Intestinal Radiation Injury Workup
- Author: Rajeev Vasudeva, MD; Chief Editor: BS Anand, MD more...
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
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.
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.
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.
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. 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).
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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