evidence, rectal sucralfate appears to have greater efficacy than anti-inflammatory agents, which are more effective if used with oral metronidazole. Furthermore, hyperbaric oxygen is emerging as promising treatment for radiation toxicity. However, bowel dysfunction post-pelvic radiotherapy is a complex clinical condition which reflects multi-site GI tract pathologies both related and unrelated to previous oncological treatments. From this review article a clear need for an adjustment to both diagnosis and treatment of these patients, as well as for further research, emerges.

Radiation colitis and proctitis

Radiation therapy is commonly utilized as a major component in the treatment of pelvic malignancy. Unfortunately, secondary toxicity to the lower gastrointestinal tract can occur. This most commonly affects the rectum, although injuries to the colon and small intestine are not uncommon. The presentation can be acute or chronic, and different mechanisms are responsible for each. Symptomatology is quite variable but can result in significant compromise for the patient. Numerous preventive and treatment strategies have been applied to this disease process. This article presents a summary of the current knowledge regarding radiation injury to the lower gastrointestinal tract with special emphasis on treatment options for radiation proctitis.

Late rectal complications after prostate brachytherapy for localized prostate cancer: incidence and management

This review of the literature on late rectal complications after prostate brachytherapy indicated that it is a highly effective treatment modality for patients with clinically localized prostate cancer but can cause chronic radiation proctitis. The most common manifestation of chronic radiation proctitis was anterior rectal wall bleeding, which often occurred within the first 2 years after brachytherapy. It is interesting to note that the rates of late rectal morbidity appear to have declined over time, which may reflect improvements in implantation techniques and imaging. Rectal biopsy as part of the workup to evaluate rectal bleeding can lead to rectal fistula and the need for colostomy, a rare but major complication. The authors recommend 1) screening colonoscopy before brachytherapy for patients who have not had a screening colonoscopy within the preceding 3 years to rule out colorectal malignancies and, thus, facilitate conservative management should rectal bleeding occur; 2) lifestyle modifications during treatment to limit exposure of the rectum to radiation; and 3) conservative management for rectal bleeding that occurs within 2 years after brachytherapy. Cancer 2009. (c) 2009 American Cancer Society.

Effective treatment of chronic radiation proctitis using radiofrequency ablation

Endoscopic argon plasma coagulation and bipolar electrocautery are currently preferred treatments for chronic radiation proctitis, but ulcerations and strictures frequently occur. Radiofrequency ablation (RFA) has been successful for mucosal ablation in the esophagus. Here we report the efficacy of RFA with the BarRx Halo(90) system in three patients with bleeding from chronic radiation proctitis. In all cases, the procedure was well tolerated and hemostasis was achieved after 1 or 2 RFA sessions. Re-epithelialization of squamous mucosa was observed over areas of prior hemorrhage. No stricturing or ulceration was seen on follow-up up to 19 months after RFA treatment. Real-time endoscopic optical coherence tomography (EOCT) visualized epithelialization and subsurface tissue microvasculature pre- and post-treatment, demonstrating its potential for follow-up assessment of endoscopic therapies.

Approaches to the prevention and management of radiation colitis

Radiation colitis refers to the characteristic changes in the mucosa of the colon and rectum secondary to pelvic radiation. Based on the interval from radiation to mucosal changes or symptoms, there are two well-defined forms of radiation colitis: acute, manifested by mucosal sloughing causing diarrhea, mucus discharge, and tenesmus; and chronic, characterized by obstructed defecation or ischemia of the mucosa due to obliterative endarteritis and resulting in mucosal telangiectasias, mucosal pallor, and friability causing rectal bleeding. Up to 25% of all patients receiving pelvic radiation develop mild symptoms, and 2% to 3% develop moderate to severe symptoms. Radiation colitis can be difficult to treat in some patients. There are several options for treating its symptoms. Argon plasma coagulation is the most common method of treating telangiectasias. Topical formaldehyde has also been used for distal telangiectasias. Obstructed defecation caused by radiation strictures (which are very fibrotic) usually can be treated successfully with stool softeners, colonic dilation, or steroid injection. Surgery should be avoided if possible because of its technical difficulty and the high incidence of postoperative complications such as anastomotic leak and fistula formation. New advances in radiation delivery techniques (eg, intensity-modulated radiation therapy) using specialized computer algorithms and medications such as amifostine may decrease the incidence of radiation colitis.

