Download Radiation enteritis

Grand round presentation
Anthony Li
Mrs J D – 54 yrs ♀
• PC:
– diarrhoea
• HPC:
– bowels ‘not right’ for 10 yrs
– worse last 1 yr
– BO normally:
•
•
•
•
•
x3 - 4 per day
firmish
floaty
some difficulty flushing
no associated abdominal pain / PR bleeding
Mrs J D – 54 yrs ♀
• HPC:
– last 6 mths - x6 episodes of severe diarrhoea:
• BO x9 in 24 hrs
• associated with:
– diffuse abdominal pain
– vomiting x4 - 5 → unable to keep any PO intake down
– no back pain / jaundice / change of colour of urine or stool
• symptoms settle next day → feels ‘exhausted’
• no obvious precipitants
• admitted to Crawley for 48 hrs with latest attack – no Ix
performed
– weight loss of approx. 1 st
Mrs J D – 54 yrs ♀
• PMH:
–
–
–
–
sterilisation
retained placenta
tonsillectomy
Hysterectomy(endometrial ca)
• DH:
–
–
–
–
–
immodium 2 tabs tds
metoclopramide 1 tab tds
temazepam 40mg nocte
norval 30mg nocte
indomethacin 25mg tds
Mrs J D – 54 yrs ♀
• allergies:
– NKDA
• FH:
–?
• SH:
–
–
–
–
occupation - home helper
smoker - 10/day
no EtOH
x3 children at home 18yrs, 15yrs, 12yrs
Mrs J D – 54 yrs ♀
• O/E:
– General:
• thin
• no jaundice / anaemia / clubbing / lymphadenopathy
– RS:
• NAD
– CVS:
• NAD
– Breasts:
• NAD
Mrs J D – 54 yrs ♀
• O/E:
– GI:
non-distended
visible SB segmentation centrally
tender RUQ over GB - no guarding
no palpable masses
BS normal
DRE:
tender left lateral pelvic wall but NAD
pale steatorrhoeic stool
Initial investigations
• sigmoidoscopy:
– 2 - 3 small telangiectases between 12 - 15 cms, otherwise normal to
15cms
• bloods:
–
–
–
–
FBC, U&Es, LFTs, Ca2+, glu – WNL
TFTs, B12, folate – WNL
Inflammotory markers- WNL
Coeliac screen - negative
• stool:
– 3 day faecal fats – marginally ↑ at 11 g/day ( up to 7.5 g/day )
– swab – no salmonella, shigella or campylobacter
• USS abdo:
– NAD – no gallstones
Further investigations
• Therapeutic trial with colestyramine did not
help
• Indomethacin withdrawal did not work
• Test for SBBO was negative
• Faecal elastase was normal
• SBFT showed-
Widespread dilated loops matted together
transverse barring from thickened valvulae conniventesstack of coin appearance
Mucosal irregularities with narrowing of lumen
IT’S ALL ABOUT THIS!
DEB GHOSH
GASTRO SPR
A 54 yr old lady presents with chronic
diarrhoea with thickened SI mucosa,
stricture and matted loops
Any Guess?
Further history
• Endometrial carcinoma treated with postop radiotherapy 10years back- weighed 6
stone at time of radiotherapy
• Severe diarrhoea two weeks post
radiotherapy lasting for couple of weeks
• Mild symptoms only for next ten years
LATE ONSET RADIATION ENTERITIS
OVERVIEW OF MANAGEMENT OF DIARRHOEA FOR NON GASTROENTEROLOGIST
What is diarrhoea?
• Abnormal passage of 3 or more loose or
liquid stools per day for > 4weeks and / or
a daily stool weight greater than 200g/day
1001 causes of Chronic diarrhoea
Major causes
• Irritable bowel
syndrome
• Inflammatory bowel
disease
• Chronic infections
• Malabsorption
syndromes
Typical symptoms, normal exam and
normal screening blood tests- no
further investigations needed
Major causes
• Irritable bowel
syndrome
• Inflammatory bowel
disease
• Chronic infections
• Malabsorption
syndromes
Major causes
•
Irritable bowel
syndrome
• Inflammatory bowel
disease
• Chronic infections
• Malabsorption
syndromes
Minor causes
•
•
•
•
•
Ischaemic colitis
Drugs
Neoplastic
Motility disorders
Radiation enteritis
Incidence of ischemic colitis at various
locations (%)
•
Descending colon
37
•
Splenic flexure
33
•
Sigmoid colon
24
•
Transverse colon
9
•
Ascending colon
7
•
Rectum
3
Minor causes
•
•
•
•
•
Ischaemic colitis
Drugs
Neoplastic
Motility disorders
Radiation enteritis
Minor causes
Lymphoma
•
•
•
•
•
Ischaemic colitis
Drugs
Neoplastic
Motility disorders
Radiation enteritis
Villous adenoma
Gastrinoma
VIPoma
carcinoid
Minor causes
•
•
•
•
•
Ischaemic colitis
Drugs
Neoplastic
Motility disorders
Radiation enteritis
Post surgical statesvagotomy/gastrectomy
EndocrineDM/Hyperthyroidism/carcinoid
Infiltrative SI diseasescleroderma
OCTTBa studies
Radionucleotide scintigraphy
Minor causes
•
•
•
•
•
Ischaemic colitis
Drugs
Neoplastic
Motility disorders
Radiation enteritis
Radiation of more than 50Gy
Ileum and rectum mostly
Mucosal damage and SBBO
Malabsorption
Luminal phase
1.
