eMedicine Specialties > Gastroenterology > Intestine
Intestinal Radiation Injury: Treatment & Medication
Updated: Jun 20, 2006
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
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).
- HBO therapy may be considered in intractable radiation proctitis before surgical intervention.
Surgical Care
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 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 severe pain.
Consultations
- 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 HBO therapy may be necessary if this modality is considered in intractable proctitis.
Diet
- Based on animal studies, a low-fat diet is recommended, with the intention of decreasing 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 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.
Activity
No restriction on activity is necessary.
Medication
The treatment of acute injury varies depending on the symptoms, and treatment of chronic injury varies depending on the location of the injury.
Antiemetics
Used to treat nausea and vomiting related to acute radiation enteritis.
Ondansetron (Zofran)
Selective 5-HT3-receptor antagonist that blocks serotonin both peripherally and centrally. Prevents nausea and vomiting associated with emetogenic cancer chemotherapy (eg, high-dose cisplatin), and complete body radiotherapy. Also beneficial in reducing the frequency of diarrhea by delaying intestinal transit.
Adult
8 mg PO tid
Pediatric
Not established
Although potential exists for cytochrome P-450 inducers (eg, barbiturates, rifampin, carbamazepine, phenytoin) to change half-life and clearance of ondansetron, dosage adjustment usually is not required
Documented hypersensitivity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
To be administered for prevention of nausea and vomiting, not for rescue of nausea and vomiting; use cautiously so that it does not mask progressive ileus; caution in breastfeeding women
Antidiarrheals
Used to treat diarrhea associated with acute radiation enterocolitis.
Loperamide (Imodium)
Acts on intestinal muscles to inhibit peristalsis and slow intestinal motility. Prolongs movement of electrolytes and fluid through bowel and increases viscosity and loss of fluids and electrolytes.
Adult
4 mg PO initially, then 2 mg after each loose stool up to 16 mg/d
Pediatric
<2 years: Not recommended
2-5 years: 1 mg PO tid
6-8 years: 2 mg PO bid
8-12 years: 2 mg PO tid
Phenothiazines, TCAs, and CNS depressants may increase toxicity
Documented hypersensitivity; diarrhea resulting from infections; pseudomembranous colitis
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Discontinue use or switch to diphenoxylate if no clinical improvement occurs in 48 h; consider interrupting radiation; because primarily metabolized in liver, monitor for CNS toxicity in patients with hepatic insufficiency; do not use if high fever or blood in stool coincides with diarrhea
Diphenoxylate and atropine (Lomotil, Lonox)
Drug combination that consists of diphenoxylate, which is a constipating meperidine congener and a subtherapeutic dose of atropine to discourage misuse. Inhibits excessive GI propulsion and motility.
Adult
20 mg/d of diphenoxylate PO qid; decrease dose when controlled
Pediatric
<2 years: Not recommended
>2 years: 0.3-0.4 mg/kg PO divided qid
May delay metabolism of drugs in liver; CNS depressants, MAOIs, and antimuscarinic agents may increase the toxicity of this drug combination
Documented hypersensitivity; narrow-angle glaucoma; hepatic insufficiency or obstructive jaundice; diarrhea associated with pseudomembranous enterocolitis or enterotoxin-producing bacteria
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
In young children, dehydration may influence variability of response and predispose patient to delayed diphenoxylate intoxication; caution in ulcerative colitis; decrease in intestinal motility may be detrimental to patients with diarrhea resulting from Shigella species, Salmonella species, and toxigenic strains of Escherichia coli; overdosage may result in severe respiratory depression and coma (if this occurs, a pure narcotic antagonist, such as naloxone, should be used)
Cholestyramine (Questran)
Forms a nonabsorbable complex with bile acids in the intestine, which, in turn, inhibits enterohepatic reuptake of intestinal bile salts. Decreases diarrhea by preventing bile salt malabsorption.
Adult
4-12 g PO qd
Pediatric
Not established
Inhibits absorption of numerous drugs, including warfarin, thyroid hormone, amiodarone, NSAIDs, methotrexate, digitalis glycosides, glipizide, phenytoin, imipramine, niacin, methyldopa, tetracyclines, clofibrate, hydrocortisone, and penicillin G
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Caution in constipation and phenylketonuria
Sucralfate (Carafate)
An aluminum-hydroxide complex of sulfated sucrose, which forms a protective barrier at the site of ulceration due to radiation. Binds bile acids and helps to treat diarrhea from secondary bile acid malabsorption. Effective when administered PO as a prophylactic agent in preventing acute and chronic radiation injury. Studies using enemas for treatment of radiation proctitis have shown promising short-term results. No dosing standards exist, and doses used in studies vary from 1 g PO q4-6h during treatment and for another 3-4 wk thereafter.
Adult
1 g PO q4-6h
3 g in 15 mL susp enema qd
Pediatric
Not established
May decrease effects of ketoconazole, ciprofloxacin, tetracycline, phenytoin, warfarin, quinidine, theophylline, and norfloxacin
Documented hypersensitivity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Caution in renal failure and conditions that impair excretion of absorbed aluminum
Topical corticosteroids
Used to treat symptoms related to radiation proctitis.
Hydrocortisone (Cortenema)
Retention enema. An adrenocorticosteroid derivative suitable for application to skin or external mucous membranes. Has mineralocorticoid and glucocorticoid effects resulting in anti-inflammatory activity. Used for its anti-inflammatory properties and effective in radiation proctitis.
Adult
1 enema PR qhs
Pediatric
Not established
None reported
Documented hypersensitivity; viral, fungal, or tubercular skin infections
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Prolonged use, applying over large surface areas, and application of potent steroids may increase systemic absorption of corticosteroids and may cause Cushing syndrome, reversible HPA axis suppression, hyperglycemia, and glycosuria
Topical formalin therapies
Used for intractable bleeding from radiation proctitis.
Formaldehyde (Formalin 4%)
Direct mucosal contact allows rectal bleeding to cease.
Adult
Mix 200 mL of 10% buffered formalin with 300 mL of water; used in 50-mL aliquots administered through a rigid proctoscope under local anesthesia; rectal mucosa is treated for 30 sec with each aliquot and irrigated with sodium chloride solution between aliquots
Pediatric
Not established
None reported
Documented hypersensitivity; fistulae or deep ulcers
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Anal canal ulceration and fissuring can occur but may be avoided by using a rigid proctoscope
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
Keywords
radiation enteropathy, radiation enteritis, radiation colitis, radiation proctitis, radiation-induced intestinal toxicity, radiation-induced injury
