What is Radiation Proctitis?
Radiation proctitis is a condition where the rectum is injured or damaged because of radiation therapy it might happen to almost half the patients with cancer in the pelvic area, who undergo radiation treatment.
This condition can show up differently in different people, and it’s divided into two stages – acute or chronic. Acute radiation proctitis usually happens during or right after radiation treatment, with symptoms such as diarrhea, feeling an urgent need to use the bathroom, and slight bleeding from the rectum. Chronic radiation proctitis, on the other hand, starts more than three months after radiation therapy has ended and can have more lasting and severe symptoms. It can lead to complications like rectum narrowing or strictures, ulcers, and even tunnels, called fistulas, between the rectum and other parts of the body. These complications can significantly affect a patient’s daily life.
As cancer treatments improve and patients live longer, we are seeing more cases of radiation proctitis. Managing this issue requires a team approach, with doctors who specialize in radiation therapy and gastrointestinal issues, nurses, pharmacists, and other healthcare professionals all working together. Treatment could involve medicines to help with symptoms, changes to the patient’s diet, and even procedures or surgeries in severe cases. There’s ongoing research happening to find new treatments and ways to prevent radiation proctitis, with the goal of improving the care and results for patients dealing with this condition.
What Causes Radiation Proctitis?
Radiation proctitis is a condition that can occur due to radiation therapy used to treat cancers in the pelvic region, such as prostate cancer, rectal cancer, and cancers of reproductive organs. The severity of this condition can differ based on how the radiation is applied, the dose of radiation, and the amount of tissue that is exposed to radiation.
Several factors can increase the risk of getting radiation proctitis, including a high dose of radiation (more than 45 Gy) to the rectum, a history of inflammatory bowel disease (a condition that causes inflammation in parts of the gut), HIV/AIDS, and it is also possible that people may have certain genes that make them more susceptible to this condition.
Risk Factors and Frequency for Radiation Proctitis
Radiation proctitis is a condition that’s hard to gauge in terms of how often it happens. Some studies suggest that between 5% and 11% of people who have radiation therapy end up with chronic radiation proctitis. Nearly 90% of these patients present with this condition within the first two years after treatment.
Who gets radiation proctitis varies by age and sex, both in the U.S. and around the world. Factors such as the types of cancers people get and how they are treated can influence these rates. In the U.S., for instance, radiation proctitis is found in both men and women who have undergone pelvic radiation treatment for cancers like prostate, cervical, and rectal cancers. How often it happens depends on how common these cancers are in each sex. Age is also a factor, with older people being more likely to have this condition, as they are more likely to have cancer.
The rates of radiation proctitis globally can also be influenced by the amount of cancer seen in different regions, how cancer is treated, and the quality of healthcare. In areas where there is a lot of pelvic cancer, or where radiation therapy is often used as a treatment, radiation proctitis may be more common.
Signs and Symptoms of Radiation Proctitis
Radiation proctitis is a condition that can occur after radiation therapy and it affects the rectum. It can lead to symptoms such as:
- Malabsorption (problems absorbing nutrients from food)
- Perforation (holes in the rectum)
- Bowel obstructions (blockages)
- Bleeding
- Stricture formation (narrowing of the rectum)
- Fistulous disease (abnormal connections between the rectum and other organs or skin)
- Fecal incontinence (loss of bowel control) when the anal sphincter is within the radiation field
If you had radiation therapy years ago and start experiencing symptoms like malabsorption, abdominal pain, increased frequency of bowel movements, and bleeding, it’s important to see your doctor. Sometimes, these symptoms can be a sign of radiation proctitis, but they could also mean that your cancer has come back.
Doctors often conduct a focused abdominal check and a digital rectal exam to diagnose radiation proctitis. If the tests cause too much pain or can’t be completed at the doctor’s office, they might be performed under anesthesia.
