Radiation colitis: Difference between revisions
| Line 104: | Line 104: | ||
== Diagnosis == | == Diagnosis == | ||
===Diagnostic Criteria=== | ===Diagnostic Criteria=== | ||
There is no definitive diagnostic criteria for radiation colitis. Diagnosis of radiation colitis is primarily clinical; it is based on history, physical examination and endoscopic findings. | There is no definitive diagnostic criteria for radiation colitis. Diagnosis of radiation colitis is primarily clinical; it is based on history, physical examination and endoscopic findings.<ref name="pmid22144997">{{cite journal| author=Do NL, Nagle D, Poylin VY| title=Radiation proctitis: current strategies in management. | journal=Gastroenterol Res Pract | year= 2011 | volume= 2011 | issue= | pages= 917941 | pmid=22144997 | doi=10.1155/2011/917941 | pmc=3226317 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22144997 }} </ref><ref name="pmid6603628">{{cite journal| author=Gilinsky NH, Burns DG, Barbezat GO, Levin W, Myers HS, Marks IN| title=The natural history of radiation-induced proctosigmoiditis: an analysis of 88 patients. | journal=Q J Med | year= 1983 | volume= 52 | issue= 205 | pages= 40-53 | pmid=6603628 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6603628 }} </ref> | ||
=== Symptoms === | === Symptoms === | ||
Obtaining a complete history is an important aspect | Obtaining a complete history including dietary history is an important aspect in making a diagnosis of radiation colitis. It provides insight into the cause, and any associated underlying conditions. Radiation colitis should be suspected in any individual who presents with intestinal symptoms and has a previous history of abdominal and/ or pelvic radiotherapy. Symptoms of radiation colitis may be categorized according to duration as follows: | ||
====Acute radiation colitis==== | ====Acute radiation colitis==== | ||
*[[Diarrhea]] | *[[Diarrhea]] | ||
*[[Abdominal pain]] which is colicky (cramping and intermittent) | *[[Abdominal pain]] which is colicky (cramping and intermittent) | ||
*[[Nausea]] | *[[Nausea]] | ||
*Urgency | *Urgency | ||
*Fecal frequency | |||
*[[Tenesmus]] | *[[Tenesmus]] | ||
*Mucus discharge | *Mucus discharge | ||
| Line 127: | Line 128: | ||
=== Physical Examination === | === Physical Examination === | ||
Physical examination findings may | Physical examination findings may reveal: | ||
* | *Signs of [[dehydration]] such as lethargy, [[Tachycardia]] and [[Hypotension]] | ||
*[[Abdominal tenderness]] | *[[Abdominal tenderness]] which may be more prominent in lower abdominal quadrants due to involvement of the distal sigmoid colon and/ or rectum | ||
*[[Fever]] due to dehydration or in individuals who have developed sepsis | *[[Fever]] due to dehydration or in individuals who have developed sepsis | ||
*[[Pallor]] | *[[Pallor]] | ||
| Line 135: | Line 136: | ||
=== Laboratory Findings === | === Laboratory Findings === | ||
Initial investigations should include hematological, biochemistry profiles and stool examination. | |||
====Hematology==== | |||
*[[Anemia]] | |||
*[[Leukocytosis]] with [[left shift]] may be seen with sepsis common, but [[leukopenia]] can be seen. | |||
====Electolytes==== | |||
*[[Hyponatremia]] | |||
===Stool Examination=== | |||
Stool analysis may show | |||
*[[Fecal blood]] | |||
*[[Fecal leukocytes]] | |||
*Microorganism on stool culture in case of sepsis | |||
===Imaging Findings=== | ===Imaging Findings=== | ||
he majority are diagnosed after colonoscopy or sigmoidoscopy with features dem- onstrating pallor, friability, and telangiectasias | |||
=== Other Diagnostic Studies === | === Other Diagnostic Studies === | ||
