Diagnosis and management of chronic radiation enteritis
- Ingram Roberts, MD, MBA
Ingram Roberts, MD, MBA
- Clinical Professor of Medicine (Adjunct)
- Temple University School of Medicine
- Section Editors
- J Thomas Lamont, MD
J Thomas Lamont, MD
- Editor-in-Chief — Gastroenterology/Hepatology
- Section Editor — Anorectal Disorders and Misc. Lower GI Disease
- Section Editor — Nutrition, Malabsorption, and Misc. Upper GI Disease
- Professor of Medicine
- Harvard Medical School
- Christopher G Willett, MD
Christopher G Willett, MD
- Section Editor — Radiation Therapy
- Duke University Medical School
Injury to the intestines can occur following radiation therapy for cancer. It can affect both the large and small intestine, is often progressive, and may lead to a variety of clinical consequences (such as diarrhea, nausea, weight loss, abdominal pain, intestinal obstruction, and perforation) depending upon the extent of the injury. It usually develops six or more months after radiation therapy. This contrasts with the timing of acute radiation enteritis (characterized by diarrhea and abdominal pain), which develops during or shortly after radiation therapy and resolves within two to six weeks after completion of treatment.
Chronic radiation enteritis is due to an obliterative arteritis that leads to intestinal ischemia, which can result in stricture, ulceration, fibrosis, and occasionally fistula formation. The physiologic consequences can include altered intestinal transit, reduced bile acid absorption, increased intestinal permeability, bacterial overgrowth and lactose malabsorption. Clinical manifestations may include nausea, vomiting, lactose intolerance, obstructive symptoms, diarrhea, weight loss, malnutrition, and bleeding (usually in patients with colonic involvement).
This topic review will focus on the diagnosis and management of chronic radiation injury to the small intestines and proximal colon. The pathogenesis, clinical manifestations, and risk factors associated with radiation enteritis, along with the prevention and treatment of chronic radiation proctitis, are presented separately. (See "Gastrointestinal toxicity of radiation therapy", section on 'Radiation enteritis' and "Clinical manifestations, diagnosis, and treatment of radiation proctitis".)
The diagnosis is usually established by suggestive radiologic findings in patients with compatible clinical features who have a history of prior radiation exposure. The patient's previous radiation treatment record should be reviewed to determine the total dose and distribution of the radiation field. This may help to determine which intestinal segments may have received excessive radiation exposure, information that can be correlated with the radiologic findings and the clinical presentation.
We usually obtain an abdominal computed tomography (CT) scan followed by an upper gastrointestinal series with small bowel follow through in patients with suspected small bowel disease. Additional imaging is reserved for patients in whom the diagnosis remains unclear. We generally perform a colonoscopy in patients with suspected colonic involvement.
- Nolan DJ. The true yield of the small-intestinal barium study. Endoscopy 1997; 29:447.
- Dixon PM, Roulston ME, Nolan DJ. The small bowel enema: a ten year review. Clin Radiol 1993; 47:46.
- Willis JR, Chokshi HR, Zuckerman GR, Aliperti G. Enteroscopy-enteroclysis: experience with a combined endoscopic-radiographic technique. Gastrointest Endosc 1997; 45:163.
- Horton KM, Corl FM, Fishman EK. CT of nonneoplastic diseases of the small bowel: spectrum of disease. J Comput Assist Tomogr 1999; 23:417.
- Wagholikar GD, Gupta RK, Kapoor VK. Polyvisceral gangrene due to radiation enteritis. Trop Gastroenterol 2002; 23:104.
- Yoshimura K, Hirata I, Maemura K, et al. Radiation enteritis: a rare complication of the transverse colon in uterine cancer. Intern Med 2000; 39:1060.
- Macheta M, Chopra R, Morgenstern G, Chang J. Chemotherapy for leukaemia following previous pelvic radiotherapy is associated with severe enteritis and haemorrhagic cystitis. Ann Hematol 2001; 80:485.
- Bender GN, Timmons JH, Williard WC, Carter J. Computed tomographic enteroclysis: one methodology. Invest Radiol 1996; 31:43.
- Maglinte DD, Bender GN, Heitkamp DE, et al. Multidetector-row helical CT enteroclysis. Radiol Clin North Am 2003; 41:249.
- Horton KM, Fishman EK. The current status of multidetector row CT and three-dimensional imaging of the small bowel. Radiol Clin North Am 2003; 41:199.
- Schmidt S, Lepori D, Meuwly JY, et al. Prospective comparison of MR enteroclysis with multidetector spiral-CT enteroclysis: interobserver agreement and sensitivity by means of "sign-by-sign" correlation. Eur Radiol 2003; 13:1303.
- Mendelson RM, Nolan DJ. The radiological features of chronic radiation enteritis. Clin Radiol 1985; 36:141.
- Kopelman Y, Groissman G, Fireman Z. Radiation enteritis diagnosed by capsule endoscopy. Gastrointest Endosc 2007; 66:599; discussion 599.
- Shepherd NA. Pathological mimics of chronic inflammatory bowel disease. J Clin Pathol 1991; 44:726.
