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Chronic Radiation Proctopathy and Colopathy
Chronic Radiation Proctopathy and Colopathy SJ Tang and F Bhaijee, University of Mississippi Medical Center, Jackson, MS, USA r 2013 Elsevier GmbH. All rights reserved. Received 11 September 2012; Revision submitted 11 September 2012; Accepted 25 September 2012
Abstract Chronic radiation-induced colonic injury occurs in up to 20% of patients following radiotherapy. The rectum and distal sigmoid colon are most susceptible to radiation damage, and chronic radiation proctopathy generally manifests with anorectal pain, diarrhea, rectal bleeding, and/or anemia. Endoscopic findings include loss of mucosal vasculature, patchy erythema, and angioectasia, which correlate with ischemic endarteritis of the submucosal arterioles, submucosal fibrosis, and angioectasia on histopathological examination. Although most patients develop symptomatic chronic radiation proctopathy within 1–2 years after radiation exposure, they can present up to 30 years after treatment. Radiation proctopathy, found incidentally during endoscopy, does not warrant any therapy. Argon plasma coagulation (APC) is the mainstay of endoscopic therapy for chronic radiation proctopathy. Laser therapy and dilute formalin (2–10%) application are associated with higher complications and are not commonly utilized. In this video presentation, endoscopic findings are described in chronic radiation proctopathy and colopathy as well as APC therapy. This article is part of an expert video encyclopedia.
Keywords Argon plasma coagulation; Endoscopy; Rectal bleeding; Radiation colopathy; Radiation proctopathy; Standard endoscopy; Video.
Video Related to this Article Video available to view or download at doi:10.1016/S22120971(13)70133-X
Material Colonoscopes: Olympus CF and PCF-Q180; Olympus America, Center Valley, PA, USA.
Background and Endoscopic Procedure Chronic radiation-induced colonic injury occurs in up to 20% of patients following radiotherapy. The rectum and distal sigmoid colon are most susceptible to radiation damage. This is likely due to the relative immobility of these segments and higher doses of radiation used for pelvic neoplasms. The term ‘radiation proctitis’ is a misnomer, because there is no inflammatory component on histopathological examination. Radiation induces ischemic endarteritis of the submucosal arterioles, submucosal fibrosis, and angioectasia. Endoscopically, loss of mucosal vasculature, patchy erythema, and angioectasia can be observed. During endoscopy, mucosal erythema and submucosal hemorrhage from barotrauma can mimic angioectasia. Acute radiation may cause diarrhea and tenesmus in up to 50% of the patients. Chronic radiation proctopathy presents with anorectal pain, diarrhea, rectal bleeding, and anemia. This article is part of an expert video encyclopedia. Click here for the full Table of Contents.
Video Journal and Encyclopedia of GI Endoscopy
Although most patients develop symptomatic chronic radiation proctopathy within 1–2 years after radiation exposure, they can present up to 30 years after treatment. Rectal bleeding is rarely life threatening and it resolves spontaneously in majority of cases. Radiation proctopathy found incidentally during endoscopy does not warrant any therapy. In patients with mild symptoms, conservative therapy consisting of rectal instillation of sucralfate has been shown to result in symptom improvement and healing. 5-aminosalicylic acid enemas and short-chain fatty acid enemas have no proven efficacy. In a systematic review, hyperbaric oxygen was shown to be associated with significant improvement in chronic radiation proctopathy. Endoscopic treatment options include: (1) thermal coagulation with argon plasma coagulation (APC), bipolar or heater probes, or radiofrequency devices; (2) cryotherapy; (3) neodymium:yttrium– aluminum–garnet (Nd:YAG) laser; and (4) topical application of formalin. APC is the mainstay of endoscopic therapy for chronic radiation proctopathy, given its tangential application ability, ease of use on retroflexed view, widespread availability, low cost, and clinical effectiveness. APC is 80–90% effective in decreasing rectal bleeding. In most cases, 1–3 treatment sessions are required. Complete bowel preparation is recommended before APC application. Power settings of 25–60 W and argon plasma flow rates of 0.5–2.5 l min 1 have been reported. If APC is not available, thermal coagulation with bipolar or heater probes can be performed. Gentle mucosal contact with 1–2-s thermal application is recommended, but applying therapy on retroflexed view with bipolar or heater probes may present technical difficulties. Cryotherapy and radio frequency ablation are novel and there is very limited data. Both devices are not widely available or cost-effective yet. Laser therapy
http://dx.doi.org/10.1016/S2212-0971(13)70133-X
307
308 Chronic Radiation Proctopathy and Colopathy
delivers a deeper tissue effect compared to APC, but is not widely practiced due to its cost, variable degrees of coagulation depth, and a higher risk of perforation. Dilute formalin (2–10%) can be locally applied endoscopically. In one study, an average of 3.5 applications of 10% formalin at 2–4 week interval yielded clinical response rates of 63–100%. However, complications such as rectal necrosis, rectovaginal fistula development, and acute colitis have been reported.
