Hyperbaric, Radiation Proctitis


Article Author:
Jeffrey Cooper


Article Editor:
Mary Hanley


Editors In Chief:
Stephen Leslie
Karim Hamawy


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
12/28/2018 5:49:41 PM

Introduction

Radiation therapy of the pelvis is used to treat a variety of cancers, for example, ovarian, uterine, cervical, prostate, bladder, and rectal cancers. Radiation damage to the gastrointestinal (GI) tract can occur, yet the treatment is beneficial in fighting cancer. Hyperbaric oxygen therapy combats this otherwise difficult-to-treat complication of radiation therapy.

Etiology

Radiation proctitis (damage to the lower parts of the colon) is soft tissue radionecrosis and a delayed effect of therapeutic radiation.  As such, it is thought to be a sequela of radiation-induced, progressive, obliterative endarteritis resulting in a lack of small blood vessels in the affected tissue with chronic mucosal ischemia, submucosal fibrosis, progressive epithelial atrophy, and new vessel formation (telangiectasia). It occurs 6 months to years after exposure to the radiation.[1]

Epidemiology

There is an incidence of 1% to 5% of developing chronic radiation proctitis after radiation doses greater than 5000 cGy for pelvic cancer.  Some report an incidence as high as 10%.

Pathophysiology

The late radiation changes cause friable inflamed mucosa (mucositis).  This can lead to ulcerations and bleeding that sometimes require recurrent transfusions. Strictures and fibrosis can occur leading to intestinal obstruction and fistula formation which often have significant morbidity.

Histopathology

Histopathological findings include arteriolar endarteritis and connective tissue fibrosis; whereas, gross findings include mucosal friability, pallor, telangiectasias, strictures, fistulas, and ulcerations.

History and Physical

Signs and symptoms include hematochezia, mucus discharge, diarrhea, tenesmus, and fecal incontinence.[2]

History should include radiation therapy report as radiation proctitis is unusual with doses less than 5000 cGy.

A physical examination may reveal perirectal fistula, anal ulceration, and a fibrotic rectum with mucus and blood.

Evaluation

The physician must keep the history of the initial disease in mind to assess for recurrence of cancer.

  1. Digital rectal examination
  2. Proctoscopic examination
  3. Colonoscopy is needed to fully delineate the extent of inflammation and ulceration and exclude malignancy

Biopsies do not contribute to the diagnosis and should be avoided because of the risk of severe rectal wall damage that may lead to necrosis and fistulas.

Treatment / Management

The American Society of Colon and Rectal Surgeons' clinical practice guidelines for the treatment of chronic radiation proctitis[2] recommend hyperbaric oxygen therapy as an effective treatment modality to reduce bleeding in patients with radiation proctitis. The society strongly recommends the therapy based on moderate-quality evidence.  It is believed hyperbaric oxygen therapy improves tissue oxygenation long-term through angiogenic effects. It also promotes re-epithelialization and stimulates collagen formation. Typically, patients require 30 to 40 treatments for successful resolution of radiation proctitis. The radiation is well tolerated with good outcomes in more than 85% of patients. It alleviates symptoms in 89% for patients with radiation proctitis and sustains the improvement for at least 6 to 12 months after treatment.[3]

Hyperbaric oxygen can be adjunctive to other therapies that are used for this condition, for example, formalin application, sucralfate retention enemas, 5-aminosalicylic acid derivatives, probiotics, antioxidants, antibiotics, and endoscopic argon beam plasma. Sucralfate enemas are very efficacious, inexpensive, and well-tolerated. They may be the best first choice for treatment. Hyperbaric oxygen therapy can be used concurrently or in the case of failure of other treatments.[4]

Bowel surgeries have a high complication rate, more than 70% in some reports.[5] Hyperbaric oxygen treatments before surgical intervention greatly reduce the complication rate and increase the chance of successful resolution.

