Radiation therapy: Managing GI tract complications

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Applied Evidence

Radiation therapy: Managing GI tract complications

J Fam Pract. 2017 August;66(8):E1-E7

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References

1. Walsh D. Deep tissue traumatism from roentgen ray exposure. Brit Med J. 1897;2:272-273.

2. Paravati AJ, Boero IJ, Triplett DP, et al. Variation in the cost of radiation therapy among Medicare patients with cancer. J Oncol Pract. 2015;11:403-409.

3. Leung HWC, Chan ALF. Direct medical cost of radiation therapy for cancer patients in Taiwan. SciRes. 2013;5:989-993.

4. Andreyev HJ. GI consequences of cancer treatment: a clinical perspective. Radiat Res. 2016;185:341-348.

5. Olopade FA, Norman A, Blake P, et al. A modified inflammatory bowel disease questionnaire and the Vaizey incontinence questionnaire are simple ways to identify patients with significant gastrointestinal symptoms after pelvic radiotherapy. Br J Cancer. 2005;92:1663-1670.

6. Lawrie TA, Kulier R, Nardin JM. Techniques for the interruption of tubal patency for female sterilization. Cochrane Database Syst Rev. 2016 Aug 5;8:CD003034.

7. ASGE. The role of endoscopy in patients with anorectal disorders. Gastrointest Endosc. 2010;72:1117-1123.

8. Stacey R, Green JT. Radiation-induced small bowel disease: latest developments and clinical guidance. Ther Adv Chronic Dis. 2014:5:15-29.

9. Chon BH, Loeffler JS. The effect of nonmalignant systemic disease on tolerance to radiation therapy. Oncologist. 2002;7:136-143.

10. Theiss VS, Sripadam R, Ramani V, et al. Chronic radiation enteritis. Clin Oncol (R Coll Radiol). 2010;22:70-83.

11. DeCosse JJ, Rhodes RS, Wentz WB, et al. The natural history of radiation induced injury of the gastrointestinal tract. Ann Surg. 1969;170:369-384.

12. Shadad AK, Sullivan FJ, Martin JD, et al. Gastrointestinal radiation injury: symptoms, risk factors and mechanisms. World J Gastroenterol. 2013;19:185-198.

13. Tabibian N, Swehli E, Boyd A, et al. Abdominal adhesions: a practical review of an often overlooked entity. Am Med Surg (Lond). 2017;15:9-13.

14. Baumann J, Lin M, Patel C. An unusual case of gastritis and duodenitis after yttrium 90-microsphere selective internal radiation. Clin Gastroenterol Hepatol. 2015;13:xxiii-xxiv.

15. Bennett MH, Feldmeier J, Hampson NB, et al. Hyperbaric oxygen therapy for late radiation tissue injury. Cochrane Database Syst Rev. 2016 Apr 28;4:CD005005.

16. Berbée M, Hauer-Jensen M. Novel drugs to ameliorate gastrointestinal normal tissue radiation toxicity in clinical practice: what is emerging from the laboratory? Curr Opin Support Palliat Care. 2012;6:54-59.

17. Marshall GT, Thirlby RC, Bredfelt JE, et al. Treatment of gastrointestinal radiation injury with hyperbaric oxygen. Undersea Hyperb Med. 2007;34:35-42.

18. Moradkhani A, Beckman LJ, Tabibian JH. Health-related quality of life in inflammatory bowel disease: psychosocial, clinical, socioeconomic, and demographic predictors. J Crohns Colitis. 2013;7:467-473.

19. Chowhan NM. Injurious effects of radiation on the esophagus. Am J Gastroenterol. 1990;85:115-120.

20. Vanagunas A, Jacob P, Olinger E. Radiation-induced esophageal injury: a spectrum from esophagitis to cancer. Am J Gastroenterol. 1990;85:808-812.

21. Agarwalla A, Small AJ, Mendelson AH, et al. Risk of recurrent or refractory strictures and outcome of endoscopic dilation for radiation-induced esophageal strictures. Surg Endosc. 2015;29:1903-1912.

22. Kaasa S, Mastekaasa A, Thorud E. Toxicity, physical function and everyday activity reported by patients with inoperable non-small cell lung cancer in a randomized trial (chemotherapy versus radiotherapy). Acta Oncol. 1988;27:343-349.

23. Maple JT, Petersen BT, Baron TH, et al. Endoscopic management of radiation-induced complete upper esophageal obstruction with an antegrade-retrograde rendezvous technique. Gastrointest Endosc. 2006;64:822-828.

24. Lewin K, Mills RR. Human radiation hepatitis. A morphologic study with emphasis on the late changes. Arch Pathol. 1973;96:21-26.

25. Sempoux C, Horsmans Y, Geubel A, et al. Severe radiation-induced liver disease following localized radiation therapy for biliopancreatic carcinoma: activation of hepatic stellate cells as an early event. Hepatology. 1997;26:128-134.

26. Bismar MM, Sinicrope FA. Radiation enteritis. Curr Gastroenterol Rep. 2002;4:361-365.

27. Andreyev HJ, Vlavianos P, Blake P, et al. Gastrointestinal symptoms after pelvic radiotherapy: role for the gastroenterologist. Int J Radiat Oncol Phys. 2005;62:1464-1471.

28. Zimmer T, Böcker U, Wang F, et al. Medical prevention and treatment of acute and chronic radiation induced enteritis—is there any proven therapy? A short review. Z Gastroenterol. 2008;46:441-448.