Rebampide enema therapy as a treatment for patients with chronic radiation proctitis: initial treatment or when other methods of conservative management have failed

INTRODUCTION

Radiation proctitis is a common complication following radiation therapy for pelvic malignancies. There have been no formal trials of treatment for radiation proctitis and a variety of methods are currently used. We assessed the efficacy of rebamipide enema to control symptoms and proctoscopic findings from radiation proctitis.

MATERIALS AND METHODS

Fifteen patients with radiation proctitis were enrolled. Enemas containing 150 mg rebamipide per dosing were administered after morning bowel movement, and always prior to bedtime, twice daily for 4 weeks. The efficacy of treatment was assessed from clinical symptoms (Subjective Objective Management Analysis Scale for Rectal Toxicity) and endoscopic findings.

RESULTS

The mean bleeding score improved from 2.67 to 0.53 (P < 0.01). The mean symptom scores improved in those patients who had pain (0.40 to 0.13), tenesmus (0.40 to 0.20), and stool frequency (0.27 to 0.13). The mean improvement in telangiectasia scores (2.13 to 0.80, P < 0.01), bleeding point scores (1.80 to 0.27, P < 0.01), and friable mucosa scores (1.33 to 0.20, P < 0.01) were all statistically significant. No side effects were noted in any patients.

CONCLUSION

Rebamipide enema therapy for radiation proctitis is a safe and effective treatment of radiation proctitis. We suggest the value of rebamipide enema in the treatment of radiation proctitis when other conservative management or first treatment has failed.

[Nonsurgical treatment of chronic radiation-induced hemorrhagic proctitis]

The incidence of radiation-induced chronic hemorrhagic proctitis is less than 10 to 20%. The onset of this proctitis is delayed relative to the radiation therapy and generally develops from 6 to 24 months later. There are numerous predisposing factors, the most important of which is the radiation therapy dose: risk increases exponentially above 40-45 Gy. Its pathophysiology involves progressive obliterating endarteritis and transmural interstitial fibrosis, which induce chronic ischemia that is irreversible and progressive during the years after radiation therapy. Its diagnosis depends most often on the combination of clinical history and typical endoscopic appearance (congestive mucosa and/or telangiectases). Topical administrative of sucralfate or corticosteroids as well as argon plasma coagulation, with formalin treatment if necessary, provides relief for most patients.

Review article: the role of butyrate on colonic function

BACKGROUND

Butyrate, a short-chain fatty acid, is a main end-product of intestinal microbial fermentation of mainly dietary fibre. Butyrate is an important energy source for intestinal epithelial cells and plays a role in the maintenance of colonic homeostasis.

AIM

To provide an overview on the present knowledge of the bioactivity of butyrate, emphasizing effects and possible mechanisms of action in relation to human colonic function.

METHODS

A PubMed search was performed to select relevant publications using the search terms: 'butyrate, short-chain fatty acid, fibre, colon, inflammation, carcinogenesis, barrier, oxidative stress, permeability and satiety'.

RESULTS

Butyrate exerts potent effects on a variety of colonic mucosal functions such as inhibition of inflammation and carcinogenesis, reinforcing various components of the colonic defence barrier and decreasing oxidative stress. In addition, butyrate may promote satiety. Two important mechanisms include the inhibition of nuclear factor kappa B activation and histone deacetylation. However, the observed effects of butyrate largely depend on concentrations and models used and human data are still limited.

CONCLUSION

Although most studies point towards beneficial effects of butyrate, more human in vivo studies are needed to contribute to our current understanding of butyrate-mediated effects on colonic function in health and disease.

