Intestinal Radiation Injury Treatment & Management
- Author: Rajeev Vasudeva, MD; Chief Editor: BS Anand, MD more...
The treatment of acute injury varies depending on the symptoms, and the treatment of chronic injury varies depending on the location of injury.
For symptom control, consider antidiarrheals, bile-sequestering agents, antiemetics, 5-aminosalicylic acid (5-ASA) moieties, and sucralfate. Simple iron supplementation may suffice in some individuals with low-grade bleeding leading to mild anemia.
Consider topical steroids and sucralfate enemas if symptoms are related to rectal involvement. 5-ASA enemas have not been found to be very helpful.
Consider formalin instillation of the rectum and therapeutic endoscopic interventions (eg, ablation with argon, Nd:YAG laser, bipolar circumactive probe [BICAP], argon plasma coagulator). A retrospective study compared formalin instillation with Argon Plasma Coagulator (APC) in a small number of patients and suggested that APC was more effective and safer than formalin in controlling hematochezia and resulted in higher hemoglobin levels.
Hyperbaric oxygen (HBO) therapy may be considered in intractable radiation proctitis before surgical intervention.
Surgical intervention usually is required as a last resort or in the case of complications (eg, perforation, obstruction, abscess drainage, fistulae, local wound infections). The surgical approach should be as conservative as possible.
Abdominopelvic operations are best avoided in patients who received high-dose radiation to the pelvis. Resection of the rectum carries an operative morbidity rate of 12-65% and a mortality rate of 0-13%.
Resection of the diseased bowel can be difficult because identifying the affected loops at laparotomy may be difficult. Doppler viewing of the bowel and intraoperative frozen sections have not been helpful.
An intestinal bypass procedure may be necessary depending on the surgical findings and technical difficulties. Although resection has been shown to cause a higher incidence of leakage and mortality than bypass, diseased bowel left behind also can cause more bleeding and can result in perforation and fistulization.
Several techniques have been described for resection with primary anastomosis or secondary anastomosis with diversion colostomy or ileostomy.
When at least 1 end of a primary anastomosis is healthy bowel, reports exist that leakage is reduced significantly.
Dilation of strictures may be required. Perforation risk is significant if the strictures are long.
Rectovaginal fistulae may close spontaneously or after diversion colostomy. Other fistulae usually require surgical repair.
Presacral sympathectomy has been used for amelioration of severe pain.
A team approach is extremely important to treat these patients. The team may include a radiation oncologist, a medical oncologist, a gastroenterologist, a nutritionist, and, possibly, a surgeon.
The services of a pain specialist may be necessary if the pain is intractable and severe.
Also, the services of a physician experienced with hyperbaric oxygen (HBO) therapy may be necessary if this modality is considered in intractable proctitis.
Although no restriction on activity is necessary, on the basis of animal studies, a low-fat diet is recommended, with the intention of reducing pancreatic and biliary secretions to decrease radiation damage. A low-fat, low-residue, and lactose-free diet has been tried with some suggested success. Elimination of insoluble fiber from the diet with the substitution of soluble fiber has been tried.
Findings from animal studies suggest that glutamine-supplemented diets (eg, polymeric, elemental) may be protective against radiation injury.
Consider an elemental diet or the use of total parenteral nutrition as the clinical situation demands. A recent Italian retrospective study in patients with mechanical bowel obstruction due to chronic radiation enteritis showed that initial treatment with bowel rest and home parenteral nutrition was superior to initial surgical intervention in long-term survival and nutrition autonomy.
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