*Radzisław Trzciński
Proposed treatment algorithm for radiation proctitis considering the Polish realities
Proponowany algorytm leczenia popromiennego zapalenia odbytnicy uwzględniający polskie realia
Jan Kochanowski University in Kielce, Branch in Piotrków Trybunalski,
Collegium Medicum, Piotrków Trybunalski
Streszczenie
Przewlekłe popromienne zapalenie błony śluzowej odbytnicy (PPZO) jest powikłaniem radioterapii przeprowadzanej z powodu nowotworów narządów zlokalizowanych w obrębie miednicy (m.in. gruczoł krokowy, trzon i szyjka macicy). Stopień nasilenia dolegliwości klinicznych ze strony odbytnicy ocenia się według skali chorobowości późnej po napromienianiu zaproponowanej przez RTOG/EORTC (Radiation Therapy Oncology Group/European Organisation for Research and Treatment of Cancer Score for late radiation proctitis). Z kolei, badanie endoskopowe pozwala na ocenę makroskopową zmian popromiennych w obrębie błony śluzowej. Etiologia PPZO nie jest w pełni poznana, dlatego podejmowane leczenie zarówno farmakologiczne, jak i zabiegowe jest jedynie objawowe, a nie przyczynowe. W pracy przedstawiono metody leczenia PPZO i zaproponowano algorytm postępowania terapeutycznego u pacjentów z PPZO.
Summary
Chronic radiation proctitis (CRP) is a complication of radiotherapy for pelvic malignancies (e.g. prostate, endometrial and cervical cancers). The severity of rectal clinical symptoms is graded based on the Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer Score for late radiation proctitis (RTOG/EORTC). Endoscopy, on the other hand, allows for macroscopic assessment of radiation-induced mucosal damage. The aetiology of chronic radiation proctitis is not fully understood, therefore symptomatic rather than causal pharmacological and surgical treatment is only used. The paper presents the available treatment options and proposes a therapeutic algorithm for chronic radiation proctitis.
Introduction
Radiation-induced intestinal damage, which manifested by abdominal pain and diarrhoea, was first described by Walsh in 1897. In 1930, Buie described a pathological syndrome, which he referred to as chronic radiation proctitis. In 1938, Todd described an early complication of acute radiation proctitis after intracavity radium treatment (1-6).
Chronic radiation proctitis (also known as radiation-induced proctitis, radiation proctopathy) is a consequence of radiotherapy for pelvic malignancies, i.e. cervical and endometrial cancer, bladder, prostate, anal and rectal cancer (1, 7-10). Based on the available data, it is estimated that approximately 1-5% of patients undergoing irradiation for pelvic cancer develop CRP, although rates of 20-47% have also been reported (1, 2, 6, 7, 11-14).
There are no clearly defined risk factors for CRP. One of the theories, known as the ‘vascular’ theory, assumes that small blood vessels are damaged as a result of the impact of ionizing radiation on the vascular endothelium, which in turn leads to proliferation and fibrosis of the intima and media. This in turn leads to structural intestinal wall remodelling, accompanied by mucosal atrophy, as well as often ulceration, perforations, fistulae (rectovaginal, vesicovaginal), and faecal incontinence (1, 6, 11, 13, 15-18).
Radiation-induced changes may involve not only the rectum, but also the sigmoid colon (radiation sigmoidopathy) and even the small bowel, with its stricture and symptoms of obstruction (radiation enteropathy, radiation enteritis). Nevertheless, it is emphasised that the rectum and the distal part of the sigmoid colon, due to their location in the abdominal cavity and relatively low mobility, are most exposed to radiation damage as a result of radiotherapy for pelvic tumours (1, 7, 19).
Clinical manifestations of radiation proctitis
Clinical symptoms of CRP vary in severity, with bleeding (the main symptom of the disease) occurring in about 80% of patients. Other conditions with symptoms suggestive of CRP should be excluded (e.g. antibiotic-induced Clostridium difficile infection, NSAID abuse, parasitic diseases, HPV or Neisseria gonorrhoeae infections, immunomodulatory therapy, and cytomegalovirus infection) (7, 8, 10, 17, 20).
It is estimated that 6-78% of patients after radiotherapy develop disturbances in the rhythm of bowel movements, which clearly affects the quality of life, while serious complications, such as bower stricture, intestinal fistulas, as well as massive bleeding requiring blood transfusions, develop in 5-10% of patients (1, 6, 15, 18, 21, 22). About 0 to 26% of patients after pelvic radiotherapy develop various forms of faecal incontinence. The symptoms of CRP most often occur in the first 2-3 years, and even 1-2 years after the end of radiotherapy, when the incidence reaches the plateau phase, but they may also develop a dozen or even several dozen years after irradiation (1, 2, 5, 18, 23).