01:07
The mucosal vasculature is more preserved in the upper rectum.
01:18
The angioectasia is better defined under digital chromoendoscopy (i.e., narrow band imaging).
01:42
In order to appreciate the full extent of rectal involvement, retroflexed examination of the rectum is necessary.
01:58
Active bleeding from the angioectasia can sometimes be seen during endoscopic examination.
Key Learning Points/Tips and Tricks
02:08
Active oozing can present as a punctate bleeding spot due to under-fill of the periphery angioectasia.
•
02:20
Endoscopic hemostasis can generally be achieved with thermal ablation using argon plasma coagulation (APC), bipolar or heater probes.
02:35
APC is the mainstay of endoscopic therapy for chronic radiation proctopathy, given its tangential application ability, ease of use on retroflexed view, widespread availability, low cost, and clinical effectiveness.
02:59
APC is 80%–90% effective in reducing rectal bleeding.
02:08
In most cases, 1–3 treatment sessions are required.
02:15
During APC treatment, gentle mucosal contact with 1–2 s thermal application is recommended.
02:30
In this patient, chronic radiation colopathy involves the distal sigmoid colon and rectum.
02:57
During endoscopy, mucosal erythema, and submucosal hemorrhage from barotrauma can mimic angioectasia.
04:15
Thank you for your attention.
• • • • • • •
• •
Chronic radiation-induced colonic injury occurs in up to 20% of patients following radiotherapy. The rectum and distal sigmoid colon are most susceptible to radiation damage. During endoscopy, loss of mucosal vasculature, patchy erythema, and angioectasia can be observed. Patients with chronic radiation proctopathy can present with anorectal pain, diarrhea, rectal bleeding, and anemia. Although most patients develop symptomatic chronic radiation proctopathy within 1–2 years after radiation, they may present up to 30 years after treatment. Radiation proctopathy found incidentally on endoscopy does not warrant therapy. Rectal bleeding is rarely life threatening and it resolves spontaneously in majority of cases. Endoscopic treatment modalities include: J Thermal coagulation – APC – Bipolar or heater probes – Radiofrequency devices J Cryotherapy J Nd:YAG laser J Topical application of formalin APC is the mainstay of endoscopic therapy for chronic radiation proctopathy, with a decrease in rectal bleeding in 80–90% of patients. Power settings of 25–60 W and argon plasma flow rates of 0.5–2.5 l min 1 have been reported. In general, 1–3 APC treatment sessions are required to achieve clinical response.
Scripted Voiceover Time (min:sec)
Voiceover text
00:02
The rectum and distal sigmoid colon are most susceptible to radiation damage.
00:10
Radiation induces ischemic endarteritis of the submucosal arterioles, submucosal fibrosis, and angioectasia.
00:24
In this histopathological image, ischemic endarteritis and angioectasia can be seen.
00:39
Submucosal fibrosis is diffusely present.
