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PubMed1998

Treatment of radiation proctitis with hyperbaric oxygen: what is the optimal number of HBO treatments?

AIM: Our objective was to investigate the effectiveness of hyperbaric oxygenation (HBO) in the treatment of radiation proctitis. The current literature was reviewed with regard to the necessary number of HBO treatments. PATIENTS AND METHODS: Two patients with proctitis after pelvic irradiation were treated with 40 and 38 HBO treatments, respectively. Hyperbaric oxygenation was delivered at 240 kPa over 90 min. RESULTS: In one patient, proctosigmoidoscopy showed a significant improvement after 40 HBO sessions. The other patient interrupted therapy after 38 HBO treatments without subjective change. The reported number of HBO sessions for a successful treatment of radiation proctitis ranges from 12 to 90. CONCLUSION: HBO should be considered before more invasive treatment modalities are performed for radiation proctitis.

Aged↗
PubMed2007

Application of 10 percent formalin for the treatment of radiation-induced hemorrhagic proctitis.

PURPOSE: Rectal instillation of 4 percent formalin solution has been described as a successful treatment for hemorrhagic radiation proctitis recalcitrant to medical treatment. We present our experience with a new method of treatment involving the topical application of 10 percent buffered formalin, which is well tolerated and suitable for office use. METHODS: Patients with marked or refractory rectal bleeding and clinical features consistent with radiation proctitis were reviewed. Treatment involved direct application of a 10 percent buffered formalin solution to the affected mucosa using a 16-inch cotton tip applicator applied through a proctoscope in the office setting. RESULTS: A total of 100 patients with a mean age of 75 (range, 49-91) years were followed for 18 (range, 1-79) months. The interval from radiation exposure to formalin treatment was 21 months. Overall, 93 percent of patients had cessation of bleeding after an average of 3.5 formalin applications at two-week to four-week intervals. Patients with severe (Grade 3) proctitis and those taking aspirin required an average of 1.5 additional treatments. A total of eight patients rebled at a mean of 24 months from treatment; however, all responded to further applications of formalin. Three patients complained of anal pain and one experienced dizziness postprocedure for a complication rate of 1.1 percent. CONCLUSIONS: We present a simple, cost-effective, and well-tolerated method of controlling hemorrhagic radiation proctitis. It is performed by using materials readily available in the office of a colon and rectal surgeon, eliminating the need for bowel preparation, anesthesia, or a surgical suite.

Administration, Rectal↗
PubMed2005

Treatment of radiation proctitis with hyperbaric oxygen.

BACKGROUND AND PURPOSE: Radiation proctitis is a potential complication following pelvic radiation therapy. There are no standard treatments and treatment outcomes are unpredictable. We report our experience with the use of hyperbaric oxygen treatment (HBOT) for radiation proctitis cases refractory to standard medical or laser therapy. PATIENTS AND METHODS: During the period 2000-2004, 10 patients with radiation proctitis were treated with HBOT (three males and seven females; mean age of 65). The median follow-up period was 25 months (range 6-43 months). Patient symptoms were retrospectively scored prior to, and following HBOT, based on the LENT-SOMA scale. RESULTS: Prior to treatment, three patients had Grade 3 toxicity (i.e. requiring blood transfusions) and seven had Grade 2 toxicity with dominant symptoms of rectal pain and/or diarrhoea. HBOT was well tolerated and 9 of the 10 patients completed a full HBOT treatment program. Rectal bleeding completely stopped in four of nine symptomatic patients and improved in three others. Rectal pain completely remitted in three of five symptomatic patients. Diarrhea remitted completely in one of five patients and improved in three others. Of the 10 patients treated, only two did not respond to HBOT. CONCLUSIONS: Significant improvement of rectal bleeding, diarrhea and rectal pain is possible using HBOT. HBOT should be offered to patients who fail conventional treatments for radiation proctitis.

Adult↗
PubMed1999

Is there more than one late radiation proctitis syndrome?

