Administration of modified Gegen Qinlian decoction for hemorrhagic chronic radiation proctitis: A case report and review of literature

BACKGROUND Hemorrhagic chronic radiation proctitis(CRP) is a common late complication of irradiation of the pelvis and seriously impairs life quality. There is no standard treatment for hemorrhagic CRP. Medical treatment, interventional treatment, and surgery are available, but they are limited in their applications due to nondefinite efficacy or side effects. Chinese herbal medicine(CHM), as a complementary or alternative therapy, may provide another option for hemorrhagic CRP treatment.CASE SUMMARY A 51-year-old woman with cervical cancer received intensity-modulated radiation therapy and brachytherapy with a total dose of 93 Gy fifteen days after hysterectomy and bilateral adnexectomy. She received six additional cycles of chemotherapy with carboplatin and paclitaxel. Nine months after radiotherapy treatment, she mainly complained of 5-6 times diarrhea daily and bloody purulent stools for over 10 d. After colonoscopy examinations, she was diagnosed with hemorrhagic CRP with a giant ulcer. After assessment, she received CHM treatment. The specific regimen was 150 mL of modified Gegen Qinlian decoction(GQD) used as a retention enema for 1 mo, followed by replacement with oral administration of 150 mL of modified GQD three times per day for 5 mo. After the whole treatment, her diarrhea reduced to 1-2 times a day. Her rectal tenesmus and mild pain in lower abdomen disappeared. Both colonoscopy and magnetic resonance imaging confirmed its significant improvement. During treatment,there were no side effects, such as liver and renal function damage.CONCLUSION Modified GQD may be another effective and safe option for hemorrhagic CRP patients with giant ulcers.

"External main and internal auxiliary" treatment on refractory radiation proctitis

Radiotherapy is an essential method in the comprehensive treatment of malignant tumors.However,radiation proctitis(RP)is a common complication of pelvic tumors after radiotherapy.Due to RP's various etiology and complex pathogenesis,it is currently no standard for traditional Chinese medicine(TCM)treatment.Professor Yuan-hong Zhao believes that refractory RP,which is named chronic hemorrhagic radiation proctitis(CHRP),should be classified as"Intestinal Wind Bleeding"(Bleeding like a note before defecation,bright red blood,no swelling and pain in the anus)and"Intestinal Afflux"(Refers to the symptoms of pus and blood in the lower mucus,similar to ulcerative colitis,peptic ulcer and other diseases in modern medicine.)in TCM.The critical pathogenesis of CHRP lies in local stasis and collaterals injury of intestinal collaterals.In general,it is a syndrome of excess and scarcity.External treatment with TCM is the preferred treatment strategy for CHRP,and the primary way is to disperse blood stasis and detoxify and nourish the intestinal collaterals.

Histopathological comparison of topical therapy modalities for acute radiation proctitis in an experimental rat model

AIM： To evaluate the prevalent topical therapeutic modalities available for the treatment of acute radiation proctitis compared to formalin. METHODS： A total of 120 rats were used. Four groups （n = 30） were analyzed with one group for each of the following applied therapy modalities： control, mesalazine, formalin, betamethasone, and misoprostol. A single fraction of 17.5 Gy was delivered to each rat. The rats in control group rats were given saline, and the rats in the other three groups received appropriate enemas twice a day beginning on the first day after the irradiation until the day of euthanasia. On d 5, 10, and 15, ten rats from each group were euthanized and a pathologist who was unaware of treatment assignment examined the rectums using a scoring system. RESULTS： The histopathologic scores for surface epithelium, glands （crypts） and lamina propria stroma of the rectums reached their maximum level on d 10. The control and formalin groups had the highest and mesalazine had the lowest, respectively on d 10. On the 15^th d, mesalazine, betamethasone, and misoprostol had the lowest scores of betamethasone. CONCLUSION： Mesalazine, betamethasone, and misoprostol are the best topical agents for radiation proctitis and formalin has an inflammatory effect and should not be used.

Endoscopic management of chronic radiation proctitis

Chronic radiation proctopathy occurs in 5%-20% of patients following pelvic radiotherapy. Although many cases resolve spontaneously,some lead to chronic symptoms including diarrhea,tenesmus,urgency and persistent rectal bleeding with iron deficiency anemia requiring blood transfusions. Treatments for chronic radiation proctitis remain unsatisfactory and the basis of evidence for various therapies is generally insuff icient. There are very few controlled or prospective trials,and comparisons between therapies are limited because of different evaluation methods. Medical treatments,including formalin,topical sucralfate,5-amino salicylic acid enemas,and short chain fatty acids have been used with limited success.Surgical management is associated with high morbidity and mortality. Endoscopic therapy using modalities such as the heater probe,neodymium:yttrium-aluminium-garnet laser,potassium titanyl phosphate laser and bipolar electrocoagulation has been reported to be of some benef it,but with frequent complications.Argon plasma coagulation is touted to be the preferred endoscopic therapy due to its eff icacy and safety profile.Newer methods of endoscopic ablation such as radiofrequency ablation and cryotherapy have been recently described which may afford broader areas of treatment per application,with lower rate of complications.This review will focus on endoscopic ablation therapies,including such newer modalities,for chronic radiation proctitis.

