Treatment of Radiation Colitis

Sucralfate enemas are the first-line treatment for radiation-induced rectal bleeding, which is the most common symptom of radiation colitis. 1

Diagnostic Approach

Perform flexible endoscopy to determine the cause of bleeding and confirm radiation colitis diagnosis 1
Assess the severity of symptoms and impact on quality of life to guide treatment decisions 1

For mild symptoms not affecting quality of life:
- Optimize bowel function and stool consistency to reduce bleeding 1
- Reassurance and observation if symptoms are not impacting daily activities 1
For symptoms affecting quality of life:
- Stop or reduce anti-coagulants if possible 1
- Sucralfate enemas (2g mixed with 30-50ml water twice daily) 1
- Technique for administration:
  - Use a soft Foley catheter attached to a bladder syringe 1
  - Patient should retain enema as long as possible 1
  - Roll through 360° initially to coat entire rectal surface 1
  - Lying prone best covers anterior wall rectal telangiectasia, the likely area of greatest bleeding 1

Metronidazole (for 4 weeks) has shown benefit in randomized controlled trials 1
Vitamin A (retinol palmitate) may be beneficial based on small RCT evidence 1
Sulfasalazine (500mg orally twice daily) can reduce radiation-induced enteropathy 1
Serotonin receptor antagonists are effective for controlling nausea and vomiting 1
Antidiarrheal agents for symptom control 1

Argon plasma coagulation (APC) should be used with extreme caution due to high complication rates (7-26%) including ulceration, perforation, fistulation, and stricture formation 1
When using APC, restrict argon flow rates and wattage with precise and brief application 1
Endoscopic laser ablation is an alternative option based on multiple case series 1

Hyperbaric oxygen therapy has shown benefit in one RCT and several case series 1
Formalin application (endoscopic or surgical) may be considered for refractory cases 1

For patients with inadequate oral nutrition, try enteral nutrition (EN) first 1
Do not delay home parenteral nutrition (HPN) in malnourished radiation enteritis patients if oral/enteral nutrition is inadequate 1
Nutritional regimen should follow the same criteria used for other causes of chronic intestinal failure 1

Avoid instrumentation of the gastrointestinal tract when possible as intestinal mucosa is friable and prone to sloughing and bleeding 1
For neutropenic patients with fever, follow Infectious Diseases Society of America recommendations for antimicrobial therapy 1
For strictures: consider dilation or self-expanding stents 1

Use tissue-sparing radiotherapy techniques to minimize radiation exposure to healthy bowel 2
Avoid altering anaerobic gut flora unless clinically indicated (e.g., abdominal wound or C. difficile enterocolitis) 1

Radiation colitis is a progressive disease that can lead to fibrosis, endarteritis, perforation, and even malignancy 2
Surgery should be avoided if possible due to technical difficulty and high risk of complications (anastomotic leak, fistula formation) 3
Corticosteroid enemas are less effective than sucralfate enemas for radiation proctitis 1
5-Amino-salicylic acid and related compounds (mesalazine, olsalazine) are not recommended for prevention of gastrointestinal mucositis 1