eMedicine Specialties > Gastroenterology > Intestine

Intestinal Radiation Injury: Differential Diagnoses & Workup

Author: Rajeev Vasudeva, MD, FACG, Clinical Professor of Medicine, Consultants in Gastroenterology, University of South Carolina School of Medicine
Contributor Information and Disclosures

Updated: Jun 20, 2006

Differential Diagnoses

Bacterial Overgrowth Syndrome
Intestinal Perforation
Colonic Obstruction
Malabsorption
Hemorrhoids
Peptic Ulcer Disease
Inflammatory Bowel Disease
Proctitis and Anusitis

Other Problems to Be Considered

Gastrointestinal malignancy
Small bowel obstruction
Diverticular bleed
Ischemic colitis

Workup

Laboratory Studies

  • Complete blood count to look for anemia due to acute or chronic bleeding, as well as malabsorption
  • Complete metabolic panel to look for azotemia, electrolyte abnormalities, and nutrition parameters secondary to vomiting and malabsorption
  • Stool studies for enteric pathogens and fat to rule out any infectious causes of diarrhea and steatorrhea

Imaging Studies

  • Plain abdominal radiographs - Flat and upright
    • These radiographs usually are nonspecific.
    • During the early phase, radiographs may show findings consistent with an ileus.
    • Results also may show dilated loops with air fluid levels in the event of a bowel obstruction.
    • Thumb printing may be due to mucosal edema.
  • Barium contrast studies of the small intestine and colon
    • Barium studies are better than plain radiographs because they provide better mucosal detail and document the presence of fistulae.
    • Usual findings include separation of loops, narrowed fixed loops with poor distension, absent haustral markings, diffuse mucosal ulceration, or a single ulcer. The single ulcer usually is located on the anterior wall of the rectum.
  • CT scan of the abdomen and pelvis
  • Excellent study to confirm bowel obstruction and its possible location
  • Can rule out the possibility of abscess
  • May help in further delineation of fistulae

Procedures

  • Colonoscopy
    • Endoscopy has the advantage over radiologic studies. Biopsies may reveal classic histologic changes consistent with radiation injury. Endoscopic therapy also can be provided in the same setting, as necessary.
    • Endoscopic findings vary depending on the timing of the procedure (ie, acute setting versus chronic setting).
    • Colonoscopy may be dangerous depending on the stage of irritation and injury of the colon. Colonoscopy needs to be performed cautiously in the acute setting.
  • Acute setting
    • Initial changes reveal a friable edematous mucosa.
    • Later changes reveal duskiness, edema, and inflammation.
    • Ulceration is infrequent but may occur later as the cumulative dose of radiation increases. In this case, the results would show necrotic mucosa with patchy areas of superficial ulceration.
  • Chronic setting
    • Fibrosis of the bowel wall may appear as smooth and symmetric strictures.
    • The mucosa may appear granular, friable, edematous, and pale, with prominent submucosal telangiectatic vasculature.
  • Small bowel capsule endoscopy: This can potentially detect strictures or a source of bleeding in the small bowel in difficult to diagnose cases.

Histologic Findings

Histologic changes vary depending on the timing of presentation. Acute changes include hyperemia, edema, and inflammatory cell infiltration of the mucosa, with villous shortening, crypt abscesses, thinning of the mucosa, and ulceration. During the subacute and chronic stages, some mucosal regeneration may occur. The endothelial cells may degenerate, and fibrin plugs may form. Large foam cells beneath the intima are considered pathognomonic for radiation injury. Submucosal fibrosis and obliteration of small blood vessels result in ischemia, which is progressive and irreversible. Ischemia initially involves the mucosa and gradually progresses to involve the submucosa and serosa. Ischemic necrosis and ulceration may lead to fistula formation.

In general, correlation between pathologic and physiologic changes in the intestines is poor.

More on Intestinal Radiation Injury

Overview: Intestinal Radiation Injury
Differential Diagnoses & Workup: Intestinal Radiation Injury
Treatment & Medication: Intestinal Radiation Injury
Follow-up: Intestinal Radiation Injury
Multimedia: Intestinal Radiation Injury
References
[ CLOSE WINDOW ]

References

  1. Abbasakoor F, Vaizey CJ, Boulos PB. Improving the morbidity of anorectal injury from pelvic radiotherapy. Colorectal Dis. Jan 2006;8(1):2-10.

  2. Ajlouni M. Radiation-induced proctitis. Curr Treat Options Gastroenterol. Feb 1999;2(1):20-26. [Medline].

  3. Andreyev J. Gastrointestinal complications of pelvic radiotherapy: are they of any importance?. Gut. Aug 2005;54(8):1051-4.

