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 intestines, is often progressive, and may lead to a variety of clinical consequences depending upon the extent of the injury. It usually develops three or more months after radiation therapy. 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 include nausea, vomiting, abdominal pain, 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 intestine and proximal colon. The pathogenesis, clinical manifestations, and risk factors for chronic radiation enteritis and other radiation-related gastrointestinal toxicities are discussed separately. (See "Overview of gastrointestinal toxicity of radiation therapy" and "Clinical manifestations, diagnosis, and treatment of radiation proctitis".)
The diagnosis of chronic radiation enteritis is suspected in patients with nausea, vomiting, abdominal pain, diarrhea, or lower gastrointestinal bleeding three or more months after completion of radiation therapy. The diagnosis is usually established by segmental bowel inflammation in regions of a known radiation field on imaging or by endoscopy and histology.
Diagnostic approach — Evaluation of a patient with suspected chronic radiation enteritis serves to exclude other causes of etiologies, establish the diagnosis of chronic radiation, and determine the extent of the disease.
●The patient's prior radiation treatment should be reviewed to determine the cumulative dose, dose per fraction, proximity of sensitive tissues and organs, and other cancer treatments (eg, abdominal surgery, concurrent chemotherapy) that can increase the risk of radiation enteritis. This may help to determine which intestinal segments may have received excessive radiation exposure, which can then be correlated with the radiologic findings and the clinical presentation.
- 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.
- 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.
- Nolan DJ. The true yield of the small-intestinal barium study. Endoscopy 1997; 29:447.
- Kopelman Y, Groissman G, Fireman Z. Radiation enteritis diagnosed by capsule endoscopy. Gastrointest Endosc 2007; 66:599; discussion 599.
- Tian C, Mehta P, Shen B. Endoscopic Therapy of Bleeding from Radiation Enteritis with Hypertonic Glucose Spray. ACG Case Rep J 2014; 1:181.
- Sekhon S. Chronic radiation enteritis: women's food tolerances after radiation treatment for gynecologic cancer. J Am Diet Assoc 2000; 100:941.
- 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.
- Yeoh EK, Horowitz M, Russo A, et al. Gastrointestinal function in chronic radiation enteritis--effects of loperamide-N-oxide. Gut 1993; 34:476.
- Phillips F, Muls AC, Lalji A, Andreyev HJ. Are bile acid malabsorption and bile acid diarrhoea important causes of loose stool complicating cancer therapy? Colorectal Dis 2015; 17:730.
- 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.
- 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.
- Lauro A, Zanfi C, Ercolani G, et al. Italian experience in adult clinical intestinal and multivisceral transplantation: 6 years later. Transplant Proc 2007; 39:1987.
- 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.
- 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.
- Boland E, Thompson J, Rochling F, Sudan D. A 25-year experience with postresection short-bowel syndrome secondary to radiation therapy. Am J Surg 2010; 200:690.