Testing for Radiation Proctitis
After conducting a detailed review of your medical history and a physical check-up, the doctor may decide to perform a procedure called sigmoidoscopy. This involves the use of a small camera to look inside your rectum and lower part of your large intestine and can be done with either a rigid or flexible device. This procedure should be undertaken gently as your bowel, which might be inflamed, is prone to damage, especially if it’s already swollen and hardened.
The test might show a delicate and easily damaged inner lining of your large intestine with signs like swelling, oozing of fluid, or sores. The appearance might sometimes be similar to conditions such as inflammatory bowel disease. If there are visible sores, the doctor may consider taking a tissue sample or biopsy, but this has to be done very carefully. There might also be multiple areas of narrowing which can be hard to distinguish from a recurring cancer.
The doctor may also choose to carry out a barium or water-soluble enema study. This is a type of X-ray test where a contrast material (barium or a water-soluble liquid) is inserted into your rectum to help create clearer images of your rectum and lower large intestine. This test helps show any obstructions, narrowing, or loss of normal curvature in the rectosigmoid area (the junction between the rectum and the lower end of your large intestine). It can also show if your rectum’s flexibility is reduced. It might also appear that the space before the sacral (lower back) bone is increased due to thickening of the rectal wall.
Once a diagnosis of radiation proctitis (swelling and damage to the lower part of the large intestine caused by radiotherapy) has been confirmed, there are several grading systems in place to determine how severe the condition is, such as the RTOG/EORTC and LENT-SOMA scales.
Treatment Options for Radiation Proctitis
Preventing acute radiation proctitis (inflammation of the rectum caused by radiation therapy) has proven challenging, and medications like sucralfate, amifostine, and misoprostol have not shown to reduce its risk in patients undergoing radiation therapy of their pelvis. There are some indications, though, that a supplement called selenium may help reduce the risk of severe diarrhea.
Various methods can reduce the risk of proctitis, such as carefully planning and delivering radiation treatment. This is particularly essential when treating conditions like prostate cancer, where the amount of radiation the rectum receives is directly linked to the risk of severe rectal damage. Adhering to specific guidelines when delivering radiation therapy can help to reduce these risks.
Also, it seems that the technique used for radiation therapy can influence risk. For instance, when treating conditions related to the reproductive system and urinary tract, modern techniques like Intensity Modulated Radiotherapy (IMRT) appear to have lower incidences of late rectal inflammation when compared to older techniques.
In addition to these measures, other preventative strategies include creating a physical barrier between the rectum and the area targeted for radiation therapy. This can be done by injecting a gel into the area surrounding the rectum, enlarging the space between the rectum and the targeted area. Studies have shown this can help reduce rectal damage without increasing early rectal toxicity.
If prevention measures fail and patients develop acute radiation proctitis, treatment is generally symptomatic, aimed at addressing issues like diarrhea, a feeling of needing to pass stool even when the bowel is empty (tenesmus), and rectal urgency. Unfortunately, experiencing these acute side effects during treatment significantly increases the likelihood of developing long-term side effects.
Patients who develop chronic inflammation of the rectum months or even years after treatment can be managed in various ways. Some measures include using sucralfate enemas (inserting a liquid form of the drug into the rectum) which have been found to offer notable improvements for many patients. Other treatments like formaldehyde can be applied directly to the affected area to cauterize (seal off with heat) the bleeding sores and dilated vessels causing the bleeding. Other options include anti-inflammatory suppositories for patients who continue to experience rectal bleeding, though some treatments may come with their own side effects.
If non-surgical treatments prove unsuccessful, treatments like hyperbaric oxygen therapy (HBO), where patients breathe in pure oxygen in a pressurized room or tube, have been found to significantly improve symptoms. In some cases, endoscopic procedures or surgery could be necessary to alleviate symptoms or treat complications associated with radiation proctitis. Surgery, however, is generally a last resort when all other interventions have been unsuccessful or if complications are severe, like strictures causing obstruction, fistulas, or perforation. In such severe cases, removing the rectum might even be necessary.