Differential Diagnosis

It is important for clinicians to eliminate the diagnosis of cancer recurrence. Symptoms alone do not adequately differentiate between radiation proctitis and a more significant pathology. In one study of 171 patients with rectal bleeding after radiation therapy, 141 had radiation proctitis. However, researchers made 95 additional diagnoses, including 8 cancer diagnoses and 9 cases of high-risk adenomas.[6]

Radiation Oncology

Acute proctitis occurs within the first few months of radiation treatment in 10% to 15% of patients. It is self-limited, lasting for only a few months. It is an inflammatory process of rectal mucosa with a loss of microvilli, edema, and ulceration. Symptoms include abdominal pain, tenesmus, diarrhea, incontinence, and urgency.[7]

Chronic proctitis, often with bleeding, develops months to years after radiation treatment and is often progressive. Severe acute proctitis is a risk factor for chronic proctitis development as are diabetes mellitus, inflammatory bowel disease, connective tissue disease, hypertension, smoking, peripheral vascular disease, and chemotherapy.

Pertinent Studies and Ongoing Trials

In the future, hyperbaric oxygen may be a preventative strategy for radiation proctitis and other soft tissue radiation effects.  Radiation induces a significant elevation of oxidative stress, antioxidants, and pro-fibrotic factors that are completely reversed and normalized by hyperbaric oxygen in animal studies.[8] The therapy may prevent radiation-induced changes by affecting oxidative stress and inflammatory cascades induced by radiation.

Treatment Planning

Patients generally require 30 to 60 hyperbaric oxygen treatments, depending on the severity of their condition. There are daily, 90-minute sessions at hyperbaric pressure. Treatment pressures vary among providers, ranging from 1.5 atmospheres absolute (ATA) to 2.5 ATA.  There is a paucity of research regarding optimal treatment pressure and protocol.

Toxicity and Side Effect Management

Patients who cannot equalize their ears may elect to undergo bilateral venting tube myringotomies to prevent significant otic barotrauma.

Prognosis

A randomized, controlled, double-blind, crossover trial showed marked improvement in refractory radiation proctitis with hyperbaric oxygen over control.[3] Complete resolution of bleeding and urgency have been reported in about 50% in retrospective studies. An Australian study reported success rates of 95% with hyperbaric oxygen therapy.[9]

Complications

Hyperbaric oxygen therapy is a relatively low-risk therapy. Otic barotrauma is common but usually not severe. Infrequent complications include oxygen toxicity seizures, transient myopia, and rare cataract formation. Patients with severe structural lung disease or poor left ventricular function are susceptible to more serious complications such as pulmonary barotrauma and acute pulmonary edema.

Contraindications to hyperbaric therapy include recent use of doxorubicin or bleomycin, claustrophobia, epilepsy, severe emphysema particularly with blebs, and certain implanted devices.

Consultations

Gastroenterology or surgical consultation for endoscopic examination to exclude other diagnoses such as cancer or high-risk polyps is warranted.

Deterrence and Patient Education

After their cancer therapy, healthcare professionals should advise patients to be aware of the potential for soft-tissue radiation effects such as radiation proctitis. Early intervention is critical for medical and hyperbaric therapies and to avoid progression to invasive procedures. Although time-consuming, hyperbaric oxygen therapy is well-tolerated, low-risk, and yields good outcomes.

Pearls and Other Issues

Biopsies do not contribute to diagnosing radiation proctitis and should be avoided because of the risk of severe rectal wall damage such as necrosis and fistulas.[1]

Radiation proctitis may improve over time, even without treatment. This is important to take into account when considering treatment.

Enhancing Healthcare Team Outcomes

In general, hyperbaric oxygen is more efficacious when done early. Early referrals may spare the need for more invasive or surgical interventions.


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Attributed To: Contributed by Tdvorak, Wikimedia Commons, (CC by 2.0) https://creativecommons.org/licenses/by/2.0/

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Hyperbaric, Radiation Proctitis - Questions

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A 70-year-old white male status post radiation therapy (6600 cGy) for prostate cancer 5 years previously has developed rectal bleeding and discomfort thought to be secondary to radiation proctitis. The patient has not responded to sucralfate or sulfasalazine. What is the most appropriate next step in this patient's evaluation and treatment?



