What is the treatment for radiation proctitis?

Treatment of Radiation Proctitis

Argon plasma coagulation is the most effective first-line endoscopic treatment for chronic radiation proctitis with bleeding, while topical anti-inflammatory agents are recommended for mild cases. 1

Classification and Presentation

Radiation proctitis occurs in two forms:

• Acute radiation proctitis:

  • Occurs during or immediately after radiotherapy
  • Lasts up to 3 months
  • Symptoms: diarrhea, cramps, tenesmus, urgency, mucus discharge, minor bleeding
  • Usually resolves spontaneously after treatment completion 1

• Chronic radiation proctitis:

  • Develops 8-12 months after radiotherapy (can appear up to 25 years later)
  • Characterized by arteriole endarteritis, submucosal fibrosis, and telangiectasias
  • Primary symptom is rectal bleeding (most common)
  • Other symptoms: strictures, perforation, fistula, rectal obstruction, tenesmus 1

Treatment Algorithm

1. Mild to Moderate Radiation Proctitis (Grade 1/2)

• First-line therapy: Topical anti-inflammatory products
  • Sulfasalazine or mesalazine alone or combined with steroids 1
  • Sulfasalazine 500mg orally twice daily is suggested to reduce radiation-induced enteropathy 1
  • Sucralfate enemas for chronic radiation-induced proctitis with rectal bleeding 1

2. Chronic Radiation Proctitis with Bleeding

• First-line endoscopic therapy: Argon plasma coagulation (APC)

  • Resolves 80-90% of cases with chronic proctitis and bleeding
  • Non-contact technique with limited coagulation depth (2-3mm)
  • Multiple sessions may be required
  • Can treat large surface areas safely on an outpatient basis 1

• Alternative endoscopic options:

  • Heater probe or bipolar electrocoagulation (both effective, but heater probe shows better reduction in blood transfusion requirements) 1
  • YAG laser (typically at 20-90W power setting) 1
  • Potassium titanyl phosphate laser for superficial injuries 1
  • Radiofrequency ablation (2-3 sessions) 1
  • Cryoablation (effective but not widely used) 1

3. Refractory Cases

• Hyperbaric oxygen therapy:

  • Induces neo-vascularization, tissue re-oxygenation, collagen deposition
  • Effective for soft tissue necrosis or chronic proctitis
  • Consider for patients who fail endoscopic therapy 1

• Formalin application:

  • For intractable or massive hemorrhage
  • Simple, inexpensive, and effective for hemorrhagic radiation proctitis 2

• Surgical intervention (last resort):

  • For severe refractory cases
  • May require colostomy or exenteration
  • Associated with high morbidity and mortality 1

Complications and Monitoring

Potential Complications

• Short-term complications of APC:

  • Anorectal pain (20% of cases, usually resolves spontaneously)
  • Tenesmus and abdominal distention 1

• Long-term complications of APC:

  • Chronic rectal ulcer
  • Rectal stricture
  • Severe complications (hemorrhage, necrosis, perforation) in 10% of cases 1

Follow-up

• Sigmoidoscopy is recommended for investigating:
  • Patient-reported bleeding
  • Evidence of occult fecal blood 1
• Regular follow-up with a multidisciplinary team (gastroenterologist, nutritionist, surgeon) is recommended 1

Prevention Strategies

• Modern radiotherapy techniques (IMRT, VMAT, tomotherapy) reduce risk of radiation proctitis 1
• Amifostine (≥340 mg/m²) may prevent radiation proctitis in patients receiving standard-dose radiotherapy for rectal cancer 1
• Oral sucralfate is NOT recommended for prevention as it does not prevent acute diarrhea and may increase gastrointestinal side effects 1

Important Considerations

• Treatment selection should be based on symptom severity, available expertise, and patient factors
• Multiple endoscopic sessions are often required for complete resolution
• Scarring and re-epithelialization with more normal tissue tend to occur over time after endoscopic treatment 1
• Patients with comorbidities (diabetes mellitus, vascular disease, hypertension, inflammatory bowel disease) have increased risk of radiation toxicity 1