- Sekhon S. Chronic radiation enteritis: women's food tolerances after radiation treatment for gynecologic cancer. J Am Diet Assoc 2000; 100:941.
- Yeoh EK, Horowitz M, Russo A, et al. Gastrointestinal function in chronic radiation enteritis--effects of loperamide-N-oxide. Gut 1993; 34:476.
- Goldstein F, Khoury J, Thornton JJ. Treatment of chronic radiation enteritis and colitis with salicylazosulfapyridine and systemic corticosteroids. A pilot study. Am J Gastroenterol 1976; 65:201.
- Resbeut M, Marteau P, Cowen D, et al. A randomized double blind placebo controlled multicenter study of mesalazine for the prevention of acute radiation enteritis. Radiother Oncol 1997; 44:59.
- Baughan CA, Canney PA, Buchanan RB, Pickering RM. A randomized trial to assess the efficacy of 5-aminosalicylic acid for the prevention of radiation enteritis. Clin Oncol (R Coll Radiol) 1993; 5:19.
- Kiliç D, Egehan I, Ozenirler S, Dursun A. Double-blinded, randomized, placebo-controlled study to evaluate the effectiveness of sulphasalazine in preventing acute gastrointestinal complications due to radiotherapy. Radiother Oncol 2000; 57:125.
- Feldmeier JJ, Hampson NB. A systematic review of the literature reporting the application of hyperbaric oxygen prevention and treatment of delayed radiation injuries: an evidence based approach. Undersea Hyperb Med 2002; 29:4.
- Hill GB, Osterhout S. Experimental effects of hyperbaric oxgen on selected clostridial species. I. In-vitro studies. J Infect Dis 1972; 125:17.
- . INHIBITION OF TOXIN PRODUCTION IN CLOSTRIDIUM PERFRINGENS IN VITRO BY HYPERBARIC OXYGEN. Antonie Van Leeuwenhoek 1965; 31:181.
- Neurath MF, Branbrink A, Meyer zum Büschenfelde KH, Lohse AW. A new treatment for severe malabsorption due to radiation enteritis. Lancet 1996; 347:1302.
- Huddy JE, Patel P, Johnson MW, et al. Hyperbaric oxygen as a treatment for malabsorption in a radiation-damaged short bowel. Eur J Gastroenterol Hepatol 2006; 18:685.
- Jain G, Scolapio J, Wasserman E, Floch MH. Chronic radiation enteritis: a ten-year follow-up. J Clin Gastroenterol 2002; 35:214.
- Scolapio JS, Ukleja A, Burnes JU, Kelly DG. Outcome of patients with radiation enteritis treated with home parenteral nutrition. Am J Gastroenterol 2002; 97:662.
- Scolapio JS, Fleming CR, Kelly DG, et al. Survival of home parenteral nutrition-treated patients: 20 years of experience at the Mayo Clinic. Mayo Clin Proc 1999; 74:217.
- Gavazzi C, Bhoori S, Lovullo S, et al. Role of home parenteral nutrition in chronic radiation enteritis. Am J Gastroenterol 2006; 101:374.
- Thompson JS. Inflammatory disease and outcome of short bowel syndrome. Am J Surg 2000; 180:551.
- Galland RB, Spencer J. Surgical management of radiation enteritis. Surgery 1986; 99:133.
- Girvent M, Carlson GL, Anderson I, et al. Intestinal failure after surgery for complicated radiation enteritis. Ann R Coll Surg Engl 2000; 82:198.
- Kuroki F, Iida M, Matsui T, et al. Intraoperative endoscopy for small intestinal damage in radiation enteritis. Gastrointest Endosc 1992; 38:196.
- Turina M, Mulhall AM, Mahid SS, et al. Frequency and surgical management of chronic complications related to pelvic radiation. Arch Surg 2008; 143:46.
- Regimbeau JM, Panis Y, Gouzi JL, et al. Operative and long term results after surgery for chronic radiation enteritis. Am J Surg 2001; 182:237.
- Nakashima H, Ueo H, Shibuta K, et al. Surgical management of patients with radiation enteritis. Int Surg 1996; 81:415.
- Libotte F, Autier P, Delmelle M, et al. Survival of patients with radiation enteritis of the small and the large intestine. Acta Chir Belg 1995; 95:190.
- Dietz DW, Remzi FH, Fazio VW. Strictureplasty for obstructing small-bowel lesions in diffuse radiation enteritis--successful outcome in five patients. Dis Colon Rectum 2001; 44:1772.
- Abu-Elmagd K, Reyes J, Todo S, et al. Clinical intestinal transplantation: new perspectives and immunologic considerations. J Am Coll Surg 1998; 186:512.
- American Gastroenterological Association. American Gastroenterological Association medical position statement: short bowel syndrome and intestinal transplantation. Gastroenterology 2003; 124:1105.
- Upper gastrointestinal series
- CT scan
- Magnetic resonance enteroclysis
- Capsule endoscopy
- DIFFERENTIAL DIAGNOSIS
- MEDICAL MANAGEMENT
- Dietary recommendations
- Antidiarrheal agents
- 5-ASA drugs
- Hyperbaric oxygen
- Parenteral nutrition
- SUMMARY AND RECOMMENDATIONS