Treatment of radiation proctitis

Late complications of pelvic radiotherapy occur in 5-20% of patients, particularly chronic radiation proctitis (CRP). Rectal bleeding is the most common symptom. Other symptoms include difficulty in defaecation or tenesmus because of loss of distensibility of the rectum or rectal structuring. Treatment options of CRP include oral therapy (5-aminosalicylates, metronidazole), rectal instillation therapy (hydrocortisone, sucralfate, 5-aminosalicylates, formalin), thermal therapy (argon plasma coagulation, heater probe or laser) and hyperbaric oxygen. It is difficult to recommend evidence-based therapy. There are no adequately powered studies of the treatment of CRP and most data are uncontrolled, non-blinded observation studies from single sites. There are no standard evaluation tools (including endoscopic grading, symptom scores and quality-of-life scores), adequate description of preceding radiotherapy dose or adequate follow-up in most studies. Many studies have poor documentation of complications and few are carried out prospectively. A pragmatic approach is to use sucralfate enemas and oral metronidazole. Thermal methods seem to be effective and safe. Simple heater probe treatment or argon plasma coagulation are the preferred methods due to their better safety profile. Intra-rectal formalin seems to be effective, but possibly has a higher rate of complications. For resistant disease, hyperbaric oxygen may be an option.

Application of 10 percent formalin for the treatment of radiation-induced hemorrhagic proctitis

PURPOSE

Rectal instillation of 4 percent formalin solution has been described as a successful treatment for hemorrhagic radiation proctitis recalcitrant to medical treatment. We present our experience with a new method of treatment involving the topical application of 10 percent buffered formalin, which is well tolerated and suitable for office use.

METHODS

Patients with marked or refractory rectal bleeding and clinical features consistent with radiation proctitis were reviewed. Treatment involved direct application of a 10 percent buffered formalin solution to the affected mucosa using a 16-inch cotton tip applicator applied through a proctoscope in the office setting.

RESULTS

A total of 100 patients with a mean age of 75 (range, 49-91) years were followed for 18 (range, 1-79) months. The interval from radiation exposure to formalin treatment was 21 months. Overall, 93 percent of patients had cessation of bleeding after an average of 3.5 formalin applications at two-week to four-week intervals. Patients with severe (Grade 3) proctitis and those taking aspirin required an average of 1.5 additional treatments. A total of eight patients rebled at a mean of 24 months from treatment; however, all responded to further applications of formalin. Three patients complained of anal pain and one experienced dizziness postprocedure for a complication rate of 1.1 percent.

CONCLUSIONS

We present a simple, cost-effective, and well-tolerated method of controlling hemorrhagic radiation proctitis. It is performed by using materials readily available in the office of a colon and rectal surgeon, eliminating the need for bowel preparation, anesthesia, or a surgical suite.

Radiation proctopathy in the treatment of prostate cancer

PURPOSE

To compile and review data on radiation proctopathy in the treatment of prostate cancer with respect to epidemiology, clinical manifestations, pathogenesis, risk factors, and treatment.

METHODS

Medical literature databases including PubMed and Medline were screened for pertinent reports, and critically analyzed for relevance in the scope of our purpose.

RESULTS

Rectal toxicity as a complication of radiotherapy has received attention over the past decade, especially with the advent of dose-escalation in prostate cancer treatment. A number of clinical criteria help to define acute and chronic radiation proctopathy, but lack of a unified grading scale makes comparing studies difficult. A variety of risk factors, related to either radiation delivery or patient, are the subject of intense study. Also, a variety of treatment options, including medical therapy, endoscopic treatments, and surgery have shown varied results, but a lack of large randomized trials evaluating their efficacy prevents forming concrete recommendations.

CONCLUSION

Radiation proctopathy should be an important consideration for the clinician in the treatment of prostate cancer especially with dose escalation. With further study of possible risk factors, the advent of a standardized grading scale, and more randomized trials to evaluate treatments, patients and physicians will be better armed to make appropriate management decisions.

The radiation-induced changes in rectal mucosa: Hyperfractionated vs. hypofractionated preoperative radiation for rectal cancer

PURPOSE

The purpose of the study was the qualitative and quantitative evaluation of acute radiation-induced rectal changes in patients who underwent preoperative radiotherapy according to two different irradiation protocols.

PATIENTS AND METHODS

Sixty-eight patients with rectal adenocarcinoma underwent preoperative radiotherapy; 44 and 24 patients underwent hyperfractionated and hypofractionated protocol, respectively. Fifteen patients treated with surgery alone served as a control group. Five basic histopathologic features (meganucleosis, inflammatory infiltrations, eosinophils, mucus secretion, and erosions) and two additional features (mitotic figures and architectural glandular abnormalities) of radiation-induced changes were qualified and quantified.

