The management of radiation proctitis

The Efficacy of Probiotic (Lactobacillus rhamnosus GG) and 5-ASA (Aminosalicylic Acid) in the Treatment of Experimental Radiation Proctitis in Rats

The aims of the study are to demonstrate the effect of probiotic use on the healing of radiation proctitis (RP) and evaluate the efficiency of fecal biomarkers at follow-up of the treatment. Thirty-two male/female rats were randomly separated into four groups of eight rats. The first group (control) was not radiated. RP was created by 17.5 Gy single dose rectal irradiation. The second group (RP) was subjected to RP, but not treated. The third group (RP+ASA) was treated with 5-aminosalicylic acid (5-ASA) 250 mg/kg daily by gastric lavage for 14 days after the irradiation, and the forth group (RP+LGG) was treated with Lactobacillus GG (LGG) 25 × 100 million CFU daily. Feces samples were taken at the 7th and 14th day of the treatment for fecal biomarkers. Rectums of the rats were resected at the 14th day by laparotomy. Samples were evaluated both macroscopically and microscopically. RP was achieved both macroscopically and microscopically. Weight loss of RP group is statistically significant (p < 0.005) than other groups. The healing ratio of RP+ASA and RP+LGG groups was significantly better than the RP group (p < 0.005) both macroscopically and microscopically. But there was no significant difference between ASA and LGG groups. Biochemically, fecal calprotectin was found to be more effective than fecal myeloperoxidase and fecal lactoferrin to show the efficacy of treatment of radiation proctitis. The results of our study demonstrate that probiotic is as effective as 5-aminosalicylic in the treatment of radiation proctitis, and fecal calprotectin is a useful biomarker in determining the response to the treatment.

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.

Late rectal toxicity after low-dose-rate brachytherapy: incidence, predictors, and management of side effects

As clinical outcomes for patients with clinically localized prostate cancer continue to improve, patients and physicians are increasing making treatment decisions based on concerns regarding long-term morbidity. A primary concern is late radiation proctitis, a clinical entity embodied by various signs and symptoms, ranging from diarrhea to rectal fistulas. Here, we present a comprehensive literature review examining the clinical manifestations and pathophysiology of late radiation proctitis after low-dose-rate brachytherapy (BT), as well as its incidence and predictors. The long-term risks of rectal bleeding after BT are on the order of 5-7%, whereas the risks of severe ulceration or fistula are on the order of 0.6%. The most robust predictor appears to be the volume of rectum receiving the prescription dose. In certain situations (e.g., salvage setting, for patients with increased radiosensitivity, and following aggressive biopsy after BT), the risk of these severe toxicities may be increased by up to 10-fold. A variety of excellent management options exist for rectal bleeding, with endoscopic methods being the most commonly used.

Two percent formalin retention enemas for hemorrhagic radiation proctitis: a preliminary report

PURPOSE

The short-term safety and efficacy of 2 percent formalin administered as a retention enema for hemorrhagic radiation proctitis was studied.

METHODS

A group of 24 patients with hemorrhagic radiation proctitis who received radical radiotherapy were administered 2 percent formalin as a retention enema and the treatment was followed up from 1 to 29 (mean, 15.34) weeks. The enema was performed on an outpatient basis under sedation with pentazocine and promethazine with a retention time of two minutes. The symptoms and proctoscope findings were graded and converted into a numeric score, ranging from 1 to 4. The mean improvements in scores before treatment and after the last follow-up were analyzed for statistical significance by using the paired t-test.

RESULTS

There was complete cessation of bleeding in 47.8 percent of patients and very negligible bleeding in 30.4 percent. A total of 78.2 percent responded positively to treatment with 2 percent formalin retention enema. More than one application was required in 34.7 percent of the patients. The procedure was well tolerated and most of the side effects were mild. Side effects were diarrhea in 23.5 percent, abdominal pain and tenesmus in 8.8 percent, and fever with vomiting in 2.9 percent of patients. There was a statistically significant reduction in bleeding and proctoscopy scores (P<0.01). None of the patients in this study required surgery to palliate their symptoms.

CONCLUSIONS

Two percent formalin when given as a retention enema is a safe, inexpensive, and effective intervention for hemorrhagic radiation proctitis. Any trained health worker using simple precautions can perform this procedure. The long-term efficacy and safety of 2 percent formalin retention enemas need further assessment with randomized, controlled trials.