Rectal clinical symptoms are graded based on the Radiation Therapy Oncology Group/European Organisation for Research and Treatment of Cancer Score for late radiation proctitis (RTOG/EORTC) (tab. 1).
Tab. 1. Clinical assessment of colorectal symptoms according to the RTOG/EORTC scoring system for late bowel toxicity
| Grade | Clinical manifestations |
| Grade 0 | no symptoms |
| Grade 1 | mild diarrhoea and mild abdominal pain; loose bowel movement up to 5 times a day; mild straining or slight bleeding; mild anal pain |
| Grade 2 | moderate diarrhoea and colic; loose bowel movement > 5 times daily; excessive rectal mucus or intermittent bleeding |
| Grade 3 | persistent pain; obstruction or bleeding requiring surgery |
| Grade 4 | necrosis/perforation/fistula |
| Grade 5 | fatal toxicity ? sepsis, multiple organ failure |
Endoscopic manifestations of radiation proctitis
Radiation proctitis should be suspected in every patient with a history of pelvic radiotherapy who reports symptoms typical of RP, even if radiation therapy was administered many years before. It is important to perform an endoscopic examination to exclude other causes of proctitis and malignancies. The mucosa is dominated by the presence of telangiectasias (small dilated blood vessels), erosions, and ulcerations; it is fragile and prone to contact bleeding, with no typical vascular pattern; focal necrosis may be present (1, 16, 21, 24-28).
Treatment of chronic radiation proctitis
The aetiology of CRP is not fully understood, therefore symptomatic rather than causal treatment is only used, which significantly limits therapeutic outcomes. Acute treatment is usually used for radiation-induced rectal injury, persistent bleeding in particular (1, 18). The most common treatment approaches for CRP are discussed below.
Sucralphate
Sucralfate stimulates formation of endogenous prostaglandins, which have a cytoprotective effect, as well as promotes healing processes through its beneficial effect on angiogenesis. The drug is administered orally (3.0-4.0 g/day) or in the form of 10% enemas. Sucralfate is currently available in Poland as Ulgastran, a suspension (1 g of sucralfate/5 mL; 10-15 mL of suspension administered through a Foley catheter, i.e. 2.0-3.0 g/day) (1, 3, 7, 13, 21, 29, 30).
5-Aminosalicylic acid (5-ASA)
Powyżej zamieściliśmy fragment artykułu, do którego możesz uzyskać pełny dostęp.
Mam kod dostępu
- Aby uzyskać płatny dostęp do pełnej treści powyższego artykułu albo wszystkich artykułów (w zależności od wybranej opcji), należy wprowadzić kod.
- Wprowadzając kod, akceptują Państwo treść Regulaminu oraz potwierdzają zapoznanie się z nim.
- Aby kupić kod proszę skorzystać z jednej z poniższych opcji.
Opcja #1
29 zł
Wybieram
- dostęp do tego artykułu
- dostęp na 7 dni
uzyskany kod musi być wprowadzony na stronie artykułu, do którego został wykupiony
Opcja #2
69 zł
Wybieram
- dostęp do tego i pozostałych ponad 7000 artykułów
- dostęp na 30 dni
- najpopularniejsza opcja
Opcja #3
129 zł
Wybieram
- dostęp do tego i pozostałych ponad 7000 artykułów
- dostęp na 90 dni
- oszczędzasz 78 zł
Piśmiennictwo
| 1. Trzciński R: Patologia Kliniczna Przewlekłego Popromiennego Zapalenia Odbytnicy. Uniwersytet Medyczny, Łódź 2016.
| 2. Trzcinski R, Mik M, Dziki L, Dziki A: Proctological Diseases in Surgical Practice. IntechOpen 2018; http://dx.doi.org/10.5772/intechopen.71454. Chapter 6 ? Radiation Proctitis: 105-117.
| 3. Bielecki K: Popromienne zapalenie błony śluzowej odbytnicy (PZBSO). Nowa Medycyna 2014; 3: 99-106.
| 4. Gilinsky NH, Burns DG, Barbezat GO et al.: The natural history of radiation-induced proctosigmoiditis: an analysis of 88 patients. Q J Med, New Series LII 1983 (Winter); 205: 40-53.
| 5. Dziki A, Krzych ŁJ (red. nauk.): Pomocy! Krwotok! Od teorii do praktyki klinicznej. Via Medica, Gdańsk 2015.