Thalidomide effect in endothelial cell of acute radiation proctitis

AIM: To determine whether thalidomide prevents microvascular injury in acute radiation proctitis in white rats. METHODS: Fourteen female Wistar rats were used: six in the radiation group, six in the thalidomide group, and two in normal controls. The radiation and thalidomide groups were irradiated at the pelvic area using a single 30 Gy exposure. The thalidomide (150 mg/kg) was injected into the peritoneum for 7 d from the day of irradiation. All animals were sacrificed and the rectums were removed on day 8 after irradiation. The microvessels of resected specimens were immunohistochemically stained with thrombomodulin (TM), von Willebrand Factor (vWF), and vascular endothelial growth factor (VEGF). RESULTS: The microscopic scores did not differ significantly between the radiation and thalidomide groups, but both were higher than in the control group. Expression of TM was significantly lower inthe endothelial cells (EC) of the radiation group than in the control and thalidomide groups (P < 0.001). The number of capillaries expressing vWF in the EC was higher in the radiation group (15.3 ± 6.8) than in the control group (3.7 ± 1.7), and the number of capillaries expressing vWF was attenuated by thalidomide (10.8 ± 3.5, P < 0.001). The intensity of VEGF expression in capillaries was greater in the radiation group than in the control group and was also attenuated by thalidomide (P = 0.003). CONCLUSION: The mechanisms of acute radiation- induced proctitis in the rats are related to endothelial cell injury of microvessel, which may be attenuated with thalidomide.

Hyperbaric oxygen therapy as a complementary treatment for radiation proctitis:Useless or useful?-A literature review

Radiotherapy(RT)is the backbone of multimodality treatment of more than half of cancer cases.Despite new modern RT techniques,late complications may occur such as radiation proctitis(RP).The natural history of RP is unpredictable.Minor symptoms may resolve spontaneously or require conservative treatment.On the other hand,for similar and uncomplicated clinical contexts,symptoms may persist and can even be refractory to the progressive increase in treatment measures.Over the last decades,an enormous therapeutic armamentarium has been considered in RP,including hyperbaric oxygen therapy(HBOT).Currently,the evidence regarding the impact of HBOT on RP and its benefits is conflicting.Additional prospective and randomised studies are necessary to validate HBOT’s effectiveness in the‘real world’clinical practice.This article reviewed the relevant literature on pathophysiology,clinical presentation,different classifications and discuss RP management including a proposal for a therapeutic algorithm with a focus on HBOT.

Qing Dai, a traditional Chinese medicine for the treatment of chronic hemorrhagic radiation proctitis

Objective： To evaluate the efficacy and safety of Qing Dai （indigo naturalis）, a traditional Chinese medicine, in the treatment for chronic hemorrhagic radiation proctitis. Methods： Ten patients with chronic hemorrhagic radiation proctitis between January 2005 to January 2008 were treated with Qing Dai. Qing Dai was administered orally at a dose of 1.5 g, bid for 5 consecutive days, every 2 weeks for two courses. Patients were followed up every 3 months. The clinical response and side-effects were evaluated. Results： Six patients showed improvement of rectal bleeding to grade 0-1 after 1 course of Qing Dai therapy. Four patients had reduced rectal bleeding to grade 0-1 after 2 courses of the therapy. The median follow-up time was 10 months （range： 6-24）. During the follow-up period, 1 patient experienced recurrent rectal bleeding and was managed with topical formalin dabbing, which controlled the symptom. No treatment toxicity was observed. Conclusion： Qing Dai may be a safe and effective treatment for chronic hemorrhagic radiation proctitis.

Efficacy and safety of berberine in the prophylactic treatment of acute radiation proctitis in postoperative patients with cervical cancer:a randomized controlled study