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.

Treatment of a radiation-induced rectal ulcer with hyperbaric oxygen therapy in a man with prostate cancer

Late radiation proctopathy is a painful and vexing complication of prostate radiation. We report a case of a 55-year-old man with prostate cancer, and complaints of tenesmus and severe rectal pain after radiation therapy. The patient was diagnosed with a locally advanced Gleason score 8 prostate cancer and an increased prostate-specific antigen of 42.3 ng/ml. His past medical history was notable for a history of bilateral lymph node dissection complicated by Clostridium difficile colitis. He subsequently received 3-dimensional conformal radiation therapy. Seven months after completing therapy, minor rectal bleeding and significant pain developed, requiring increasing doses of opioid analgesics. Fourteen months after 3-dimensional conformal radiation therapy, sigmoidoscopy revealed a single chronic deep ulcer at the anorectal junction. As an alternative to diverting colostomy, the patient underwent a course of hyperbaric oxygen. Within 1 month of completing hyperbaric oxygen treatment, his symptoms completely resolved. Nine months from completion of hyperbaric oxygen therapy, he has had no recurrence of symptoms. Hyperbaric oxygen therapy can be considered a treatment option after failure of standard treatments in patients with severe radiation proctopathy.

Histopathological comparison of topical therapy modalities for acute radiation proctitis in an experimental rat model

AIM: To evaluate the prevalent topical therapeutic modalities available for the treatment of acute radiation proctitis compared to formalin.

METHODS: A total of 120 rats were used. Four groups (n = 30) were analyzed with one group for each of the following applied therapy modalities: control, mesalazine, formalin, betamethasone, and misoprostol. A single fraction of 17.5 Gy was delivered to each rat. The rats in control group rats were given saline, and the rats in the other three groups received appropriate enemas twice a day beginning on the first day after the irradiation until the day of euthanasia. On d 5, 10, and 15, ten rats from each group were euthanized and a pathologist who was unaware of treatment assignment examined the rectums using a scoring system.

RESULTS: The histopathologic scores for surface epithelium, glands (crypts) and lamina propria stroma of the rectums reached their maximum level on d 10. The control and formalin groups had the highest and mesalazine had the lowest, respectively on d 10. On the 15^th d, mesalazine, betamethasone, and misoprostol had the lowest scores of betamethasone.

CONCLUSION: Mesalazine, betamethasone, and misoprostol are the best topical agents for radiation proctitis and formalin has an inflammatory effect and should not be used.

Endoluminal formalin application for haemorrhagic radiation proctitis

BACKGROUND

Radiation proctitis is a common complication following radiation therapy for pelvic malignancies. This is associated with significant morbidity which adversely affects the quality of life. Local application of formalin has been used effectively in the treatment of radiation proctitis.

METHODOLOGY

Thirty patients with haemorrhagic radiation proctitis who underwent endoluminal application of 4% formalin between January 1998 to October 2002 were followed up prospectively to assess the efficacy of the treatment.

RESULTS

The follow up ranged from 5 to 36 months (mean 18.1 months). Nineteen (63.3%) patients had complete response to formalin application while 7 (23.3%) patients had partial response. There were 4 (13.3%) failures. No procedure related complication was observed.

CONCLUSION

Local application of formalin is a simple, safe, inexpensive and fairly effective outpatient treatment modality for chronic radiation proctitis.

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.

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.

Argon plasma coagulation is an effective treatment for refractory hemorrhagic radiation proctitis

INTRODUCTION

Chronic radiation proctitis complicating pelvic radiotherapy can be debilitating. It commonly presents with rectal bleeding, which can be difficult to control. Medical management of hemorrhagic radiation proctitis is not very successful, although surgery carries high risks. Thus, endoscopic treatments are preferred. The aim of this study is to assess the efficacy of argon plasma coagulation applied endoscopically to treat hemorrhagic radiation proctitis that has been refractory to topical formalin therapy.

METHODS

Twelve patients who had ongoing bleeding from radiation proctitis, after previously failed formalin therapy, underwent endoscopic treatment using argon plasma coagulation. The efficacy of treatment was assessed by grading the frequency and severity of bleeding (0-4, 0 being no bleeding), hemoglobin level, and transfusion requirements.

