Colonoscopy in radiation colitis

Chronic radiation proctitis: tricks to prevent and treat

OBJECTIVE

The purpose of this study was to give an overview of the measures used to prevent chronic radiation proctitis (CRP) and to provide an algorithm for the treatment of CRP.

METHODS

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

RESULTS

CRP is a relatively frequent late side effect (5-20%) and mainly dependent on the dose and volume of irradiated rectum. Radiation treatment (RT) techniques to prevent CRP are constantly improving thanks to image-guided RT and intensity-modulated RT. Also, newer techniques like protons and new devices such as rectum spacers and balloons have been developed to spare rectal structures. Biopsies do not contribute to diagnosing CRP and should be avoided because of the risk of severe rectal wall damage, such as necrosis and fistulas. There is no consensus on the optimal treatment of CRP. A variety of possibilities is available and includes topical and oral agents, hyperbaric oxygen therapy, and endoscopic interventions.

CONCLUSIONS

CRP has a natural history of improving over time, even without treatment. This is important to take into account when considering these treatments: first be conservative (topical and oral agents) and be aware that invasive treatments can be very toxic.

Pathogenesis, diagnosis, and management of ulcerative proctitis, chronic radiation proctopathy, and diversion proctitis

Chronic proctitis refers to persistent or relapsing inflammation of the rectum, which results from a wide range of etiologies with various pathogenic mechanisms. The patients may share similar clinical presentations. Ulcerative proctitis, chronic radiation proctitis or proctopathy, and diversion proctitis are the 3 most common forms of chronic proctitis. Although the diagnosis of these disease entities may be straightforward in the most instances based on the clinical history, endoscopic, and histologic features, differential diagnosis may sometimes become problematic, especially when their etiologies and the disease processes overlap. The treatment for the 3 forms of chronic proctitis is different, which may shed some lights on their pathogenetic pathway. This article provides an overview of the latest data on the clinical features, etiologies, diagnosis, and management of ulcerative proctitis, chronic radiation proctopathy, and diversion proctitis.

Endoscopic assessment of inflammatory bowel disease: colonoscopy/esophagogastroduodenoscopy

Endoscopy plays an important role in the initial diagnosis of IBD, including the evaluation of disease severity, activity, and extent. The implications of complete mucosal healing further confirm the function of endoscopy in the follow-up of IBD patients. The use of therapeutic endoscopy, for example stricture dilatation, can avoid the need for bowel resection. Modalities such as capsule endoscopy, EUS, NBI, CE, and other emerging techniques are likely to have an increasing role in the management of IBD, particularly in the area of dysplasia surveillance and treatment.

Argon plasma coagulation treatment of hemorrhagic radiation proctopathy: the optimal settings for application and long-term outcome

BACKGROUND

No standard treatment exists for hemorrhagic radiation proctopathy (HRP). Recently it was reported that argon plasma coagulation (APC) is effective for HRP. However, previous studies documented complications such as ulcers, strictures, and perforations in as many as 20% of APC-treated patients.

OBJECTIVE

The aim of this study was to determine the optimal parameters for APC by using swine rectum and to assess the safety and effectiveness of APC in HRP patients.

DESIGN

Prospective case series.

SETTING

University teaching hospital.

PATIENTS

Sixty-five patients with HRP were prospectively enrolled between 2000 and 2010.

INTERVENTIONS

APC for HRP.

MAIN OUTCOME MEASUREMENTS

Optimal APC parameters, number of treatments, success rate, complications, clinical remissions.

