Efficacy and complications of argon plasma coagulation for hemorrhagic chronic radiation proctitis

BACKGROUND Chronic radiation proctitis(CRP) is a complication which occurs in 1%-5% of patients who undergo radiotherapy for pelvic malignancies. Although a wide range of therapeutic modalities are available, there is no literature to date showing any particularly appropriate therapeutic modality for each disease stage. Argon plasma coagulation(APC) is currently recommended as the firstchoice treatment for hemorrhagic CRP, however, its indication based on longterm follow-up is still unclear. On the hypothesis that the long-term efficacy and safety of APC are not fully understood, we reviewed APC treatment for patients with hemorrhagic CRP from a single center.AIM To assess the long-term efficacy and safety of APC for hemorrhagic CRP.METHODS This is a retrospective study of consecutive patients treated with APC for hemorrhagic CRP from January 2013 to October 2017. Demographics, clinical variables, and typical endoscopic features were recorded independently. Success was defined as either cessation of bleeding or only occasional traces of bloody stools with no further treatments for at least 12 mo after the last APC treatment.We performed univariate and multivariate analyses to identify factors associated with success and risk factors for fistulas.RESULTS Forty-five patients with a median follow-up period of 24 mo(range: 12-67 mo)were enrolled. Fifteen(33.3%) patients required blood transfusion before APC.Successful treatment with APC was achieved in 31(68.9%) patients. The mean number of APC sessions was 1.3(1-3). Multivariate analysis showed that APC failure was independently associated with telangiectasias present on more than50% of the surface area [odds ratio(OR) = 6.53, 95% confidence interval(CI): 1.09-39.19, P = 0.04] and ulcerated area greater than 1 cm^2(OR = 8.15, 95%CI: 1.63-40.88, P = 0.01). Six(13.3%) patients had severe complications involving rectal fistulation. The only factor significantly associated with severe complications was ulcerated area greater than 1 cm^2(P = 0.035).CONCLUSION The long-term efficacy of APC for hemorrhagic CRP is uncertain in patients with telangiectasias present on > 50% of the surface area and ulceration > 1 cm^2.     

Haemorrhagic radiation proctitis: endoscopic severity may be useful to guide therapy

Background and aims Management of haemorrhagic radiation proctitis remains controversial. Both endoscopically delivered argon plasma coagulation and rectal administration of formalin have been recommended. We evaluated the efficacy of argon plasma coagulation according to endoscopic severity of radiation proctitis.Patients and methods Fourteen patients treated with argon plasma coagulation for rectal bleeding due to radiation proctitis were reviewed. Patients were classified with a new endoscopic score for haemorrhagic radiation proctitis, comprising three factors: telangiectasia distribution, surface area involved, and presence of fresh blood. Seven patients were categorised as having grade A (mild), four grade B (moderate), and three grade C (severe) radiation proctitis. Rectal bleeding was assessed pre- and post-treatment using a five-point bleeding scale.Results All patients with grade A and B radiation proctitis were treated successfully by argon plasma coagulation (mean 1.5 sessions). In one patient with grade C radiation proctitis argon plasma coagulation was successful after four sessions, but in the other two patients bleeding could not be controlled; a subsequent single formalin administration was successful in both. Overall in 12 patients (85.7%) bleeding ceased or improved significantly. The mean rectal bleeding scale reduced significantly from 2.6 to 0.9. One patient treated with argon plasma coagulation developed an asymptomatic rectosigmoid stenosis.Conclusion Argon plasma coagulation is a simple, safe and efficacious therapy for mild/moderate radiation proctitis. In patients with severe radiation proctitis several sessions are usually necessary, and success is not certain; in these cases, topical formalin administration may be more effective. Endoscopic severity of haemorrhagic radiation proctitis may be useful to guide appropriate therapy.An erratum to this article can be found at     

Colostomy is a simple and effective procedure for severe chronic radiation proctitis

