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Radiation Proctitis

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  • 1. Radiation Proctitis Dr Darren Tonkin Colorectal Registrar
  • 2. Contents
    • Acute radiation proctitis
    • Chronic radiation proctitis
    • Pathology
    • Investigation
    • Management
    • Conclusions
  • 3. 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
  • 4. Clinical Manifestations - ARP
    • Diarrhoea (predominant)
    • Mucous discharge
    • Tenesmus
    • Abdominal & anal pain
    • Rectal bleeding (uncommon)
  • 5. 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
  • 6. Clinical Manifestations - CRP
    • Bleeding (70%)
    • Mucous discharge
    • Diarrhoea
    • Pain
    • Urgency
    • Tenesmus
    • Incontinence
    • Fistulae
    • Stricture
    • Obstruction
    • Perforation
  • 7. Pathology
    • Mucosal ulceration
    • Eosinophilic crypt abscesses
    • Obliterative endarteritis
    • Submucosal fibrosis
    • Neovascularization (telangiectasia)
  • 8. Influencing Factors - CRP
    • Radiotherapy regimen
        • Radiation dose (>50Gy)
        • N o. fields
        • Shielding
        • Delivery method (intracavity > EBRT)
    • Radiosensitizers, chemotherapy
    • Patient Factors
        • Diabetes
        • Previous abdominal surgery
        • Hypertension
        • Age
  • 9. Investigation (1)
    • Flexible sigmoidoscopy, colonoscopy ± Bx
    Pale mucosa + telangiectasia Ulceration, bleeding, fibrosis
  • 10. Investigation (2)
    • CT chest, abdomen
    • Contrast enema
    • Anorectal manometry
    • Transanal ultrasound
  • 11. Management - Medical
    • Enemas (no proven efficacy)
        • Steroids
        • Sucralfate
        • 5-aminosalicylates
        • Butyrate
    • Hyperbaric O 2
        • Limited data
        • Expensive
        • Time-consuming (20 - 40 treatments required)
  • 12. 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
  • 13. Management - Endoscopic (2)
    • Diathermy
        • Electrode “sticks” to mucosa
        • Unpredictable depth of coagulation
        • Ineffective in excessive bleeding
  • 14. 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
  • 15. 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
  • 16. 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
  • 17. 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
  • 18. 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