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Intestinal Radiation Injury Workup

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

Laboratory Studies

Obtain the following laboratory studies:

  • Complete blood cell (CBC) count: To look for anemia due to acute or chronic bleeding, as well as malabsorption
  • Complete metabolic panel: To look for azotemia, electrolyte abnormalities, and nutrition parameters secondary to vomiting and malabsorption
  • Stool studies for enteric pathogens and fat: To rule out any infectious causes of diarrhea and steatorrhea
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Imaging Studies

Plain abdominal radiographs

Flat and upright radiographs are usually nonspecific. During the early phase, the radiographs may show findings consistent with an ileus. Findings may also may show dilated loops with air fluid levels in the event of a bowel obstruction.

The presence of thumb printing may be due to mucosal edema.

Barium contrast studies of the small intestine and colon

Barium studies are better than plain radiographs, because they provide better mucosal detail and document the presence of fistulae. Usual findings include separation of loops, narrowed fixed loops with poor distension, absent haustral markings, diffuse mucosal ulceration, or a single ulcer. The single ulcer usually is located on the anterior wall of the rectum.

Computed tomography (CT) scanning of the abdomen and pelvis

Abdominal and pelvic CT imaging is an excellent study to confirm bowel obstruction and its possible location. This imaging modality can rule out the possibility of abscess, and it may help in further delineation of fistulae.

Video capsule endoscopy

Video capsule endoscopy has been utilized for diagnosing radiation enteritis in anecdotal reports.[7, 8] However, clinicians must exercise caution due to a potentially increased risk of bowel obstruction at the site of fibrotic strictures.

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Procedures

Lower endoscopy

Endoscopy has the advantage over radiologic studies. Biopsies may reveal classic histologic changes consistent with radiation injury. Endoscopic therapy also can be provided in the same setting, as necessary.

Endoscopic findings vary depending on the timing of the procedure (ie, acute setting versus chronic setting).

Colonoscopy may be dangerous depending on the stage of irritation and injury of the colon. Colonoscopy needs to be performed cautiously in the acute setting.

Acute setting

Initial changes reveal a friable edematous mucosa, whereas later changes reveal duskiness, edema, and inflammation.

Ulceration is infrequent but may occur later as the cumulative dose of radiation increases. In this case, the results would show necrotic mucosa with patchy areas of superficial ulceration.

Chronic setting

Fibrosis of the bowel wall may appear as smooth and symmetric strictures.

The mucosa may appear granular, friable, edematous, and pale, with prominent submucosal telangiectatic vasculature.

Small bowel capsule endoscopy

This procedure can potentially detect strictures or a source of bleeding in the small bowel in difficult to diagnose cases.

A retrospective review of 31 patients by Yang et al suggested that capsule endoscopy may be safe and effective in visually identifying the etiology of subacute small bowel obstruction, particularly in cases of suspected intestinal tumors or Crohn disease not found with routine studies.[9] Of the 31 cases, capsule endoscopy provided a definitive diagnosis in 12 (38.7%): 4 Crohn disease, 2 carcinomas, and 1 each of intestinal tuberculosis, ischemic enteritis, abdominal cocoon, intestinal duplication, diverticulum, and ileal polypoid tumor. There were no cases of acute small bowel obstruction, but the capsule was retained in 3 (9.7%) patients due to Crohn disease (n = 2) or tumor (n = 1).[9]

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Histologic Findings

Histologic changes vary depending on the timing of presentation. Acute changes include hyperemia, edema, and inflammatory cell infiltration of the mucosa, with villous shortening, crypt abscesses, thinning of the mucosa, and ulceration.

During the subacute and chronic stages, some mucosal regeneration may occur. The endothelial cells may degenerate, and fibrin plugs may form. Large foam cells beneath the intima are considered pathognomonic for radiation injury. Submucosal fibrosis and obliteration of small blood vessels result in ischemia, which is progressive and irreversible. Ischemia initially involves the mucosa and gradually progresses to involve the submucosa and serosa. Ischemic necrosis and ulceration may lead to fistula formation.

In general, correlation between pathologic and physiologic changes in the intestines is poor.

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Contributor Information and Disclosures
Author

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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