Treatment Of Chronic Radiation Proctitis Research Articles

Explosive proctitis: potential treatments and pitfalls in the treatment of chronic radiation proctitis

A 73-year-old man presented to the authors' clinic with profuse rectal bleeding, defaecatory urgency and symptomatic anaemia. He had been treated for prostatic adenocarcinoma 12 months previously, with neoadjuvant hormones and radiotherapy (total dose of 60 Gy). Chronic radiation proctitis was confirmed endoscopically and histologically in the absence of any other left-sided colonic pathology. His initial medical management with sucralfate enemas and oral metronidazole failed. However, he withheld consent for further topical or endoscopic treatment despite continued symptomatic deterioration and transfusion dependency, presenting a therapeutic impasse. Oral thalidomide (75 mg/day) was started and he made an excellent symptomatic response and became transfusion independent. However, 23 days after starting thalidomide peripheral neuropathy ensued, a well documented side effect (Mileshkin and Prince, 2006), which resolved rapidly following its discontinuation. His symptoms and anaemia rapidly re-emerged and at this point he consented to endoscopic therapy with argon plasma coagulation. An unprepared flexible sigmoidoscopy, to the rectosigmoid junction, demonstrated features of chronic radiation proctitis and argon plasma coagulation was applied exclusively to the rectum. However, the patient developed sudden onset abdominal pain necessitating abandonment of the procedure. A chest radiograph showed free air under the right hemidiaphragm. An emergency laparotomy revealed multiple perforations and lacerations in the proximal descending colon without abdominal contamination. A Hartmann's procedure was performed. A direct perforation as a sequelae of the procedure is unlikely as multiple perforations and lacerations were evident proximal to the upper limit of the examination. Furthermore, no perforation was observed in the rectum or sigmoid where the argon plasma coagulation was applied. As bowel preparation was not administered before the flexible sigmoidoscopy and given the aforementioned findings at laparotomy, the likely cause of the perforation was an intracolonic gas explosion, a rare iatrogenic complication of using thermocoagulative endoscopic techniques within the colon. The patient died 16 days postoperatively of multiorgan failure.

W1307 The Role of Argon Plasma Coagulation (APC) in the Treatment of Chronic Radiation Proctitis

Radiation proctitis is a common complication of radiation treatment for pelvic malignancies. Approximately 5 to 20 % of patients who receive radiation treatment will develop chronic complications including bleeding, fistulae and stictures. To date there are no standard recommendations for the treatment of the chronic blood loss from radiation proctitis. Studied treatments, including hyperbaric oxygen, formaldehyde, 5-ASA have had varied results. Endoscopic treatment is gaining popularity in the treatment of radiation proctitis with both APC and bipolar heater probe being studied. A number of case reports suggest APC may be useful and safe in the treatment of chronic radiation proctitis. However none have utilized a validated scoring system for treatment effect.We plan to study both the endoscopic and the clinical response of APC in the treatment of rectal bleeding from radiation proctitis. Method: Patients referred from radiation oncology with chronic blood loss from suspected radiation proctitis were approached for consent to participate in this study. The patients baseline rectal bleeding was scored using a five point bleeding scale; the patient then underwent a colonoscopy to confirm the source of bleeding. The severity of radiation proctitis was scored using a validated scoring system the rectal telangiectasia density grading score (RTG). Patients were then treated with APC and then re-evaluated in 8 weeks time. At this time, baseline bleeding score was obtained and RTG score evaluated with sigmoidoscopy. If further treatment was required the patient was again re-evaluated in 8 weeks time. Results: There were 19 patients enrolled in this study. Mean age was 72.1 (STD=8.0) and mean Hb is 134.2 g/l(STD=21.7). Three of them did not complete the study. Among the 16 patients who underwent the APC treatment, both the clinical bleeding score and RTG score were reduced after the treatment. The bleeding score reduced 0.93±1.34 (Mean ±STD), while the RTG score reduced 0.81±0.98 (Mean ±STD). The p-values for comparing the pre and post treatment bleeding and RTG scores were 0.02 and <0.01 (Wilcoxon signed ranked test) respectively. Conclusion: In this small prospective trial, APC treatment for radiation proctitis improves the clinical bleeding score and the endoscopic outcomes.

Treatment of hemorrhagic radiation proctitis with 4 percent formalin.

The purpose of this study was to review our results in patients undergoing treatment with 4 percent formalin for radiation-induced injury to the rectum. A retrospective review of office charts was performed, identifying all patients undergoing formalin treatment. Patient gender, initial malignancy, prior treatments, response to treatment with formalin, complications, and length of follow-up were reviewed. All patients had flexible endoscopy to assess for proximal sources of bleeding. The indication for treatment was a symptomatic patient with endoscopic evidence of radiation injury. A cotton pledget was used for direct application of 4 percent formalin to the affected area via a rigid proctoscope or anoscope. The treatment was repeated if blanching did not occur or if bleeding continued. Patients were followed up at three-week to four-week intervals and treatment was repeated based on the above indications. Treatments were continued until cessation of bleeding occurred or, when treatment failed, operative treatment was required. Thirty-six patients were identified. Three were lost to follow-up. Symptoms included bleeding in all but one patient, who presented with an ulcer. There were 33 (26 male) patients. Seventeen (51.5 percent) patients had prior treatment. The number of formalin treatments ranged from 1 to 13, with a mean of 3.4. The follow-up ranged from 1 to 60 months, with a mean of 18 months. Twenty-nine (88 percent) patients had improvement or cessation of symptoms. Four (12 percent) patients failed treatment. Two patients were noted to have full-thickness ulcers and both failed formalin treatment. No complications were noted related to formalin treatment. We conclude that formalin therapy is a safe and effective form of treatment that can be performed in the office with minimal discomfort and no complications. It can be performed multiple times until results are achieved. Formalin therapy may be useful as a first-line treatment for chronic radiation proctitis, however, a prospective controlled trial comparing modalities is required to prove this to be true.

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.

The treatment of chronic radiation proctitis with hyperbaric oxygen in patients with prostate cancer.

The treatment of chronic radiation proctitis with hyperbaric oxygen in patients with prostate cancer.

Short-chain fatty acid (SCFA) enemas are useful for the treatment of chronic radiation proctitis (CRP): [formula omitted], M. Chen, W. Combs, I. Tanabe. Dept. of Medicine, University of South Florida, Tampa, FL

Short-chain fatty acid (SCFA) enemas are useful for the treatment of chronic radiation proctitis (CRP): [formula omitted], M. Chen, W. Combs, I. Tanabe. Dept. of Medicine, University of South Florida, Tampa, FL