Perspectives in clinical gastroenterology and hepatology
Management of Intestinal Complications in Patients With Pelvic Radiation Disease

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Gastrointestinal toxicity after radiotherapy for pelvic cancer is a major complication—the most commonly reported symptoms include rectal bleeding, diarrhea, and fecal incontinence, which substantially impair patients' quality of life. Management of these symptoms can be a challenge, although available treatment strategies generally are ignored or underused. Radiation-induced symptoms have multiple mechanisms of pathogenesis; the first step for the correct management is to identify the mechanism that is causing the symptoms. Optimal management requires close liaisons among physicians, gastroenterologists with specialist interests, radiotherapists, oncologists, dieticians, nurses, and surgeons. Patients should be reassured that treatment options (medical, endoscopic, and surgical) exist and are in most cases successful if patients are referred to experts in pelvic radiation disease. However, although new therapeutic approaches are not yet always supported by high-quality trials, research projects are underway to improve management of patients. Clinicians should focus on using proven treatments correctly and avoiding misuse.

Section snippets

What Is Pelvic Radiation Disease?

Many of the terms used to describe the effects of radiation are imprecise; although an inflammatory reaction does not mediate the chronic, late-onset symptoms in the GI tract, terms such as radiation proctitis, colitis, or ileitis are common. These terms lead to ineffective treatment choices. To avoid further confusion, Andreyev et al18 proposed calling these symptoms “pelvic radiation disease,” defined as “transient or longer-term problems, ranging from mild to very severe, arising in

Therapy-Related Factors

Higher doses of radiation are associated with improved tumor control, but also increase side effects. Multicenter, randomized, and observational trials have shown that increasing the dose of radiation increases the incidence of late-onset, severe rectal bleeding.22, 23, 24 The dose of radiation delivered to the anterior rectal wall is related directly to the risk of developing rectal bleeding. The risk of other side effects of radiotherapy, however, might depend on other factors (Table 2).

Can Pelvic Radiation Disease Be Prevented?

Despite the strict application of dose-volume constraints, the adoption of highly developed localization procedures, and the use of advanced radiation delivery techniques (such as IMRT), intestinal, radiation-induced side effects are reduced but not abolished. Researchers therefore are investigating the effects of administering cytoprotective and anti-inflammatory drugs during radiation treatment (Supplementary Table 1).

The rationale of this approach is to reduce the damage to normal tissues

Rectal Bleeding

Rectal bleeding, regardless of its severity, is an important feature of pelvic radiation disease. The presence of any blood in the stool significantly reduces quality of life and increases anxiety, depression, and irritability.13, 57 Prospective, endoscopy-based studies showed that, after radiation treatment, about 50% of patients develop multiple angiectasias in the rectum (Figure 1) and at least 33% have bleeding.13, 58, 59 The mucosal lesion that typically is associated with

Endoscopy

Endoscopy is frequently the first treatment option for patients with rectal bleeding. However, there have been few high-quality controlled studies to evaluate its safety and efficacy in these patients. Studies have been limited because there are no standardized assessments of symptoms or symptom severity, based on endoscopy. All endoscopic treatment approaches (Table 3) should be used with caution for these patients because of the frequency of serious procedure-related side effects.63, 64, 65,

Medicine

Patients with radiation-induced injuries have minimal amounts of inflammation, although pelvic radiation disease frequently is called radiation proctitis. This misleading term results in inappropriate treatment, such as with anti-inflammatory agents (steroids and 5-aminosalicylic acids), which are, erroneously, frequently proposed as first-line treatment for pelvic radiation disease.15 A systematic review of randomized and nonrandomized, prospective, comparative trials clearly show that these

Diarrhea

Diarrhea can affect up to 50% of patients with radiation therapy disease,89 and significantly reduces their quality of life. There are many causes of diarrhea and it can be a challenge to identify the main pathogenetic mechanism for each particular patient, which is required for proper treatment (Supplementary Table 2).61 Similar to the management of patients with rectal bleeding, causes of diarrhea unrelated to radiotherapy, such as celiac disease or thyroid dysfunction, should always be

Future Directions

This review has focused on the management of intestinal symptoms that frequently complicate radiotherapy of pelvic cancers. As more patients survive cancer, there will be an increasing number of patients with late effects from radiation therapy. Management of these patients is particularly challenging because of the lack of high-quality evidence and dedicated service. Efforts should focus on the development of clear referral pathways, and patients should be treated by multidisciplinary teams

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    Conflicts of interest The authors disclose no conflicts.

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