Radiation enteritis is an intestinal complication of pelvic, abdominal, and retroperitoneal malignancies caused by radiation therapy. It can involve the small intestine, colon and rectum, respectively, so it is also called radioactive proctitis, colitis and small intestitis. According to the urgency of the onset, the radiation disease is generally divided into acute and chronic. The acute cases mostly occur during the emission treatment or after 2 weeks of receiving the emission treatment. The disease belongs to the category of “violent diarrhea or prolonged drainage” in Chinese medicine. The diagnosis of radiation enteritis is generally not difficult with a history of radiation therapy combined with clinical manifestations and relevant examinations can determine the nature and location of the lesion to clearly diagnose the advanced manifestations of radiation enteritis and the recurrence and metastasis of cancer, requiring barium x-ray examination of the mesenteric angiography endoscopy biopsy for differentiation
I. Diagnostic points
1.History of obvious emission treatment.
2.Symptoms
(1) Early symptoms: Due to the reaction of the nervous system to radiation, symptoms of gastrointestinal tract can appear at an early stage. They usually appear within 1 to 2 weeks after the start of radiotherapy. The main symptoms are abdominal pain, diarrhea, mucus and blood stools, and those involving the rectum are accompanied by shortness of breath. There is also nausea, vomiting, loss of appetite, and leukopenia. Persistent blood in the stool may cause iron deficiency anemia. Constipation is rare. Occasionally, there is a low fever. Spasmodic abdominal pain suggests small intestine involvement, and sigmoidoscopy reveals mucosal edema, congestion, and in severe cases, erosion or ulceration.
(2) Late symptoms: If the symptoms in the acute stage are prolonged or significant until 6 months to several years after the end of radiotherapy, it indicates the continuation of the lesion, which will eventually develop to cause fibrosis or stenosis. Symptoms during this period can occur as early as six months after radiotherapy or as late as 10 or even 30 years later, and are mostly related to vasculitis of the intestinal wall as well as to the continuation of the lesion.
The manifestations of colitis and proctitis often appear 6 to 18 months after irradiation, with the main symptoms using diarrhea, blood in the stool, mucus stool and urgency, thinning of the stool and progressive constipation or the appearance of abdominal pain suggesting the occurrence of intestinal stricture. Severe lesions with adjacent organs form fistulas for radiation enteritis, such as rectovaginal fistula fecal discharge from the vagina; rectal bladder may show pneumaturia; rectal small bowel fistula may show celiac disease mixed with fecal discharge, or peritonitis peritoneum due to intestinal perforation. Intestinal obstruction can occur due to narrowing of the intestine and entanglement of intestinal collaterals. If the small intestine is severely damaged by radiation, severe abdominal pain, nausea and vomiting, and bloody diarrhea may occur. However, the late manifestation is dominated by digestive malabsorption, accompanied by intermittent abdominal pain, fatty diarrhea, wasting, weakness, anemia, etc.
3.Signs
In the early stage or in the case of mild injury, there may be no special findings on finger examination. There may also be only anal sphincter contracture and tenderness. In some cases, the anterior rectal wall may be edematous, thickened and hardened, and the finger stained with blood. Sometimes ulcers, strictures or fistulas may be palpable, and in cases of severe rectal damage, rectovaginal fistulas may form. Vaginal examination can help in diagnosis.
4.Auxiliary examination
Fiberoptic colonoscopy: the lesions seen are divided into 4 degrees.
Degree 1: rectal and colonic mucosa can be seen as mild congestion, edema, capillary dilatation, and easy bleeding;
Degree 2: ulcer formation in the intestinal mucosa, with gray-white crust, necrosis of the mucosa, and sometimes mild stenosis;
Grade 3: severe narrowing of the intestinal lumen and obstruction;
X-ray examination: barium examination of the intestine can help to determine the extent and nature of the lesion. However, the signs are not specific.
Clinical classification
1, light systemic no obvious symptoms, Jin anal burning pain, urgency, increased frequency of stool, mainly mucus stool, less blood stool, colonoscopy can be seen in the rectal mucosa congestion edema.
2, medium-sized moderate anemia, wasting, more frequent stools, anal cramps and abdominal pain, more mucus and blood stools, rectal mucosal erosion and debridement, superficial small mucosal ulcers.
3.Heavy anal pain, more bloody stools, less mucus stools, accompanied by severe anemia and emaciation, prolapse of rectal mucosa and granuloma, or see deeper ulcers in the mucosa, or see semi-annular fibrosis rectal stenosis, defecation difficulties.
Third, the principle of treatment
Conservative treatment is the main treatment, only in the presence of life-threatening surgical aspects of serious complications, and by the system of regular conservative treatment is ineffective, before prudent consideration of surgical treatment.
1.Chinese medicine treatment.
(1) Damp-heat infusion treatment is recommended to clear damp-heat, regulate Qi and blood flow, and the formula is based on Scutellaria Tang plus or minus.
(2) The treatment of cold dampness should be warming up the cold dampness, and the formula should be added or subtracted according to Stomach Ling Tang.
(3) Weakness of the spleen and stomach should be treated by strengthening the spleen and benefiting the qi, nourishing the blood and stopping bleeding.
(4) For deficiency of both qi and blood, it is recommended to nourish qi and blood, using Bajhen Tang plus or minus.
2. Western medicine treatment mainly includes the following.
(1) astringent and antispasmodic: available topical eggplant combination compound camphor tincture pomegranate peel decoction (pomegranate peel 30g with water 200-300ml decoction 50ml once a day orally) aspirin can effectively control the early diarrhea of radiation enteritis may be related to the inhibition of prostaglandin synthesis.
(2) local analgesics and stool softeners: those with significant post-rash and pain can be used 2% benzocaine cottonseed oil retention enema or with warm paraffin oil retention enema or warm water sitz bath.
3, hormone enema: succinyl hydrocortisone 50mg plus 200ml of warm saline retention enema can be used for colon and rectal inflammation, especially effective in the post-acute.
4, pre-sacral closed therapy: 0.5% procaine 40ml vitamin B6100mg vitamin B1200mg alpha-chymotrypsin 2-5mg streptomycin 0.5g every 5-7 days closed 1 time treatment 1 to 3 times can make the pain significantly reduced.
5, hemostasis: low intestinal bleeding can be compressed under direct endoscopic view to stop bleeding or use hemostatic agents to stop bleeding at higher sites can be made norepinephrine 4-6mg or neofolin 10-20mg diluted in 200ml of warm saline to retain the enema or use thrombin 100-1000 units plus 200ml of warm saline to retain the enema a large number of difficult to control high bleeding need to be surgical treatment.
6.Anti-infection: antibiotics are needed when there is secondary infection.
7. α2 macroglobulin: 6ml of α2 macroglobulin is injected intramuscularly every other day or 3ml is injected intramuscularly every day for 2 months as a course of treatment. After the medication, the mucosal bleeding and pain improve significantly and the ulcer tends to heal.
IV. Prevention
1.Patients who need radiation therapy should be actively supplemented with herbal drug therapy and immunomodulatory therapy treatment to reduce the amount of radiation as much as possible.
2.The best possible irradiation position should be taken during radiotherapy to reduce the irradiation of adjacent tissues.
3.In case of complications such as radioactive proctitis, active treatment should be given in the acute stage to prevent deterioration.