2.
3.
4.
5.
Gastric surgery
Chronic pancreatitis
Cystic fibrosis
Bile acid malabsorption
Bacterial overgrowth
Mucosal phase
1.
2.
3.
4.
5.
Coeliac disease
Whipple disease
Lactose intolerence
Intestinal resection
Ileal disease
Malabsorption
Luminal phase
1.
2.
3.
4.
5.
Gastric surgery
Chronic pancreatitis
Cystic fibrosis
Bile acid malabsorption
Bacterial overgrowth
Mucosal phase
1.
2.
3.
4.
5.
Coeliac disease
Whipple disease
Lactose intolerence
Intestinal resection
Ileal disease
Malabsorption
Luminal phase
1.
2.
3.
4.
5.
Gastric surgery
Chronic pancreatitis
Cystic fibrosis
Bile acid malabsorption
Bacterial overgrowth
Mucosal phase
1.
2.
3.
4.
5.
Coeliac disease
Whipple disease
Lactose intolerence
Intestinal resection
Ileal disease
Malabsorption
Luminal phase
1.
2.
3.
4.
5.
Gastric surgery
Chronic pancreatitis
Cystic fibrosis
Bile acid malabsorption
Bacterial overgrowth
Mucosal phase
1.
2.
3.
4.
5.
Coeliac disease
Whipple disease
Lactose intolerence
Intestinal resection
Ileal disease
Malabsorption
Luminal phase
1.
2.
3.
4.
5.
Gastric surgery
Chronic pancreatitis
Cystic fibrosis
Bile acid malabsorption
Bacterial overgrowth
Mucosal phase
1.
2.
3.
4.
5.
Coeliac disease
Whipple disease
Lactose intolerence
Intestinal resection
Ileal disease
Malabsorption
Luminal phase
1.
2.
3.
4.
5.
Gastric surgery
Chronic pancreatitis
Cystic fibrosis
Bile acid malabsorption
Bacterial overgrowth
Mucosal phase
1.
2.
3.
4.
5.
Coeliac disease
Lactose intolerence
Intestinal resection
Ileal disease
Whipple disease
Understanding of patient’s complain of diarrhoea
1.
consistency
2.
frequency of stools
3.
urgency or faecal soiling
Stool characteristics
1.
presence of visible blood- IBD or cancer
2.
greasy stools that float and are malodorous -fat malabsorption
– Duration of symptoms, nature of onset (sudden or
gradual)
– The volume of the diarrhoea
1. voluminous watery diarrhoea -small bowel
2. small-volume frequent diarrhoea -colon
– Occurrence of diarrhoea during fasting or at nightsecretory or organic diarrhoea
•Travel history
•Risk factors for HIV infection
•Family history of IBD
•Weight loss
•Systemic symptoms as fevers, joint pains, mouth ulcers, eye
redness-IBD
•Previous therapeutic interventions- surgery and radiotherapy
•A relevant dietary (sugar free products containing sorbitol and
use of alcohol)
•All medications (including over-the-counter drugs and
supplements)
•Association of symptoms with specific food ingestion (such as
dairy products or potential food allergens)
•A sexual history
•anal intercourse-infectious proctitis
•promiscuous sexual activity -HIV infection
Physical examination
rarely provides a specific diagnosis.
•
Findings suggestive of IBD (eg, mouth ulcers, a skin rash, episcleritis, an anal
fissure or fistula, the presence of visible or occult blood on digital examination,
•
Abdominal masses or abdominal pain,
•
Evidence of malabsorption (such as wasting, physical signs of anemia, scars
indicating prior abdominal surgery),
•
Lymphadenopathy (possibly suggesting HIV infection), and
•
Abnormal anal sphincter pressure or reflexes (possibly suggesting fecal
incontinence).
•
Palpation of the thyroid and examination for exopthalmus and lid retraction
may provide support for a diagnosis of hyperthyroidism.