| 6. Trzcinski R, Dziki A, Brys M et al.: Expression of vascular endothelial growth factor and its correlation with clinical symptoms and endoscopic findings in patients with chronic radiation proctitis. Colorectal Dis 2017; 20: 321-330.
| 7. Weiner JP, Wong AT, Schwartz D et al.: Endoscopic and non-endoscopic approaches for the management of radiation-induced rectal bleeding. World J Gastroenterol 2016; 22(31): 6972-6986.
| 8. Mallick S, Madan R, Julka PK et al.: Radiation Induced Cystitis and Proctitis ? Prediction, Assessment and Management. APJCP 2015; 16: 5589-5594.
| 9. Huang EY, Lin H, Wang ChJ et al.: Impact of treatment time-related factors on prognoses and radiation proctitis after definitive chemoradiotherapy for cervical cancer. Cancer Med 2016; 5(9): 2205-2212.
| 10. Pita I, Bastos P, Dinis-Ribeiro M: Pelvic Catastrophe after Elastic Band Ligation in an Irradiated Rectum. GE Port J Gastroenterol 2018; 25: 42-46.
| 11. Bidziński M (red. nauk.): Nowotwory Trzonu Macicy. CMKP, Warszawa 2011.
| 12. Zhong QH, Liu ZhZh, Yuan ZH et al.: Efficacy and complications of argon plasma coagulation for hemorrhagic chronic radiation proctitis. World J Gastroenterol 2019; 25(13): 1618-1627.
| 13. Paquette IM, Vogel JD, Abbas MA et al.: The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Chronic Radiation Proctitis. Dis Colon Rectum 2018; 61: 1135-1140.
| 14. Dahiya DS, Kichloo A, Tuma F et al.: Radiation Proctitis and Management Strategies. Clin Endosc 2022; 55: 22-32.
| 15. Nasierowska-Guttmejer A: Zmiany w błonie śluzowej przewodu pokarmowego wywołane radio- i chemioterapia nowotworów. OncoReview 2012; 2: 39-44.
| 16. Andreyev J: Gastrointestinal symptoms after pelvic radiotherapy: a new understanding to improve management of symptomatic patients. Lancet Oncol 2007; 8: 1007-1017.
| 17. Jang H, Kwak SY, Park S et al.: Pravastatin Alleviates Radiation Proctitis by Regulating Thrombomodulin in Irradiated Endothelial Cells. Int J Med Sci 2020; 21: 1897.
| 18. O’Brien PC: Radiation injury of the rectum. Radiother Oncol 2001; 60: 1-14.
| 19. Leiper K, Morris AI: Treatment of radiation proctitis. Clin Oncol 2007; 19: 724-729.
| 20. Costa DA, Amaro CE, Nunes A et al.: Hyperbaric oxygen therapy as a complementary treatment for radiation proctitis: Useless or useful? ? A literature review. World J Gastroenterol 2021; 27: 4413-4428.
| 21. Vanneste BGL, De Voorde LV, de Ridder RJ et al.: Chronic radiation proctitis: tricks to prevent and treat. Int J Colorectal Dis 2015; 30: 1293-1303.
| 22. Andreyev HJN, Benton BE, Lalji A et al.: Algorithm-based management of patients with gastrointestinal symptoms in patients after pelvic radiation treatment (ORBIT): a randomised controlled trial. Lancet 2013; 382: 2084-2092.
| 23. Dziki Ł, Kujawski R, Mik M et al.: Formalin therapy for hemorrhagic radiation proctitis. Pharmacol Rep 2015; 67: 896-900.
| 24. Krol R, Smeenk RJ, van Lin ENJT et al.: Systematic review: anal and rectal changes after radiotherapy for prostate cancer. Int J Colorectal Dis 2014; 29: 273-283.
| 25. Andreyev HJN, Davidson SE, Gillespie C et al.: Practice guidance on the management of acute and chronic gastrointestinal problems arising as a result of treatment for cancer. Gut 2012; 61: 179-192.
| 26. Kim TG, Huh SJ, Park W: Endoscopic findings of rectal mucosal damage after pelvic radiotherapy for cervical carcinoma: correlation of rectal mucosal damage with radiation dose and clinical symptoms. Radiat Oncol J 2013; 31: 81-87.
| 27. Wachter S, Gerstner N, Goldner G et al.: Endoscopic scoring of late rectal mucosal damage after conformal radiotherapy for prostatic carcinoma. Radiother Oncol 2000; 54: 11-19.
