Endoscopic Treatment of Chronic Radiation
Proctopathy
Jack I. Ramage Jr, MD, and Christopher J. Gostout, MD
Radiation therapy for pelvic organ malignancy can result in
chronic radiation proctopathy with significant morbidity. Treat-
ments include medical and endoscopic techniques with surgical
intervention reserved for resistant cases. There is limited efficacy
data and no standardization of treatment regimens, which makes
therapeutic recommendations somewhat anecdotal. The more
frequently used endoscopic techniques are described in detail
with recommendations for particular patient scenarios based on
our experience.
© 2003 Elsevier Inc. All rights reserved.
B
he most commonly used endoscopic methods for control of
bleeding from chronic radiation proctopathy (CRP) are
reviewed. CRP can be a quite disabling outcome from either
external-beam radiation or brachytherapy used in the treatment
of pelvic malignancies. Morbidity includes diarrhea, impaired
defecation, rectal pain, tenesmus, incontinence, fistulas, and
bleeding. Bleeding typically presents 6 months to 1 year after
completion of radiation therapy in up to one third of these
patients.
1
Although there have been many topical treatments
attempted for mild bleeding, endoscopic coagulation tech-
niques are the most effective therapy, especially for patients
with anemia and/or transfusion dependency. Unfortunately,
well-designed randomized, placebo-controlled trials are lack-
ing and efficacy is based mainly on case series data. Studies have
neither had consistent definitions of CRP nor validated out-
come measures.
The endoscopic findings of CRP include mucosal pallor, fri-
ability, spontaneous oozing, angiectasia, and rarely ulceration
2
(Fig 1). The angiectasias are the main culprit with regards to
bleeding and typically begin at the dentate line and extend into
the distal rectum. On occasion, particularly in women, there is
sigmoid involvement that impacts treatment strategy. The his-
tology is characteristic: an obliterative endarteritis leading to
lamina propria fibrosis, mucosal ischemia, and epithelial atro-
phy.
3
General Principles
Endoscopic therapy has become the preferred treatment for
control of hematochezia that is frequent and/or the cause of
transfusion dependency. Multiple modalities are available and
include Nd:YAG and argon lasers, bipolar, monopolar and ar-
gon plasma coagulation, and formalin instillation. Characteris-
tics of the more ideal candidates for endoscopic therapy are
shown in Table 1, and measures of efficacy are shown in Table
2. Treatment is typically performed in the outpatient setting
after an initial complete colonoscopy is performed to assess
extent of involvement. A complete bowel preparation is given at
each treatment session involving bipolar or argon plasma coag-
ulation to decrease the theoretical risk of gaseous explosion.
Three critical principles apply to all endoscopic treatment
methods must be emphasized. Attention to these will improve
the outcome for both the endoscopist and the patient.
1. Endoscope selection: although it has not been formally stud-
ied, the gastroscope has several advantages. The narrow
caliber minimizes contact induced bleeding and facilitates
access to lesions close to the dentate line via increased ret-
roflexion and maneuverability.
2. Coagulation energy: minimizing coagulating energy is the
most important technical point of thermal therapies to help
avoid creation of deep, slowly resolving problematic ther-
mal ulcers as well as strictures. Bleeding from the margins of
these ulcers can exceed that from the CRP before treatment
and is not amenable to supplemental endoscopic therapy.
Significant rectal and perineal pain is often present as well.
Similarly, overtreatment should be avoided when coagu-
lated areas bleed as thermally induced edema, which ap-
pears within minutes, often stops the bleeding. The end-
point should be a uniform white coagulum and not a dark
eschar (Figs 2 and 3).
3. Complete treatment: all angiectasias should be treated in
any single session. Changing the patient’s position and fre-
quent washing and suctioning of blood and clot facilitate
this. More dependent areas should be treated first followed
by more proximal lesions (Fig 4). These maneuvers also
From the Division of Gastroenterology and Hepatology, Mayo Clinic,
Rochester, MN.
Address reprint requests to Jack I. Ramage, Jr, MD, Division of
Gastroenterology and Hepatology, Mayo Clinic, 200 First St SW, Roch-
ester, MN 55905.
© 2003 Elsevier Inc. All rights reserved.
1096-2883/03/0504-0003$30.00/0
doi:10.1053/j.tgie.2003.10.007
TABLE 2. Measurements of Efficacy
Decreased rectal bleeding
Reduced transfusion requirements
Increased hemoglobin level
Improved endoscopic appearance
Improved patient quality of life
TABLE 1. Ideal Candidates for Endoscopic Therapy
Chronic hematochezia
Refractory to medical management
Transfusion dependency Ն 6 months
No tumor recurrence
No active non-rectal bleeding source
No post-radiation fistula, ulceration or strictures
Techniques in Gastrointestinal Endoscopy, Vol 5, No 4 (October), 2003: pp 155-159
155