Update on the management of the gastrointestinal effects of radiation

Table 1 Treatment modalities for radiation proctopathy and associated bleeding

Treatment modality	Benefit	Drawback
Sucralfate enema	(1) Inexpensive; (2) Safe[41]; and (3) Effective first line in > 70%[46]	Patient training to self-administer or access to qualified clinician in nonclinical setting
Formalin enema	Efficacy in at least 75% cases[47]	(1) Requires qualified therapist; and (2) Variable morbidity, serious side effects such as fistulization and severe colitis[42]
Hyperbaric oxygen	Improved bowel related symptoms following radiation treatment	(1) Not readily available; (2) Requires recurrent treatments to provide efficacy[30]; and (3) No strong RCT evidence for benefit
APC	(1) Direct visualization allows for treatment of a distinct bleeding point; and (2) Readily available within secondary care	(1) Procedural complications, e.g., perforation, bleeding; (2) Strictures; and (3) Ulceration

APC: Argon plasma coagulation; RCT: Randomized controlled trial.

Table 2 Overview of specific therapies for side effects associated with radiation therapy

Area	Side effect	Treatment
Oral mucosa	Mucositis; xerostomia; candidiasis	Opioids, topical benzydamine; artificial saliva; topical antifungals
Esophagus	Esophagitis; strictures	Analgesia, topical anesthesia, PPI; esophageal dilatation, CARD, esophageal stents
Small bowel	Enteritis; small bowel overgrowth; strictures; bile acid malabsorption; malnutrition	Antidiarrheal; antibiotics; surgery; bile acid sequestrants; nutritional adjuncts (i.e. PN)
Rectum	Proctopathy	Sucralfate, formalin, HBOT, APC

APC: Argon plasma coagulation; CARD: Combined antegrade and retrograde dilation; HBOT: Hyperbaric oxygen therapy; PN: Parenteral nutrition; PPI: Proton pump inhibitor.