00:51
In this patient with chronic radiation proctopathy, loss of mucosal vasculature, patchy erythema, and angioectasia are observed.
Further Reading Buchi, K. Radiation Proctitis: Therapy and Prognosis. J. Am. Med. Assoc. 1991, 265, 1180–1186. Daram, S. R.; Lahr, C.; Tang, S. J. Anorectal Bleeding: Etiology, Evaluation, and Management (With Videos). Gastrointest. Endosc. 2012, 76, 406–417. Haas, E. M.; Bailey, H. R.; Farragher, I. Application of 10 Percent Formalin for the Treatment of Radiation-Induced Hemorrhagic Proctitis. Dis. Colon Rectum 2007, 50, 213–217. Hou, J. K.; Abudayyeh, S.; Shaib, Y. Treatment of Chronic Radiation Proctitis With Cryoablation. Gastrointest. Endosc. 2011, 73, 383–389. Kochhar, R.; Patel, F.; Dhar, A.; et al. Radiation-Induced Proctosigmoiditis: Prospective, Randomized, Double-Blind Controlled Trial of Oral Sulfasalazine Plus Rectal Steroids Versus Rectal Sucralfate. Dig. Dis. Sci. 1991, 36, 103–107. Pikarsky, A. J.; Belin, B.; Efron, J.; et al. Complications Following Formalin Installation in the Treatment of Radiation Induced Proctitis. Int. J. Colorectal Dis. 2000, 15, 96–99. Sato, Y.; Takayama, T.; Sagawa, T.; et al. Argon Plasma Coagulation Treatment of Hemorrhagic Radiation Proctopathy: The Optimal Settings for Application and Long-Term Outcome. Gastrointest. Endosc. 2011, 73, 543–549. Villavicencio, R. T.; Rex, D. K.; Rahmani, E. Efficacy and Complications of Argon Plasma Coagulation for Hematochezia Related to Radiation Proctopathy. Gastrointest. Endosc. 2002, 55(1), 70–74. Zhou, C.; Adler, D. C.; Becker, L.; et al. Effective Treatment of Chronic Radiation Proctitis Using Radiofrequency Ablation. Therap. Adv. Gastroenterol. 2009, 2, 149–156.
Abstract Chronic radiation-induced colonic injury occurs in up to 20% of patients following radiotherapy. The rectum and distal sigmoid colon are most susceptible to radiation damage, and chronic radiation proctopathy generally manifests with anorectal pain, diarrhea, rectal bleeding, and/or anemia. Endoscopic findings include loss of mucosal vasculature, patchy erythema, and angioectasia, which correlate with ischemic endarteritis of the submucosal arterioles, submucosal fibrosis, and angioectasia on histopathological examination. Although most patients develop symptomatic chronic radiation proctopathy within 1–2 years after radiation exposure, they can present up to 30 years after treatment. Radiation proctopathy, found incidentally during endoscopy, does not warrant any therapy. Argon plasma coagulation (APC) is the mainstay of endoscopic therapy for chronic radiation proctopathy. Laser therapy and dilute formalin (2–10%) application are associated with higher complications and are not commonly utilized. In this video presentation, endoscopic findings are described in chronic radiation proctopathy and colopathy as well as APC therapy. This article is part of an expert video encyclopedia.
Keywords Argon plasma coagulation; Endoscopy; Rectal bleeding; Radiation colopathy; Radiation proctopathy; Standard endoscopy; Video.
Video Related to this Article Video available to view or download at doi:10.1016/S22120971(13)70133-X
Material Colonoscopes: Olympus CF and PCF-Q180; Olympus America, Center Valley, PA, USA.
