Radiation proctitis management

Radiation proctitis management

Radiation proctopathy is epithelial damage to the rectum caused by radiation exposure and is associated with minimal or no inflammation.

• Acute radiation proctitis occurs during or within 6 weeks of radiation therapy.

• Chronic radiation proctitis has a delayed onset, typically occurring 9–14 months after radiation exposure, but symptoms may develop at any time up to 30 years post-irradiation.

Clinical presentation

Acute radiation proctitis

• Diarrhea

• Mucus discharge

• Urgency

• Tenesmus

• Uncommonly, rectal bleeding

Chronic radiation proctitis

• Diarrhea

• Mucus discharge

• Urgency

• Tenesmus

• Rectal bleeding (usually more severe than in acute disease)

• Constipation due to strictures and obstructed defecation

• Rectal pain

• Rarely, fecal incontinence due to overflow

Associated complications

• Fistulas

• Small bowel obstruction

• Small intestinal bacterial overgrowth

• Urethral stenosis

• Cystitis

Investigations

Stool studies

• Clostridioides difficile toxin assay

• Routine stool cultures:

  • Salmonella

  • Shigella

  • Campylobacter

  • Yersinia

  • Escherichia coli O157:H7

• Stool microscopy for ova and parasites (three samples)

Sexually transmitted infection testing

• Chlamydia trachomatis

• Neisseria gonorrhoeae

• Herpes simplex virus (HSV)

• Treponema pallidum

Endoscopic and imaging investigations

• Colonoscopy with biopsy

• Magnetic resonance imaging (MRI)

Pharmacological treatment

Sulfasalazine

• Sulfasalazine (PO) 3 g 24 hourly for 4 weeks

AND

Sucralfate enemas

• Sucralfate enema (rectal preparation) 2 g 12 hourly for 4 weeks

Referral and management of complications

Refer to a higher-level facility with expertise and experience in the management of radiation proctitis complications, particularly bleeding.

Endoscopic therapy

• Argon plasma coagulation (APC) for bleeding

Surgical management

Surgery should be reserved for patients with intractable symptoms or complications, including:

• Stricture

• Persistent pain

• Severe bleeding

• Perforation

• Fistula formation