AIM: To assess the efficacy and safety of diverting colostomy in treating severe hemorrhagic chronic radiation proctitis (CRP).METHODS: Patients with severe hemorrhagic CRP who were admitted from 2008 to 2014 were enrolled into this study. All CRP patients were diagnosed by a combination of pelvic radiation history, clinical rectal bleeding, and endoscopic findings. Inclusion criteria were CRP patients with refractory bleeding with moderate to severe anemia with a hemoglobin level < 90 g/L. The study group included patients who were treated by diverting colostomy, while the control group included patients who received conservative treatment. The remission of bleeding was defined as complete cessation or only occasional bleeding that needed no further treatment. The primary outcome was bleeding remission at 6 mo after treatment. Quality of life before treatment and at follow-up was evaluated according to EORTC QLQ C30. Severe CRP complications were recorded during follow-up.RESULTS: Forty-seven consecutive patients were enrolled, including 22 in the colostomy group and 27 in the conservative treatment group. When compared to conservative treatment, colostomy obtained a higher rate of bleeding remission (94% vs 12%), especially in control of transfusion-dependent bleeding (100% vs 0%), and offered a better control of refractory perianal pain (100% vs 0%), and a lower score of bleeding (P < 0.001) at 6 mo after treatment. At 1 year after treatment, colostomy achieved better remission of both moderate bleeding (100% vs 21.5%, P = 0.002) and severe bleeding (100% vs 0%, P < 0.001), obtained a lower score of bleeding (0.8 vs 2.0, P < 0.001), and achieved obvious elevated hemoglobin levels (P = 0.003), when compared to the conservative treatment group. The quality of life dramatically improved after colostomy, which included global health, function, and symptoms, but it was not improved in the control group. Pathological evaluation after colostomy found diffused chronic inflammation cells, and massive fibrosis collagen depositions under the rectal wall, which revealed potential fibrosis formation.CONCLUSION: Diverting colostomy is a simple, effective and safe procedure for severe hemorrhagic CRP. Colostomy can improve quality of life and reduce serious complications secondary to radiotherapy.     

Short chain fatty acids are effective in short-term treatment of chronic radiation proctitis

PURPOSE: Short chain fatty acids are the main energy source of coloncytes and their use may be impaired in chronic radiation proctitis. The aim of the present study was to evaluate the therapeutic effect of short chain fatty acid enemas in patients with chronic radiation proctitis. METHODS: A prospective, randomized, double-blind trial comparing short chain fatty acid enemas with placebo was conducted in 19 patients with chronic radiation proctitis. Short chain fatty acid enemas contained 60 mM sodium acetate, 30 mM sodium propionate, and 40 mM sodium butyrate. The treatment period lasted five weeks and patients were followed up for six months. RESULTS: On admission, both groups were similar regarding all parameters evaluated. After five weeks short chain fatty acid-treated patients showed a significant decrease in the number of days with rectal bleeding from the previous week (4.4±1.8 to 1.4±2.2;P=0.001) and an improvement of endoscopic score (4.8±1.4 to 2.2±1.2;P=0.001). Hemoglobin values were also significantly higher in short chain fatty acid-treated patients (13.1±0.9 g/dlvs. 10.7±2.1 g/dl;P=0.02). Mucosal DNA and protein concentrations decreased in both groups but significantly so only in placebotreated patients (P=0.05). Changes in histologic parameters were not significant in either group. Although short chain fatty acid-treated patients did not get worse in the next six months, placebo-treated ones gradually improved, and at the end of six months, differences between the two groups were no longer observed. CONCLUSIONS: Short chain fatty acid enemas can accelerate the process of healing in chronic radiation proctitis, but treatment has to be continuous if a complete and sustained clinical, endoscopic, and histologic response is to be obtained.Presented in part at The Digestive Disease Week Scientific Sessions, New Orleans, Louisiana, May 15 to 18, 1994.     

Severe hemorrhagic radiation proctitis advancing to gradual cessation with hyperbaric oxygen

Summary We report a case of a male patient suffering from a severe hemorrhagic radiation proctitis which gradually ceased with hyperbaric oxygen. We discuss the mechanisms of chronic radiation injury and the effect of the hyperbaric oxygen. This therapy is proposed as an alternative to surgical intervention for this abnormality.     