RESULTS

Acute radiation-induced reactions were found in 66 patients. The most common were eosinophilic and plasma-cell inflammatory infiltrations (65 patients), erosions, and decreased mucus secretion (54 patients). Meganucleosis and mitotic figures were more common in patients who underwent hyperfractionated radiotherapy. The least common were the glandular architectural distortions, especially in patients treated with hypofractionated radiotherapy. Statistically significant differences in morphologic parameters studied between groups treated with different irradiation protocols were found.

CONCLUSION

The system of assessment is a valuable tool in the evaluation of radiation-induced changes in the rectal mucosa. A greater intensity of regenerative changes was found in patients treated with hyperfractionated radiotherapy.

Argon plasma coagulation as first-line treatment for chronic radiation proctopathy

BACKGROUND AND AIM

Chronic radiation proctopathy is a troublesome complication of radiotherapy to the pelvis, for which current treatment modalities are unsatisfactory. The present prospective study was designed to determine the usefulness and safety of argon plasma coagulation in the management of chronic radiation proctopathy.

METHODS

Twenty-five consecutive patients (M:F 24:1, mean age: 69 years) with radiation proctopathy were prospectively included. All patients received argon plasma coagulation by a standard protocol. Response to treatment was assessed by symptom response, bleeding severity score, hematological parameters and transfusion requirements over a median 14-month follow up.

RESULTS

Patients received a median of one treatment session with argon plasma coagulation. There was significant improvement in rectal bleeding in all patients, with complete cessation of bleeding in 21 (81%) of the patients. The median bleeding severity score fell from 3 to 0 (P < 0.0005). The mean hemoglobin level rose from 10.05 +/- 2.21 g/dL before treatment to 12.44 +/- 1.09 g/dL at 6 months following treatment (P < 0.002). There was also improvement in other symptoms such as urgency and diarrhea. Over the period of follow up, there was no recurrence of anemia and no complications were noted.

CONCLUSION

These results suggest that argon plasma coagulation is a safe and effective modality in the treatment of chronic radiation proctopathy.

Hyperbaric oxygen therapy in the treatment of radio-induced lesions in normal tissues: a literature review

Late complications are one of the major factors limiting radiotherapy treatment, and their treatment is not codified. Hyperbaric oxygen (HBO) has been used in combination with radiotherapy for over half a century, either to maximise its effectiveness or in an attempt to treat late complications. In this latter case, retrospective trials and case reports are prevailing in literature. This prompted European Society for Therapeutic Radiotherapy and Oncology and European Committee for Hyperbaric Medicine to organise a consensus conference in October 2001, dealing with the HBO indications on radiotherapy for the treatment and prevention of late complications. This updated literature review is part of the documents the jury based its opinion on. A systematic search was done on literature from 1960 to 2004, by only taking into account the articles that appeared in peer review journals. Hyperbaric oxygen treatment involving complications to the head and neck, pelvis and nervous system, and the prevention of complications after surgery in irradiated tissues have been studied. Despite the small number of controlled trials, it may be indicated for the treatment of mandibular osteoradionecrosis in combination with surgery, haemorrhagic cystitis resistant to conventional treatments and the prevention of osteoradionecrosis after dental extraction, whose level of evidence seems to be the most significant though randomised trials are still necessary. The other treatment methods are also outlined for each location.

Gastrointestinal mucositis

OBJECTIVE

To review the management of radiotherapy- and chemotherapy-induced gastrointestinal mucositis.

DATA SOURCE

Articles and research studies.

CONCLUSION

Gastrointestinal damage is becoming a common dose-limiting toxicity. However, there is only limited research into the mechanism and possible treatment of this toxicity.

IMPLICATIONS FOR NURSING PRACTICE

It is important to document the frequency and severity of gastrointestinal mucositis, and to alleviate symptoms wherever possible.