  4. Babb RR. Radiation proctitis: a review. Am J Gastroenterol. Jul 1996;91(7):1309-11. [Medline].

  5. Baum CA, Biddle WL, Miner PB. Failure of 5-aminosalicylic acid enemas to improve chronic radiation proctitis. Dig Dis Sci. May 1989;34(5):758-60. [Medline].

  6. Campos FG, Waitzberg DL, Mucerino DR, et al. Protective effects of glutamine enriched diets on acute actinic enteritis. Nutr Hosp. May-Jun 1996;11(3):167-77. [Medline].

  7. Churnratanakul S, Wirzba B, Lam T, et al. Radiation and the small intestine. Future perspectives for preventive therapy. Dig Dis. 1990;8(1):45-60. [Medline].

  8. Cross MJ, Frazee RC. Surgical treatment of radiation enteritis. Am Surg. Feb 1992;58(2):132-5. [Medline].

  9. Deutsch AA, Stern HS. Technique of insertion of pelvic Vicryl mesh sling to avoid postradiation enteritis. Dis Colon Rectum. Jul 1989;32(7):628-30. [Medline].

  10. Donaldson SS, Jundt S, Ricour C, et al. Radiation enteritis in children. A retrospective review, clinicopathologic correlation, and dietary management. Cancer. Apr 1975;35(4):1167-78. [Medline].

  11. Dubois A, Earnest DL. Radiation enteritis and colitis. In: Feldman M, Scharschmidt BF, Sleisenger MH, eds. Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. 6th ed. Philadelphia, Pa:. WB Saunders Co;1998:1696-1707.

  12. Empey LR, Papp JD, Jewell LD, Fedorak RN. Mucosal protective effects of vitamin E and misoprostol during acute radiation-induced enteritis in rats. Dig Dis Sci. Feb 1992;37(2):205-14. [Medline].

  13. Feldman MI, Kavanah MT, Devereux DF, Choe S. New surgical method to prevent pelvic radiation enteropathy. Am J Clin Oncol. Feb 1988;11(1):25-33. [Medline].

  14. Franzen L, Nyman J, Hagberg H, et al. A randomised placebo controlled study with ondansetron in patients undergoing fractionated radiotherapy. Ann Oncol. Aug 1996;7(6):587-92. [Medline].

  15. Fu YT, Lam JC, Tze JM. Measurement of irradiated small bowel volume in pelvic irradiation and the effect of a bellyboard. Clin Oncol (R Coll Radiol). 1995;7(3):188-92. [Medline].

  16. Galland RB, Spencer J. Natural history and surgical management of radiation enteritis. Br J Surg. Aug 1987;74(8):742-7. [Medline].

  17. Gavazzi C, Bhoori S, Lovullo S. Role of home parenteral nutrition in chronic radiation enteritis. Am J Gastroenterol. Feb 2006;101(2):374-9.

  18. Gilinsky NH, Burns DG, Barbezat GO, et al. The natural history of radiation-induced proctosigmoiditis: an analysis of 88 patients. Q J Med. Winter 1983;52(205):40-53. [Medline].

  19. Green N, Iba G, Smith WR. Measures to minimize small intestine injury in the irradiated pelvis. Cancer. Jun 1975;35(6):1633-40. [Medline].

  20. Henriksson R, Bergstrom P, Franzen L, et al. Aspects on reducing gastrointestinal adverse effects associated with radiotherapy. Acta Oncol. 1999;38(2):159-64. [Medline].

  21. Henriksson R, Franzen L, Littbrand B. Effects of sucralfate on acute and late bowel discomfort following radiotherapy of pelvic cancer. J Clin Oncol. Jun 1992;10(6):969-75. [Medline].

  22. Horwhat JD, Dubois A. Radiation enteritis. Curr Treat Options Gastroenterol. 1999;2:371-381.

  23. Jao SW, Beart RW Jr, Gunderson LL. Surgical treatment of radiation injuries of the colon and rectum. Am J Surg. Feb 1986;151(2):272-7. [Medline].

  24. Kneebone A, Mameghan H, Bolin T. Effect of oral sucralfate on late rectal injury associated with radiotherapy for prostate cancer: A double-blind, randomized trial. Int J Radiat Oncol Biol Phys. Nov 15 2004;60(4):1088-97.

  25. Lee DW, Poon AO, Chan AC. Diagnosis of small bowel radiation enteritis by capsule endoscopy. Hong Kong Med J. Dec 2004;10(6):419-21.

  26. Localio SA, Stone A, Friedman M. Surgical aspects of radiation enteritis. Surg Gynecol Obstet. Dec 1969;129(6):1163-72. [Medline].

  27. Lucarotti ME, Mountford RA, Bartolo DC. Surgical management of intestinal radiation injury. Dis Colon Rectum. Oct 1991;34(10):865-9. [Medline].