RESULTS

APC in swine rectal wall ex vivo was optimal with a 40-W current, 1.2-L/min gas flow rate, and 2-second application, which was sufficient to treat the submucosal telangiectasia but did not adversely affect the muscle layer. Sixty-five patients (46 men, 19 women; median age 72 years) with HRP occurring at a mean of 20 months after radiotherapy were studied. Proctopathy was classified as grade A (mild) in 7 patients (10.8%), grade B (moderate) in 41 (63.1%), and grade C (severe) in 17 (26.2%). The treatment success rate was 98.5% after a median of 2 (range 1-5) APC sessions. The median clinical score for rectal bleeding was significantly decreased after APC (P < .0001), and the hemoglobin level was significantly increased (P < .0001). APC was well tolerated, and no significant side effects or complications occurred. During a mean follow-up of 34.6 months (range 3.6 -121.1 months), 4 patients (6.3%) had minor recurrent rectal bleeding and 60 (93.8%) remained in remission.

LIMITATIONS

Nonrandomized study.

CONCLUSIONS

HRP treatment with optimal APC settings yields a high success rate and long-lasting clinical remission with no significant complications.

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.

Gastrointestinal problems after pelvic radiotherapy: the past, the present and the future

Up to 300,000 patients per year undergo pelvic radiotherapy worldwide. Nine out of 10 will develop a permanent change in their bowel habit as a result. Five out of 10 of all patients will say that this change in their bowel habit affects quality of life and two to three out of 10 will say that this effect on quality of life is moderate or severe. Between one in 10 and one in 20 patients will develop very serious complications within the first 10 years after treatment. This number will increase to two out of 10 by 20 years from the end of treatment. Although research carried out into the basic molecular, cytokine and physiological changes underlying radiation-induced bowel symptoms and the optimal treatment that should be provided to symptomatic patients is scant, it does seem probable that a significant proportion of these patients can be cured or improved by specialist gastroenterological intervention. However, most patients never get referred to a specialist gastroenterologist and research into late radiation bowel damage has not been considered a priority. With the advent of more effective cancer therapies leading to greater numbers of affected long-term survivors, much more emphasis is urgently required to provide better information to patients at the start and after treatment, developing techniques that might reduce the frequency of significant bowel toxicity and researching better ways of measuring and treating late-onset side-effects.

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.

Gastrointestinal symptoms after pelvic radiotherapy: role for the gastroenterologist?

PURPOSE

To analyze the cause of GI symptoms after pelvic radiotherapy (RT) in a consecutive series of patients with symptoms beginning after RT. A striking lack of evidence is available concerning the optimal treatment for the 50% of patients who develop permanent changes in bowel habits affecting their quality of life after pelvic RT. As a result, in the UK, most such patients are never referred to a gastroenterologist.

METHODS AND MATERIALS

All diagnoses were prospectively recorded from a consecutive series of patients with symptoms that started after RT and who were referred during a 32-month period to a gastroenterology clinic. Patients either underwent direct access flexible sigmoidoscopy or were investigated in a standard manner by one gastroenterologist after first being seen in the clinic.

RESULTS

A total of 265 patients referred from 15 institutions were investigated. They included 90 women (median age, 61.5 years; range, 22-84 years) and 175 men (median age, 70 years; range, 31-85 years). RT had been completed a median of 3 years (range, 0.1-34 years) before the study in the women and 2 years (range, 0-21 years) before in the men. Of the 265 patients, 171 had primary urologic, 78 gynecologic, and 16 GI tumors. The GI symptoms included rectal bleeding in 171, urgency in 82, frequency in 80, tenesmus, discomfort, or pain in 79, fecal incontinence in 79, change in bowel habit in 42, weight loss in 19, vomiting without other obstructive symptoms in 18, steatorrhea in 7, nocturnal defecation in 8, obstructive symptoms in 4, and other in 24. After investigation, significant neoplasia was found in 12%. One-third of all diagnoses were unrelated to the previous RT. More than one-half of the patients had at least two diagnoses. Many of the abnormalities diagnosed were readily treatable. The symptoms were generally unhelpful in predicting the diagnosis, with the exception of pain, which was associated with neoplasia (p < 0.001).