== Treatment == | == Treatment == | ||
Revision as of 20:25, 28 November 2016
|
WikiDoc Resources for Radiation colitis |
|
Articles |
|---|
|
Most recent articles on Radiation colitis Most cited articles on Radiation colitis |
|
Media |
|
Powerpoint slides on Radiation colitis |
|
Evidence Based Medicine |
|
Cochrane Collaboration on Radiation colitis |
|
Clinical Trials |
|
Ongoing Trials on Radiation colitis at Clinical Trials.gov Trial results on Radiation colitis Clinical Trials on Radiation colitis at Google
|
|
Guidelines / Policies / Govt |
|
US National Guidelines Clearinghouse on Radiation colitis NICE Guidance on Radiation colitis
|
|
Books |
|
News |
|
Commentary |
|
Definitions |
|
Patient Resources / Community |
|
Patient resources on Radiation colitis Discussion groups on Radiation colitis Patient Handouts on Radiation colitis Directions to Hospitals Treating Radiation colitis Risk calculators and risk factors for Radiation colitis
|
|
Healthcare Provider Resources |
|
Causes & Risk Factors for Radiation colitis |
|
Continuing Medical Education (CME) |
|
International |
|
|
|
Business |
|
Experimental / Informatics |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Qasim Salau, M.B.B.S., FMCPaed [2]
Synonyms and keywords:
Overview
Radiation therapy is a common treatment modality for Abdominal and pelvic malignancy. Radiation colitis may complicate this radiotherapy. Radiation colitis tends to develop insidiously and it is often progressive.
Historical Perspective
Classification
Pathophysiology
- Occur following radiation therapy for Abdominal and pelvic malignancies .[1][2][3][4][5][6]
- More common with radiation doses higher than 45Gy.[4]
- The main site of damage is the DNA. Pathogenesis involves direct ionizing damage to the DNA resulting in inhibition mitosis. Radiation may also affect RNA, proteins and cell membranes. Oxidative injury to the DNA may also be contributory to the development of radiation colitis.
- Injury occur few hours to days, up to three months after irradiation in acute radiation colitis. It affects rapidly dividing cells of the epithelium and mucosa crypts. This leads to cell death, recruitment and activation of polymorphonuclear (PMN) inflammatory cells, mucosal edema and damage to small blood vessels. The effect of this damage to the mucosa is fluid, electrolyte and nutrient loss. Radiation also reduces bowel motility. Acute radiation colitis is usually transient and self limiting, with regeneration of the epithelium.
- In chronic radiation colitis, mesenchymal tissue is involved. The damage is progressive with atrophy of the mucosa, fibrosis of the intestinal wall, obliteration of small arteries, chronic ischemia, ulcers, strictures and fistula formation. This changes usually occur three months to years after radiation. Secondary colonic malignancy may occur.
Genetics
There is no specific genetic cause for radiation colitis.
Gross Pathology
Endoscopy should be gentle and with care especially in acute radiation colitis.
- The mucosa may appear erythematous or pale, is edematous, friable with or without small erosions in acute radiation colitis.
- In chronic radiation colitis, mucosa atrophy, fibrosis, obliterative arteritis, stenosis, strictures, fistula and ulcers are seen.
Microscopic Histopathology
Histopathological findings of radiation colitis may be categorized into the following
- Acute: Reduced mitosis, increased apoptosis bodies, mucin depletion, eosinophilia, presence of crypt abscesses and evidence of regeneration
- Chronic: Dilated capillaries and lymphatics, hyaline fibrosis, atypical fibroblast and endothelial cells and distortion of the crypts.