Objective The aiom of this study was to study the efficacy and safety of berberine as a prophylactic treatment of acute radiation proctitis in postoperative patients with cervical cancer.Methods A total of 120 postoperative patients with cervical cancer were enrolled between July 2016 and October 2019,and randomly divided into a treatment group(berberine 300 mg three times a day,n=60)and a control group(receiving vitamin C tablets,100 mg three times a day;n=60)using the random number table method.All patients received pelvic intensity-modulated radiation therapy(IMRT)and concurrent sensitizing chemotherapy weekly.The difference in the percentage of irradiation volume to the rectum and small intestine as well as the incidence,onset time,severity,and duration of acute radiation proctitis and cystitis during radiotherapy were compared between the two groups.The completion rate,completion time,number of chemotherapy sessions,and quality of life during radiotherapy were also compared.Results There were no statistical differences in age,FIGO stage,pathological type,complications,highrisk factors,and rectum and small intestine irradiation dose distribution(V20,V30,V40,and V50)between the two groups(P>0.05).No acute radiation proctitis of grade 3 or above occurred in the two groups.There was no significant difference in the incidence of acute radiation cystitis,grade 2 acute radiation proctitis,completion rate of IMRT,and frequency of sensitization chemotherapy between the two groups.After prophylactic treatment with berberine,the incidence of grade 1 acute radiation proctitis,occurrence of grade 1 radiation proctitis,and completion time of radiotherapy in the treatment group were significantly lower than those in the control group(P<0.05).The SF-36 score of the treatment group after radiotherapy was 67.53±4.21,which was significantly better than that of the control group(64.90±6.32;P<0.05).The incidence of grade 3-4 neutropenia in the treatment group was 10%and lower than that in the control group(31.7%,P=0.003).No adverse reactions related to berberine were observed.Conclusion Prophylactic prescription with oral berberine can reduce the incidence,onset time,and duration of grade 1 acute radiation proctitis,and improve the quality of life of postoperative patients with cervical cancer receiving concurrent chemoradiotherapy.

A Meta-Analysis of Treating Radiation Proctitis by Retention Enema with Integrated Traditional Chinese and Western Medicine

Objective:To systematically and objectively evaluate clinical efficacy of retention enema with integrated traditional Chinese and western medicine on radiation proctitis(RP).Methods:CNKI,WANFANG,VIP,CMB and foreign language databases like Embase,Central and Medline were searched.Search dates were from establishment of the databases until May 2020.Randomized controlled trials(RCTs)of retention enema with integrated traditional Chinese and western medicine for RP were retrieved.Two system reviewers selected literature materials,extracted literature data,and evaluated the quality of the literatures.RevMan 5.3 software was used for data analysis.Results:A total of 12 studies were included,including 941 patients.Meta-analysis results showed:Clinical efficacy in the retention enema group with integrated traditional Chinese and western medicine was better than that in the simple western medicine enema or blank enema group(OR=5.96,95%CI[5.50,14.29],P<0.00001).Improvement of abdominal pain in the retention enema group with integrated traditional Chinese and western medicine was better than that in the control group(MD=-0.57,95%CI[-0.72,-0.42],P<0.00001).Treatment for hematochezia in the retention enema group with integrated traditional Chinese and western medicine was better than that in the control group(MD=-0.55,95%CI[-0.69,-0.42],P<0.00001).Improvement of diarrhea in the retention enema group with integrated traditional Chinese and western medicine was better than that in the control group(MD=-0.69,95%CI[-0.91,-0.48],P<0.00001).KPS scores in the retention enema group with integrated traditional Chinese and western medicine were better than those in the control group(MD=11.91,95%CI[3.81,20.01],P<0.00001).Conclusion:Clinical efficacy of retention enema with integrated traditional Chinese and western medicine on RP is better than simple western medicine enema or blank enema.Due to the low quality of the included clinical literatures,it is necessary to carry out more deliberate,detailed,high-quality,randomized,double-blind,and multi-center RCTs in order to give more powerful demonstration on its clinical efficacy on RP.

Treatment of severe radiation proctitis with high dosage of vitamin C in combination with cyclooxygenase-2 inhibitor

Objective:To explore the new treatment strategies for radiation proctitis,which is the most common complication of pelvic tumor malignancies.Methods:Four cases of patients with severe radiation proctitis were treated with high-dosage vitamin C(VC,12–24 g/d,iv)combined with cyclooxygenase-2(cyclooxygenase-2,COX-2)inhibitors.Results:For these four cases,the diarrhea,hematochezia,tenesmus,pain,and other symptoms were significantly improved.The edema of the rectal wall is also significantly improved in the imaging review.Conclusion:The high-dosage VC combined with the treatment of severe radiation proctitis is safe and effective.

Safety and Efficacy of Qingre Buyi Decoction(清热补益煎剂)in the Treatment of Acute Radiation Proctitis:A Prospective,Randomized and Controlled Trial

Objective:To investigate the efficiency,safety,and possible mechanisms of Qingre Buyi Decoction(清热补益煎剂,QBD)in the treatment of acute radiation proctitis(ARP).Methods:This study was a single center,prospective,single blind,randomized,and placebo-controlled clinical trial.A total of 60 patients with ARP was equally and randomly distributed into the control group(conventional treatment)and the combination group(conventional treatment plus QBD).The changes of main Chinese medicine clinical symptoms and signs,in...

