Severe Procotitis from prostate radiation

[windcolour99]

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I would appreciate your advice and help on this case:
66 yo male with high risk prostate cancer, ADT then IMRT 70 GY in 28 fractions done 6 months ago. He started to have mild rectal bleeding one month ago, scoped by GI and saw tipical procotitis, started on concervative medication management, now requires hospitalization with one unit of blood infusion.

It seems there is not a concensus on next step of managment:
Despite good clinical success with endoscopic therapies, especially during an episode of active rectal bleeding, there is a lack of quality controlled studies.
13A small study comparing rectal formalin to endoscopic argon plasma coagulation (APC) therapy did show better performance of endoscopic treatment with 79% patients responding to APC compared with only 27% in the formalin group.
14Some of the endoscopic modalities used for treating vascular ectasias in the rectum include APC, radiofrequency ablation, endoscopic bipolar probe, heater probe, endoscopic lasers, and cryoablation.

The local GI physicians do not do ablation or APC.

Does any one know if there is any big center in the US offering ablation or APC? I would like to send my patient there.

After stopping the bleeding, I will set him up for hyperbaric oxygen therapy.

Thank you very much in advance.

 

[OTN]

I would appreciate your advice and help on this case:
66 yo male with high risk prostate cancer, ADT then IMRT 70 GY in 28 fractions done 6 months ago. He started to have mild rectal bleeding one month ago, scoped by GI and saw tipical procotitis, started on concervative medication management, now requires hospitalization with one unit of blood infusion.

It seems there is not a concensus on next step of managment:
Despite good clinical success with endoscopic therapies, especially during an episode of active rectal bleeding, there is a lack of quality controlled studies.
13A small study comparing rectal formalin to endoscopic argon plasma coagulation (APC) therapy did show better performance of endoscopic treatment with 79% patients responding to APC compared with only 27% in the formalin group.
14Some of the endoscopic modalities used for treating vascular ectasias in the rectum include APC, radiofrequency ablation, endoscopic bipolar probe, heater probe, endoscopic lasers, and cryoablation.

The local GI physicians do not do ablation or APC.

Does any one know if there is any big center in the US offering ablation or APC? I would like to send my patient there.

After stopping the bleeding, I will set him up for hyperbaric oxygen therapy.

Thank you very much in advance.

Our local GI docs do APC no problem- I’m surprised there’s no one nearby who can help you. I don’t think you necessarily need a large center, but maybe I’m just spoiled by our GI partners.

 

[RickyScott]

Our local GI docs do APC no problem- I’m surprised there’s no one nearby who can help you. I don’t think you necessarily need a large center, but maybe I’m just spoiled by our GI partners.

Out of curiosity, did he have diabetes? Would also give trental and vit e?

 

[theradiator]

I would appreciate your advice and help on this case:
66 yo male with high risk prostate cancer, ADT then IMRT 70 GY in 28 fractions done 6 months ago. He started to have mild rectal bleeding one month ago, scoped by GI and saw tipical procotitis, started on concervative medication management, now requires hospitalization with one unit of blood infusion.

It seems there is not a concensus on next step of managment:
Despite good clinical success with endoscopic therapies, especially during an episode of active rectal bleeding, there is a lack of quality controlled studies.
13A small study comparing rectal formalin to endoscopic argon plasma coagulation (APC) therapy did show better performance of endoscopic treatment with 79% patients responding to APC compared with only 27% in the formalin group.
14Some of the endoscopic modalities used for treating vascular ectasias in the rectum include APC, radiofrequency ablation, endoscopic bipolar probe, heater probe, endoscopic lasers, and cryoablation.

The local GI physicians do not do ablation or APC.

Does any one know if there is any big center in the US offering ablation or APC? I would like to send my patient there.

After stopping the bleeding, I will set him up for hyperbaric oxygen therapy.

Thank you very much in advance.

Conservative management includes Carafate enemas. Was that actually tried before resorting to more invasive measures? I personally never liked the idea of ablating the irradiated rectum when stool continues to pass every day.

 

[fiji128]

Most GI's in my experience will do APC in this scenario (significant blood loss requiring transfusion) without a second thought or even touching base with the treating rad onc. I would agree with it completely working about 80% of the time. The patient on various forms of anticoagulation are usually the bleeders. I have seen a rectal ulcer develop once after APC but this healed up on its own in a few months without invasive intervention.

 

[evilbooyaa]

I presume any interventional type GI would be willing to do APC. I've had one who did it on my ESRD patient on blood thinners without calling.

If your local GI docs do not offer it as a treatment, then would call around locally to find someone who does. I presume you will find someone willing to do it without issue, especially in a city. If they do ERCP they should do APC... right?

 

[seper]

I second APC.
Diverting colostomy and bowel rest is the next step.
Did you look at your plan and cone beams - anything unusual?

 

[metview]

How about HBO as well? It seems like it is recommended

Hyperbaric Treatment of Radiation Proctitis - StatPearls - NCBI Bookshelf

The American Society of Colon and Rectal Surgeons' clinical practice guidelines for the treatment of chronic radiation proctitis[2]recommend hyperbaric oxygen therapy as an effective treatment modality to reduce bleeding in patients with radiation proctitis.

 

[ramsesthenice]

How about HBO as well? It seems like it is recommended

Hyperbaric Treatment of Radiation Proctitis - StatPearls - NCBI Bookshelf

The American Society of Colon and Rectal Surgeons' clinical practice guidelines for the treatment of chronic radiation proctitis[2]recommend hyperbaric oxygen therapy as an effective treatment modality to reduce bleeding in patients with radiation proctitis.

Yes. I have done this with great success. There is a major limitation though: Medicare won’t pay for it. Hopefully they have private or supplemental.

The concerns with APC seem to have died back. Use to be a lot more hesitancy to use APC for radiation proctitis but it’s done with little hesitation now. Admittedly, results are often meh. If you have bleeding from telangiectasias it’s great and more often than not it is an immediate fix. If it’s more the ooze from a diffuse proctitis it’s rarely helpful. Formalin or sulfasalazine enemas are good as well.