Perspectives in clinical gastroenterology and hepatologyManagement of Intestinal Complications in Patients With Pelvic Radiation Disease
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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Effect of Kegel exercises on the prevention of urinary and fecal incontinence in patients with prostate cancer undergoing radiotherapy
2021, European Journal of Oncology NursingCitation Excerpt :Presence of FI is closely related to fatigue and significantly affects patients' quality of life (QoL) (Cicchetti et al., 2018; Krol et al., 2013). The frequency of urinary and fecal incontinence can be reduced by regular application of pharmacological or behavioral methods (pelvic floor muscle training, biofeedback, pelvic floor electrical stimulation) (Sandhu et al., 2019; Chughtai et al., 2013; DeMaagd and Davenport, 2012; Fuccio et al., 2012). Kegel exercises, also known as pelvic floor muscle exercises (PFME), are a non-invasive, safe and effective behavioral treatment method for prevention and treatment of incontinence (Patel et al., 2013; Chughtai et al., 2013; Woodley et al., 2017; Harari and Igbedioh, 2009).
Fecal incontinence and CRC
2021, Foundations of Colorectal CancerRadiation enteritis: Diagnostic and therapeutic issues
2020, Journal of Visceral SurgeryCitation Excerpt :Consequently, parenteral nutrition, potentially in a specialized nutritional assistance unit, may be necessary in case of insufficient compensation and/or diagnostic delay. Last, RE can be diagnosed based on findings at emergency operation for complications (i.e., obstruction, abscess, perforations, fistulas) [29]. Just as an example, following RT for rectal cancer, obstruction and fistula are observed in 0.8 to 13% and 0.6 to 4.8% of cases, respectively [3–5].
Squamous cell anal cancer: Management and therapeutic options
2020, Annals of Medicine and SurgeryCitation Excerpt :After abdominoperineal amputation, patients should be re-evaluated every 3–6 mo for 5 years, with clinical evaluation of the lymph nodes or their evaluation with pelvic CT. Prevention and management of both acute and chronic gastrointestinal (GI) side effects of pelvic RT have been a focus of recent research and reviews [78–80]. The most common acute toxicity, diarrhea, is typically managed with a combination of antidiarrheal agents (ie.
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2019, Clinical and Translational Radiation OncologyEvolution and Management of Treatment-Related Toxicity in Anal Cancer
2017, Surgical Oncology Clinics of North AmericaCitation Excerpt :Lastly, guidelines regarding the prevention and management of chemotherapy-related myelosuppression and associated infection have been published extensively and are beyond the scope of this article.61–63 Prevention and management of both acute and chronic GI side effects of pelvic RT have been a focus of recent research and reviews.64–66 The most common acute GI toxicity, diarrhea, is typically managed with a combination of antidiarrheal agents (ie, loperamide and diphenoxylate/atropine), bulking agents, dietary modification, hydration and medication management (to minimize or substitute those medications that may promote diarrhea).
Conflicts of interest The authors disclose no conflicts.