OMED E-Newsletter Issue 2, 2009: Brainteaser/image of the month

This was found in the rectum of a 65 year old homosexual man complaining of bright red rectal bleeding. He admits to drinking 2-3 whiskey's per day. He does not take any medication and his only past history is of prostatic carcinoma, treated 2 years ago. There is no family history.

How would you initially manage the patient?

1. rectal steroids
2. rectal aminosalicylates
3. cautery using a heater probe or argon coagulator
4. antibiotics
5. surgical resection

Explanation

The best answer is cautery using argon plasma coagulation. The risk of acute radiation proctitis complicating radiotherapy increases with the radiation dose. Acute radiation injury can present with diarrhoea, rectal bleeding and pain. In most cases it settles spontaneously if the radiotherapy is stopped. Chronic radiation proctopathy is unrelated to the acute condition. It develops in up to 10% of cases who usually present between 6 months and 2 years following radiotherapy with bleeding, mucus discharge, diarrhea, pain, fistula or rectal stenosis. However, delayed onset has been described up until 30 years following treatment.

Histology is usually non-specific with loss of crypts, increased intimal thickening and thrombosis of submucosal arterioles mimicking ischaemic colitis.

The initial therapy should be endoscopic cautery, preferably the APC. For cases with more extensive post-radiotherapy telangiectasia, oral sucralfate, topical phenol and formalin has been described.

Sasai used oral sucralfate in three patients with radiation proctitis with a reduction in bleedingⁱ. Kochhar et alⁱⁱ compared prednisolone enemas in association with oral sulfasalazine to sucralfate enemas in 18 patients. Sucralfate was found to be more effective and better tolerated.

Topical phenol and topical instillation of formalin was originally described to treat haemorrhagic cystitisⁱⁱⁱ. Based on its success, Saclarides reported success in 12 out of 16 patients following a single instillation of 4% formalin, left in contact with the mucosa for about 30 second. However, four of the 16 patients complained of post-procedure anal pain. Faragher and Bailey^iv reported direct application of 10 percent formalin to areas of haemorrhage with a cotton-tipped applicator through a proctoscope. They performed this as an office procedure on seven patients with haemorrhagic radiation proctitis. One to four applications were necessary, but bleeding stopped in all seven patients. No significant complications were observed.

Myers et al^v studied the pathophysiology of formalin instillation in pigs. They found serum formalin levels peaked within thirty minutes and then returned to baseline, with no ill effects (at least the pigs did not complain). They also determined that formalin caused no change in rectal compliance or collagen content. Cessation of bleeding was thought to have resulted from temporary mucosal sloughing and eventual decrease in the number of mucosal blood vessels. There has been a case report of treatment of severe radiation proctitis with a combination of oestrogen-progesterone hormone therapy^vi.

Gilinsky et al^vii followed 88 patients with radiation proctitis for more than 8 years. Although most patients improved, one quarter continued to suffer symptoms.

The APC protein is a huge protein which no doubt helps to control cell division, cell attachment and preserving the chromosome number through the cell division in many different ways.

ⁱ Sasai, T, Hiraishi, H, Suzuki Y, Masuyama H et al. Treatment of chronic post-radiation proctitis with oral administration of sucralfate. American Journal of Gastroenterology 1998; 93:1593.

ⁱⁱ Kochhar R, Patel F, Dhar A et al. Radiation-Induced proctosigmoiditis. Prospective, Randomized, Double-Blind controlled Trial Of Oral Sulfasalazine Plus Rectal Steroids Versus rectal Sucralfate. Dig Dis Sci 1991; 36:103-107.

ⁱⁱⁱ Shrom SH et al. Cancer 1976;38:1785-1789.

^iv Faragher I, Bailey H. Dis Colon Rectum 1997;40:A28.

^v Myers. Dis Colon Rectum 1997;40:A28-29.

^vi Am J Gastro 1998; 93:2536-2538.

^vii Gilinsky NH, Burns DG, Barbezat GO et al. - The natural history of radiation-induced proctosigmoiditis: an analysis of 88 patients. Q J Med 1983; 52:40-53.