Radiation Proctitis

Dr Darren Tonkin
Colorectal Registrar
Contents
 Acute radiation proctitis
 Chronic radiation proctitis
 Pathology
 Investigation
 Management
 Conclusions
Acute Radiation Proctitis (ARP)
 ~75% of pts treated with pelvic XRT
 Occurs during treatment and for several
weeks after completion
 Symptoms usually mild and self limiting
 Symptomatic treatment only
Clinical Manifestations - ARP
 Diarrhoea (predominant)
 Mucous discharge
 Tenesmus
 Abdominal & anal pain
 Rectal bleeding (uncommon)
Chronic Radiation Proctitis (CRP)
 2 to 20% of patients
 Months to yrs following XRT
(median 8 - 13 months)
 Significant negative effect on quality of
life
 Natural history poorly understood
Clinical Manifestations - CRP
 Bleeding (70%)  Fistulae
 Mucous discharge  Stricture
 Diarrhoea  Obstruction
 Pain  Perforation
 Urgency
 Tenesmus
 Incontinence
Pathology
 Mucosal ulceration
 Eosinophilic crypt abscesses
 Obliterative endarteritis
 Submucosal fibrosis
 Neovascularization (telangiectasia)
Influencing Factors - CRP
 Radiotherapy regimen
 Radiation dose (>50Gy)
 No. fields
 Shielding
 Delivery method (intracavity > EBRT)
 Radiosensitizers, chemotherapy
 Patient Factors
 Diabetes
 Previous abdominal surgery
 Hypertension
 Age
Investigation (1)
 Flexible sigmoidoscopy, colonoscopy ± Bx

Pale mucosa + telangiectasia Ulceration, bleeding, fibrosis

Investigation (2)
 CT chest, abdomen
 Contrast enema
 Anorectal manometry
 Transanal ultrasound
Management - Medical
 Enemas (no proven efficacy)
 Steroids
 Sucralfate
 5-aminosalicylates
 Butyrate
 Hyperbaric O 2

 Limited data
 Expensive
 Time-consuming (20 - 40 treatments required)
Management - Endoscopic (1)
 Topical Formalin
 Adapted from use in radiation cystitis
 4% formalin solution applied

 Contact time 2-3 min

 59 – 100% short term response

 Minimal relapse

 Protection of perianal skin important

 GA often required

 Fissures, ulcers, strictures reported

Management - Endoscopic (2)
 Diathermy
 Electrode “sticks” to mucosa
 Unpredictable depth of coagulation

 Ineffective in excessive bleeding

Management - Endoscopic (3)
 Laser (Nd:YAG, Argon)
 87% short term response
 2 - 3 treatments required
 70% relapse after cessation of bleeding
 Maintenance treatments required at 7 month intervals
 Disadvantages
 Expensive
 Inaccessible
 Risk of perforation
 Protective precautions required
Management - Endoscopic (4)
 Argon Plasma Coagulation
 Bipolar diathermy current via ionized Argon gas stream
 Effective in short term
 2 - 4 treatments required
 Minimal relapse
 Advantages
 Reduced perforation risk
 Easier painting of large areas
 More affordable/accessible than laser
 Disadvantages
 Rectal strictures reported
 Ineffective with excessive bleeding
 Overdistension with Argon gas
Management – Surgery (1)
 Complicated disease
 Strictures
 Fistulae

 Refractory bleeding

 High complication rate (15 - 79%)

 Postop fistulae (up to 25%)
 Anastomotic leaks

 Wound dehiscence

 Pelvic sepsis
Management – Surgery (2)
 Excision - preferred approach
 Anterior resection + reconstruction
 APR – perineal wound breakdown in 45%

 Diversion
 Prior to definitive surgery for strictures or
fistulae
 Not indicated for bleeding
Conclusions
 Medical management of little benefit
 Topical formalin or Argon plasma
coagulation most effective
 Surgery as last resort in complicated
cases
 Poorly investigated in the past
 Prospective, randomized trials required