  28. Mitsuhashi N, Takahashi I, Takahashi M, et al. Clinical study of radioprotective effects of amifostine (YM-08310, WR- 2721) on long-term outcome for patients with cervical cancer. Int J Radiat Oncol Biol Phys. Jun 15 1993;26(3):407-11. [Medline].

  29. Nakada T, Kubota Y, Sasagawa I, et al. Therapeutic experience of hyperbaric oxygenation in radiation colitis. Report of a case. Dis Colon Rectum. Oct 1993;36(10):962-5. [Medline].

  30. Nussbaum ML, Campana TJ, Weese JL. Radiation-induced intestinal injury. Clin Plast Surg. Jul 1993;20(3):573-80. [Medline].

  31. Olgaç V, Erbil Y, Barbaros U. The efficacy of octreotide in pancreatic and intestinal changes: radiation-induced enteritis in animals. Dig Dis Sci. Jan 2006;51(1):227-32.

  32. Russ JE, Smoron GL, Gagnon JD. Omental transposition flap in colorectal carcinoma: adjunctive use in prevention and treatment of radiation complications. Int J Radiat Oncol Biol Phys. Jan 1984;10(1):55-62. [Medline].

  33. Saclarides TJ. Radiation injuries of the gastrointestinal tract. Surg Clin North Am. Feb 1997;77(1):261-8. [Medline].

  34. Saclarides TJ, King DG, Franklin JL, Doolas A. Formalin instillation for refractory radiation-induced hemorrhagic proctitis. Report of 16 patients. Dis Colon Rectum. Feb 1996;39(2):196-9. [Medline].

  35. Smit WG, Helle PA, van Putten WL, et al. Late radiation damage in prostate cancer patients treated by high dose external radiotherapy in relation to rectal dose. Int J Radiat Oncol Biol Phys. Jan 1990;18(1):23-9. [Medline].

  36. Spitzer TR, Bryson JC, Cirenza E, et al. Randomized double-blind, placebo-controlled evaluation of oral ondansetron in the prevention of nausea and vomiting associated with fractionated total-body irradiation. J Clin Oncol. Nov 1994;12(11):2432-8. [Medline].

  37. Swan RW, Fowler WC Jr, Boronow RC. Surgical management of radiation injury to the small intestine. Surg Gynecol Obstet. Mar 1976;142(3):325-7. [Medline].

  38. Taylor JG, DiSario JA, Buchi KN. Argon laser therapy for hemorrhagic radiation proctitis: long-term results. Gastrointest Endosc. Sep-Oct 1993;39(5):641-4. [Medline].

  39. Ugheoke EA, Norris T. Radiation Proctitis (RTP): Is there a role for hyperbaric oxygen (HBO) therapy?. Am J Gastroenterol. 1998;93:1700.

  40. Willett CG, Ooi CJ, Zietman AL, et al. Acute and late toxicity of patients with inflammatory bowel disease undergoing irradiation for abdominal and pelvic neoplasms. Int J Radiat Oncol Biol Phys. Mar 1 2000;46(4):995-8. [Medline].

  41. Woo TC, Joseph D, Oxer H. Hyperbaric oxygen treatment for radiation proctitis. Int J Radiat Oncol Biol Phys. Jun 1 1997;38(3):619-22. [Medline].

  42. Yeoh E, Horowitz M. Radiation enteritis. Br J Hosp Med. Jun 1988;39(6):498-504. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

radiation enteropathy, radiation enteritis, radiation colitis, radiation proctitis, radiation-induced intestinal toxicity, radiation-induced injury

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Rajeev Vasudeva, MD, FACG, Clinical Professor of Medicine, Consultants in Gastroenterology, University of South Carolina School of Medicine
Rajeev Vasudeva, MD, FACG is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, and South Carolina Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Anil Minocha, MD, FACP, FACG, Clinical Professor, School of Pharmacy, Professor of Medicine, Director of Digestive Diseases, Medical Director of Nutrition Support, Medical Director of Gastrointestinal Endoscopy, Internal Medicine Department, University of Mississippi Medical Center
Anil Minocha, MD, FACP, FACG is a member of the following medical societies: American Academy of Clinical Toxicology, American Association for the Study of Liver Diseases, American College of Forensic Examiners, American College of Gastroenterology, American College of Physicians, American Federation for Clinical Research, American Gastroenterological Association, and American Society of Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Douglas M Heuman, MD, FACP, Director of Hepatology, McGuire Veterans Affairs Medical Center, Professor, Department of Internal Medicine, Division of Gastroenterology, Virginia Commonwealth University School of Medicine
Douglas M Heuman, MD, FACP is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Physicians, and American Gastroenterological Association
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Assistant Dean for Medical Curriculum, Associate Professor of Medicine, Division of General Internal Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.