RESULTS

At a median follow-up of 11 months, ten patients (83 percent) had a significant reduction in the severity and frequency of bleeding, with complete cessation in six (50 percent). The presence of coexistent radiation-induced sigmoiditis in two patients was associated with reduced but persistent bleeding, because of difficulty in targeting the bleeding sites in the sigmoid colon. The median number of treatment sessions per patient was two (range, 1-3), with the number of sessions correlated with the extent of the proctitis. All patients had an improvement in their hemoglobin level, with the mean increasing from 11.2 to 12.3 g/dl. In the six months before starting therapy, all patients had been taking iron supplements, and four had required blood transfusions (median 3 units, range, 2-6). Iron supplements were ceased four weeks after the completion of therapy in all cases, and no further transfusions were required during the study period. None of the patients experienced any significant side effects or complications.

CONCLUSIONS

Argon plasma coagulation is an effective and safe treatment for hemorrhagic radiation proctitis that has been refractory to topical formalin therapy.

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.

A prospective randomized placebo-controlled double-blinded pilot study of misoprostol rectal suppositories in the prevention of acute and chronic radiation proctitis symptoms in prostate cancer patients

OBJECTIVE

Radiation proctitis is a known complication of radiation therapy for prostate cancer. Available medical treatment is usually ineffective and has focused on relieving symptoms after damage has occurred. Our study aimed at evaluating the use of misoprostol rectal suppositories in the prevention of acute as well as chronic radiation proctitis symptoms.

METHODS

A prospective, randomized, placebo-controlled, double-blinded trial was conducted in patients with recently diagnosed stages B and C prostate cancer who underwent external beam irradiation. Patients received either a misoprostol or a placebo suppository 1 h before each radiation session. Misoprostol suppositories were made from two 200-microg tablets (Cytotec, Searle Pharmaceuticals, Skokie, IL), whereas the placebo was made from cocoa butter. A 12-point radiation proctitis symptom score was obtained from each patient at 4, 8, 12, and 36 wk after radiation therapy.

RESULTS

A total of 16 patients were enrolled. Seven patients received placebo, and nine patients received misoprostol. Mean radiation proctitis symptom scores in the placebo group were 4.86, 5.86, 5.71, and 3.83 at 4, 8, 12, and 36 wk, respectively. The mean scores in the misoprostol group were 0.78, 0.67, 0.33, and 0.37 at 4, 8, 12, and 36 wk, respectively. The difference between the two groups was statistically significant (p < 0.05) at 4, 8, 12, and 36 wk.

CONCLUSION

Misoprostol rectal suppositories significantly reduce acute and chronic radiation proctitis symptoms in patients receiving radiation therapy for prostate cancer.

Prospective evaluation of formalin therapy for radiation proctitis

BACKGROUND

Radiation proctitis is a troublesome complication of radiation therapy for as many as 75% of patients after pelvic irradiation. Five percent progress to chronic radiation proctitis complicated by telangiectasias and hemorrhage. The utility of formalin rectal instillation for treatment of bleeding is prospectively evaluated in this study.

METHODS

Eleven patients (9 male, 2 female) with rectal bleeding after pelvic irradiation were treated with formalin therapy. In a single treatment, 4% formalin was instilled into the rectum in four separate 20-cc aliquots with total mucosal contact time of approximately 15 minutes. Patients were initially evaluated at 7 to 10 days and 1 month postoperatively and assessed for bleeding.

RESULTS

All patients presented with rectal bleeding. Twenty-seven percent required transfusion. Thirty-six percent had failed other previous therapy. In follow-up of 3 to 64 months, 100% had initial success with cessation of bleeding. Three patients had recurrent bleeding; none required transfusion. One patient required repeat formalin instillation, with no further bleeding at 3 months follow-up.

CONCLUSION

Local rectal instillation of 4% formalin is an efficacious therapy for treatment of radiation-induced lower gastrointestinal bleeding.

Argon beam coagulation for treatment of symptomatic radiation-induced proctitis

BACKGROUND

Radiation proctitis is a complication of radiotherapy for malignant pelvic disease. Argon beam coagulation is a new and rapidly evolving technology that permits a "no-touch" electrocoagulation of diseased tissue.

