eMedicine Specialties > Gastroenterology > Intestine

Intestinal Radiation Injury: Follow-up

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

Follow-up

Deterrence/Prevention:

  • Prevention is the single most important element in dealing with intestinal radiation injury.
  • Although pretreatment calculation of the dose is important, sensitive probes have been replaced by computer calculations. Three-dimensional treatment-planning techniques have been employed and have been shown to be more accurate and safer.
  • A small decrease in radiation (as small as 10%) with an increase in the duration may reduce adverse effects significantly without affecting the total radiation dose.
  • Pretreatment barium contrast studies to determine how much of the small intestine is in the pelvis might be a guide in custom shielding.
  • Filling the urinary bladder may push the small bowel away from the pelvis.
  • Body positioning in the prone position, decubitus, or the Trendelenburg position may be helpful. A special table with a central cavity, which allows the bowel loops to drop away from the target tissue, has been described.
  • Pharmacologic therapy
    • A number of promising innovative pharmacologic therapies are being studied. Unfortunately, most of the data are from animal studies, and trials in humans are lacking. These agents include antioxidants in the form of vitamin E and vitamin E-like compounds, as well as the lazaroids (ie, 21-amino steroids) and more recently octreotide.
    • Although nonsteroidal anti-inflammatory drugs have shown some promise in animal studies, the results with a prostaglandin analogue, misoprostol, have been less than satisfactory.
    • Other emerging therapies include intravenous and intra-arterial vasopressin, epidermal growth factor, growth hormone, and nitric oxide (NO) inhibitors.
    • Sucralfate therapy in doses varying from 1 g every 4-6 hours during treatment and for another 3-4 weeks thereafter has been shown effective during pelvic irradiation. However, a recent study showed that oral sucralfate was not effective in preventing late rectal injury in patients with prostate cancer.
    • The Food and Drug Administration (FDA) recently approved the use of IV amifostine (Ethyol) as a radioprotectant agent. Administered as a daily dose, amifostine is to be used in the prevention of radiation-induced xerostomia in the postoperative setting. Its efficacy in the prevention of radiation intestinal injuries has yet to be established. Concern about tumor protection appears to be unwarranted. Adverse effects, such as nausea and hypotension, the need for daily injections, and cost concerns may limit its wide acceptance.
  • The most important aspect is prevention; therefore, a number of innovative prophylactic surgical therapies have been proposed, and include the following:
    • Biodegradable mesh slings
    • Sodium chloride–filled tissue expanders
    • Inflatable prosthesis
    • Abdominopelvic omentopexy
    • Suturing the bladder to the sacrum

Complications:

  • Small or large bowel obstruction
  • Small or large bowel bleeding
  • Fistulae - Rectovaginal, enterovesical, rectovesical, or enterocolic
  • Malabsorption, electrolyte abnormalities, and dehydration
  • Perforation
  • Urethral stenosis
  • Cystitis

Prognosis:

  • The natural history of radiation enteritis is hard to ascertain due to the lack of follow-up information in these patients. Often, these patients succumb to their original malignancy. Reports exist that 50% of patients with radiation-induced enteritis who survived more than 3 months after surgery and who were observed for as long as 12 years did well, while the remainder had persistent symptoms, developed complications, or both. The 5-year survival rate for the entire group was 40%.
  • In terms of radiation proctitis, Gilinsky et al (1983) developed the following classification system based on outcome:
    • Group I is comprised of 44% of patients with the most favorable outcome; 70% achieved resolution in 18 months, 5% required surgery, and 15% died from complications.
    • Group II is comprised of 36% of patients with a less favorable outcome and 25% mortality rate.
    • Group III is comprised of 20% of patients with intractable bleeding, all of whom required surgery. The overall mortality rate was 41%.

Miscellaneous

Medicolegal Pitfalls

  • Failure by endoscopists to exercise extreme caution, especially in acute severe injury and stricture dilation
  • Failure to use surgical intervention with great caution and as a last resort: Patients should be well informed of the risks and the potential adverse short-term and long-term outcomes, which can be devastating.
  • Failure to use all available modalities to try to prevent or minimize radiation-induced injury
  • Failure to investigate patients with GI symptoms on the presumption that these symptoms are a consequence of radiation damage. A recent prospective study of 265 patients showed that more than one half had more than one GI diagnosis contributing to their symptoms. Significant neoplasia was found in at least 12% of patients and one third of all diagnoses were unrelated to prior radiation therapy.
 


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
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Further Reading

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Keywords

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

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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.

 
 
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