Radiation proctitis

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Q) In radiation proctitis surgery is needed in all except 

a) Pain Abdomen

b) Rectal stricture

c) Haemorrhage

d) Vesical Fistula

Free Question on management of raiation proctiitis 

Ans a, 

In radiation proctitis, surgery is typically indicated for complications that are severe or unmanageable through conservative measures. The options can be considered as follows:

  • A) Pain Abdomen: While abdominal pain can be a symptom associated with radiation proctitis, it is not an indication for surgery on its own. Pain management and other conservative treatments can be employed first.
  • B) Rectal stricture: This can cause significant obstruction and may require surgical intervention to restore normal bowel function.
  • C) Haemorrhage: Severe bleeding due to radiation proctitis may necessitate surgical intervention if it is not controlled by endoscopic or conservative measures.
  • D) Vesical Fistula: The formation of a fistula between the bladder and rectum (vesical fistula) is a serious complication that often requires surgical repair.

Acute Radiation proctitis - Occurs within 6 mths of starting the treatment

Chronic - After 6 mths, Most patients develop symptoms at a median of 8 to 12 months after completion of radiotherapy

Modified Radiation Therapy Oncology Group rectal toxicity scale

Grade 1 Mild and self-limiting Minimal, infrequent bleeding or clear mucus discharge, rectal discomfort not requiring analgesics, loose stools not requiring medications
Grade 2 Managed conservatively, lifestyle (performance status) not affected Intermittent rectal bleeding not requiring regular use of pads, erythema of rectal lining on proctoscopy, diarrhea requiring medications
Grade 3 Severe, alters patient lifestyle Rectal bleeding requiring regular use of pads and minor surgical intervention, rectal pain requiring narcotics, rectal ulceration
Grade 4 Life threatening and disabling Bowel obstruction, fistula formation, bleeding requiring hospitalization, surgical intervention required

Prevention

  1. Use of newer conformal radiation therapy techniques.
  2. Amifostine is a prodrug that is metabolized to a thiol metabolite that is thought to scavenge reactive oxygen species
  3. Placebo-controlled phase III trials have detected no benefit from either topical or oral sucralfate.

Treatment  of radiation proctitis 

Medical

  1. Butyrates
  2. ASA
  3. Sucralfate
  4. Metronidazole
  5. Short chain FA
  6. Topical formalin
  7. Hyperbaric o2

Endoscopic

  1. dilatation
  2. Heater and bipolar cautrey
  3. ND YAG
  4. APC
  5. RFA

Surgery

Diverting ostomies for severe stricture - Better for incontinence, stricture and limited benefit  for bleed

Reconstruction with Flaps -  rectourethral or rectovaginal fistula with a pedunculated gracilis or a Martius flap to facilitate healing by introducing well-vascularized healthy tissue,

Proctectomy  complicated fistulous disease, especially when accompanied by significant pain and incontinence, or in cases of severe and intractable bleeding

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