METHODS

We analyzed retrospectively the records of 7 patients with prostatic and endometrial cancers treated with irrradiation (median radiation dose was 6840 cGy, range 2400 to 7200 cGy). The median time to onset of symptoms after the conclusion of radiotherapy was 20 months (range 16 to 48 months); symptoms consisted of rectal bleeding and tenesmus in all patients. The patients underwent argon beam coagulation after colonoscopic evaluation. The usual treatment interval was 3 weeks (range 1 to 3 weeks).

RESULTS

A median of 2 treatment sessions (range 2 to 4) was necessary for complete symptom relief. All interventions were well tolerated without complications. During follow-up (median 24 months, range 18 to 24 months), there was no recurrence of symptoms (bleeding, tenesmus).

CONCLUSIONS

Argon beam coagulation is a safe, well tolerated, and effective treatment option in symptomatic radiation proctitis.

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

PURPOSE

Treatment of chronic radiation proctitis remains unsatisfactory. Short-chain fatty acids are the preferred energy source for the colonic epithelium. We aimed to determine for the first time whether topical butyric acid enemas relieve symptoms and improve the macroscopic and microscopic findings in chronic radiation proctitis.

METHODS

A randomized, double-blind, placebo-controlled, cross-over pilot trial compared patients given two weeks of butyric acid enemas (40 mmol) twice per day with those given placebo, with a one-week washout period; 15 patients were randomized and 12 completed both arms of the trial. A total symptom score combined six symptom items per week (rectal pain, episodes of rectal bleeding, amount of blood passed, days with diarrhea, number of stools, and urgency). Symptom, endoscopic, and histologic scores were obtained at the beginning of the study and again at the last week of each treatment arm.

RESULTS

Total symptom score at baseline (median, 5.5) improved for those patients receiving active treatment (median, 3.5), but compared with placebo (median, 4.5), the change was not significant. Endoscopic appearances were largely unaltered by active treatment. Histology was abnormal in 82 percent of patients receiving placebo compared with 55 percent of those given butyric acid enemas (P = not significant).

CONCLUSION

Butyric acid enemas do not appear to be superior to placebo in the treatment of chronic radiation proctitis.

Hyperbaric oxygen treatment for radiation proctitis

PURPOSE

Our objective was to assess, retrospectively, the efficacy of hyperbaric oxygen treatment in radiation proctitis in all patients who have completed treatment for this disease at the Fremantle Hyperbaric Oxygen Unit. This unit is the only one of its kind in Western Australia.

METHODS AND MATERIALS

Patients were assessed by a review of hospital records, blood bank records, and clinic review (if this was convenient), and all patients responded to a telephone survey. Patients were questioned regarding radiation proctitis symptoms and the degree to which each had improved.

RESULTS

Most patients had previously been treated with radiotherapy for prostate carcinoma. Patients with proctitis mainly suffered from bleeding, diarrhoea, incontinence, and pain. In more than half of these patients, symptoms partially or completely resolved after hyperbaric oxygen treatment.

CONCLUSION

Radiation-induced proctitis is a difficult clinical problem to treat and will probably become more significant with the rising incidence of diagnosis of prostate cancer. Hyperbaric Oxygen should be considered in the treatment of radiation-induced proctitis. Further prospective trials with strict protocol guidelines are warranted.

Formalin instillation for refractory radiation-induced hemorrhagic proctitis. Report of 16 patients

PURPOSE

Our goal was to evaluate use of topical (4 percent) formalin in management of radiation-induced hemorrhagic proctitis, refractory to other methods of treatment. Specifically, we wished to determine its safety, ability to stop bleeding, and complications associated with therapy.

METHODS

Sixteen patients with radiation-induced hemorrhagic proctitis were treated with topical (4 percent) formalin. All had been previously treated with conservative regimens such as cautery, topical steroids, or laser, but these had failed. Five-hundred milliliters (ml) of a 4 percent formalin solution was instilled into the rectum in 50-ml aliquots. Each aliquot was kept in contact with rectal mucosa for approximately 30 seconds. Treatments were performed under local anesthesia in nine patients, sedation only in four, spinal in two, and general in one patient.

