2. Nusiskundimai
• Kraujavimas iš tiesiosios žarnos
Anamnesis morbi
• Kraujavimas prasidėjo prieš mėnesį, dėl to
kreipėsi į BPG, buvo nukreipta koloproktologo
konsultacijai, rekomenduotas kolonoskopijos
atlikimas ir ištyrimas gastroenterologijos skyriuje.
3. Anamnesis vitae
• Dėl gimdos kaklelio Ca taikyta spindulinė terapija.
• SP nutraukta prieš 6 mėn.
Status praesens
• Palpuojant pilvas jautrus apatinėje dalyje.
4. Bendras kraujo tyrimas
• Eritrocitai – 3,54x1012/l (↓)
• Hemoglobinas – 114g/l (↓)
• Hematokritas – 34% (↓)
Fibrokolonoskopija
• 20cm atstumu nuo anus iki 35cm stebimas cirkuliarus
išopėjimas dengtas fibrinu, išreikštas spontaninis
kraujavimas. Paimta biopsija.
Biopsijos mikroskopinis aprašymas
• storžarnės gleivinė vidutiniškai infiltruota
limfocitais, negausiai leukocitais, plazmocitais.
• Išvada: lėtinis mažai aktyvus uždegimas.
7. Radiation proctitis: a decade‘s experience; Singapore Med J 2010; 51(4): 315
Wong M T C, Lim J F, Ho K S, Ooi B S, Tang C L, Eu K W
8. Po švitinimo sutrinka elementarūs
biocheminiai procesai, denatūruoja
baltymai, pakinta fermentų sistemos, ypač
reguliuojančios nukleorūgščių sintezę.
Pažeidžiama ląstelių mitozė ir ryškiai
sutrinka regeneracija.
Radiation Enteritis and Proctitis, 2011; Neelu Pal, MD
http://emedicine.medscape.com/article/197483-overview
9. Labiausiai pažeidžiamos trumpai
egzistuojančios ląstelės, tarp jų - virškinamojo
trakto dengiamasis epitelis.
Nepakankamo atsinaujinimo simptomai:
• Audinių destrukcija
• Nekrozė
• Defektai
Išsivysčiusi talangiektazinė gleivinės
neovaskuliarizacija lemia gleivinės trapumą ir
polinkį kraujuoti.
Radiation Enteritis and Proctitis, 2011; Neelu Pal, MD
http://emedicine.medscape.com/article/197483-overview
10. Pasireiškia ST metu arba per 6 sav. po ST
nutraukimo
• Viduriavimas
• Tenezmai
• Rečiau – kraujavimas
• Baigus spindulinę terapiją gali praeiti arba pereiti į
lėtinę formą.
Clinical features, diagnosis, and treatment of radiation proctitis. 2012
Timothy T Nostrant, MD; www.uptodate.com
11. Pasireiškia mažiausiai po 90d. pabaigus
spindulinų gydymą
• Striktūrų formavimasis
• Kraujavimas
Clinical features, diagnosis, and treatment of radiation proctitis. 2012
Timothy T Nostrant, MD; www.uptodate.com
12. Klinika+ anamnezė
Fibrokolonoskopija
Clinical features, diagnosis, and treatment of radiation proctitis. 2012
Timothy T Nostrant, MD; www.uptodate.com
13.
14. Butyrato (sviesto rūgšties) klizmos
Clinical features, diagnosis, and treatment of radiation proctitis. 2012
Timothy T Nostrant, MD; www.uptodate.com
15. 5-ASA per os arba klizmos
Prednizolono klizmos kartu su 5-ASA
Sukralfato klizmos
Metronidazolis su mesalazinu (5-ASA) ir
betametazonu (GKK).
Metronidazole in the treatment of chronic radiation proctitis: clinical trial. Croat Med J. 2000;41(3):314.
Natural history of late radiation proctosigmoiditis treated with topical sucralfate suspension. Dig Dis Sci.