Differentiating radiation colitis from other Diseases
Symptoms of acute radiation proctitis may overlap with other causes of acute colitis, but prior history of radiation will help in distinguishing the cause. Differential diagnosis of acute radiation colitis include:
- Allergic colitis
- Chemical colitis
- NSAID induced colitis
- Ischemic colitis
Differential diagnosis of chronic radiation colitis include:
- Ischemic colitis
- Inflammatory bowel disease
Epidemiology and Demographics
The exact prevalence and incidence of radiation colitis is not certain due to different methods of definition. The incidence of acute radiation injury to the bowel is said to be about 75% to 80% of patients receiving pelvic radiotherapy, while 15% to 20% of patients receiving pelvic radiotherapy will develop chronic radiation injury to the bowel. [4][7][8][6]
Age
The prevalence of radiation colitis is more among older age group (over 60 years) patients. This may be a reflection of the increase frequency of predisposing malignancy requiring radiotherapy in this age group. [7][8]
Gender
Men and women are affected equally by radiation colitis.
Race
There is no racial predilection to radiation colitis.
Risk Factors
Common risk factors for developing radiation colitis include:[8][5][9]
- Radiation dose greater than 54 Gy
- Elderly (above 60 years)
- Past radical abdominal or pelvic surgery such as radical hysterectomy and radical colectomy
- Asthenic individuals
- Smoking
- Chronic co-morbid medical diseases such as diabetes mellitus, hypertension and atherosclerosis
- Past pelvic inflammatory disease
- Collagen vascular disease
- HIV infection- Hypothesized to increase risk for radiation toxicity in the colon
Screening
There are no established screening guidelines for radiation colitis[10]
Natural History, Complications and Prognosis
Natural History
The symptoms and extent of radiation colitis are variable and usually develop insidiously. The symptoms depend on the dose and duration of the radiation and the how sensitive the bowel is to radiation. In acute radiation colitis, symptoms usually starts shortly after commencement of radiation therapy and progress reaching a peak 1 to 2 weeks later. The symptoms of acute radiation colitis may not start for up to 3 months after commencement of radiation. In most cases, the symptoms of acute radiation colitis are self-limiting and resolve following termination of radiation therapy. The symptoms of chronic radiation colitis often become noticeable months to years after the completion of radiotherapy. The symptoms may occasionally follow acute radiation colitis. However, previous acute radiation colitis does not increase the risk of a patient developing chronic radiation colitis. Also, absence of acute radiation colitis, does not prevent chronic radiation colitis from occurring. injuryTreatment is required for chronic radiation colitis because resolution of the symptoms is uncommon without intervention. [4][11]
Complications
Possible complications of radiation colitis include:[4][11]
- Anemia
- Intestinal obstruction
- Intestinal perforation
- Fistula
- Fecal incontinence
- Strictures
- Malabsorption
- Failure to thrive
- Sepsis due to loss of the mucosal protective barrier
- Secondary malignancy (uncommon)
Prognosis
The prognosis of radiation colitis varies with the subtype, severity, duration and responsiveness to treatment.[11] [9][4]
- Acute radiation colitis is usually self-limiting, with resolution of symptoms few weeks after stopping radiotherapy.
- Chronic radiation colitis is progressive and difficult to manage. The patients may develop secondary radiation-associated malignancy which has a poor prognosis due to late diagnosis.
Diagnosis
Diagnostic Criteria
There is no definitive diagnostic criteria for radiation colitis. Diagnosis of radiation colitis is primarily clinical; it is based on history, physical examination and endoscopic findings.[4][11]
Symptoms
Obtaining a complete history including dietary history is an important aspect in making a diagnosis of radiation colitis. It provides insight into the cause, and any associated underlying conditions. Radiation colitis should be suspected in any individual who presents with intestinal symptoms and has a previous history of abdominal and/ or pelvic radiotherapy. Symptoms of radiation colitis may be categorized according to duration as follows:
Acute radiation colitis
- Diarrhea
- Abdominal pain which is colicky (cramping and intermittent)
- Nausea
- Urgency
- Fecal frequency
- Tenesmus
- Mucus discharge
- Rectal bleeding
Chronic radiation colitis
- Symptoms of acute radiation colitis
- Rectal bleeding, which may be severe
- Symptoms of sepsis
- Constipation
- Abdominal pain
- Abdominal distension
- Vomiting
- Fecal vomiting especially when stricture develops
Physical Examination
Physical examination findings may reveal:
- Signs of dehydration such as lethargy, Tachycardia and Hypotension
- Abdominal tenderness which may be more prominent in lower abdominal quadrants due to involvement of the distal sigmoid colon and/ or rectum
- Fever due to dehydration or in individuals who have developed sepsis
- Pallor
- Toxic appearance in those with bowel perforation and sepsis
Laboratory Findings
Initial investigations should include hematological, biochemistry profiles and stool examination.