Conservative therapies for hemorrhagic radiation proctitis: a review

Chronic radiation proctitis represents a challenging condition seen with increased frequency due to the common use of radiation for treatment of pelvic cancer. Hemorrhagic radiation proctitis represents the most feared complication of chronic radiation proctitis. There is no consensus for the management of this condition despite the great number of clinical approaches and techniques that have been employed. Rectal resection represents an available option although associated with high morbidity and risk of permanent colostomy. The effectiveness of nonoperative approaches remains far from desirable, and hemorrhagic recurrence represents a major drawback that leads to a need for consecutive therapeutic sessions and combination of techniques. We conducted a critical review of published reports regarding conservative management of hemorrhagic chronic radiation proctitis. Although prospective randomized trials about hemorrhagic radiation proctitis are still lacking, there is enough evidence to conclude that topical formalin therapy and an endoscopic approach delivering an argon plasma coagulation represent available options associated with elevated effectiveness for interruption of rectal bleeding in patients with chronic radiation proctitis.

Long-term outcome of argon plasma coagulation therapy for bleeding caused by chronic radiation proctopathy

BACKGROUND

Radiation-induced proctopathy is a serious complication of radiation therapy for pelvic malignancy.

AIM

To assess the safety and efficacy of argon plasma coagulation in the treatment of haemorrhagic radiation-induced proctopathy.

PATIENTS

Twenty-four patients with rectal bleeding due to radiation-induced proctopathy were prospectively enrolled in the study.

METHODS

Indications for treatment were iron deficiency anaemia (n = 16) and persistent bleeding, despite pharmacotherapy (n = 8). Argon flow and power used were 0.8-1.2 l/min and 40 W, respectively. An interval of at least 4 weeks was allowed between treatment sessions. Haemoglobin level, bleeding severity score, number of admissions and transfusion requirements were recorded after endoscopic coagulation and before 12 and 24 months.

RESULTS

A median of 2.5 therapeutic sessions per patient were performed (range 1-6). All patients reported clinical improvement and/or cessation of rectal bleeding. The mean value of the bleeding severity score decreased from 2.9 to 0.8 (P < 0.01), while average haemoglobin levels increased by a mean of 1.9 mg/dl at the end of the treatments (P < 0.05). During a minimum follow-up of 24 months (range 24-60), rectal bleeding recurred in two cases and was successfully retreated endoscopically. One patient developed a recto-vaginal fistula.

CONCLUSIONS

Argon plasma coagulation appears to be a safe and effective technique for management of rectal bleeding caused by radiation-induced proctopathy.

Haemorrhagic radiation proctitis: endoscopic severity may be useful to guide therapy

BACKGROUND AND AIMS

Management of haemorrhagic radiation proctitis remains controversial. Both endoscopically delivered argon plasma coagulation and rectal administration of formalin have been recommended. We evaluated the efficacy of argon plasma coagulation according to endoscopic severity of radiation proctitis.

PATIENTS AND METHODS

Fourteen patients treated with argon plasma coagulation for rectal bleeding due to radiation proctitis were reviewed. Patients were classified with a new endoscopic score for haemorrhagic radiation proctitis, comprising three factors: telangiectasia distribution, surface area involved, and presence of fresh blood. Seven patients were categorised as having grade A (mild), four grade B (moderate), and three grade C (severe) radiation proctitis. Rectal bleeding was assessed pre- and post-treatment using a five-point bleeding scale.

RESULTS

All patients with grade A and B radiation proctitis were treated successfully by argon plasma coagulation (mean 1.5 sessions). In one patient with grade C radiation proctitis argon plasma coagulation was successful after four sessions, but in the other two patients bleeding could not be controlled; a subsequent single formalin administration was successful in both. Overall in 12 patients (85.7%) bleeding ceased or improved significantly. The mean rectal bleeding scale reduced significantly from 2.6 to 0.9. One patient treated with argon plasma coagulation developed an asymptomatic rectosigmoid stenosis.

CONCLUSION

Argon plasma coagulation is a simple, safe and efficacious therapy for mild/moderate radiation proctitis. In patients with severe radiation proctitis several sessions are usually necessary, and success is not certain; in these cases, topical formalin administration may be more effective. Endoscopic severity of haemorrhagic radiation proctitis may be useful to guide appropriate therapy.

Frequency and outcomes of rectal ulcers during argon plasma coagulation for chronic radiation-induced proctopathy

BACKGROUND

Argon plasma coagulation is suitable for treating hemorrhagic GI tract lesions. This study evaluated the frequency and clinical outcomes of complications arising during use of argon plasma coagulation to treat chronic radiation-induced proctopathy.

