Review
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Aug 21, 2016; 22(31): 6972-6986
Published online Aug 21, 2016. doi: 10.3748/wjg.v22.i31.6972
Endoscopic and non-endoscopic approaches for the management of radiation-induced rectal bleeding
Joseph Paul Weiner, Andrew Thomas Wong, David Schwartz, Manuel Martinez, Ayse Aytaman, David Schreiber
Joseph Paul Weiner, Andrew Thomas Wong, David Schwartz, David Schreiber, Department of Radiation Oncology, VA NY Harbor Healthcare System, Brooklyn Campus, Brooklyn, NY 11209, United States
Joseph Paul Weiner, Andrew Thomas Wong, David Schwartz, David Schreiber, Department of Radiation Oncology, SUNY Downstate Medical Center, Brooklyn, NY 11203, United States
Manuel Martinez, Ayse Aytaman, Department of Gastroenterology, VA NY Harbor Healthcare System, Brooklyn Campus, Brooklyn, NY 11209, United States
Manuel Martinez, Department of Gastroenterology, SUNY Downstate Medical Center, Brooklyn, NY 11203, United States
Author contributions: Weiner JP and Schreiber D equally contributed to this paper with conception and design of the review article, literature review and analysis, drafting and critical revision and editing, and final approval of the final version; Wong AT, Schwartz D, Martinez M and Aytaman A contributed to the critical revision and editing and final approval of the final version.
Conflict-of-interest statement: No potential conflicts of interest, no financial support.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: David Schreiber, MD, Department of Radiation Oncology, VA NY Harbor Healthcare System, Brooklyn Campus, 800 Poly Place, Brooklyn, NY 11209, United States. David.Schreiber@va.gov
Telephone: +1-718-6303605 Fax: +1-718-6302857
Received: March 29, 2016
Peer-review started: April 4, 2016
First decision: May 30, 2016
Revised: June 12, 2016
Accepted: July 6, 2016
Article in press: July 6, 2016
Published online: August 21, 2016
Processing time: 139 Days and 10 Hours
Abstract

Pelvic radiation is a commonly utilized treatment for malignancy of the genitourinary and lower gastrointestinal tract. Radiation proctitis and the resultant clinical picture varies from asymptomatic to potentially life threatening. Similarly, treatment options also vary greatly, from medical therapy to surgical intervention. Commonly utilized medical therapy includes sucralfate enemas, antibiotics, 5-aminosalicylic acid derivatives, probiotics, antioxidants, short-chain fatty acids, formalin instillation and fractionated hyperbaric oxygen. More invasive treatments include endoscopic-based, focally ablative interventions such as dilation, heater and bipolar cautery, neodymium/yttrium aluminum garnet argon laser, radiofrequency ablation or argon plasma coagulation. Despite its relatively common frequency, there is a dearth of existing literature reporting head-to-head comparisons of the various treatment options via a randomized controlled approach. The purpose of our review was to present the reader a consolidation of the existing evidence-based literature with the goal of highlighting the comparative effectiveness and risks of the various treatment approaches. Finally, we outline a pragmatic approach to the treatment of radiation proctitis. In light of the lack of randomized data, our goal is to pursue as least invasive an approach as possible, with escalation of care tailored to the severity of the patient’s symptoms. For those cases that are clinically asymptomatic or only mildly symptomatic, observation or medical management can be considered. Once a patient fails such management or symptoms become more severe, invasive procedures such as endoscopically based focal ablation or surgical intervention can be considered. Although not all recommendations are supported by level I evidence, reported case series and single-institutional studies in the literature suggest that successful treatment with cessation of symptoms can be obtained in the majority of cases.

Keywords: Prostate cancer; Radiation therapy; Radiation proctitis; Radiation proctopathy; Medical treatment; Endoscopic treatment; Hyperbaric oxygen; Neodymium/yttrium aluminum garnet argon laser; Argon plasma coagulation

Core tip: Rectal bleeding due to radiation proctitis is a relatively common and potentially devastating consequence of modern radiation therapy. Possible treatment options for radiation proctitis include observation, medical therapy, endoscopic-based therapy and surgery. There is a lack of data from randomized controlled trials to help inform the clinician’s decision making process with respect to treatment. Our objective is to consolidate current literature to better inform the reader of potential risks, benefits and outcomes of such treatment approaches as well as present a practical approach for the management of radiation proctitis.