PURPOSE: To investigate the significance of the various late rectal symptoms that appear after radical prostatic irradiation. PATIENTS AND METHODS: Patients with localised prostate cancer treated between 1987 and 1994 at the Mater Hospital, Newcastle with radical megavoltage irradiation were recalled for examination and to complete a detailed questionnaire concerning late radiation-induced symptoms and their effects on normal daily life. The influence of patient age treatment related variables and acute proctitis symptoms occurring during therapy or the late symptoms recorded were assessed and the relationship between late symptoms and late EORTC/RTOG score and impact on normal daily life were studied. RESULTS: The presence of symptoms of acute proctitis was the only factor to predict any of three late symptoms (urgency, frequency and diarrhoea) and late EORTC/RTOG score in this series (odds ratios: 1.7-2.57, P-values: 0.009-0.0007). Cluster and discriminant function analyses revealed the presence of five subgroups of patients with varying permutations of different late rectal symptoms, including one group with minimal symptoms (P < 0.0001). While bleeding and rectal discharge were the major contributors to late EORTC/RTOG score (P < 0.0001 and 0.04), faecal urgency and bleeding were the most important factors to impact on normal daily life (P < 0.0001 and P < 0.0003). A relatively low concordance was found between late EORTC/RTOG score and the patients' self assessment on the effect of their symptoms on their normal daily lives. Some late symptoms, including bleeding and rectal discharge become less prevalent after 3 years of follow-up with a resulting improvement in EORTC/RTOG score. CONCLUSIONS: There may be more than one late (chronic) proctitis syndrome which may be linked in greater or lesser degrees to acute proctitis symptoms occurring during therapy. Urgency is a common late symptom which often has an important impact on normal daily life and deserves recognition in late normal tissue scoring systems. Assessment of the incidence of bleeding as a measure of late rectal morbidity following prostate irradiation may underestimate the impact of these chronic effects. Confirmatory studies are necessary.

Aged↗
PubMed2000

A review of radiation proctitis in the treatment of prostate cancer.

Pelvic radiation is a common therapy for the treatment of prostate cancer. A complication of this therapy, radiation proctitis, may be limited to the direct posttreatment period or it may appear as serious complications that occur months to years after therapy has been completed. Mucosal damage, present with both acute and chronic radiation proctitis, produces a variety of symptoms including mucoid diarrhea, pain upon defecation, serious rectal bleeding, stenosis, and fistula formation. The treatment of radiation proctitis is symptom related, and the goals of therapy include the prevention or correction of mucosal changes and eradication of rectal bleeding. This article will review the pathophysiology of radiation proctitis and its treatment.

Humans↗
PubMed2002

Systematic review for non-surgical interventions for the management of late radiation proctitis.

Chronic radiation proctitis produces a range of clinical symptoms for which there is currently no recommended standard management. The aim of this review was to identify the various non-surgical treatment options for the management of late chronic radiation proctitis and evaluate the evidence for their efficacy. Synonyms for radiation therapy and for the spectrum of lower gastrointestinal radiation toxicity were combined in an extensive search strategy and applied to a range of databases. The included studies were those that involved interventions for the non-surgical management of late radiation proctitis. Sixty-three studies were identified that met the inclusion criteria, including six randomised controlled trials that described the effects of anti-inflammatory agents in combination, rectal steroids alone, rectal sucralfate, short chain fatty acid enemas and different types of thermal therapy. However, these studies could not be compared. If the management of late radiation proctitis is to become evidence based, then, in view of its episodic and variable nature, placebo controlled studies need to be conducted to clarify which therapeutic options should be recommended. From the current data, although certain interventions look promising and may be effective, one small or modest sized study, even if well-conducted, is insufficient to implement changes in practice. In order to increase recruitment to trials, a national register of cases with established late radiation toxicity would facilitate multi-centre trials with specific entry criteria, formal baseline and therapeutic assessments providing standardised outcome data.