Hematology
- Anemia
- Leukocytosis with left shift may be seen with sepsis common, but leukopenia can be seen.
Electolytes
Stool Examination
Stool analysis may show
- Fecal blood
- Fecal leukocytes
- Microorganism on stool culture in case of sepsis
Imaging Findings
he majority are diagnosed after colonoscopy or sigmoidoscopy with features dem- onstrating pallor, friability, and telangiectasias
Other Diagnostic Studies
Treatment
Medical Therapy
Surgery
Prevention
References
- ↑ Keith NM, Whelan M (1926). "A STUDY OF THE ACTION OF AMMONIUM CHLORID AND ORGANIC MERCURY COMPOUNDS". J Clin Invest. 3 (1): 149–202. doi:10.1172/JCI100072. PMC 434619. PMID 16693707.
- ↑ Bansal N, Soni A, Kaur P, Chauhan AK, Kaushal V (2016). "Exploring the Management of Radiation Proctitis in Current Clinical Practice". J Clin Diagn Res. 10 (6): XE01–XE06. doi:10.7860/JCDR/2016/17524.7906. PMC 4963751. PMID 27504391.
- ↑ Nelamangala Ramakrishnaiah VP, Krishnamachari S (2016). "Chronic haemorrhagic radiation proctitis: A review". World J Gastrointest Surg. 8 (7): 483–91. doi:10.4240/wjgs.v8.i7.483. PMC 4942748. PMID 27462390.
- ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 Do NL, Nagle D, Poylin VY (2011). "Radiation proctitis: current strategies in management". Gastroenterol Res Pract. 2011: 917941. doi:10.1155/2011/917941. PMC 3226317. PMID 22144997.
- ↑ 5.0 5.1 Kennedy GD, Heise CP (2007). "Radiation colitis and proctitis". Clin Colon Rectal Surg. 20 (1): 64–72. doi:10.1055/s-2007-970202. PMC 2780150. PMID 20011363.
- ↑ 6.0 6.1 Hayne D, Vaizey CJ, Boulos PB (2001). "Anorectal injury following pelvic radiotherapy". Br J Surg. 88 (8): 1037–48. doi:10.1046/j.0007-1323.2001.01809.x. PMID 11488787.
- ↑ 7.0 7.1 Tortora A, Purchiaroni F, Scarpellini E, Ojetti V, Gabrielli M, Vitale G; et al. (2012). "Colitides". Eur Rev Med Pharmacol Sci. 16 (13): 1795–805. PMID 23208963.
- ↑ 8.0 8.1 8.2 Shadad AK, Sullivan FJ, Martin JD, Egan LJ (2013). "Gastrointestinal radiation injury: symptoms, risk factors and mechanisms". World J Gastroenterol. 19 (2): 185–98. doi:10.3748/wjg.v19.i2.185. PMC 3547560. PMID 23345941.
- ↑ 9.0 9.1 Kountouras J, Zavos C (2008). "Recent advances in the management of radiation colitis". World J Gastroenterol. 14 (48): 7289–301. PMC 2778112. PMID 19109862.
- ↑ US preventive service task force.radiation colitis. http://www.uspreventiveservicestaskforce.org/accessed on November 13, 2016
- ↑ 11.0 11.1 11.2 11.3 Gilinsky NH, Burns DG, Barbezat GO, Levin W, Myers HS, Marks IN (1983). "The natural history of radiation-induced proctosigmoiditis: an analysis of 88 patients". Q J Med. 52 (205): 40–53. PMID 6603628.