Radiation Proctitis

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  • Radiation Proctitis

    1. 1. Radiation Proctitis Dr Darren Tonkin Colorectal Registrar
    2. 2. Contents <ul><li>Acute radiation proctitis </li></ul><ul><li>Chronic radiation proctitis </li></ul><ul><li>Pathology </li></ul><ul><li>Investigation </li></ul><ul><li>Management </li></ul><ul><li>Conclusions </li></ul>
    3. 3. Acute Radiation Proctitis (ARP) <ul><li>~75% of pts treated with pelvic XRT </li></ul><ul><li>Occurs during treatment and for several weeks after completion </li></ul><ul><li>Symptoms usually mild and self limiting </li></ul><ul><li>Symptomatic treatment only </li></ul>
    4. 4. Clinical Manifestations - ARP <ul><li>Diarrhoea (predominant) </li></ul><ul><li>Mucous discharge </li></ul><ul><li>Tenesmus </li></ul><ul><li>Abdominal & anal pain </li></ul><ul><li>Rectal bleeding (uncommon) </li></ul>
    5. 5. Chronic Radiation Proctitis (CRP) <ul><li>2 to 20% of patients </li></ul><ul><li>Months to yrs following XRT (median 8 - 13 months) </li></ul><ul><li>Significant negative effect on quality of life </li></ul><ul><li>Natural history poorly understood </li></ul>
    6. 6. Clinical Manifestations - CRP <ul><li>Bleeding (70%) </li></ul><ul><li>Mucous discharge </li></ul><ul><li>Diarrhoea </li></ul><ul><li>Pain </li></ul><ul><li>Urgency </li></ul><ul><li>Tenesmus </li></ul><ul><li>Incontinence </li></ul><ul><li>Fistulae </li></ul><ul><li>Stricture </li></ul><ul><li>Obstruction </li></ul><ul><li>Perforation </li></ul>
    7. 7. Pathology <ul><li>Mucosal ulceration </li></ul><ul><li>Eosinophilic crypt abscesses </li></ul><ul><li>Obliterative endarteritis </li></ul><ul><li>Submucosal fibrosis </li></ul><ul><li>Neovascularization (telangiectasia) </li></ul>
    8. 8. Influencing Factors - CRP <ul><li>Radiotherapy regimen </li></ul><ul><ul><ul><li>Radiation dose (>50Gy) </li></ul></ul></ul><ul><ul><ul><li>N o. fields </li></ul></ul></ul><ul><ul><ul><li>Shielding </li></ul></ul></ul><ul><ul><ul><li>Delivery method (intracavity > EBRT) </li></ul></ul></ul><ul><li>Radiosensitizers, chemotherapy </li></ul><ul><li>Patient Factors </li></ul><ul><ul><ul><li>Diabetes </li></ul></ul></ul><ul><ul><ul><li>Previous abdominal surgery </li></ul></ul></ul><ul><ul><ul><li>Hypertension </li></ul></ul></ul><ul><ul><ul><li>Age </li></ul></ul></ul>
    9. 9. Investigation (1) <ul><li>Flexible sigmoidoscopy, colonoscopy ± Bx </li></ul>Pale mucosa + telangiectasia Ulceration, bleeding, fibrosis
    10. 10. Investigation (2) <ul><li>CT chest, abdomen </li></ul><ul><li>Contrast enema </li></ul><ul><li>Anorectal manometry </li></ul><ul><li>Transanal ultrasound </li></ul>
    11. 11. Management - Medical <ul><li>Enemas (no proven efficacy) </li></ul><ul><ul><ul><li>Steroids </li></ul></ul></ul><ul><ul><ul><li>Sucralfate </li></ul></ul></ul><ul><ul><ul><li>5-aminosalicylates </li></ul></ul></ul><ul><ul><ul><li>Butyrate </li></ul></ul></ul><ul><li>Hyperbaric O 2 </li></ul><ul><ul><ul><li>Limited data </li></ul></ul></ul><ul><ul><ul><li>Expensive </li></ul></ul></ul><ul><ul><ul><li>Time-consuming (20 - 40 treatments required) </li></ul></ul></ul>
    12. 12. Management - Endoscopic (1) <ul><li>Topical Formalin </li></ul><ul><ul><ul><li>Adapted from use in radiation cystitis </li></ul></ul></ul><ul><ul><ul><li>4% formalin solution applied </li></ul></ul></ul><ul><ul><ul><li>Contact time 2-3 min </li></ul></ul></ul><ul><ul><ul><li>59 – 100% short term response </li></ul></ul></ul><ul><ul><ul><li>Minimal relapse </li></ul></ul></ul><ul><ul><ul><li>Protection of perianal skin important </li></ul></ul></ul><ul><ul><ul><li>GA often required </li></ul></ul></ul><ul><ul><ul><li>Fissures, ulcers, strictures reported </li></ul></ul></ul>