Administration, Rectal↗
PubMed2003

Formaldehyde application for haemorrhagic radiation-induced proctitis: a clinical and histological study.

OBJECTIVES: Haemorrhagic radiation-induced proctitis is a serious complication of radiotherapy of pelvic organs. In severe cases, massive haemorrhage may necessitate hospitalization and repeated transfusions. Application of formaldehyde under direct vision is one of the most efficient treatments. The aim of this study was to evaluate the results of this treatment as well as the histological changes induced by formaldehyde on the rectal mucosa. MATERIAL AND METHODS: From January 1991 to September 2001, 13 patients who presented a haemorrhagic radiation-induced proctitis have been treated in our outpatient clinic with 4% formaldehyde cotton soaked applications. They were followed up to one year after the treatment. Endoscopic biopsies were performed before, immediately after the application, 1 month later, as well as at the one-year follow-up. RESULTS: In eight cases bleeding stopped after the first application. In two patients a second application was necessary to control the haemorrhage and in two other patients bleeding ceased definitively after the fourth application. Follow-up evaluation at 12 months showed no sign of acute proctitis or rebleeding. One asymptomatic patient had a mild stenosis of the rectum. Baseline biopsies showed signs of acute inflammation. Those performed after the application of formaldehyde showed fresh thromboses of the vessels of the mucosa. Biopsies at 1 month and 1 year showed only chronic changes secondary to the radiotherapy. CONCLUSION: Local application of 4% formaldehyde for the treatment of haemorrhagic radiation-induced proctitis gives good results, is well tolerated and easy to perform. Formaldehyde applied selectively causes thromboses of the bleeding vessels, without deep lesions or extended necrosis.

Aged↗
PubMed1981

Chlamydia trachomatis proctitis.

One hundreds seventy-one homosexual men, 96 of whom had symptoms suggestive of proctitis and 75 of whom had no such symptoms, were consecutively enrolled in a study of the prevalence, clinical spectrum, and histopathology of Chlamydia trachomatis rectal infections. C. trachomatis was isolated from the rectums of 14 men. Three of the isolates, which had lymphogranuloma venereum (LGV) immunotypes, were recovered from three men with symptoms and signs of severe proctitis, two of whom had granulomatous inflammation that was observed at rectal biopsy and was initially suggestive of Crohn's disease. Eleven isolates, which had non-LGV immunotypes, were obtained from eight symptomatic and three asymptomatic men, all of whom had fecal leukocytes and mild abnormalities of the mucosa present at sigmoidoscopy, usually with mild nongranulomatous inflammatory changes that were seen on rectal biopsy. These observations suggest that the presence of LGV immunotypes of C. trachomatis in the rectum is associated with severe acute proctitis that mimics Crohn's disease of the rectum, whereas the non-LGV immunotypes are associated with a mild proctitis with or without symptoms.

Adult↗
PubMed1983

Herpes simplex virus proctitis in homosexual men. Clinical, sigmoidoscopic, and histopathological features.

Acute herpes simplex virus (HSV) infection was detected in 23 of 102 consecutively examined, sexually active male homosexuals who presented with anorectal pain, discharge, tenesmus, or hematochezia, as compared with 3 of 75 homosexual men without gastrointestinal symptoms (P less than 0.01). Findings that were significantly more frequent in men with HSV proctitis than in men with proctitis due to other infectious causes included fever (48 per cent), difficulty in urinating (48 per cent), sacral paresthesias (26 per cent), inguinal lymphadenopathy (57 per cent), severe anorectal pain (100 per cent), tenesmus (100 per cent), constipation (78 per cent), perianal ulcerations (70 per cent), and the presence of diffuse ulcerative or discrete vesicular or pustular lesions in the distal 5 cm of the rectum (50 per cent). Serologic evidence indicated that 85 per cent of the men with symptomatic HSV proctitis were having their first episode of HSV-2 infection. The diagnosis of HSV proctitis is suggested by the presence of severe anorectal pain, difficulty in urinating, sacral paresthesias or pain, and diffuse ulceration of the distal rectal mucosa.