What else can Radiation Proctitis be?
When trying to diagnose radiation proctitis, a condition linked to inflammation and GI distress, it’s important that physicians also think about other problems that can cause similar symptoms.
- Diverticulitis
- Crohn’s disease
- Irritable bowel syndrome (IBS)
- Infectious colitis
- Reoccurrence of cancer
Due to the overlapping symptoms of these conditions, doctors need to carry out a thorough examination. This involves endoscopic procedures (camera tests), microscopical examination of cell tissue (histology), and body scans (imaging) to make sure they correctly diagnose radiation proctitis and differentiate it from other potential causes.
What to expect with Radiation Proctitis
Your health outcome can greatly depend on how severe your condition is. Around 30% of people with really bad symptoms might see a significant drop in their overall health and day-to-day life quality. If you have radiation proctitis (a condition caused by radiation therapy where the inner lining of the rectum gets inflamed), you are also at risk of getting a secondary cancer, usually in the colon or rectum.
In a lot of cases, acute radiation proctitis (the early stage of this condition) will get better on its own, with symptoms improving after radiation therapy stops. However, if the condition progresses into what is called chronic radiation proctitis (continuing for more than 3 months after treatment), it becomes a bit more complex. This chronic condition could lead to ongoing problems that impact your everyday life.
While some people might experience symptoms that are easy to manage with conservative treatment, for others, there might be more difficult complications, such as rectal strictures (the narrowing of the rectum) or fistulas (an abnormal connection between two parts of the body).
However, detecting the condition earlier, frequently monitoring your health, and a treatment plan specifically tailored to your needs can greatly improve your outcome. This can allow for quick treatment of symptoms and reduces the chance of severe complications.
Possible Complications When Diagnosed with Radiation Proctitis
Radiation proctitis can cause complications that dramatically affect the life quality of those getting pelvic radiation therapy. These include:
- Inflammation of the colon (colitis)
- Tearing in the bowel wall (bowel perforation)
- Wide-spread infection in the body (sepsis)
- Abnormal connections between organs (fistula formation)
- Cancer linked to exposure to radiation (radiation associated malignancies)
In the early stages, patients may deal with symptoms like diarrhea, bleeding in the rectum, and stomach pain. If the condition becomes chronic, which means it lasts for more than three months after treatment, it can lead to lasting and possibly serious complications. Chronic symptoms can be narrowing of the rectum, an urgent need to pass stools, inability to control bowel movements, which can cause significant disruption to everyday activities. In certain cases, radiation proctitis can even lead to severe outcomes like abnormal connections between organs or tears in the bowel wall that need surgery to fix. The challenge of handling these complications highlights the need for monitoring early on, intervening promptly, and a team of various healthcare professionals to provide all-around care for individuals who have been affected by radiation proctitis.
Preventing Radiation Proctitis
Helping prevent the effects of radiation proctitis, a condition that causes inflammation and damage to the lower part of the colon, is heavily reliant on teaching patients about it and how to care for themselves. Healthcare professionals can give people who are undergoing pelvic radiation therapy the knowledge to spot the early signs and symptoms. This includes teaching patients how to adjust their lifestyles, diet, and personal care to lower risks and keep the rectum healthy.
Patients should know that eating foods high in fiber can help soften the stool and alleviate some symptoms. Taking fiber supplements, like psyllium, can also help improve symptoms. Patients should try to avoid things like caffeine, smoking, complex sugars, and alcohol, as these can make diarrhea worse and can increase pain and bleeding.
Patients should also know the importance of sticking to their treatment plan and making all required appointments. This can help spot and treat any problems early. If a patient is bleeding a lot, or they feel dizzy and weak, they should get medical help immediately.
Preventing radiation proctitis is not only about avoiding the condition but also about giving patients the tools to actively take part in their care. This encourages teamwork between the healthcare professionals and patients to get the best results and helps improve overall health during and after radiation therapy.