Background and Endoscopic Procedure Chronic radiation-induced colonic injury occurs in up to 20% of patients following radiotherapy. The rectum and distal sigmoid colon are most susceptible to radiation damage. This is likely due to the relative immobility of these segments and higher doses of radiation used for pelvic neoplasms. The term ‘radiation proctitis’ is a misnomer, because there is no inflammatory component on histopathological examination. Radiation induces ischemic endarteritis of the submucosal arterioles, submucosal fibrosis, and angioectasia. Endoscopically, loss of mucosal vasculature, patchy erythema, and angioectasia can be observed. During endoscopy, mucosal erythema and submucosal hemorrhage from barotrauma can mimic angioectasia. Acute radiation may cause diarrhea and tenesmus in up to 50% of the patients. Chronic radiation proctopathy presents with anorectal pain, diarrhea, rectal bleeding, and anemia. This article is part of an expert video encyclopedia. Click here for the full Table of Contents.
Video Journal and Encyclopedia of GI Endoscopy
Although most patients develop symptomatic chronic radiation proctopathy within 1–2 years after radiation exposure, they can present up to 30 years after treatment. Rectal bleeding is rarely life threatening and it resolves spontaneously in majority of cases. Radiation proctopathy found incidentally during endoscopy does not warrant any therapy. In patients with mild symptoms, conservative therapy consisting of rectal instillation of sucralfate has been shown to result in symptom improvement and healing. 5-aminosalicylic acid enemas and short-chain fatty acid enemas have no proven efficacy. In a systematic review, hyperbaric oxygen was shown to be associated with significant improvement in chronic radiation proctopathy. Endoscopic treatment options include: (1) thermal coagulation with argon plasma coagulation (APC), bipolar or heater probes, or radiofrequency devices; (2) cryotherapy; (3) neodymium:yttrium– aluminum–garnet (Nd:YAG) laser; and (4) topical application of formalin. APC is the mainstay of endoscopic therapy for chronic radiation proctopathy, given its tangential application ability, ease of use on retroflexed view, widespread availability, low cost, and clinical effectiveness. APC is 80–90% effective in decreasing rectal bleeding. In most cases, 1–3 treatment sessions are required. Complete bowel preparation is recommended before APC application. Power settings of 25–60 W and argon plasma flow rates of 0.5–2.5 l min 1 have been reported. If APC is not available, thermal coagulation with bipolar or heater probes can be performed. Gentle mucosal contact with 1–2-s thermal application is recommended, but applying therapy on retroflexed view with bipolar or heater probes may present technical difficulties. Cryotherapy and radio frequency ablation are novel and there is very limited data. Both devices are not widely available or cost-effective yet. Laser therapy
http://dx.doi.org/10.1016/S2212-0971(13)70133-X
307
308 Chronic Radiation Proctopathy and Colopathy
delivers a deeper tissue effect compared to APC, but is not widely practiced due to its cost, variable degrees of coagulation depth, and a higher risk of perforation. Dilute formalin (2–10%) can be locally applied endoscopically. In one study, an average of 3.5 applications of 10% formalin at 2–4 week interval yielded clinical response rates of 63–100%. However, complications such as rectal necrosis, rectovaginal fistula development, and acute colitis have been reported.
01:07
The mucosal vasculature is more preserved in the upper rectum.
01:18
The angioectasia is better defined under digital chromoendoscopy (i.e., narrow band imaging).
01:42
In order to appreciate the full extent of rectal involvement, retroflexed examination of the rectum is necessary.
01:58
Active bleeding from the angioectasia can sometimes be seen during endoscopic examination.
Key Learning Points/Tips and Tricks
02:08
Active oozing can present as a punctate bleeding spot due to under-fill of the periphery angioectasia.
•
02:20
Endoscopic hemostasis can generally be achieved with thermal ablation using argon plasma coagulation (APC), bipolar or heater probes.
02:35
APC is the mainstay of endoscopic therapy for chronic radiation proctopathy, given its tangential application ability, ease of use on retroflexed view, widespread availability, low cost, and clinical effectiveness.
02:59
APC is 80%–90% effective in reducing rectal bleeding.
02:08
In most cases, 1–3 treatment sessions are required.
02:15
During APC treatment, gentle mucosal contact with 1–2 s thermal application is recommended.
02:30
In this patient, chronic radiation colopathy involves the distal sigmoid colon and rectum.