Acute Disease↗
PubMed2004

Resurgence of lymphogranuloma venereum in Western Europe: an outbreak of Chlamydia trachomatis serovar l2 proctitis in The Netherlands among men who have sex with men.

BACKGROUND: Lymphogranuloma venereum (LGV) is a sexually transmitted disease (STD) and is rare in the Western world. Recently, 3 men who have sex with men presented with LGV proctitis at the Erasmus Medical Center, Rotterdam, The Netherlands. We investigated a possible outbreak in a sexual network of men who have sex with men (MSM). METHODS: After active case finding, a total of 15 men presented and were investigated. Serum antibody titers to Chlamydia trachomatis were determined. Urine and rectum specimens were analyzed by polymerase chain reaction (PCR) for the presence of C. trachomatis. C. trachomatis-positive specimens were genotyped to detect the specific C. trachomatis serovars. All subjects underwent routine STD screening. Sociodemographic, clinical, and endoscopic characteristics were evaluated. RESULTS: Thirteen subjects had high immunoglobulin (Ig) G and IgA titers to C. trachomatis, suggesting an invasive infection. Rectal specimens of 12 subjects were PCR-positive for C. trachomatis. All urine specimens were negative. Genotyping revealed serovars L(2) (n=8) and L(1) (n=1). An ulcerative proctitis was found in all subjects obtaining sigmoidoscopy (n=9). Eleven of 13 subjects with an LGV diagnosis were seropositive for human immunodeficiency virus (HIV), 6 had another concomitant STD, and 1 had recently acquired a hepatitis C virus infection. Further sexual contacts were reported from The Netherlands, Germany, Belgium, the United Kingdom, and France. CONCLUSIONS: We revealed an outbreak of LGV proctitis among MSM in The Netherlands. The ulcerous character favors transmission of HIV, other STDs, and blood-borne diseases. From a public health perspective, it seems important to increase the awareness of possible LGV in MSM with symptomatic proctitis.

Adult↗
PubMed1986

Experimental proctitis due to rectal infection with Chlamydia trachomatis in nonhuman primates.

To serially examine the immunopathogenesis and histopathology of rectal infection with Chlamydia trachomatis, we inoculated five cynomolgus monkeys with C. trachomatis serovar E (non-LGV) and five with serovar L2 (LGV). After inoculation, C. trachomatis was isolated from rectal cultures in three of five non-LGV-infected monkeys and in all five LGV-infected monkeys for a period of 10 weeks. LGV-infected monkeys developed a severe hemorrhagic ulcerative proctitis, in contrast to a mild proctitis in the non-LGV-infected monkeys. Hyperplasia of lymphoid follicles and a mucosal polymorphonuclear leukocyte and mononuclear cell infiltrate were evident in all infected monkeys. Crypt abscesses with giant cells and a rare granuloma formation were present in two of five LGV-infected monkeys. C. trachomatis inclusions were initially present in epithelial cells and later in tissue histiocytes. Experimental primate infection with C. trachomatis appears to clinically and histopathologically mimic rectal infection in humans and provides a model for immunopathogenesis studies in chlamydial proctitis and granulomatous proctitis.

Animals↗
PubMed2006

Clinical guidelines for the medical management of left-sided ulcerative colitis and ulcerative proctitis: summary statement.

