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Intestinal Radiation Injury Follow-up

  • Author: Rajeev Vasudeva, MD; Chief Editor: BS Anand, MD  more...
Updated: Sep 04, 2015


Note the following:

  • 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  • Although pretreatment calculation of the dose is important, sensitive probes have been replaced by computer calculations.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.[11, 12, 13] 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 to be effective during pelvic irradiation. However, a more recent study showed that oral sucralfate was not effective in preventing late rectal injury in patients with prostate cancer.

The US 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.

Animal studies

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.[14]

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.[15]

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 mice. In addition, the cultured intestinal epithelial cells were protected from apoptosis and microbial adherence and possible invasion.[6] The investigators noted that PEG 15-20 exerted a protective effect by preventing coalescence of lipid rafts by binding them.[15]

There have been some exciting reports in animal studies that probiotics may be helpful in preventing radiation induced intestinal damage.[15, 16, 17, 18] It remains to be seen whether this intervention turns out to be a preventative or therapeutic tool in human subjects.

Prophylactic surgical intervention

As noted above, the most important aspect of intestinal radiation injury 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
Contributor Information and Disclosures

Rajeev Vasudeva, MD Clinical Professor of Medicine, Consultants in Gastroenterology, University of South Carolina School of Medicine

Rajeev Vasudeva, MD is a member of the following medical societies: American College of Gastroenterology, Columbia Medical Society, South Carolina Gastroenterology Association, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, South Carolina Medical Association

Disclosure: Received honoraria from Pricara for speaking and teaching; Received consulting fee from UCB for consulting.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Douglas M Heuman, MD, FACP, FACG, AGAF Chief of Hepatology, Hunter Holmes McGuire Department of Veterans Affairs Medical Center; Professor, Department of Internal Medicine, Division of Gastroenterology, Virginia Commonwealth University 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, American Gastroenterological Association

Disclosure: Received grant/research funds from Novartis for other; Received grant/research funds from Bayer for other; Received grant/research funds from Otsuka for none; Received grant/research funds from Bristol Myers Squibb for other; Received none from Scynexis for none; Received grant/research funds from Salix for other; Received grant/research funds from MannKind for other.

Chief Editor

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Additional Contributors

Anil Minocha, MD, FACP, FACG, AGAF, CPNSS 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, AGAF, CPNSS is a member of the following medical societies: American Academy of Clinical Toxicology, American Society for Gastrointestinal Endoscopy, American Federation for Clinical Research, American Association for the Study of Liver Diseases, American College of Forensic Examiners Institute, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association

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. 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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