Failure of 5-Aminosalicylic acid enemas to improve chronic radiation proctitis

Radiation proctitis is a well-known complication of abdominal and pelvic radiation. Conventional medical and surgical treatment often is disappointing. 5-Aminosalicylic Acid (5-ASA)is the active component in sulfasalazine and is effective in the treatment of distal ulcerative colitis. Four patients with radiation proctitis were treated with 4 g 5-ASA by enema nightly for two to six months. Patients were seen monthly, interviewed, and a sigmoidoscopic exam performed. No change was seen in the degree of mucosal inflammation on follow-up sigmoidoscopic exams. Three patients noted no change in their symptoms of bleeding, pain, or tenesmus. One patient noted initial improvement, but this was not sustained. 5-ASA enemas do not appear to be effective in the treatment of radiation proctitis.     

Endoscopic management of chronic radiation proctitis

Chronic radiation proctopathy occurs in 5%-20% of patients following pelvic radiotherapy. Although many cases resolve spontaneously,some lead to chronic symptoms including diarrhea,tenesmus,urgency and persistent rectal bleeding with iron deficiency anemia requiring blood transfusions. Treatments for chronic radiation proctitis remain unsatisfactory and the basis of evidence for various therapies is generally insuff icient. There are very few controlled or prospective trials,and comparisons between therapie...     

福尔马林治疗出血性放射性直肠炎临床分析

目的评价经内镜下喷洒福尔马林液治疗出血性放射性直肠炎的效果及安全性。 方法回顾性分析2013年1月至2017年7月于民航总医院消化内科住院治疗的出血性放射性直肠炎10例患者的临床资料,并检索Pubmed、EMBASE数据库1996年~2017年的相关文献,结合文献复习进行治疗效果评价。 结果纳入出血性放射性直肠炎患者10例,平均年龄（71.1±6.9）岁,经过内镜下喷洒福尔马林治疗,总有效率100%。检索文献20篇,纳入病例数515,总体有效率为84.5%。经治疗后部分患者存在腹痛、腹泻、发热、里急后重、肛门疼痛、肛门溃疡、肛门狭窄、排便困难等不良反应。 结论经内镜下喷洒福尔马林液治疗出血性放射性直肠炎疗效确切,不良反应发生率低。     

复方血竭灌肠与庆大霉素联合地塞米松灌肠对放射性直肠炎的疗效比较

[目的]比较复方血竭与庆大霉素联合地塞米松灌肠对放射性直肠炎的疗效。[方法]采用完全随机、三盲方法将187例放射性肠炎患者分为治疗组与对照组;治疗组99例采用复方血竭灌肠液灌肠,对照组88例采用庆大霉素联合地塞米松灌肠,疗程均为20d;观察2组治疗后临床疗效及内镜评价疗效。[结果]治疗组临床总有效率为88.7%,内镜评价总有效率为88.6%;对照组临床总有效率为75.9%;内镜评价总有效率为72.4%。2组在临床、内镜评价上均差异有统计学意义(P0.05)。[结论]用复方血竭和庆大霉素联合地塞米松灌肠方法治疗放射性直肠炎均有良好疗效,但复方血竭优于庆大霉素联合地塞米松。     

Endoscopic treatments for chronic radiation proctitis

Chronic radiation proctitis is a complication that occurs in patients who receive radiation therapy for pelvic malignancies. The common presentation is with rectal bleeding, but also rectal pain, diarrhea, tenesmus and even passage of mucus can occur. The optimal treatment of bleeding due to radiation proctitis remains unclear. Among various therapeutic options, medical management is generally ineffective and surgical intervention has a high incidence of morbidity. Promising advances have been made in endoscopic therapy, including argon plasma coagulation (APC), formalin application as well as new techniques such as radio-frequency ablation and cryoablation. APC is a safe, highly effective and long-lasting therapy in patients with rectal bleeding associated with radiation proctitis. It has been shown that several sessions of APC reduce the rate of bleeding and therefore the blood transfusion requirements. Moreover, the effect of treatment is long lasting. However, best results are achieved in patients with mild to moderate radiation proctitis, leaving space for alternative treatments for patients with more severe disease. In patients with severe or refractoryradiation proctitis intra rectal formalin application is an appropriate treatment option. Radiofrequency ablation and cryoablation have shown efficacy as alternative methods in a limited number of patients with refractory chronic radiation proctitis.     