There are few published guidelines for the treatment of inflammatory bowel disease. Physicians choose therapy based on evidence-based data, peer and expert opinion, and personal experience. This article provides treatment guidelines for the induction and maintenance of ulcerative proctitis and left-sided colitis and the management of disease refractory to 5-aminosalicylic acid (5-ASA) compounds and corticosteroids The guidelines are derived from evidence-based data and, when lacking, expert opinion or the authors' experience. The comprehensive review of the literature is presented in the accompanying article, "The Medical Management of Left-Sided Ulcerative Colitis and Ulcerative Proctitis: Critical Evaluation of Therapeutic Trials". Rectally administered 5-ASA and corticosteroid suppositories are effective treatment for most ulcerative proctitis patients. Corticosteroid and 5-ASA enemas, which reach the splenic flexure of the colon, are recommended for patients with left-sided ulcerative colitis. The combination of rectally administered 5-ASA enemas and oral 5-ASA agents may afford better treatment of left-sided colitis and possibly prevent proximal extension of disease. Patients refractory to 5-ASAs and corticosteroids may require an immunomodulator or biological response modifier therapy. Those who have ongoing signs and symptoms of ulcerative proctitis and left-sided ulcerative colitis despite maximal medical therapy require a proctocolectomy.

Adrenal Cortex Hormones↗
PubMed2006

Endoluminal formalin application for haemorrhagic radiation proctitis.

BACKGROUND: Radiation proctitis is a common complication following radiation therapy for pelvic malignancies. This is associated with significant morbidity which adversely affects the quality of life. Local application of formalin has been used effectively in the treatment of radiation proctitis. METHODOLOGY: Thirty patients with haemorrhagic radiation proctitis who underwent endoluminal application of 4% formalin between January 1998 to October 2002 were followed up prospectively to assess the efficacy of the treatment. RESULTS: The follow up ranged from 5 to 36 months (mean 18.1 months). Nineteen (63.3%) patients had complete response to formalin application while 7 (23.3%) patients had partial response. There were 4 (13.3%) failures. No procedure related complication was observed. CONCLUSION: Local application of formalin is a simple, safe, inexpensive and fairly effective outpatient treatment modality for chronic radiation proctitis.

Adult↗
PubMed2001

Successful and sustained treatment of chronic radiation proctitis with antioxidant vitamins E and C.

OBJECTIVE: Chronic radiation proctitis, a common sequelae of pelvic radiation, is characterized by obliteration of the submucosal vasculature with subsequent ischemia and reperfusion injury. Oxidative stress is thought to be a major mechanism in radiation proctitis. Therefore, antioxidants (vitamins E and C) may be beneficial. METHODS: Twenty consecutive symptomatic outpatients with endoscopically documented radiation proctitis seen in a single gastroenterology clinic were given a combination of vitamin E (400 IU tid) and vitamin C (500 mg tid). Previous radiation therapy was given for prostatic (n = 10) or gynecological (n = 10) malignancies. These patients presented with one or more of the following symptoms: rectal bleeding, rectal pain, diarrhea, or fecal urgency. Using a questionnaire, these symptoms were rated by the patients in terms of their severity (grade 0-4) and frequency (grade 0-4) before and after treatment with vitamins E and C. A symptom index was calculated by the addition of the severity and frequency scores (8 = most symptomatic). The lifestyle impact of the symptoms was also assessed by questionnaire grading from 0 (no effect on daily activity) to 4 (afraid to leave home). Among these 20 patients, 10 patients who received vitamins E and C for 1 yr were assessed again to determine whether their initial responses were sustained. RESULTS: There was a significant (p < 0.05; Wilcoxon rank) improvement in the symptom index (before treatment vs after treatment with vitamins E and C) for bleeding (median score: 4 vs 0), diarrhea (median score: 5 vs 0), and urgency (median score: 6 vs 3). Patients with rectal pain did not improve significantly. Bleeding resolved in four of 11 patients, diarrhea resolved in eight of 16 patients, fecal urgency resolved in three of 16 patients, and rectal pain resolved in two of six patients. Lifestyle improved in 13 patients, including seven patients who reported a return to normal. Two of the patients with no improvement in their daily symptoms also had radiation ileitis. All 10 patients who underwent a second follow-up interview reported sustained improvement in their symptoms 1 yr later. CONCLUSION: A substantial number of patients with radiation proctitis seem to benefit from antioxidant therapy. A double-blind placebo-controlled trial is needed to confirm this open-labeled pilot study.

Aged↗
PubMed1980

Proctitis and herpes simplex virus in homosexual men.