29. Kita H, Yamamoto H, Yano T, et al. Double balloon endoscopy in two hundred fifty cases for the diagnosis and treatment of small bowel intestinal disorders. Inflammopharmacology. 2007;15:74-77.

30. Girvent M, Carlson GL, Anderson I, et al. Intestinal failure after surgery for complicated radiation enteritis. Ann R Coll Surg Engl. 2000;82:198-201.

31. Thompson JS, DiBaise JK, Iyer KR, et al. Postoperative short bowel syndrome. J Am Coll Surg. 2005;201:85-89.

32. Hampson NB, Holm JR, Wreford-Brown CE, et al. Prospective assessment of outcomes in 411 patients treated with hyperbaric oxygen for chronic radiation tissue injury. Cancer. 2012;118:3860-3868.

33. Chun M, Kang S, Kil HJ, et al. Rectal bleeding and its management after irradiation for uterine cervical cancer. Int J Radiat Oncol Phys. 2004;58:98-105.

34. Ashburn JH, Kalady MF. Radiation-induced problems in colorectal surgery. Clin Colon Rectal Surg. 2016;29:85-91.

35. Villavicencia RT, Rex DK, Rahmani E. Efficacy and complications of argon plasma coagulation for hematochezia related to radiation proctopathy. Gastrointest Endosc. 2002;55:70-74.

36. Dall’Era MA, Hampson NB, His RA, et al. Hyperbaric oxygen therapy for radiation-induced proctopathy in men treated for prostate cancer. J Urol. 2006;176:87-90.

37. Henson C. Chronic radiation proctitis: issues surrounding delayed bowel dysfunction post-pelvic radiotherapy and an update on medical treatment. Therap Adv Gastroenterol. 2010;3:359-365.

38. Gilinsky NH, Kottler RE. Idiopathic obstructive eosinophilic enteritis with raised IgE: response to oral disodium cromoglycate. Postgrad Med J. 1982;58:239-243.

39. Tabibian JH, Kochman ML. Over-the-wire technique to facilitate over-the-scope clip closure of fistulae. Gastrointest Endosc. 2017;85:454-455.

40. Nicolay NH, Lopez Perez R, Debus J, et al. Mesenchymal stem cells — a new hope for radiotherapy-induced tissue damage? Cancer Lett. 2015;366:133-140.

Rectum

The rectum has tolerance to XRT similar to the colon,³⁸ but because of its anatomical location, rectal radiation injury is more common, and is typically seen after XRT for prostate, bladder, cervical, or uterine cancer. Acute rectal radiation injury is seen in 50% to 78% of patients,³⁶ and symptoms are similar to that of injury to the sigmoid (eg, tenesmus, loose evacuations, hematochezia), all of which are consequences of direct radiation injury to the mucosa.

Use of mesenchymal stem cells has also been described for rectal and other fistulae, but use is mostly experimental.

Chronic rectal radiation injury may present in a variety of ways. Tenesmus and incontinence are seen in 8% to 20% of patients, frequent defecation in 50%, urgency in 47%, and rectal cancer in up to 2% to 3% after 10 years.^36,37 Other complications include anorectal strictures, fissures, fistulae, and bleeding from rectal telangiectasias. While anoscopy can diagnose many of these, flexible sigmoidoscopy is needed to examine more proximal rectal sites as well as for treatment. Treatment of these chronic complications of XRT is analogous to those of the colon⁷ with the following exceptions:

Anorectal strictures. In contrast to sigmoid strictures, these are generally more amenable to dilatation. If symptoms recur frequently, patients may be instructed on self-dilatations at home.
Bleeding from rectal telangiectasias. In the rare cases where endoscopic APC is not feasible or successful, an alternative treatment would be radiofrequency ablation or the application of 2% to 10% formalin intra-rectally. This is reported to have up to a 93% success rate;³⁷ however, because formalin can also cause rectal pain, spasm, ulcerations, or stenosis, it is not a first-line therapy.
Tenesmus, urgency, and incontinence. These represent a therapeutic challenge, often with no satisfactory outcomes. An array of empiric treatments may be used for symptomatic relief, including but not limited to, a trial of loperamide or fiber supplementation, which may be helpful for frequent evacuation.
Fistulous tracts associated with rectal radiation. Endoscopic clip closure of XRT-related and other fistulous tracts is an option. This has been attempted via a variety of techniques, but results depend on the size and location of the fistulous tract, as well as other characteristics of the fistula and its surrounding tissue.^7,38,39Use of mesenchymal stem cells has also been described for rectal and other fistulae,⁴⁰ but its indications have yet to be elucidated, and current use is mostly experimental.

CASE The patient’s recent-onset symptoms and clinical history were most suggestive of radiation proctopathy; a shared decision was made to pursue endoscopic evaluation with possible therapeutic intervention.

Given that data were not available about the quality of the colon preparation during the exam 7 years earlier, and to rule out a more proximal colonic lesion, the patient was scheduled for colonoscopy. This revealed numerous telangiectasias and moderate friability involving the distal third of the rectum, consistent with radiation proctopathy. The telangiectasias were treated with APC. Follow-up flexible sigmoidoscopy 2 months later showed a few remaining scattered telangiectasias, which were also treated with APC.

The patient has been clinically well, without evidence of bleeding for 6 months and with resolution of anemia_.

CORRESPONDENCE
James H. Tabibian, Division of Gastroenterology, Department of Medicine, 14445 Olive View Dr., 2B-182, Sylmar, CA 91342; JTabibian@dhs.lacounty.gov.