    13. 13. Management - Endoscopic (2) <ul><li>Diathermy </li></ul><ul><ul><ul><li>Electrode “sticks” to mucosa </li></ul></ul></ul><ul><ul><ul><li>Unpredictable depth of coagulation </li></ul></ul></ul><ul><ul><ul><li>Ineffective in excessive bleeding </li></ul></ul></ul>
    14. 14. Management - Endoscopic (3) <ul><li>Laser (Nd:YAG, Argon) </li></ul><ul><ul><ul><li>87% short term response </li></ul></ul></ul><ul><ul><ul><li>2 - 3 treatments required </li></ul></ul></ul><ul><ul><ul><li>70% relapse after cessation of bleeding </li></ul></ul></ul><ul><ul><ul><li>Maintenance treatments required at 7 month intervals </li></ul></ul></ul><ul><ul><ul><li>Disadvantages </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Expensive </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Inaccessible </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Risk of perforation </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Protective precautions required </li></ul></ul></ul></ul></ul>
    15. 15. Management - Endoscopic (4) <ul><li>Argon Plasma Coagulation </li></ul><ul><ul><ul><li>Bipolar diathermy current via ionized Argon gas stream </li></ul></ul></ul><ul><ul><ul><li>Effective in short term </li></ul></ul></ul><ul><ul><ul><li>2 - 4 treatments required </li></ul></ul></ul><ul><ul><ul><li>Minimal relapse </li></ul></ul></ul><ul><ul><ul><li>Advantages </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Reduced perforation risk </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Easier painting of large areas </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>More affordable/accessible than laser </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Disadvantages </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Rectal strictures reported </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Ineffective with excessive bleeding </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Overdistension with Argon gas </li></ul></ul></ul></ul></ul>
    16. 16. Management – Surgery (1) <ul><li>Complicated disease </li></ul><ul><ul><ul><li>Strictures </li></ul></ul></ul><ul><ul><ul><li>Fistulae </li></ul></ul></ul><ul><ul><ul><li>Refractory bleeding </li></ul></ul></ul><ul><li>High complication rate (15 - 79%) </li></ul><ul><ul><ul><li>Postop fistulae (up to 25%) </li></ul></ul></ul><ul><ul><ul><li>Anastomotic leaks </li></ul></ul></ul><ul><ul><ul><li>Wound dehiscence </li></ul></ul></ul><ul><ul><ul><li>Pelvic sepsis </li></ul></ul></ul>
    17. 17. Management – Surgery (2) <ul><li>Excision - preferred approach </li></ul><ul><ul><ul><li>Anterior resection + reconstruction </li></ul></ul></ul><ul><ul><ul><li>APR – perineal wound breakdown in 45% </li></ul></ul></ul><ul><li>Diversion </li></ul><ul><ul><ul><li>Prior to definitive surgery for strictures or fistulae </li></ul></ul></ul><ul><ul><ul><li>Not indicated for bleeding </li></ul></ul></ul>
    18. 18. Conclusions <ul><li>Medical management of little benefit </li></ul><ul><li>Topical formalin or Argon plasma coagulation most effective </li></ul><ul><li>Surgery as last resort in complicated cases </li></ul><ul><li>Poorly investigated in the past </li></ul><ul><li>Prospective, randomized trials required </li></ul>

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