Formalin instillation for refractory radiation-induced hemorrhagic proctitis

PURPOSE: Our goal was to evaluate use of topical (4 percent) formalin in management of radiation-induced hemorrhagic proctitis, refractory to other methods of treatment. Specifically, we wished to determine its safely, ability to stop bleeding, and complications associated with therapy. METHODS: Sixteen patients with radiation-induced hemorrhagic proctitis were treated with topical (4 percent) formalin. All had been previously treated with conservative regimens such as cautery, topical steroids, or laser, but these had failed. Five-hundred milliliters (ml) of a 4 percent formalin solution was instilled into the rectum in 50-ml aliquots. Each aliquot was kept in contact with rectal mucosa for approximately 30 seconds. Treatments were performed under local anesthesia in nine patients, sedation only in four, spinal in two, and general in one patient. RESULTS: In 12 patients, bleeding stopped after a single formalin instillation; in 3, bleeding was considerably reduced but continued sporadically. One patient required three treatments before bleeding stopped. Four patients developed postoperative anal pain, of which one also had significant tenesmus and reduced capacity. Of these four patients, only two had significant anal pain and fissures that lasted longer than one month. CONCLUSIONS: Topical (4 percent) formalin is safe and effective in treatment of radiation-induced hemorrhagic proctitis. A single treatment will stop bleeding in 75 percent of patients.Supported in part by the Bowman Research Fund.Read at the meeting of The American Society of Colon and Rectal Surgeons, Montreal, Quebec, Canada, May 7 to 12, 1995.     

Diverting colostomy is an effective and reversible option for severe hemorrhagic radiation proctopathy

A total of 738 continual CRP patients were screened.After exclusion,14 patients in the colostomy group and 25 in the conservative group were included in the final analysis.Preoperative Hb was only 63 g/L±17.8 g/L in the colostomy group compared to 88.2 g/L±19.3 g/L(P<0.001)in the conservative group.All 14 patients in the former group achieved complete remission of bleeding,and the colostomy was successfully reversed in 13 of 14(93%),excepting one very old patient.The median duration of stoma was 16(range:9-53)mo.The Hb level increased gradually from 75 g/L at 3 mo,99 g/L at 6 mo,and 107 g/L at 9 mo to 111 g/L at 1 year and 117 g/L at 2 years after the stoma,but no bleeding cessation or significant increase in Hb levels was observed in the conservative group.Endoscopic telangiectasia and bleeding were greatly improved.Endoultrasound showed decreased vascularity,and magnetic resonance imaging revealed an increasing presarcal space and thickened rectal wall.Anorectal functions and quality of life were significantly improved after stoma reversal,when compared to those before stoma creation.CONCLUSION Diverting colostomy is a very effective method in the remission of refractory hemorrhagic CRP.Stoma can be reversed,and anorectal functions can be recovered after reversal.     

Histopathological comparison of topical therapy modalities for acute radiation proctitis in an experimental rat model

AIM: To evaluate the prevalent topical therapeutic modalities available for the treatment of acute radiation proctitis compared to formalin. METHODS: A total of 120 rats were used. Four groups (n = 30) were analyzed with one group for each of the following applied therapy modalities: control, mesalazine, formalin, betamethasone, and misoprostol. A single fraction of 17.5 Gy was delivered to each rat. The rats in control group rats were given saline, and the rats in the other three groups received appropriate enemas twice a day beginning on the first day after the irradiation until the day of euthanasia. On d 5, 10, and 15, ten rats from each group were euthanized and a pathologist who was unaware of treatment assignment examined the rectums using a scoring system. RESULTS: The histopathologic scores for surface epithelium, glands (crypts) and lamina propria stroma of the rectums reached their maximum level on d 10. The control and formalin groups had the highest and mesalazine had the lowest, respectively on d 10. On the 15th d, mesalazine, betamethasone, and misoprostol had the lowest scores of betamethasone. CONCLUSION: Mesalazine, betamethasone, and misoprostol are the best topical agents for radiation proctitis and formalin has an inflammatory effect and should not be used.     