METHODS

This uncontrolled prospective study included 27 consecutive patients. Fever and any rectal symptoms or signs were assessed by telephone with a structured questionnaire. Patients with symptoms underwent endoscopy; follow-up examination was performed when rectal complications developed.

RESULTS

Fifty-nine therapeutic sessions were performed (mean 2 per patient; mean interval between sessions, 72.5 days); mean follow-up was 11.5 months. The treatment reduced the mean bleeding severity score from 2.8 to 0.5 (p < 0.001). Two patients (7%) experienced fever and anal pain, and 14 (52%) developed rectal ulcers but remained asymptomatic; ulcer detection never precluded further treatment. Ulcer healing was assessed in 7 patients after a mean of 141 days; no strictures were observed.

CONCLUSIONS

The frequency of complications during argon plasma coagulation for radiation-induced proctopathy was high in the present series (59%), the most frequent untoward event being the development of rectal ulcers in asymptomatic patients. However, given the benign outcome, these lesions do not necessitate discontinuation of treatment or additional monitoring.

Systematic review for non-surgical interventions for the management of late radiation proctitis

Chronic radiation proctitis produces a range of clinical symptoms for which there is currently no recommended standard management. The aim of this review was to identify the various non-surgical treatment options for the management of late chronic radiation proctitis and evaluate the evidence for their efficacy. Synonyms for radiation therapy and for the spectrum of lower gastrointestinal radiation toxicity were combined in an extensive search strategy and applied to a range of databases. The included studies were those that involved interventions for the non-surgical management of late radiation proctitis. Sixty-three studies were identified that met the inclusion criteria, including six randomised controlled trials that described the effects of anti-inflammatory agents in combination, rectal steroids alone, rectal sucralfate, short chain fatty acid enemas and different types of thermal therapy. However, these studies could not be compared. If the management of late radiation proctitis is to become evidence based, then, in view of its episodic and variable nature, placebo controlled studies need to be conducted to clarify which therapeutic options should be recommended. From the current data, although certain interventions look promising and may be effective, one small or modest sized study, even if well-conducted, is insufficient to implement changes in practice. In order to increase recruitment to trials, a national register of cases with established late radiation toxicity would facilitate multi-centre trials with specific entry criteria, formal baseline and therapeutic assessments providing standardised outcome data.

Non surgical interventions for late radiation proctitis in patients who have received radical radiotherapy to the pelvis

BACKGROUND

Chronic radiation proctitis (inflammation of the rectum) may develop after the completion of pelvic radiotherapy. Presently there is no recommended standard management.

OBJECTIVES

To assess the effects of various non-surgical treatment options for the management of late chronic radiation proctitis.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register, issue 1, 2001, MEDLINE 1966 to 2001, EMBASE 1980 to 2001, CANCERCD 1980 to 2001, Science Citation Index 1991 to 2001, CINAHL 1982 to 2001, as well as sources of grey literature. We also hand searched relevant textbooks and contacted experts in the field.

SELECTION CRITERIA

Studies (preferentially randomised controlled trials) of interventions for the non-surgical management of late radiation proctitis in patients who have undergone pelvic radiotherapy as part of their cancer treatment.

DATA COLLECTION AND ANALYSIS

The inclusion criteria were independently applied by two of the reviewers (AD and EJM) and where there was disagreement this was resolved by involving a third reviewer to form a consensus.

MAIN RESULTS

Six randomised controlled trials were included. None of the trials compared anti-inflammatories with placebo. However rectal sucralfate showed greater clinical improvement for proctitis than anti-inflammatories (odds ratio 14.00, 95% confidence interval 1.46 to 134.26; n=1 study), though no difference was seen for endoscopic improvement (odds ratio 2.74, 95% confidence interval 0.64 to 11.76, n=1 study). The addition of metronidazole to the anti-inflammatory regime also appeared to improve the response rate, as measured by the reduction in rectal bleeding, diarrhoea, erythema and ulceration (n=1 study). Similarly rectal hydrocortisone appeared to be more effective than rectal betamethasone for clinical improvement although no difference was seen in endoscopic improvement (n=1 study). Short chain fatty acid enemas did not appear to be effective compared to placebo (n=2 studies). In the comparison of the heater probe and bipolar electrocautery (n=1 study), there was no discernible difference for severe bleeding after one year, but the heater probe demonstrated a greater increase in the haematocrit and reduced transfusion requirements.