In a study of the prevalence of rectal infection with herpes simplex virus (HSV) in a group of homosexual men the magnified appearance of the rectal mucosa correlated with isolation of the virus. HSV was isolated from rectal material from five of 77 men with proctitis of unknown cause but from none of 44 control patients without proctitis; two of four men with HSV proctitis were asymptomatic. Thus, the magnified rectal mucosal image, showing severe congestion, haemorrhage, and pus, appears to be a sensitive indicator of the presence of HSV proctitis.

Adult↗
PubMed2000

A rat model for radiation-induced proctitis.

Radiation proctitis is a frequent acute complication encountered with pelvic irradiation. This study was aimed at establishing the optimal radiation dose for radiation-induced proctitis in rats. Female Wistar rats were used. The rectal specimens were examined morphologically at 5th and 10th day following 10-30 Gy irradiation in single fraction. With increasing dose, mucosal damage became worse, and there was a prominent reaction after > or =15 Gy. We selected 17.5 Gy as an optimal dose for radiation proctitis and examined specimens at day 1-14 and at week 4, 6, 8, and 12 after 17.5 Gy. The rectal mucosa revealed characteristic histological changes with time. An edema in lamina propria started as early as 1-2 days after irradiation and progressed into acute inflammation. On day 7 and 8, regeneration was observed with or without ulcer. Four weeks later, all regeneration processes have been completed with end result of either fibrosis or normal appearing mucosa. This study showed that the radiation injury of the rectum in rat develops in dose-dependent manner as it has reported in previous studies and suggested that 17.5 Gy in single fraction is the optimum dose to evaluate the protective effect of various medications for radiation proctitis in face of the clinical situation.

Animals↗
PubMed2005

Argon plasma coagulation in the treatment of hemorrhagic radiation proctitis.

Hemorrhagic radiation proctosigmoiditis is a serious complication of pelvic radiation therapy. Pharmacotherapy is generally ineffective in the treatment of chronic radiation proctitis. Argon plasma coagulation is an effective, safe and well-tolerated therapy option for radiation proctitis. We report a case of hemorrhagic radiation proctosigmoiditis treated successfully with Argon plasma coagulation. We used argon plasma coagulation for mucosal coagulation in painting pattern set at 1.5 L/min and 60 W. After five therapy sessions with argon plasma coagulation, the patient's rectal bleeding and anemia resolved. After four months of argon plasma coagulation therapy, the patient is well and her endoscopic examination showed remarkable improvement of the vascular lesions. Blood transfusion requirement was resolved after therapy, and hemoglobin level increased from 8.2 g/dl to 11.5 g/dl. Argon plasma coagulation therapy may be useful as alternative treatment for hemorrhagic radiation proctitis. Future prospective controlled trials are necessary to confirm the efficacy of argon plasma coagulation in the treatment of radiation proctitis.

Aged↗
PubMed1993

A pathophysiologic study of diversion proctitis.

Diversion proctitis occurs with variable frequency after exclusion of the fecal stream. Its importance lies in the inability to differentiate it from other types of proctitis that may result in inappropriate therapy and a reluctance to recommend stoma closure. The effect of fecal diversion (n = 18) and restoration of intestinal continuity (n = 10) on human rectal mucosa in patients without inflammatory intestinal disease has been prospectively evaluated. Fecal diversion was associated with macroscopic inflammation in 55 percent of the patients and histologic inflammation in 72 percent, with a variable incidence of aphthoid ulceration, crypt abscess formation and submucosal nodularity. Restoration of continuity was associated with improvement in histologic features in all patients, but the mucosa returned to normal in only 50 percent of the patients. Onset or resolution of diversion proctitis was not associated with any significant changes in colonic cellular proliferation, glycoprotein synthesis or mucosa-associated or luminal flora. The only diagnostic feature of defunctioned proctitis remains its resolution on reintroducing the fecal stream.

Diagnosis, Differential↗