RESULTS

In 12 patients, bleeding stopped after a single formalin instillation; in 3, bleeding was considerably reduced but continued sporadically. One patient required three treatments before bleeding stopped. Four patients developed postoperative anal pain, of which one also had significant tenesmus and reduced capacity. Of these four patients, only two had significant anal pain and fissures that lasted longer than one month.

CONCLUSIONS

Topical (4 percent) formalin is safe and effective in treatment of radiation-induced hemorrhagic proctitis. A single treatment will stop bleeding in 75 percent of patients.

Argon laser therapy for hemorrhagic radiation proctitis: long-term results

In chronic radiation proctitis bleeding occurs from mucosal friability and neovascular telangiectasias. Fourteen patients with bleeding from chronic radiation proctitis underwent endoscopic argon laser therapy at 4 to 8 W. The goal of treatment was obliteration of all telangiectasias. The average follow-up was 35 months. Of the 51 procedures, 48 (94%) were performed on outpatients with enema preparation and little or no sedation. A median of three procedures was performed per patient, with two sessions required for initial control of bleeding. Ten patients (71%) required maintenance therapy for recurrent bleeding from telangiectasias that developed after initial therapy. The mean interval between maintenance sessions was 7 months. No immediate or late complications occurred.

Endoscopic Nd:YAG laser coagulation of bleeding from radiation proctopathy

Hematochezia from mucosal vascular lesions usually confined to the rectum represents an uncommon but problematic late complication of pelvic radiotherapy. We studied 47 patients with medically refractory hematochezia resulting from radiation-induced rectosigmoid mucosal vascular lesions. All lesions were endoscopically coagulated with Nd:YAG laser. Median duration of hematochezia before laser therapy was 11 months, despite previous medical treatment (98%) or bypass colostomy (6%). Within 3 to 6 months after laser treatment, the number of patients with daily hematochezia fell from 40 (85%) to 5 (11%; p < 0.001), and the median hemoglobin level increased from 9.7 gm/dl to 11.7 gm/dl (p < 0.001). Complications occurred in three patients (6%); no deaths occurred. The condition in six patients (12.8%) was not improved by laser treatment. Two patients (4%) ultimately required surgical treatment for bleeding control. On the basis of symptomatic, hematologic, and endoscopic responses, Nd:YAG laser photocoagulation controlled bleeding from radiation proctopathy in most patients with an acceptably low morbidity. Patients with sigmoid colon involvement responded less favorably. Endoscopic laser photocoagulation should be considered before surgical intervention for treatment of hematochezia from radiation proctopathy.

A simple and effective treatment for hemorrhagic radiation proctitis using formalin

Radiation proctitis is a common complication of radiotherapy for pelvic malignancy. In the more severe form, it leads to intractable or massive hemorrhage, which may require repeated hospital admissions and blood transfusions. Medical therapy in patients with radiation proctitis is usually ineffective, whereas surgery is associated with a high morbidity and mortality. Eight patients (seven females and one male) with hemorrhagic radiation proctitis were treated over a six-month period with endoluminal formalin. The technique used ensured minimal contact with formalin. The median age of the patients was 68 years (range, 42-73 years). Seven patients had had cancer of the uterine cervix, and one patient had had cancer of the prostate treated with radiotherapy at a median time of 30 months (range, 9-46 months) previously. The median duration of time of symptomatic rectal hemorrhage before formalin therapy was eight months (range, 1-12 months). The median number of units of blood transfused previously per patient was four (range, 2-32). The time taken for formalin therapy was 20 minutes (range, 10-70 minutes). One patient required repeat formalin application at two weeks. Bleeding ceased immediately in seven patients after formalin treatment. No further bleeding was noted, nor was any blood transfusion needed, at follow-up at four months (range, 1-6 months). Formalin therapy is a simple, inexpensive, and effective treatment for hemorrhagic radiation proctitis.

Severe hemorrhagic radiation proctitis advancing to gradual cessation with hyperbaric oxygen

We report a case of a male patient suffering from a severe hemorrhagic radiation proctitis which gradually ceased with hyperbaric oxygen. We discuss the mechanisms of chronic radiation injury and the effect of the hyperbaric oxygen. This therapy is proposed as an alternative to surgical intervention for this abnormality.