1999;44(5):973.
16. Hiperbarinis
gydymas
• Paremtas bakterijų
augimo ir toksinų
inhibicija
• Atliktas tyrimas su
120 pacientų,
gydytiems aukšto
slėgio kamerose
reikėjo mažiau kitų
gydymo priemonių
Clinical features, diagnosis, and treatment of radiation proctitis. 2012 ; Timothy T Nostrant, MD
Hyperbaric oxygen treatment of chronic refractory radiation proctitis, 2008; Clarke RE, Tenorio LM, Hussey JR
17. Formalino aplikacija
• Kontakto metu sukelia koaguliacinę audinio
nekrozę
• Gerai toleruojama pacientų
Nauja formalino aplikacijos gydant radiacinį hemoraginį proktitą metodika
Narimantas Evaldas Samalavičius; LIETUVOS CHIRURGIJA 2008, 6(1), p. 72–75
18. Į išangę įkišamas Fanslerio proktoskopas ir
identifikuojamas pažeistos tiesiosios žarnos
gleivinės plotas.
Paruoštu 4% formalino tirpalu sumirkoma (iš
viso apie 40 ml) chirurginė skarelė ir ji
aplikuojama tiksliai į pažeistos tiesiosios
žarnos gleivinės plotą 4 minutes.
Ją pašalinus, tiesiosios žarnos spindis
išsausinamas, kad išvengtume ilgesnės
ekspozicijos ar riestinės þarnos gleivinės
pažeidimo.
Nauja formalino aplikacijos gydant radiacinį hemoraginį proktitą metodika
Narimantas Evaldas Samalavičius; LIETUVOS CHIRURGIJA 2008, 6(1), p. 72–75
19.
20.
21. Taikoma tik esant
• Neveiksmingam kraujavimo stabdymui
• Striktūroms
• Fistulėms
• Sunkus anastomozių gyjimas
22. Radiation proctitis: a decade‘s experience; Singapore Med J 2010; 51(4): 315
Wong M T C, Lim J F, Ho K S, Ooi B S, Tang C L, Eu K W
Editor's Notes
Gastrointestinal syndrome — The gastrointestinal syndrome typically develops within five days of the initial exposure (table 5). At doses <1.5 Gy, only the prodromal phase of nausea, vomiting, and gastric atony are observed [68].More severe symptoms develop at doses between 5 and 12 Gy [69], secondary to loss of intestinal crypt cells and breakdown of the mucosal barrier, with sloughing of the epithelial cell layer and denudation of the bowel wall. These changes result in crampy abdominal pain, diarrhea, nausea and vomiting, gastrointestinal bleeding with resultant anemia, and abnormalities of fluid and electrolyte balance. This early phase is often followed by a latent phase lasting five to seven days, during which symptoms abate. Vomiting and severe diarrhea accompanied by high fever make up the manifest illness. Systemic effects at this time may include malnutrition from malabsorption.Impaired barrier function of the gastrointestinal tract results in the passage of bacteria and their toxins through the intestinal wall into the bloodstream, predisposing to infection and sepsis, which may be further compromised by immunosuppression and cytopenias secondary to development of the hematopoietic syndrome (see below).Other severe complications include ulceration and necrosis of the bowel wall, leading to stenosis, ileus, and perforation. In the latter case, recovery is most unlikely, as radiosensitive stem cells in the crypts of the gastrointestinal tract are permanently damaged. Consequently, there is no replacement of cells that are lost from the surface of the villi through the sloughing process, precluding recovery [28,70].However, mild gastrointestinal symptoms limited to one or two episodes of diarrhea with associated abdominal pain are accompanied by virtually certain recovery, provided that the hematopoietic syndrome that follows is reversible (see below)
Acute radiation proctitis — Acute radiation proctitis occurs during and within six weeks of radiation therapy.Symptoms include diarrhea and rectal urgency or tenesmus, and, uncommonly, bleeding. Acute radiation injury is caused by direct mucosal damage from radiation exposure and usually resolves after radiation is discontinued [1,2], although some patients report persistent symptoms for at least one year [3]. Raised levels of fecal calprotectin and fecal lactoferrin are seen in all patients with acute proctitis and may be predictive of progression to chronic proctitis if elevated four weeks after completion of radiation [4,5]