Diverting colostomy is an effective and reversible option for severe hemorrhagic radiation proctopathy

BACKGROUND Severe chronic radiation proctopathy(CRP) is difficult to treat.AIM To evaluate the efficacy of colostomy and stoma reversal for CRP.METHODS To assess the efficacy of colostomy in CRP,patients with severe hemorrhagic CRP who underwent colostomy or conservative treatment were enrolled.Patients with tumor recurrence,rectal-vaginal fistula or other types of rectal fistulas,or who were lost to follow-up were excluded.Rectal bleeding,hemoglobin(Hb),endoscopic features,endo-ultrasound,rectal manometry,and magnetic resonance imaging findings were recorded.Quality of life before stoma and after closure reversal was scored with questionnaires.Anorectal functions were assessed using the CRP symptom scale,which contains the following items:Watery stool,urgency,perianal pain,tenesmus,rectal bleeding,and fecal/gas incontinence.RESULTS A total of 738 continual CRP patients were screened.After exclusion,14 patients in the colostomy group and 25 in the conservative group were included in the final analysis.Preoperative Hb was only 63 g/L ± 17.8 g/L in the colostomy group compared to 88.2 g/L ± 19.3 g/L(P < 0.001) in the conservative group.All14 patients in the former group achieved complete remission of bleeding,and the colostomy was successfully reversed in 13 of 14(93%),excepting one very old patient.The median duration of stoma was 16(range:9-53) mo.The Hb level increased gradually from 75 g/L at 3 mo,99 g/L at 6 mo,and 107 g/L at 9 mo to111 g/L at 1 year and 117 g/L at 2 years after the stoma,but no bleeding cessation or significant increase in Hb levels was observed in the conservative group.Endoscopic telangiectasia and bleeding were greatly improved.Endoultrasound showed decreased vascularity,and magnetic resonance imaging revealed an increasing presarcal space and thickened rectal wall.Anorectal functions and quality of life were significantly improved after stoma reversal,when compared to those before stoma creation.CONCLUSION Diverting colostomy is a very effective method in the remission of refractory hemorrhagic CRP.Stoma can be reversed,and anorectal functions can be recovered after reversal.

Rectitis Radiation a Problem of Therapeutic Management in Senegal about Two Cases

Radiotherapy occupies an important place in the management of cancers of the pelvic-perineal organs, it is at the origin of the fact of the ionizing radiations of radiation proctitis which is most often revealed by hematochezia. Diagnosis is based on rectoscopy which highlights a telengiectatic proctitis aspect. The standard treatment is endoscopic and based on argon plasma electrocoagulation. We report two cases of radiation proctitis occurring a few months after radiotherapy. Case number 1: A 76-year-old hypertensive patient known to have a history of cancer of the cervix treated with radiochemotherapy, she was received in an array of hematochezia of medium abundance;total colonoscopy found an aspect of telengiectatic proctitis making retain radiation proctitis. She had benefited from medical treatment, however, after a two-month follow-up, there was a recurrence of rectal bleeding despite medical treatment, due to the unavailability of endoscopic treatment based on argon plasma, surgical treatment of a type of protectomy had been carried out on postoperative follow-up was marked by a regression of hemorrhage with the occurrence of a. Case number 2: An 87-year-old patient, hypertensive, with a history of prostate adenocarcinoma 3 years ago treated with brachytherapy and hormone therapy;he was hospitalized with hematochesia. Rectosigmoidoscopy found an aspect of telengiectatic proctitis. The diagnosis of radiation proctitis had been retained and the patient had received medical treatment. The short-term evolution was marked by an amendment of the hematochezia with a long-term recurrence requiring endoscopic destruction via the diathermic loop of the telengiectatic lesions with good evolution without relapse after the procedure. Conclusion: Radiation proctitis is a major side effect of pelvic radiotherapy. Management is very difficult in our regions due to the unavailability of endoscopic means, in particular argon plasma.

Rectal ulcer:Due to ketoprofen, argon plasma coagulation and prostatic brachytherapy

Prostatic brachytherapy with permanent seed implants is a recent and safe radiation therapy technique associated with radiation-induced digestive disease.Argon plasma coagulation procedure is a validated modality in the management of haemorrhagic radiation proctitis,which is known to occasionally induce chronic rectal ulcers.We report here an original case report of an acute painful rectal ulcer as a consequence of the combination of shortterm therapy with non-steroidal anti-inflammatory drugs therapy,prostatic brachytherapy with malposition of seed implants and argon plasma coagulation procedure in a patient with haemorrhagic radiation proctitis.The description of this clinical observation is essential to recommend the discontinuation of non-steroidal anti-inflammatory drugs therapy and the control of the position of seed implants in case of prostatic brachytherapy before argon plasma coagulation for radiation-induced proctitis.