REVIEWER'S CONCLUSIONS

Late radiation complications are a relatively rare manifestation, with many potential carers and poor diagnostic criteria. Although certain interventions look promising and may be effective (such as rectal sucralfate, adding metronidazole to the anti-inflammatory regime and heater probes), single small studies (even if well conducted) provide insufficient evidence. The episodic and variable nature of late radiation proctitis also requires placebo controlled studies to establish whether particular treatments are effective. Regional or centralised registers of radiation toxicity should be established so that interventions can be administered in the setting of multi-centre trials with specific entry criteria, formal baseline and therapeutic assessments providing standardised outcome data including quality of life evaluations.

Effective use of argon plasma coagulation in the treatment of severe radiation proctitis

PURPOSE

Chronic radiation proctitis, a well described complication of pelvic radiation therapy, can result in severe bleeding that is refractory to conventional treatment. Argon plasma coagulation is an effective treatment for hemorrhagic lesions of the gastrointestinal tract. The aim of this study was to assess the efficacy and safety of argon plasma coagulation in the management of severe radiation proctitis resistant to medical treatment.

METHODS

Eleven patients (10 males) aged between 54 and 86 years (mean +/- standard error of the mean, 73 +/- 3 years), with chronic radiation proctitis after radiotherapy for prostate (n = 9), uterine (n = 1) or rectal (n = 1) cancer were enrolled in this prospective study. Traditional therapies had failed including mainly topical steroids, 5-aminosalicylic acid and sometimes sucralfate. All patients had active bleeding from diffuse telangiectasias responsible for chronic anemia and seven of them required blood transfusions. The mean duration of the sessions was 20 minutes and one to five sessions (mean, 3.2 +/- 0.4), usually without anesthesia, were required to stop bleeding. Mean follow-up time was 19 +/- 2 (range, 7-30) months.

RESULTS

Rectal bleeding disappeared in nine patients and was greatly reduced in two. All the patients were free of transfusions during the mean follow-up of 19 months. The mean hemoglobin level was 7.7 +/- 2.8 g/dl at the first session and increased significantly (P = 0.003) to 11.5 +/- 2.6 g/dl after treatment. In two patients, a rectal stenosis appeared 7 and 11 months after the first session.

CONCLUSION

Argon plasma coagulation is a simple, inexpensive and effective treatment for severe refractory radiation proctitis with telangiectasias. Follow-up supervision is in progress to evaluate long term benefits and the risk of rectal stenosis.

Chronic radiation proctitis

BACKGROUND

Increasing use of radiation therapy in pelvic malignancy has led to an increase in the incidence of chronic radiation proctitis. The commonest presenting complaint is rectal bleeding.

METHODS

A comprehensive MEDLINE search was undertaken for all articles relating to radiation proctitis.

RESULTS

The natural history of the disease is poorly documented but improvement is likely in milder forms, with persistence of symptoms in more severe forms. The pathological manifestations of the disease are summarized with particular comparison to acute radiation proctitis. The common clinical presentations and the principles of assessing patients with radiation-induced proctitis will be reviewed. The present article also reviews current treatment options, with particular reference to newer endoscopic therapies and surgical principles of management.

CONCLUSIONS

The initial therapy for problematic rectal bleeding related to radiation-induced proctitis shoud be endoscopic therapy with argon plasma coagulation or topical formalin therapy. Surgery is reserved as a last resort for resistant rectal bleeding and for complicated radiation-induced strictures and fistulas.

Anorectal injury following pelvic radiotherapy

BACKGROUND

Current knowledge of the effects of radiation on the anorectum is based on a limited number of studies. Variability in delivery techniques, both currently and historically, combined with a paucity of prospective and randomized studies makes interpretation of the literature difficult. This review presents the existing evidence and identifies areas that require further work.

METHODS

This review is based on a literature search (Medline and PubMed) and manual cross-referencing.

