Intestinal Radiation Injury Follow-up

  • Author: Rajeev Vasudeva, MD, FACG; Chief Editor: Julian Katz, MD   more...
 
Updated: Mar 22, 2011
 

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  • Although pretreatment calculation of the dose is important, sensitive probes have been replaced by computer calculations.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.
    • A murine study by Qiu et al described a novel molecular mechanism of growth factors in suppressing p53 upregulated modulator of apoptosis (PUMA) in acute radiation-induced gastrointestinal damage and gastrointestinal syndrome through the phosphoinositide 3-kinase (PI3K)/protein kinase B (AKT)/p53 axis in the intestinal stem cells.[10]
      • In a murine and rat study, Valuckaite et al investigated the ability of a high-molecular-weight polyethylene glycol-based copolymer, PEG 15-20, to protect the intestine against the early and late effects of radiation as well as assessed its mechanism of action in cultured rat intestinal epithelia.[11]
      • PEG 15-20 was able to prevent radiation-induced intestinal injury in the rats, as well as prevent apoptosis and lethal sepsis attributable to Pseudomonas aeruginosa in the mice. In addition, the cultured intestinal epithelial cells were protected from apoptosis and microbial adherence and possible invasion.[12] The investigators noted it appeared PEG 15-20 exerted a protective effect by preventing coalescence of lipid rafts by binding them.[11]
    • 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) 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
  • There have been some exciting reports in animal studies that probiotics may be helpful in preventing radiation induced intestinal damage.[13, 14, 15, 11] It remains to be seen whether this intervention turns out to be a preventative or therapeutic tool in human subjects.
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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
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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 developed the following classification system based on outcome[12] :
    • 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%.
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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, Columbia Medical Society, South Carolina Gastroenterology Association, and South Carolina Medical Association

Disclosure: Pricara Honoraria Speaking and teaching; UCB Consulting fee Consulting

Specialty Editor Board

Anil Minocha, MD, FACP, FACG  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; Clinical Professor, University of Mississippi School of Pharmacy

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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Douglas M Heuman, MD, FACP, FACG, AGAF  Chief of GI, Hepatology, and Nutrition at North Shore University Hospital/Long Island Jewish Medical Center; Professor, Department of Medicine, Hofstra North Shore-LIJ School of Medicine

Douglas M Heuman, MD, FACP, FACG, AGAF 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: Novartis Grant/research funds Other; Bayer Grant/research funds Other; Otsuka Grant/research funds None; Bristol Myers Squibb Grant/research funds Other; Scynexis None None; Salix Grant/research funds Other; MannKind Other

Alex J Mechaber, MD, FACP  Senior Associate Dean for Undergraduate Medical Education, Associate Professor of 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

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 & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

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Intestinal radiation injury. Characteristic mucosal changes observed in radiation proctitis with multiple telangiectasias.
Intestinal radiation injury. Friability and oozing of blood from atrophic-appearing mucosa due to radiation.
Intestinal radiation injury. Appearance of mucosa after therapy with bipolar circumactive probe (BICAP) probe.
This slide illustrates disorderly crypts, fibrosis of lamina propria, and vascular dilatation, all of which are characteristic of colonic injury due to radiation. (This slide was provided courtesy of Ronald Burns, MD, Palmetto Richland Memorial Hospital, Columbia, SC.)
A deep rectal ulcer from prostate cancer radiation years ago. Patient presented with significant rectal bleeding.
After 6 months of treatment with daily Canasa (5-ASA) suppositories
Retroflexed view of the same radiation induced ulcer after 6 months of treatment
 
 
 
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