radiation enteritis proctitis n.
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Radiation Enteritis/ Proctitis. Raneen Omary. Contents. Definition Pathogenesis Epidemiology Acute Radiation Enteritis Chronic Radiation Enteritis Risk Factors Diagnosis DD Medical Management Surgery Prognosis. Definition. Radiation Enteritis/ Proctitis

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contents
Contents
  • Definition
  • Pathogenesis
  • Epidemiology
  • Acute Radiation Enteritis
  • Chronic Radiation Enteritis
  • Risk Factors
  • Diagnosis
  • DD
  • Medical Management
  • Surgery
  • Prognosis
definition
Definition
  • Radiation Enteritis/Proctitis

Functional disorder of the small and large intestines secondary to abdominal/ pelvic radiation

* Both radiation enteritis and proctitis have acute and chronic manifestations

pathogenesis
Pathogenesis
  • Cells with a high proliferative rate, such as the gastrointestinal epithelium, are susceptible to injury from radiation
  • The primary effect of radiation is on mucosal stem cells within the crypts of Lieberkuhn
  • Inflammation, edema, shortening of villi (small absorption area)
  • Histological changes within hours
  • Inflammation, abbcess- 2-4 weeks.
  • ulcers
slide5

** Subsequent Changes:

  • Vasculitis
  • Fibrosis (submucosa)
  • Thickening of the small intestine (ischemia, lymphatic damage)
  • Also: ulceration perforation, fistula, abcess./Fibrosis, stricture, obstruction
  • Absorption of fats, carbohydrates, protein, bile salts, B12 vitamin.
  • Lactose (bacterial overgrowth?)
epidemiology
Epidemiology
  • Almost every patient undergoing RT to the abdomen or pelvis will show signs of acute enteritis
  • Only 5% to 15% of patients treated with abdominal/pelvic RT will develop chronic enteritis
  • No sex, age, or race correlation
acute radiation enteritis
Acute Radiation Enteritis
  • Occurs as a result of the direct effects of radiation on the bowel mucosa
  • Symptoms include:  diarrhea, abdominal pain, nausea and vomiting, anorexia, and malaise
  • Acute pathologic effects resolve and typically disappear two to six weeks after the completion of RT
  • Patients who develop acute intestinal toxicity are at increased risk for chronic effects
chronic radiation enteritis
Chronic Radiation Enteritis
  • Late radiation effects typically are manifested 8 to 12 months after RT, although toxicity may not appear until years later in some cases
  • Symptoms include:  diarrhea, nausea, weight loss, abdominal pain..
  • intestinal obstruction, perforation, malabsorption, lactose intolerance
  • Chronic radiation enteritis is due to an obliterativearteritis that leads to intestinal ischemia, which can result in stricture, ulceration, fibrosis and occasionally fistula formation
risk factors
Risk Factors
  • Dose of radiation, and duration
  • Volume of normal bowel treated
  • Concomitant chemotherapy
  • Individual patient variables
diagnosis
Diagnosis
  • History of prior radiation exposure
  • Upper Gastointestinal Series
  • Enteroclysis
  • CT
  • Enteroscopy
  • Capsule Endoscopy
  • Colonoscopy
slide11

Capsule endoscopy showing a jejunal stricture secondary to radiation enteritis.

Abnormal jejunalvilli secondary to radiation enteritis as seen during capsule endoscopy.

differential diagnosis
DIFFERENTIAL DIAGNOSIS
  • Post-surgical adhesions
  • Abdominal metastases
  • Lymphoma
  • Crohn's disease
  • Infections
  • Ischemic or ulcerative colitis
  • Intestinal pseudo-obstruction
medical management
Medical Management
  • Prevention is the key to avoiding chronic radiation enteritis
slide14

* Once established, treatment should be as conservative as possible focusing on relief of symptoms

  • Dietary Recommendations – avoiding high fiber diet, lactose.
  • Anti-diarrheal Agents-loperamide
  • Antibiotics
  • 5-ASA Drugs -sulfasalazine
surgery
Surgery
  •  Surgery for radiation enteritis should be avoided if possible because of several inherent difficulties in operating on patients with chronic radiation injury
  • Approximately 1/3 of patients progress to the point where surgery is required
  • The most common indications for surgery have been persistent ileus, intestinal fistulization, and massive adhesions
  • Surgical mortality rates are as high as 10 to 22 percent and many patients require more than one laparotomy
prognosis
Prognosis
  • Variable
  • Early mortality is usually due to cancer recurrence
  • 5-year survival is approximately 70% in those without cancer recurrence, although many patients continue to have troubling digestive symptoms