RESULTS AND CONCLUSION

More than three-quarters of patients receiving pelvic radiotherapy experience acute anorectal symptoms and up to one-fifth suffer from late-phase radiation proctitis. About 5 per cent develop other chronic complications, such as fistula, stricture and disabling faecal incontinence. The risk of rectal cancer may be increased. Conservative treatment options are of limited value. Surgery may be considered if symptoms are severe, provided sphincter function is adequate and recurrent disease is excluded. Large prospective studies with accurate dosimetric data and long-term follow-up are needed to provide meaningful information on which to base new strategies to minimize the side-effects from radiotherapy.

Successful and sustained treatment of chronic radiation proctitis with antioxidant vitamins E and C

OBJECTIVE

Chronic radiation proctitis, a common sequelae of pelvic radiation, is characterized by obliteration of the submucosal vasculature with subsequent ischemia and reperfusion injury. Oxidative stress is thought to be a major mechanism in radiation proctitis. Therefore, antioxidants (vitamins E and C) may be beneficial.

METHODS

Twenty consecutive symptomatic outpatients with endoscopically documented radiation proctitis seen in a single gastroenterology clinic were given a combination of vitamin E (400 IU tid) and vitamin C (500 mg tid). Previous radiation therapy was given for prostatic (n = 10) or gynecological (n = 10) malignancies. These patients presented with one or more of the following symptoms: rectal bleeding, rectal pain, diarrhea, or fecal urgency. Using a questionnaire, these symptoms were rated by the patients in terms of their severity (grade 0-4) and frequency (grade 0-4) before and after treatment with vitamins E and C. A symptom index was calculated by the addition of the severity and frequency scores (8 = most symptomatic). The lifestyle impact of the symptoms was also assessed by questionnaire grading from 0 (no effect on daily activity) to 4 (afraid to leave home). Among these 20 patients, 10 patients who received vitamins E and C for 1 yr were assessed again to determine whether their initial responses were sustained.

RESULTS

There was a significant (p < 0.05; Wilcoxon rank) improvement in the symptom index (before treatment vs after treatment with vitamins E and C) for bleeding (median score: 4 vs 0), diarrhea (median score: 5 vs 0), and urgency (median score: 6 vs 3). Patients with rectal pain did not improve significantly. Bleeding resolved in four of 11 patients, diarrhea resolved in eight of 16 patients, fecal urgency resolved in three of 16 patients, and rectal pain resolved in two of six patients. Lifestyle improved in 13 patients, including seven patients who reported a return to normal. Two of the patients with no improvement in their daily symptoms also had radiation ileitis. All 10 patients who underwent a second follow-up interview reported sustained improvement in their symptoms 1 yr later.

CONCLUSION

A substantial number of patients with radiation proctitis seem to benefit from antioxidant therapy. A double-blind placebo-controlled trial is needed to confirm this open-labeled pilot study.

KTP laser therapy for bleeding from chronic radiation proctopathy

BACKGROUND

Endoscopic laser photocoagulation is commonly used to treat bleeding from the neovascular lesions of chronic radiation proctopathy. The KTP laser is an Nd/YAG-driven unit that emits light with a wavelength of 532 nm. This wavelength of energy is absorbed by hemoglobin and penetrates tissue to a depth of only 1 to 2 mm.

METHODS

Twenty-three patients were treated with KTP laser and followed for a median of 29 months (range 5 to 51 months); 21 had received radiation for prostate cancer and 2 for uterine cancer. The median age was 77 years (range 68 to 87 years). A median of 2 sessions (range 1 to 5 sessions) was performed using 4 to 10 Watts of power and a median energy of 816 Joules per session (range 204 to 2430 Joules).

RESULTS

After treatment there was a significant reduction in the frequency (p = 0.0005) of bleeding, increase in hematocrit level (p < 0.0001), improvement in activities of daily life (p = 0.01), and a reduction in use of health care resources (p < 0.0001). There was a trend toward decreased use of iron supplements (11 to 4 patients) and transfusions (4 to 0 patients). Two patients (9%) developed rectal ulcers after treatment.

CONCLUSIONS

KTP laser photocoagulation is a safe and effective therapy for bleeding from chronic radiation proctopathy that improves activities of daily living and reduces use of health care resources.