What are the primary goals of care and admission orders for a patient with severe proctitis due to radiation therapy?

Goals of Care for Severe Radiation Proctitis

The primary goals are to control bleeding, manage pain, prevent complications (hemorrhage, perforation, necrosis), and restore bowel function to preserve quality of life, with admission orders focused on hemodynamic stabilization, bowel rest, and initiation of topical anti-inflammatory therapy. 1

Immediate Stabilization Goals

Hemodynamic Management

• Assess and correct volume status through IV fluid resuscitation if active bleeding is present, as severe complications including hemorrhage occur in 10% of cases 1
• Monitor hemoglobin and transfuse packed red blood cells if hemoglobin drops below 7-8 g/dL or patient is symptomatic 2
• Stop or reduce anticoagulants and antiplatelet agents if medically safe, as this is first-line management recommended by the American Gastroenterological Association 3

Symptom Control

• Control rectal bleeding, which is the most common and debilitating symptom, typically appearing months after treatment and peaking within 3 years 2, 3
• Manage pain, tenesmus, and defecation difficulties resulting from rectal wall fibrosis and loss of distensibility 3
• Address urgency and mucus discharge that significantly impact quality of life 4

Medical Management Goals

Topical Anti-Inflammatory Therapy

• Initiate topical anti-inflammatory products such as sulfasalazine or mesalamine alone or combined with steroids for Grade 1/2 proctitis, as these are the recommended first-line treatments 1, 2
• Administer sucralfate enemas via soft Foley catheter inserted rectally, with the patient rolling through 360 degrees to coat the entire rectal surface 1, 3

Bowel Function Optimization

• Optimize stool consistency to prevent trauma to damaged rectal mucosa 3
• Maintain adequate hydration as part of basic bowel care 1
• Consider loperamide for diarrhea control if present 1

Diagnostic and Monitoring Goals

Endoscopic Evaluation

• Perform sigmoidoscopy to investigate patient-reported bleeding or evidence of occult fecal blood to confirm radiation-induced telangiectasia and exclude alternative pathology 1, 3
• Avoid biopsy unless neoplastic process is strongly suspected, given the risk of complications in radiation-damaged tissue 3

Assessment of Severity

• Evaluate for severe complications including hemorrhage, necrosis, and perforation that occur in 10% of cases 1
• Assess for signs of chronic proctitis, which results from vascular endothelial cell damage developing with latency of 1-25 years 1, 2

Advanced Treatment Planning

Second-Line Interventions

• Consider hyperbaric oxygen therapy if initial treatments fail, as it induces neo-vascularization, tissue re-oxygenation, collagen neo-deposition, and fibroblast proliferation, eliciting responses in the majority of patients with chronic proctitis 1
• Plan for Argon Plasma Coagulation if medical management fails, as repeated applications resolve 80-90% of chronic proctitis cases with bleeding 1, 2

Surgical Consultation

• Obtain early surgical consultation for refractory cases, as surgery (colostomy or exenteration) may be required but carries high morbidity up to 60% 1, 4

Quality of Life Preservation

Long-Term Management

• Recognize that without treatment, chronic radiation proctitis can persist indefinitely and cause permanent changes in bowel habits in approximately 90% of patients 2, 3
• Address the moderate to severe effects on quality of life that occur in 20-40% of cases 2, 3
• Note that in 20% of cases, anal or rectal pain resolves spontaneously 1

Admission Orders Summary

For severe radiation proctitis requiring admission, orders should include:

• NPO or clear liquid diet initially for bowel rest 3
• IV fluid resuscitation (crystalloid bolus if bleeding) 3
• Complete blood count, coagulation studies, type and screen 3
• Hold anticoagulation/antiplatelet agents if safe 3
• Sulfasalazine or mesalamine suppositories/enemas with or without corticosteroids 1, 2
• Sucralfate enemas administered via Foley catheter 1, 3
• Pain management (avoid NSAIDs if bleeding) 5
• Stool softeners to optimize consistency 3
• Gastroenterology consultation for sigmoidoscopy 1, 3
• Surgical consultation if severe complications suspected 1, 4

Critical Pitfalls to Avoid

• Do not use oral sucralfate, as it does not prevent acute diarrhea and is associated with more gastrointestinal side-effects including rectal bleeding compared to placebo 1
• Avoid cytoprotective agents like sucralfate, balsalazide, mesalazine, and misoprostol for prevention, as they should not be treatment of choice due to conflicting evidence on efficacy 1
• Do not perform biopsies routinely during sigmoidoscopy unless malignancy is strongly suspected, given increased perforation risk in radiation-damaged tissue 3
• Recognize that ablative therapies carry significant risk of serious complications in radiation-damaged tissue and require informed consent 3