Radiation-induced proctosigmoiditis. Prospective, randomized, double-blind controlled trial of oral sulfasalazine plus rectal steroids versus rectal sucralfate

In a prospective study, 37 consecutive patients with radiation-induced proctosigmoiditis were randomized to receive a four-week course of either 3.0 g oral sulfasalazine plus 20 mg twice daily rectal prednisolone enemas (group I, N = 18) or 2.0 g twice daily rectal sucralfate enemas plus oral placebo (group II, N = 19). The two groups were comparable with respect to demographic features, duration of symptoms, and clinical and endoscopic staging of the disease. Fifteen patients in group I and 17 in group II completed the trial. At four weeks, both groups showed significant clinical improvement (P less than 0.01 for group I and P less than 0.001 for group II) and endoscopic healing (P less than 0.01 for group I and P less than 0.001 for group II). When the two groups were compared, sucralfate enemas showed a significantly better response as assessed clinically (P less than 0.05), although endoscopically the response was not statistically different (P greater than 0.05). We conclude that both treatment regimens are effective in the management of radiation proctitis. Sucralfate enemas give a better clinical response, are tolerated better, and because of the lower cost should be the preferred mode of short-term treatment.

Laser therapy for severe radiation-induced rectal bleeding

Four patients with chronic hematochezia and transfusion-dependent anemia from postradiation rectal vascular lesions were successfully managed by endoscopic laser coagulation. In all four patients, symptomatic, hematologic, and endoscopic improvement was evident. Laser therapy for severe radiation-induced rectal bleeding seems to be safe and efficacious and should be considered before surgical intervention.

Intracolonic WR 2721 protection of the rat colon from acute radiation injury

The radioprotective thiophosphate compound WR 2721, when given intraperitoneally, has been shown to effectively protect normal murine tissues, but not tumors, from radiation injury. Intravenous administration in humans has produced limiting nausea and vomiting at protective doses. The accessibility of the colon, coupled with the frequency of acute radiation injury to the rectum during pelvic irradiation, stimulated us to determine if WR 2721 was radioprotective when administered intracolonically. Double-blind histologic evaluation of colons from irradiated rats treated with intracolonic WR 2721 demonstrated a radioprotective effect with a dose modifying factor of 1.8 when compared with controls. A contact time of 30-60 min was optimal as was a WR 2721 dose of at least 15 mg. No systemic absorption was found. These data demonstrate that WR 2721 exerts its radioprotective effect without the coincident development of secondary tissue hypoxia and provide rationale for a clinical trial in humans.

Surgical treatment of radiation injuries of the colon and rectum

Between 1950 and 1983, radiation-induced proctitis was diagnosed proctoscopically in 720 patients at the Mayo Clinic. Sixty-two patients with severe colorectal symptoms were treated surgically. The interval from cessation of radiotherapy to onset of symptoms ranged from 3 weeks to 24 months (mean 33 months). The 62 patients underwent a total of 143 operations with 8 operative deaths (13 percent), and 40 patients (65 percent) had 61 complications. The morbidity rate was lower after colostomy alone (44 percent in 27 patients) than after more aggressive operations (80 percent in 35 patients). Transverse loop colostomy and descending colostomy were safer than sigmoid colostomy. The dissection adhesions, opening of tissue planes, and careless manipulation of intestine may result in necrosis and perforation of the intestine, bladder, or vaginal wall; these were the main causes of fecal and other internal fistulas in our study.

Pelvic complications after definitive treatment of prostate cancer by interstitial or external beam radiation

Radiation complications, after definitive treatment of localized prostatic carcinoma by either external beam or interstitial implantation with Iodine-125 seeds, are reviewed. Late serious complications to immediately adjacent structures of the anterior rectal wall, prostatic urethra, bladder neck, and external sphincter occurred with similar frequency in both treatment groups. However, late serious complications of the remotely adjacent structures of the bladder, urethra, distal ureters, and circumferential rectal wall occurred more frequently in the external beam treatment series, a reflection of the fact that larger tissue volumes were irradiated. Rectal ulceration, while occurring in both treatment groups, was amenable to surgical correction or underwent spontaneous healing only in the 125I group. At this point in our experience, morbidity from late radiation complications has been less among those patients having interstitial implantation for definitive treatment of localized prostatic carcinoma.