CONCLUSION

The results of our study have shown that radiation enteritis is not a single disease entity. More than one-half of the patients had more than one GI diagnosis contributing to their symptoms. After pelvic RT, specific GI symptoms were not a reliable measure of the underlying diagnoses, and the evaluation of new GI symptoms is worthwhile. An algorithm for this purpose is proposed.

The significance of rectal bleeding after pelvic radiotherapy

BACKGROUND

Rectal bleeding after pelvic radiotherapy is often attributed to radiation proctitis and patients do not routinely undergo flexible endoscopy.

AIMS

To assess the significance of bleeding after radiotherapy.

METHODS

We maintained a prospective register of all such patients referred to our endoscopy unit.

RESULTS

One hundred and thirty-nine men (median age 70 years; range 31-82), and 32 women (median age 61 years; range 30-81) were referred with rectal bleeding (median 2 years; range 0-21) after pelvic radiotherapy. Primary tumour sites were urological (n = 139), gastrointestinal (n = 7) and gynaecological (n = 25). Ninety patients had bleeding alone; 81 had other symptoms. One hundred and forty-one had typical radiation proctitis; in 65 this was the sole diagnosis; eight had cancer, nine had high-risk adenomas, and six had three or more small adenomas. Ninety-five other diagnoses were made. Eleven (73%) patients with advanced polyps or cancer required only flexible sigmoidoscopy to make the diagnosis, while four (27%) diagnoses were made only after colonoscopy; 47% of these patients had no other symptoms apart from rectal bleeding.

CONCLUSIONS

After pelvic radiotherapy, clinical symptoms are not reliable in differentiating between radiation proctitis alone or more significant pathology. It is mandatory that all patients with new onset rectal bleeding are investigated with, at least, flexible sigmoidoscopy.

Spontaneous improvement in late rectal mucosal changes after radiotherapy for prostate cancer

PURPOSE

To describe the natural history of mucosal changes, in particular the development of telangiectases in the rectum, after radiotherapy (RT) for prostate cancer.

METHODS AND MATERIALS

Twenty patients undergoing local-field, nonconformal RT for prostate cancer underwent flexible sigmoidoscopy every 6 months for up to 3 years after RT completion. Telangiectasis was scored as absent, single, multiple, or multiple confluent. The site and circumferential extent were also documented. The patients filled in a diary to document the symptoms they were experiencing, including rectal bleeding.

RESULTS

Of the 20 patients, 12 developed multiple telangiectases, and 10 of these had rectal bleeding, which in all cases was mild. Telangiectasis was most commonly seen between 4 (anorectal junction) and 8 cm from the anal verge. In 5 patients, 4 of whom had multiple telangiectases, spontaneous resolution occurred.

CONCLUSION

Late radiation effects in the rectum do not appear to be permanent in all cases. This first prospective prolonged evaluation may provide an explanation for the observation that rectal bleeding resolves in a large proportion of patients with mild symptoms after RT. The reasons for improvement in the late radiation changes in the rectum compared with the permanent changes seen in organs such as the skin are unknown.

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.

Review article: current therapeutic options for radiation proctopathy

Radiation proctopathy is a common unfortunate complication following radiation therapy of pelvic malignancies. Symptoms of chronic radiation proctopathy include haematochezia, urgency, constipation, tenesmus, diarrhoea and rectal pain. Currently, a wide variety of pharmacological options, endoscopic cautery techniques and surgical procedures have been proposed for the treatment of chronic radiation proctopathy. Although these have been proposed primarily as treatment for rectal bleeding, the control of other symptoms has been noted with some of these agents. Pharmacological options include 5-aminosalicylic acid preparations, coticosteroid enemas, sucralfate (oral, enemas), formalin, short chain fatty acid enemas, oestrogen/progesterone, hyperbaric oxygen, antioxidants, sodium pentosan polysulphate and misoprostol rectal suppositories. Of these, sucralfate and formalin therapy appear to be effective for bleeding control. Misoprostol rectal suppositories and oral sucralfate may be useful in the prevention of acute and chronic symptoms of radiation proctopathy. Endoscopic cautery techniques have included the use of Nd:YAG laser and argon laser for coagulation of bleeding neovascular telangiectasias. Argon plasma coagulation offers a safe non-contact method of delivering haemostasis which has proven to be particularly useful in targeting difficult to reach lesions tangentially. Surgery is generally reserved for severe refractory cases involving ongoing haemorrhage, obstruction, stricture formation, fistulas and perforation. Given that formal randomized placebo-controlled studies are lacking for most treatments, the management of these patients is often challenging and unclear. Hence, there is a need for more research and education on radiation proctopathy.

