Endoscopic and non-endoscopic approaches for the management of radiation-induced rectal bleeding

Table 1 Modified radiation therapy oncology group rectal toxicity scale

	Clinical summary	Symptom and intervention
Grade 0	No impact	No discernable symptoms or intervention
Grade 1	Mild and self-limiting	Minimal, infrequent bleeding or clear mucus discharge, rectal discomfort not requiring analgesics, loose stools not requiring medications
Grade 2	Managed conservatively, lifestyle (performance status) not affected	Intermittent rectal bleeding not requiring regular use of pads, erythema of rectal lining on proctoscopy, diarrhea requiring medications
Grade 3	Severe, alters patient lifestyle	Rectal bleeding requiring regular use of pads and minor surgical intervention, rectal pain requiring narcotics, rectal ulceration
Grade 4	Life threatening and disabling	Bowel obstruction, fistula formation, bleeding requiring hospitalization, surgical intervention required
Grade 5	Death	Death directly related to radiation effects

Table 2 Comparison of acute vs chronic radiation proctitis

	Acute proctitis	Chronic proctitis
Symptom development	≤ 3 mo from start of radiation	> 3 mo from start of radiation to years later
Incidence	Common (50%-100%)	Less common (2%-20%)
Common symptoms	Diarrhea, urgency, pain	Rectal bleeding
Rare symptoms	Significant rectal bleeding	Stricture, obstruction, fistula
Histopathology	Epithelial cell depletion with inflammatory infiltrate	Small vessel changes without inflammatory infiltrate
Treatment	Conservative, medical	Conservative, medical, endoscopic, surgical

Table 3 Non-endoscopic medical therapy for radiation proctitis

	Proposed mechanism	Indications
Sucralfate	Protection from injury	RCT supports treatment of chronic proctitis
Metronidazole	Antibiotic/Immunomodulator	RCT supports treatment of chronic proctitis
5-aminosalicylic acid derivatives	Anti-inflammatory	Mixed results
Probiotics/antioxidants	Immunomodulator/free radical scavenger	Mixed results, but with minimal side effects
Butyrate	Colonocyte nutrient	RCT supports treatment of acute proctitis
Topical formalin	Coagulative necrosis	Effective for chronic proctitis though significant morbidity
Hyperbaric oxygen	Promotes angiogenesis and healing	RCT supports treatment of chronic proctitis

RCT: Randomized controlled trial.

Table 4 Endoscopic therapy for radiation proctitis

	Proposed mechanism	Indications
Dilatation	Mechanical	Single institution studies support treatment of stricture, no RCT to date
Bipolar cautery and heater probe	Thermoelectric cauterization	RTC supports treatment of chronic proctitis
Nd:YAG, KTP laser	Coherent wavelength of electromagnetic radiation	Single institution studies support treatment of chronic proctitis, no RCT to date
Radiofrequency ablation	Rapidly alternating radiofrequency waves	Single institution studies support treatment of chronic proctitis, no RCT to date
Argon plasma coagulation	Noncontact electrocoagulation	RTC supports treatment of chronic proctitis, largest amount of data

Nd:YAG: Neodymium/yttrium aluminum garnet argon; KTP: Potassium titanyl phosphate; RCT: Randomized controlled trial.

Table 5 Surgical therapy for radiation proctitis

	Proposed mechanism	Indications
Diverting ostomy	Diversion of fecal stream allows for healing	Single institution studies support treatment of chronic radiation proctitis if refractory to medical and endoscopic measures, moderate morbidity and mortality associated
Local excision/flap reconstruction	Removal of poorly vascularized tissue and replacement with well perfused tissue	Little data exists to support the routine use of excision and reconstruction for patients with radiation proctitis
Proctectomy/exenteration	Removal of damaged tissue	Single institution studies support treatment of chronic radiation proctitis if refractory to medical and endoscopic measures, significant morbidity and mortality associated