Basic laboratory evaluation
•
•
•
•
•
•
•
FBC
Thyroid function tests
ESR/CRP
U/E
Total protein and albumin, and
Ferritin/ folate/B12/Ca
Stool culture and microscopy
Further investigation as per BSG
protocol
History or Findings suggestive of
MALABSORPTION
Small bowel
Pancreatic
CT Pancreas
Faecal elastase
Coeliac screen
D2 biopsy
BaFT
Enteropathy
Review histology
Enteroscopy or capsule endoscopy
Bacterial overgrowth
Glucose hydrogen breath test
Jejunal aspirate and culture
Further structural tests
ERCP or MRCP
Further investigation as per BSG
protocol
History or Findings suggestive of
Colonic or terminal ileal disease
Flexible sigmoidoscopy if <45
Complement with Ba enema if >45
Colonoscopy preferred if >45
Terminal ileal disease excluded?
Ba FT
99mTc HMPAO
75SeHCAT
Further investigation as per BSG
protocol
Difficult diarrhoea
Inpatient assessment
24-72 hour stool weights
Stool osmotic gap
Laxative screen
Gut hormone
Serum gastrin
VIP
Urinary 5 - HIAA
Treatment
• General measures:
– Hydration and electrolyte balance
– Vitamins supplements
– Loperamide (also improves bile acid absorption )
• Therapeutic trials
–
–
–
–
–
–
–
Colestyramine for BAM
Lactose free diet
Antibiotics for SBBO
For bleeding from proctitis in RE
Stool softener
Argon plasma coagulation
Formalin irrigation ( experimental )
RADIATION ENTEROCOLITIS
Dr.E.M.Phillips
Historical aspects
Self exposure
Deep tissue traumatisation from Roentgen ray exposure
Walsh,D: Br Med J 1897: 272 – 273
Animal experiments
Roentgen ray intoxication. Warren S, Whipple GH:
J Exp Med 1922: 35: 187 – 202
Post radiotherapy pathology
38 patients
Warren S, Friedman NB: Pathology and pathological diagnosis of
radiation lesions in the gastrointestinal tract: Am J Path 1942: 499 – 513
1950s super voltage therapy
100 patients
DeCosse JJ et al. Natural history & management of radiation induced
injury of the gastrointestinal tract Ann Surg 1969; 170: 369 - 384
Symptoms
Early
During therapy and up to six
months
Late
Five to 31 years after radiotherapy
Peak onset 12 – 15 years after
Early
Symptoms
Diarrhoea
Colic
Nausea
Mucosal Pathology
Decrease:
enterocyte turnover &
villous height
Increase:
enterocyte death;
mucosal oedema &
inflammatory infiltrate
with mucosal slough
Acute radiation proctitis
Inflamm infiltrate
and oedema
Withering of crypts
Cystic dilatation of crypt
Late
Symptoms
Pathology
SB
Arteriolar
Diarrhoea/malabsorp’n endothelial spasm,
damage &
Blind loop syndrome
obliterative vasculitis
Subacute obstruction
Submucosa
to
serosa
Colon tenesmus &
ischaemia, ulceration,
mucus
and perforation;
Both haemorrhage,
increase in bizarre
fistula
fibroblasts; stricture,
perforation
webs and fistula
Chronic Radiation Proctitis
Vascular ectasia
Thickening of lamina propria
with fibrosis
Associated factors
Causal
Radiotherapy
• High dose DXT
• Total volume gut
irradiated (e.g. paraaortic nodes incl.)
• Low body weight
Surgery
• Adhesions
Also relates to severity
of in-therapy toxicity
Not associated
Vascular risk factors:
Diabetes
Hypertension
Dyslipidaemias
(Smoking??)
Concomitant chemo.
Pelvic sepsis
Dose of rads. & damage
Minimal tolerated dose
gives 5% radiation enterocolitis within 5 years:
SB
Trans. colon rectosig.
Rads.
4000
5500
5000
Increased
Rads. for 6000
7500
7000
high risk
tumour
Gives 50% radiation enterocolitis within 5 years
Roswit B et al. Amer. J Roentgenology 1972; 114: 460
Surgery & radiation damage
Chronic radiation ileitis
n=97
Surgery
Nil
1 op.
2 op.
3 op.
Ileitis %
2.2
10.1
22.2
50
Daly NJ et al. Radiother Oncol. 1989 14(4): 287 - 95
Majority of patients with
radiation enterocolitis
are tumour free
Prognosis of Rad. enterocolitis
ca. 30% may come to surgery: complications:Anastomotic leak 65 – 100%
Range Morbidity
11 – 65%
Range Mortality
0 – 45%
4 review articles: 1979, 1983, 1986, 1991
Outcome improved by attention to detail:
• Make anastomosis without clamps
• Vessels at cut ends to be pulsatile
• Anastomosis tension free with omental wrap
• Defunctioning stoma above for at least 1 year
Recent case report in GUT Nov
2005
• Late intestinal toxicity in form of ischaemia and
stricture formation is seen in 5% of cases of
radiation treatment for intraabdominal
malignancy
• 40 year old presented with recurrent bowel obs
with normal BaFT was found to have web
formation by capsule endoscopy
• Ach induced dilatation in radiated small bowel
was reduced because of endothelial dysfunction
THANK YOU