Rectal bleeding after radiation therapy for prostate cancer: endoscopic evaluation

PURPOSE

To analyze the frequency and clinical importance of proctitis and hematochezia after radiation therapy for prostate cancer.

MATERIALS AND METHODS

Of 63 patients with prostate cancer treated with curative intent by a single radiation oncologist between July 1, 1993, and December 31, 1997, 30 were asymptomatic, but 33 had heme-positive digital rectal examination (DRE) results or hematochezia at routine follow-up. Twenty-six of these patients underwent endoscopy of the sigmoid colon or colon for evaluation of these symptoms. Median doses of 60.0 Gy at postoperative radiation therapy and 68.4 Gy at definitive radiation therapy were delivered to four fields daily by using blocking customized on the basis of computed tomographically documented evidence of disease. The Fisher exact test and the Kaplan-Meier method were used to analyze the results.

RESULTS

The frequency of rectal bleeding approached 80% at 3 years after radiation therapy in definitively treated patients. Only 14 patients had proctitis: eight as the only sign, and six in association with other disease. Six patients had other disease without proctitis, and four patients had normal examination findings. The frequency of rectal bleeding in the presence of proctitis was similar to that in the presence of other disease (Fisher exact test, P =.68).

CONCLUSION

Hematochezia or positive DRE findings are frequent sequelae of definitive radiation therapy for prostate cancer; however, causes other than proctitis are often documented at endoscopy. Symptomatic individuals warrant rigorous evaluation to rule out serious coexistent disease.

The importance of clinicopathological correlation in the diagnosis of inflammatory conditions of the colon: histological patterns with clinical implications

Histological reaction patterns within the colon are not disease-specific but reflect mechanisms of injury and duration of disease. By correlating these patterns with known causes of colonic inflammation, we provide guidelines to enhance the diagnostic value of colonoscopic samples. Normal histological features are reviewed, and the sequence of inflammation and repair is used as the basis for appreciating pathological deviations. The common histological patterns of acute colitis with and without features of pseudomembranous or ischemic colitis and the morphological features of chronic colitis with and without crypt destruction are collated with clinical and endoscopic features to emphasize the importance of dialogue between the pathologist and gastroenterologist. Less common patterns, including eosinophilic colitis, graft-versus-host disease, chronic mucosal prolapse, portal hypertensive colopathy, and nonspecific or idiopathic ulcer, illustrate variations in the basic reaction patterns. Difficulties in differential diagnosis are underscored, and biopsy strategies are suggested.

Endoscopic treatment of chronic radiation proctopathy

Radiation proctopathy can be a disabling delayed outcome of radiation therapy directed at pelvic malignancies. Rectal outlet bleeding can be severe enough to result in anemia and transfusion dependency. Bleeding typically develops from 6 months to 1 year after completion of radiation therapy and is caused by friable mucosal angioectasias. Although many approaches to controlling bleeding from chronic radiation proctopathy have been attempted, ranging from topical enema formulations to surgical diversion of the rectum, endoscopic coagulation therapy remains the most effective. This review provides the background issues surrounding the development of chronic bleeding radiation proctopathy and focuses on endoscopic methods of treatment.