Effective use of argon plasma coagulation in the treatment of severe radiation proctitis

PURPOSE: Chronic radiation proctitis, a well described complication of pelvic radiation therapy, can result in severe bleeding that is refractory to conventional treatment. Argon plasma coagulation is an effective treatment for hemorrhagic lesions of the gastrointestinal tract. The aim of this study was to assess the efficacy and safety of argon plasma coagulation in the management of severe radiation proctitis resistant to medical treatment. METHODS: Eleven patients (10 males) aged between 54 and 86 years (mean ± standard error of the mean, 73±3.years), with chronic radiation proctitis after radiotherapy for prostate (n=9), uterine (n=1) or rectal (n=1) cancer were enrolled in this prospective study. Traditional therapies had failed including mainly topical steroids, 5-aminosalicylic acid and sometimes sucralfate. All patients had active bleeding from diffuse telangiectasias responsible for chronic anemia and seven of them required blood transfusions. The mean duration of the sessions was 20 minutes and one to five sessions (mean, 3.2±0.4), usually without anesthesia, were required to stop bleeding. Mean follow-up time was 19±2 (range, 7–30) months. RESULTS: Rectal bleeding disappeared in nine patients and was greatly reduced in two. All the patients were free of transfusions during the mean follow-up of 19 months. The mean hemoglobin level was 7.7±2.8 g/dl at the first session and increased significantly (P=0.003) to 11.5±2.6 g/dl after treatment. In two patients, a rectal stenosis appeared 7 and 11 months after the first session. CONCLUSION: Argon plasma coagulation is a simple, inexpensive and effective treatment for severe refractory radiation proctitis with telangiectasias. Follow-up supervision is in progress to evaluate long term benefits and the risk of rectal stenosis.Presented in abstract form at the meeting of the American Gastroenterological Association, San Diego, California, May 21 to 24, 2000.     

A simple and effective treatment for hemorrhagic radiation proctitis using formalin

Radiation proctitis is a common complication of radiotherapy for pelvic malignancy. In the more severe form, it leads to intractable or massive hemorrhage, which may require repeated hospital admissions and blood transfusions. Medical therapy in patients with radiation proctitis is usually ineffective, whereas surgery is associated with a high morbidity and mortality. Eight patients (seven females and one male) with hemorrhagic radiation proctitis were Treated over a six-month period with endoluminal formalin. The technique used ensured minimal contact with formalin. The median age of the patients was 68 years (range, 42–73 years). Seven patients had had cancer of the uterine cervix, and one patient had had cancer of the prostate treated with radiotherapy at a median time of 30 months (range, 9–46 months) previously. The median duration of time of symptomatic rectal hemorrhage before formalin therapy was eight months (range, 1–12 months). The median number of units of blood transfused previously per patient was four (range, 2–32). The time taken for formalin therapy was 20 minutes (range, 10–70 minutes). One patient required repeat formalin application at two weeks. Bleeding ceased immediately in seven patients after formalin treatment. No further bleeding was noted, nor was any blood transfusion needed, at follow-up at four months (range, 1–6 months). Formalin therapy is a simple, inexpensive, and effective treatment for hemorrhagic radiation proctitis.     

Argon plasma coagulation for treatment of hemorrhagic radiation gastroduodenitis

A 79‐year‐old man who had received radiotherapy for portal vein thrombosis due to hepatocellular carcinoma (HCC) 5 months earlier, showed progressive anemia and melena. Endoscopy on admission revealed diffuse bleeding from multiple telangiectasias on the anterior wall of the antrum and bulbus. We treated this patient with a new non‐contact hemostatic method: the argon plasma coagulator (APC). The melena stopped after the first session and the hemoglobin level remained stable for 7 months. No delayed complications have been observed. Gastrointestinal bleeding from chronic radiation gastroduodenitis is rarely reported compared with radiation proctitis. This case demonstrates that APC is effective for hemostasis of diffuse bleeding from radiation gastroduodenitis, just as for radiation proctitis.