Late radiation injury is due to progressive epithelial atrophy and fibrosis associated with obliterative endarteritis and chronic mucosal ischemia. The end result is a chronically ischemic intestinal segment that is prone to stricture formation and bleeding. The term "proctitis" is somewhat misleading since it inaccurately implies a chronic inflammatory condition. As a result, authorities prefer to refer to it as a chronic radiation "proctopathy". Concomitant injury to the genitourinary tract or small bowel may lead to fistulas, small bowel obstruction, small bowel bacterial overgrowth, urethral stenosis, and cystitis. These symptoms may be associated with a significant decrease in health-related quality of life in up to 30 percent of patients
Chronic radiation proctitis or sigmoiditis should be suspected in patients who have the above clinical features developing nine months or more after pelvic radiation exposure. In most patients, the diagnosis can be confirmed during colonoscopy or sigmoidoscopy. Mucosal features consistent with radiation injury include pallor with friability, and telangiectasias [15], which can be multiple, large, and serpiginous; these changes tend to be continuous without skip lesions but can be patchy in intensity.
Other therapies have not been consistently found to be of benefit in this setting
Jis veikia vietiškai (opos paviršiuje): prisijungia prie žuvusio audinio baltymų ir sudaro apsauginį sluoksnį, kuris apsaugo nuo pepsino, skrandžio rūgšties ir tulžies rūgščių virškinamojo poveikio. Sukralfatas skatina dvylikapirštės žarnos ir skrandžio opų gijimą, mažina stemplės uždegimą, neleidžia opai atsinaujinti. Be to, šis vaistinis preparatas neleidžia rezorbuotis fosfatui virškinimo trakte.In a prospective, double-blind trial, 37 patients with proctosigmoiditis were randomly assigned to a four-week course of oral sulfasalazine (3.0 g/day) plus prednisolone enemas (20 mg twice daily) or sucralfate enemas (2.0 g twice daily) [31]. Clinical improvement was noted in both groups at the end of the study. However, the response was better for sucralfate enemas, which were also better tolerated.Metronidazole — The efficacy of metronidazole was evaluated in study that included 60 patients with rectal bleeding and diarrhea who were randomly assigned to treatment with mesalamine plus betamethasone enemas with or without metronidazole (400 mg orally three times daily) [26]. The incidence of rectal bleeding and mucosal ulcers was lower in the metronidazole groups at four weeks, three months, and 12 months. Diarrhea and edema were also reduced in the metronidazole group
Hyperbaric oxygen — The theoretical benefit of hyperbaric oxygen therapy (HBO) may be via inhibition of bacterial growth [40], preservation of marginally perfused tissue, and inhibition of toxin production [41]. HBO has been used for treatment of refractory foot ulcers in diabetes and in other conditions.A potential role for hyperbaric oxygen in patients with chronic radiation proctitis has been described in several observational studies and in at least one randomized controlled trial [42-46]. The controlled trial included 120 patients with refractory radiation proctitis who were randomly assigned to hyperbaric oxygen or to a sham procedure [43]. The clinical response rate was significantly higher in the intervention group (89 versus 63 percent). In addition, symptom improvement was accompanied by a decreased requirement for other treatments. The study was potentially limited by a large number of dropouts after allocation and unclear blinding.The equipment needed for hyperbaric oxygen treatment is expensive and not widely available. Thus, at the present time, it is not a practical means of treating chronic radiation proctitis outside of centers specializing in this approach. (See "Hyperbaric oxygen therapy".