Radiation injuries of the colon and rectum

Approximately 5% to 10% of patients receiving abdominopelvic radiation therapy will develop a colon or rectal injury. Thorough evaluation of the patient to determine the extent of the injury and the presence of concomitant lesions and to rule out recurrent malignancy is urged. Many radiation complications can be managed with medical regimens. Although colostomy remains a valuable and frequently utilized mode of treatment, it is by no means the sole alternative when surgical intervention is required. Rectal resection with colorectal or coloanal anastomosis can be performed safely for some injuries involving the distal rectum. Surgery for irradiated bowel should be focused on minimizing dissection to minimize injuries and on providing healthy non-irradiated tissues to provide adequate blood supply to promote healing. Patients who have received abdominopelvic radiation are at greater risk of developing colorectal cancer, and cancer surveillance should be commenced 5 years after completion of therapy.

Endoscopic Nd:YAG laser treatment of severe radiation injury of the lower gastrointestinal tract: long-term follow-up

We report a series of patients with severe radiation injury treated with endoscopic laser photocoagulation. Eight patients with recurrent lower gastrointestinal bleeding secondary to procosigmoiditis were treated with endoscopic Nd:YAG laser therapy. Patients were followed for an average of 21.7 months after the first laser treatment. Average transfusion requirements and hospital admissions per patient-month were 0.93 and 0.27, respectively, in the prelaser period and 0.18 and 0.06, respectively, in the entire period following the first laser treatment. A total of 26 laser treatments were performed. There were three major (prolonged ileus) and one minor (pain) complication. We conclude that endoscopic Nd:YAG laser photocoagulation is a safe, effective, and lasting treatment in severe, symptomatic radiation injury of the lower gastrointestinal tract.

Clinical and laboratory approaches to evaluate diarrheal disorders

Diarrheal disorders are the result of excessive fluid and electrolyte loss through the gastrointestinal tract. Many different underlying mechanisms are known to cause diarrhea. Fordtran suggested that in secretory diarrhea the osmolality of stool water should be accounted for by its electrolyte contents. Therefore, the osmotic gap between the measured osmolality and that estimated from electrolyte contents should be small. In osmotic diarrhea, due to the presence of the osmotic agent, there should be a greater gap between the measured and the estimated osmolalities. Osmotic gaps varying from 100 to 40 mOsm have been used arbitrarily in literatures to define the underlying pathogenesis. Because of the uncertainty, the usefulness of these measurements remains in question. In this article, methods used to measure stool osmolality and electrolyte contents are reviewed. Limitations of these measurements are discussed. Measurements derived from various diarrheal disorders revealed that the basic concepts put forward by Fordtran are corrected. However, we found that the osmotic gaps (measured osmolality - 2 [Na + K] in secretory diarrheal disorders are frequently negative numbers. In osmotic diarrhea, the osmotic gap (greater than 160 mOsm) is substantially greater than the figures used in the literature. In many diarrheal disorders the osmotic gap falls between the two extremes and the pathogenesis is multifactorial in origin. Under these circumstances, stool osmolality and electrolyte measurements provide little insight into the underlying mechanism causing the diarrhea. Furthermore, stool contains many biologically active organisms which can alter the stool osmolality. Unless these effects are appreciated, an inaccurate interpretation of these measurements may result.

Use of the flexible sigmoidoscope in women with previous pelvic irradiation

Pelvic irradiation has been reported to be a risk factor for colonic malignancy. We performed flexible sigmoidoscopy with serial pinch biopsies in 20 asymptomatic women treated with irradiation for cervical cancer more than 10 years ago in order to determine the feasibility of the technique and to detect late radiation effects. The examination was well tolerated by 14 (70%) of the patients, and the instrument was passed to 40 cm in 14 (74%) of 19 women. Abnormal mucosal or vascular changes were found in 12 (60%) and nonspecific microscopic abnormalities were seen in 18 (90%) of the 20 women.