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Which of the following is not a mechanism by which hyperbaric oxygen therapy is effective in the treatment of radiation proctitis?



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A patient is undergoing radiation therapy for prostate cancer and receives 6500 cGy. He asks if he will need hyperbaric oxygen therapy afterward. What is the approximate incidence of radiation proctitis?



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A 60-year-old male develops radiation proctitis 2 years after being treated for prostate cancer. He has rectal bleeding and tenesmus. What is the likelihood he will benefit from hyperbaric oxygen (HBO2) therapy?



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A 74-year-old man 2 years status post radiation treatment for bladder cancer presents with rectal bleeding, mucus discharge, and fecal urgency. The evaluation should include all of the following for presumed radiation proctitis except which one?



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A 73-year-old male patient is referred to for hyperbaric oxygen treatment for radiation proctitis. The patient was diagnosed with colon cancer 20 years ago and was successfully treated with chemotherapy, surgery, and radiation therapy. He had done very well until recently when he began to pass bright red blood from the rectum. His bleeding has dropped his hemoglobin from 12 to 8 and is significantly impacting his quality of life. A recent colonoscopy showed areas of the rectum which had signs of recent bleeding and radiation proctitis. The patient is skeptical about undergoing hyperbaric oxygen treatment. He asks how this can be related to the radiation treatments he received 20 years ago. What should he be told?



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Hyperbaric, Radiation Proctitis - References

References

Chronic radiation proctitis: tricks to prevent and treat., Vanneste BG,Van De Voorde L,de Ridder RJ,Van Limbergen EJ,Lambin P,van Lin EN,, International journal of colorectal disease, 2015 Oct     [PubMed]
Paquette IM,Vogel JD,Abbas MA,Feingold DL,Steele SR, The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Chronic Radiation Proctitis. Diseases of the colon and rectum. 2018 Oct     [PubMed]
Gilinsky NH,Burns DG,Barbezat GO,Levin W,Myers HS,Marks IN, The natural history of radiation-induced proctosigmoiditis: an analysis of 88 patients. The Quarterly journal of medicine. 1983 Winter     [PubMed]
Clarke RE,Tenorio LM,Hussey JR,Toklu AS,Cone DL,Hinojosa JG,Desai SP,Dominguez Parra L,Rodrigues SD,Long RJ,Walker MB, Hyperbaric oxygen treatment of chronic refractory radiation proctitis: a randomized and controlled double-blind crossover trial with long-term follow-up. International journal of radiation oncology, biology, physics. 2008 Sep 1     [PubMed]
Oscarsson N,Ny L,Mölne J,Lind F,Ricksten SE,Seeman-Lodding H,Giglio D, Hyperbaric oxygen treatment reverses radiation induced pro-fibrotic and oxidative stress responses in a rat model. Free radical biology     [PubMed]
Tahir AR,Westhuyzen J,Dass J,Collins MK,Webb R,Hewitt S,Fon P,McKay M, Hyperbaric oxygen therapy for chronic radiation-induced tissue injuries: Australasia's largest study. Asia-Pacific journal of clinical oncology. 2015 Mar     [PubMed]
Williams HR,Vlavianos P,Blake P,Dearnaley DP,Tait D,Andreyev HJ, The significance of rectal bleeding after pelvic radiotherapy. Alimentary pharmacology     [PubMed]
Kochhar R,Sriram PV,Sharma SC,Goel RC,Patel F, Natural history of late radiation proctosigmoiditis treated with topical sucralfate suspension. Digestive diseases and sciences. 1999 May     [PubMed]
Nelamangala Ramakrishnaiah VP,Krishnamachari S, Chronic haemorrhagic radiation proctitis: A review. World journal of gastrointestinal surgery. 2016 Jul 27     [PubMed]

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