Introduction Up to 50% of patients develop rectal bleeding after pelvic radiotherapy. Radiation-induced bleeding may be trivial and after appropriate endoscopic assessment, patients can be reassured and do not need treatment. Others develop troublesome bleeding affecting quality of life. 1–5% become transfusion dependent. The optimal treatment of radiation-induced bleeding and safety of available treatment modalities is controversial.
Methods A service evaluation was performed to assess outcomes of patients treated with intra-rectal formalin for radiation-induced rectal bleeding. Patients were offered formalin treatment if bleeding affected quality of life, they had no evidence of rectal ulceration and bowel function had been otherwise optimised. 5% formalin was delivered to the rectum using a gastroscope after full bowel preparation with the unsedated patient lying prone. Wet gauze was firmly applied to the perineum to prevent formalin leakage. 30–35mls formalin, sufficient to cover the telangiectasia, was instilled. The gastroscope was not removed. After 3 minutes, the formalin was washed out with water. If required, treatments were repeated 6–8 weeks later. Patients completed a questionnaire before each treatment and at follow-up. They were also asked to indicate on a 10cm visual analogue scale (VAS) the degree of nuisance currently caused by bleeding.
Results 27 men, median age 73 (range 56–81) were treated between 2008 and 2012. All received radiotherapy for prostate cancer in the previous 4 years. 41% (n = 11) had required ≥1 blood transfusions, 48% (n = 13) iron supplementation. 52% (n = 14) regularly soiled their clothes with blood. 22% (n = 6) had not responded to previous argon plasma coagulation. Median follow-up was 28 months (range 2–48).
67% (n = 18) reported improvement; reduction in frequency (52%, n = 14), and/or amount (44%, n = 12) of bleeding. Patients required 1–4 treatments (median 2) to achieve adequate improvement. Median baseline VAS score was 6.7cm (range 4.3–9.9). After one treatment, VAS scores improved by a median of 2.5cm (range 0.6–5.0), after 2 treatments by 3cm from baseline (range 0.7–6.1cm) and at follow up by 3.8cm (range 0–8.7). Two patients experienced serious complications. One who had chronic lymphocytic leukaemia developed septicaemia and pneumonia the following day. The organism responsible was not a bowel organism. The other developed an anterior rectal wall fistula in an area of intense radiation change requiring surgery 18 months later. Neither complication was considered to be caused by the formalin.
Conclusion 67% patients with radiation-induced rectal bleeding experience a satisfactory reduction in bleeding following treatment with intra-rectal formalin. Further studies comparing with other treatment modalities are required.
Disclosure of Interest None Declared
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