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

Abstract

Pelvic radiation is a commonly utilized treatment for malignancy of the genitourinary and lower gastrointestinal tract. Radiation proctitis and the resultant clinical picture varies from asymptomatic to potentially life threatening. Similarly, treatment options also vary greatly, from medical therapy to surgical intervention. Commonly utilized medical therapy includes sucralfate enemas, antibiotics, 5-aminosalicylic acid derivatives, probiotics, antioxidants, short-chain fatty acids, formalin instillation and fractionated hyperbaric oxygen. More invasive treatments include endoscopic-based, focally ablative interventions such as dilation, heater and bipolar cautery, neodymium/yttrium aluminum garnet argon laser, radiofrequency ablation or argon plasma coagulation. Despite its relatively common frequency, there is a dearth of existing literature reporting head-to-head comparisons of the various treatment options via a randomized controlled approach. The purpose of our review was to present the reader a consolidation of the existing evidence-based literature with the goal of highlighting the comparative effectiveness and risks of the various treatment approaches. Finally, we outline a pragmatic approach to the treatment of radiation proctitis. In light of the lack of randomized data, our goal is to pursue as least invasive an approach as possible, with escalation of care tailored to the severity of the patient’s symptoms. For those cases that are clinically asymptomatic or only mildly symptomatic, observation or medical management can be considered. Once a patient fails such management or symptoms become more severe, invasive procedures such as endoscopically based focal ablation or surgical intervention can be considered. Although not all recommendations are supported by level I evidence, reported case series and single-institutional studies in the literature suggest that successful treatment with cessation of symptoms can be obtained in the majority of cases.

Keywords: Prostate cancer, Radiation therapy, Radiation proctitis, Radiation proctopathy, Medical treatment, Endoscopic treatment, Hyperbaric oxygen, Neodymium/yttrium aluminum garnet argon laser, Argon plasma coagulation

Core tip: Rectal bleeding due to radiation proctitis is a relatively common and potentially devastating consequence of modern radiation therapy. Possible treatment options for radiation proctitis include observation, medical therapy, endoscopic-based therapy and surgery. There is a lack of data from randomized controlled trials to help inform the clinician’s decision making process with respect to treatment. Our objective is to consolidate current literature to better inform the reader of potential risks, benefits and outcomes of such treatment approaches as well as present a practical approach for the management of radiation proctitis.