Elsevier

Clinical Oncology

Volume 22, Issue 1, February 2010, Pages 70-83
Clinical Oncology

Overview
Chronic Radiation Enteritis

https://doi.org/10.1016/j.clon.2009.10.003Get rights and content

Abstract

Chronic radiation enteritis is an increasing problem, as more patients receive radiotherapy as part of their cancer therapy and as the long-term survival of these patients improves. This review addresses the causes, investigation, treatment and prevention of this disease. A review of published studies was carried out using a variety of search terms, including radiation enteritis, investigation, treatment and prevention. Chronic radiation enteritis has been reported in up to 20% of patients receiving pelvic radiotherapy, although this may underestimate its true prevalence, as not all patients with gastrointestinal symptoms after radiotherapy will seek medical attention. Predisposing factors to chronic radiation enteritis include a low body mass index, previous abdominal surgery and the presence of co-morbid conditions; the radiation dose, fractionation and technique, as well as the concomitant use of chemotherapy, may also play a role. Clinical features of chronic radiation enteritis are multiple as the disease can affect any part of the gastrointestinal tract. Moreover, symptom aetiology within any one patient may be multifactorial and therefore it is important to adopt a structured approach when planning investigations. The evidence base for current therapies is limited, but nutrition, anti-diarrhoeals, anti-inflammatories, antibiotics, probiotics, pentoxifylline, tocopherol, cholestyramine, hyperbaric oxygen, endoscopic and surgical therapies have all received attention. Given the significant morbidity and mortality associated with chronic radiation enteritis, current available preventative strategies are reviewed, including tissue-sparing radiotherapy techniques. In conclusion, the evidence base for therapeutic and preventative strategies in treating chronic radiation enteritis is limited, but adopting a structured approach to investigating gastrointestinal symptoms after radiotherapy should allow better targeting of current therapies. Closer collaboration between oncologists and gastroenterologists will facilitate a more structured approach, not only in managing individual patients, but also in establishing clinical and research networks for this expanding disease, in order to improve the evidence base for its management.

Section snippets

Statement of Search Strategies Used and Sources of Information

Relevant publications for review were identified using the PubMed database. Only English-language papers were reviewed using the following keywords alone or in combination: (chronic) radiation enteritis/ enteropathy AND investigation/ treatment/ management/ therapy/ (histo)pathology/ symptoms/ presentation/ prevention; (chronic) radiation enteritis/ enteropathy AND dietary management/ diet/ low residue/ gluten free/ elemental/ nutritional therapy; (chronic) radiation enteritis/ enteropathy AND

Pathogenesis

Radiation can cause injury by directly or indirectly targeting cellular DNA, which, in turn, leads to impaired cell division or immediate cell death [21]. The direct injurious effect of radiation results from the absorption of energy from incident radiation and usually occurs with high linear energy transfer radiation, such as protons and neutrons. The indirect effect of radiation is usually mediated by the release of free radicals that result from the interaction of radiation with cellular

Clinical Features and Diagnosis

The clinical features of chronic radiation enteritis are multiple, not least because the degree of injury to the gastrointestinal tract is influenced by a number of factors, as outlined above. Because radiation toxicity can affect separate parts of the gastrointestinal tract, the range of symptoms that patients can present with is vast, ranging from abdominal pain and vomiting to diarrhoea and flatulence [11]. Current symptom questionnaires, such as the LENT-SOMA (late effects normal tissue

Treatment

Despite the high prevalence of chronic radiation enteritis, the evidence base for treatment is limited (Table 4, Table 5). Nevertheless, there are a variety of potential therapeutic options available, which can be tailored to the clinical presentation and underlying aetiology.

Conclusion

The incidence of chronic radiation enteritis is increasing as more patients undergo pelvic radiotherapy for cancer treatment. Because symptom aetiology within any one patient is often multifactorial, it is important to adopt a structured approach when investigating gastrointestinal symptoms in patients who have received radiotherapy, as this should allow better targeting of the therapies that are available. However, because the evidence base for these therapies is currently limited, oncologists

Conflict of Interest

The authors declare that they have no proprietary, financial, professional or other personal interest that could be construed as influencing the data presented in this overview, but a note is made that Dr Lal has been a member of advisory boards for IBD medication and Dr Theis is married to an Astra Zeneca employee.

Acknowledgements

The authors would like to thank Dr Dominic Blunt, Consultant Radiologist, Hammersmith Hospital, London and Dr John Curtis, Consultant Radiologist, Aintree University Hospital, Liverpool for their help providing radiology images. We are also indebted to Dr Monica Terlizzo, Consultant Histopathologist, Aintree University Hospital, Liverpool for providing histopathology slides.

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