Introduction Chronic radiation proctopathy (CRP) is a recognised complication of pelvic radiotherapy. Symptoms include diarrhoea, rectal pain, bleeding and tenesmus. In 2014, we set up an enhanced, dedicated, multidisciplinary, specialist service for managing the gastro-intestinal (GI) complications of CRP, based on The Royal Marsden Protocol.1 Here we review the management of CRP at a tertiary referral centre over one year.
Methods Patients with CRP reported at lower GI endoscopy (December 2014–15), were identified by an Endoscopy Database search for ‘radiation’. Case notes were reviewed. Indication for procedure, previous cancer and radiotherapy, endoscopy findings, treatment and outcomes were recorded.
Results 86 patients had endoscopic evidence of CRP. M:F ratio 8:1. Cancer history: prostate 87% (75), cervical 6% (5), rectal 4% (3), bladder 1% (1), ovarian 1% (1), endometrial 1% (1). Mean time since radiotherapy: 4.5 years (range: 1–13 years). 24% (21) were referred via the 2 WW pathway and 16% (14) by the bowel cancer screening program (BCSP). 23% (20) were identified during surveillance colonoscopies for cancer/ polyps or colitis. 36% (31) were referred from GI clinic. Indications: rectal bleeding 47% (40), change in bowel habit 5% (4), iron deficiency anaemia (IDA) 8% (7) and faecal occult blood 16% (14). 41% (35) were asymptomatic.
27% (23) required intervention for CRP (haemorrhagic angiectasia with rectal bleeding causing anaemia and/or significant impact on quality of life). Sucralfate enemas 2 g bd, ± metronidazole oral 400 mg tds, ± Normacol were prescribed. 65% (15/23) were referred to a Specialist Nurse for follow up, 53% (8/15), of which, responded to medical therapy within 8 weeks. One patient was unable to tolerate sucralfate enemas. 13% (3/23) patients required escalation to rectal formalin instillation. ‘Off protocol’,7% (6) were treated with Argon Plasma Coagulation (APC) as their index therapy. A solitary rectal ulcer was found in 5% (4) of patients, two were a complication of APC. Two patients were referred for hyperbaric oxygen therapy. 62% of patients did not require any therapeutic intervention.
Conclusion A significant number of patients with CRP are now referred via 2 WW and BCSP. Full colonoscopic assessment is appropriate to exclude other pathology, however, the majority do not require medical or endoscopic intervention, many are asymptomatic and few have IDA. For patients that require intervention for CRP, a multidisciplinary approach should be employed, medical therapy is effective and well tolerated, endoscopic intervention should be reserved for individuals who fail medical treatment. APC should only be used in carefully selected cases due to risk of ulceration. CRP services should be audited to ensure appropriate management and minimise complications.
Reference 1 Frontline Gastroenterol (2015) 6 (1): 53–72.
Disclosure of Interest None Declared
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