| 28. Mahmood S, Bollipo S, Steele S et al.: It’s All the RAVE: Time to Give up on the „Chronic Radiation Proctitis” Misnomer. Commentaries. Gastroenterol 2021; 160: 635-638.
| 29. Kennedy GD, Heise CP: Radiation colitis and proctitis. Clin Colon Rectal Surg 2007; 20: 64-72.
| 30. McElvanna K, Wilson A, Irwin T: Sucralfate paste enema: a new method of topical treatment for haemorrhagic radiation proctitis. Colorectal Dis 2014; 16: 281-284.
| 31. Denton AS, Andreyev HJN, Forbes A et al.: Systematic review for non-surgical interventions for the management of late radiation proctitis. Br J Cancer 2002; 87: 134-143.
| 32. Cullen SN, Frenz M, Mee A: Treatment of haemorrhagic radiation-induced proctopathy using small volume topical formalin instillation. Aliment Pharmacol Ther 2006; 23: 1575-1579.
| 33. Zheng YM, He XX, Xia HHX et al.: Multi-donor multi-course faecal microbiota transplantation relieves the symptoms of chronic hemorrhagic radiation proctitis. Medicine 2020; 99: 39.
| 34. Chruscielewska-Kiliszek MR, Rupinski M, Kraszewska E et al.: The protective role of antiplatelet treatment against ulcer formation due to argon plasma coagulation in patients treated for chronic radiation proctitis. Colorectal Dis 2014; 16: 293-297.
| 35. Hopkins JC, Wood JJ, Gilbert H et al.: Trans-anal rectoscopic ball diathermy (TARD) for radiotherapy-induced haemorrhagic telangiectasia: a safe and effective treatment. Colorectal Dis 2013; 15: 566-568.
| 36. Rustagi T, Corbett FS, Mashimo H: Treatment of chronic radiation proctopathy with radiofrequency ablation (with video). Gastrointest Endosc 2015; 81: 428-436.
| 37. Haas EM, Bailey HR, Farragher I: Application of 10 percent formalin for the treatment of radiation-induced hemorrhagic proctitis. Dis Colon Rectum 2006; 50: 213-217.
| 38. De Parades V, Etienney I, Bauer P et al.: Formalin application in the treatment of chronic radiation-induced hemorrhagic proctitis ? an effective but not risk-free procedure: a prospective study of 33 patients. Dis Colon Rectum 2005; 48: 1535-1541.
| 39. Ismail MA, Qureshi MA: Formalin dab for haemorrhagic radiation proctitis. Ann R Coll Surg Engl 2002; 84: 263-264.
| 40. Pui WCh, Chieng TH, Siow SzL et al.: A Randomized Controlled Trial of Novel Treatment for Hemorrhagic Radaition Proctitis. Asian Pac J Cancer Prev 2020; 21: 2927-2934.
| 41. Pattarajierapan S, Amornwichet N, Khomvila S: Rectal irrigation as rescue therapy for refractory and severe hemorrhagic radiation proctitis: A case report. Clin Case Rep 2021; 9: e04985.
| 42. Laranjo A, Carvalho M, Rei A, Veloso N, Medeiros I: The Effect of Hyperbaric Oxygen Therapy on Rectal Ulcers after Argon Plasma Coagulation. GE Port J Gastroenterol 2021; 28: 288-291.
| 43. Yoshimizu S, Chino A, Miyamoto Y et al.: Efficacy of hyperbaric oxygen therapy in patients with radiaotion-induced rectal ulcers: report of five cases. Dig Endosc 2017; 29: 718-722.
| 44. Yuan ZX, Qin QY, Zhu MM et al.: Diverting colostomy is an effective and reversible option for severe hemorrhagic radiation proctopathy. World J Gastroenterol 2020; 26(8): 850-864.
| 45. Ayerdi J, Moinuddeen K, Loving A et al.: Diverting loop colostomy for the treatment of refractory gastrointestinal bleeding secondary to radiation proctitis. Mil Med 2001;166: 1091-1093.
| 46. Dahiya DS, Kichloo A, Tuma F et al.: Radiation Proctitis and Management Strategies. Clin Endosc 2022; 55: 22-32.
otrzymano: 2023-01-25
zaakceptowano do druku: 2023-02-15 Adres do korespondencji: *Radzisław Trzciński Filia Uniwersytetu Jana Kochanowskiego w Kielcach Collegium Medicum ul. Juliusza Słowackiego 114/118, 97-300 Piotrków Trybunalski tel.: 697-407-585 trzcinskir@wp.pl Nowa Medycyna 1/2023Strona internetowa czasopisma Nowa MedycynaPozostałe artykuły z numeru 1/2023: | 