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

By

Neshan Tabibian, MD

Aisha Umbreen, MD

Ehab Swehli, MD

Anne Boyd, MD, FAAFP, FACSM

James H. Tabibian, MD, PhD

Here’s how to recognize radiation-related adverse effects so that you can expedite care and help preserve your patient’s quality of life.

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PRACTICE RECOMMENDATIONS

› Correlate the patient’s symptoms with the radiation therapy history to determine if the onset, anatomical location, and nature of the symptoms suggest a (causal) relationship. B

› Refer patients for radiographic, endoscopic, or other diagnostic modalities according to the suspected pathology and treat (eg, pharmacologically, endoscopically, or surgically) when possible. B

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

References

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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.

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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.

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CASE A 57-year-old man presented for evaluation of painless, intermittent passage of bright red blood per rectum for several months. His bowel habits were otherwise unchanged, averaging 2 soft bowel movements daily without straining. His medical history was significant for radiation therapy for prostate cancer 18 months earlier and a recent finding of mild microcytic anemia. A colonoscopy 7 years ago was negative for polyps, diverticula, or other lesions. He denied any family history of colon cancer or other gastrointestinal disorders. He wanted to know what he could do to stop the bleeding or if further testing would be needed.

Next steps?

Radiation therapy and its effect on the GI tract

In 1895, Dr. Wilhelm Roentgen first introduced the use of x-rays for diagnostic radiographic purposes. A year later, Dr. Emil Gruble made the first attempt to use radiation therapy (XRT) to treat cancer. In 1897, Dr. David Walsh described the first case of XRT-induced tissue injury in the British Medical Journal.¹

Since then, XRT has been used extensively to treat cancer, and its delivery techniques have improved and diversified. Like chemotherapy, XRT has its greatest effect on rapidly dividing cells, but as a result, the adverse effects of therapy are also greatest on rapidly dividing normal tissues, as well as others in the radiation field.

A large proportion of cancer patients will receive XRT, yet XRT-related costs account for less than 5% of total cancer care expenditure, suggesting cost effectiveness.^2,3 However, even with the great progress achieved in the delivery of XRT, it continues to have its share of acute and chronic complications, among the most common of which is gastrointestinal (GI) tract toxicity. These adverse effects are often first reported to, diagnosed, or treated by the primary care provider, who frequently remains pivotally involved in the patient’s longitudinal care.

Radiation therapy's adverse effects are often first reported to, diagnosed, or treated by family physicians, who frequently remain centrally involved in longitudinal care.

Approximately 50% to 75% of patients undergoing XRT will have some degree of GI symptoms of acute injury, but the majority will recover fully within a few weeks following completion of treatment.^4-6 However, in about 5% of patients,^4-6 there will be long-term consequences of varying degrees that may develop as soon as one year or as long as 10 years after XRT. These can pose substantial challenges for patients, as well as both the primary care provider and consulting specialists.

In the review that follows, we detail the potential acute and chronic complications of XRT on the GI tract and how best to manage them. But first, a word about the related terminology.