02:57
During endoscopy, mucosal erythema, and submucosal hemorrhage from barotrauma can mimic angioectasia.
04:15
Thank you for your attention.
• • • • • • •
• •
Chronic radiation-induced colonic injury occurs in up to 20% of patients following radiotherapy. The rectum and distal sigmoid colon are most susceptible to radiation damage. During endoscopy, loss of mucosal vasculature, patchy erythema, and angioectasia can be observed. Patients with chronic radiation proctopathy can present with anorectal pain, diarrhea, rectal bleeding, and anemia. Although most patients develop symptomatic chronic radiation proctopathy within 1–2 years after radiation, they may present up to 30 years after treatment. Radiation proctopathy found incidentally on endoscopy does not warrant therapy. Rectal bleeding is rarely life threatening and it resolves spontaneously in majority of cases. Endoscopic treatment modalities include: J Thermal coagulation – APC – Bipolar or heater probes – Radiofrequency devices J Cryotherapy J Nd:YAG laser J Topical application of formalin APC is the mainstay of endoscopic therapy for chronic radiation proctopathy, with a decrease in rectal bleeding in 80–90% of patients. Power settings of 25–60 W and argon plasma flow rates of 0.5–2.5 l min 1 have been reported. In general, 1–3 APC treatment sessions are required to achieve clinical response.
Scripted Voiceover Time (min:sec)
Voiceover text
00:02
The rectum and distal sigmoid colon are most susceptible to radiation damage.
00:10
Radiation induces ischemic endarteritis of the submucosal arterioles, submucosal fibrosis, and angioectasia.
00:24
In this histopathological image, ischemic endarteritis and angioectasia can be seen.
00:39
Submucosal fibrosis is diffusely present.
00:51
In this patient with chronic radiation proctopathy, loss of mucosal vasculature, patchy erythema, and angioectasia are observed.
Further Reading Buchi, K. Radiation Proctitis: Therapy and Prognosis. J. Am. Med. Assoc. 1991, 265, 1180–1186. Daram, S. R.; Lahr, C.; Tang, S. J. Anorectal Bleeding: Etiology, Evaluation, and Management (With Videos). Gastrointest. Endosc. 2012, 76, 406–417. Haas, E. M.; Bailey, H. R.; Farragher, I. Application of 10 Percent Formalin for the Treatment of Radiation-Induced Hemorrhagic Proctitis. Dis. Colon Rectum 2007, 50, 213–217. Hou, J. K.; Abudayyeh, S.; Shaib, Y. Treatment of Chronic Radiation Proctitis With Cryoablation. Gastrointest. Endosc. 2011, 73, 383–389. Kochhar, R.; Patel, F.; Dhar, A.; et al. Radiation-Induced Proctosigmoiditis: Prospective, Randomized, Double-Blind Controlled Trial of Oral Sulfasalazine Plus Rectal Steroids Versus Rectal Sucralfate. Dig. Dis. Sci. 1991, 36, 103–107. Pikarsky, A. J.; Belin, B.; Efron, J.; et al. Complications Following Formalin Installation in the Treatment of Radiation Induced Proctitis. Int. J. Colorectal Dis. 2000, 15, 96–99. Sato, Y.; Takayama, T.; Sagawa, T.; et al. Argon Plasma Coagulation Treatment of Hemorrhagic Radiation Proctopathy: The Optimal Settings for Application and Long-Term Outcome. Gastrointest. Endosc. 2011, 73, 543–549. Villavicencio, R. T.; Rex, D. K.; Rahmani, E. Efficacy and Complications of Argon Plasma Coagulation for Hematochezia Related to Radiation Proctopathy. Gastrointest. Endosc. 2002, 55(1), 70–74. Zhou, C.; Adler, D. C.; Becker, L.; et al. Effective Treatment of Chronic Radiation Proctitis Using Radiofrequency Ablation. Therap. Adv. Gastroenterol. 2009, 2, 149–156.