Radiation Proctitis

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Radiation  proctopathy  is  defined  as  epithelial  damage  to  the  rectum  due  to  radiation  that  is  associated  with  minimal  or  no  inflammation.  Acute  radiation  proctitis  occurs  during  or  within  six  weeks of radiation therapy. Chronic radiation proctitis has a more delayed onset. The first symptoms  often occur 9 to 14 months following radiation exposure but can occur any time post-irradiation up to  30 years after exposure. 

Clinical presentation 

  • Symptoms  of  acute  radiation  proctitis  include  diarrhea,  mucus  discharge,  urgency, tenesmus, and, uncommonly, bleeding.
  • Patients  with  chronic  radiation  proctitis  have  similar  symptoms  as  patients  with  acute radiation  proctitis,  but  bleeding  is  usually  more  severe.  In  addition,  patients  may  have symptoms of obstructed defecation due to strictures with constipation, rectal pain, urgency, and, rarely, fecal incontinence due to overflow.
  • Concomitant  injury  to  the  genitourinary  tract  or  small  bowel  may  lead  to  fistulas,  small bowel obstruction, small intestinal bacterial overgrowth, urethral stenosis, and cystitis
  • Acute radiation proctitis should be suspected in patients with diarrhea, mucus discharge, urgency, tenesmus, or bleeding during or within six weeks of radiation therapy. Chronic radiation  proctitis  should  be  suspected  in  patients  who  develop  these  symptoms  nine months or more after pelvic radiation exposure.

Investigations 

  • Stool studies for C. difficile toxin, routine stool cultures (Salmonella, Shigella, Campylobacter, and Yersinia), Escherichiacoli O157:H7. Microscopy for ova and parasites (three samples)
  • Testing for STI, including C. trachomatis, N. gonorrhoeae, HSV, and Treponema pallidum, Endoscopy (colonoscopy and biopsy)
  • Magnetic resonance imaging

Pharmacological Treatment 

D: sulfasalazine (PO) 3g 24hourly for 4weeks 

AND 

S: sucralfate enemas (rectal preparation) 2g 12hourly for 4weeks 

Note: Refer to higher level facility with expertise and experience in the management complications such as  bleeding. Endoscopic therapy — Argon plasma coagulation (APC) for bleeding. Surgery — Surgery  should be reserved for patients who have. intractable symptoms such as a stricture, pain, bleeding,  perforation, or a fistula