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.

Colostomy is a simple and effective procedure for severe chronic radiation proctitis

AIM: To assess the efficacy and safety of diverting colostomy in treating severe hemorrhagic chronic radiation proctitis(CRP). METHODS: Patients with severe hemorrhagic CRP who were admitted from 2008 to 2014 were enrolled into this study. All CRP patients were diagnosed by a combination of pelvic radiation history, clinical rectal bleeding, and endoscopic findings. Inclusion criteria were CRP patients with refractory bleeding with moderate to severe anemia with a hemoglobin level < 90 g/L. The study group included patients who were treated by diverting colostomy, while the control group included patients who received conservative treatment. The remission of bleeding was defined as complete cessation or only occasional bleeding that needed no further treatment. The primary outcome was bleeding remission at 6 mo after treatment. Quality of life beforetreatment and at follow-up was evaluated according to EORTC QLQ C30. Severe CRP complications were recorded during follow-up.RESULTS: Forty-seven consecutive patients were enrolled, including 22 in the colostomy group and 27 in the conservative treatment group. When compared to conservative treatment, colostomy obtained a higher rate of bleeding remission(94% vs 12%), especially in control of transfusion-dependent bleeding(100% vs 0%), and offered a better control of refractory perianal pain(100% vs 0%), and a lower score of bleeding(P < 0.001) at 6 mo after treatment. At 1 year after treatment, colostomy achieved better remission of both moderate bleeding(100% vs 21.5%, P = 0.002) and severe bleeding(100% vs 0%, P < 0.001), obtained a lower score of bleeding(0.8 vs 2.0, P < 0.001), and achieved obvious elevated hemoglobin levels(P = 0.003), when compared to the conservative treatment group. The quality of life dramatically improved after colostomy, which included global health, function, and symptoms, but it was not improved in the control group. Pathological evaluation after colostomy found diffused chronic inflammation cells, and massive fibrosis collagen depositions under the rectal wall, which revealed potential fibrosis formation. CONCLUSION: Diverting colostomy is a simple, effective and safe procedure for severe hemorrhagic CRP. Colostomy can improve quality of life and reduce serious complications secondary to radiotherapy.

Formalin irrigation for hemorrhagic chronic radiation proctitis

AIM: To assess the efficacy and safety of a modified topical formalin irrigation method in refractory hemorrhagic chronic radiation proctitis(CRP). METHODS: Patients with CRP who did not respond to previous medical treatments and presented with grade II-III rectal bleeding according to the Common Terminology Criteria for Adverse Events were enrolled. Patients with anorectal strictures, deep ulcerations, and fistulas were excluded. All patients underwent flexible endoscopic evaluation before treatment. Patient demographics and clinical data, including primary tumor, radiotherapy and previous treatment options, were collected. Patients received topical 4% formalin irrigation in a clasp-knife position under spinal epidural anesthesia in the operating room. Remission of rectal bleeding and related complications were recorded. Defecation, remission of bleeding, and other symptoms were investigated at follow-up. Endoscopic findings in patients with rectovaginal fistulas were analyzed.RESULTS: Twenty-four patients(19 female, 5 male) with a mean age of 61.5 ± 9.5 years were enrolled. The mean time from the end of radiotherapy to the onset of bleeding was 11.1 ± 9.0 mo(range: 2-24 mo). Six patients(25.0%) were blood transfusion dependent. The median preoperative Vienna Rectoscopy Score(VRS) was 3 points. Nineteen patients(79.2%) received only one course of topical formalin irrigation, and five(20.8%) required a second course. No side effects were observed. One month after treatment, bleeding cessation was complete in five patients and obvious in14; the effectiveness rate was 79.1%(19/24). For longterm efficacy, 5/16, 1/9 and 0/6 patients complained of persistent bleeding at 1, 2 and 5 years after treatment, respectively. Three rectovaginal fistulas were found at 1 mo, 3 mo and 2 years after treatment. Univariate analysis showed associations of higher endoscopic VRS and ulceration score with risk of developing rectovaginal fistula. CONCLUSION: Modified formalin irrigation is an effective and safe method for hemorrhagic CRP, but should be performed cautiously in patients with a high endoscopic VRS.

Chronic haemorrhagic radiation proctitis: A review

Chronic haemorrhagic radiation proctitis(CHRP) is a difficult problem faced by the patients following radiation for pelvic malignancy. There is no standardtreatment for this condition, but many methods of treatment are available. The aim of this study was to review the literature to see whether there is an improvement in the available evidence in comparison with previously published systematic reviews in treating patients with CHRP. The Pub Med/Medline database and Google Scholar search was selectively searched. Studies, which treated patients with rectal bleeding due to chronic radiation proctitis or CHRP, were included. Seventy studies were finally selected out of which 14 were randomized controlled clinical trials. Though these studies could not be compared, it could be seen that there was an improvement in the methodology of the studies. There was an objective assessment of symptoms, signs and an objective assessment of outcomes. But, still, there were only a few studies that looked into the quality of life following treatment of CHRP. To increase recruitment to trials, a national registry of cases with established late radiation toxicity would facilitate the further improvement of such studies. Some of the conclusions that could be reached based on the available evidence are 4% formalin should be the first line treatment for patients with CHRP. Formalin and argon plasma coagulation(APC) are equally effective, but formalin is better for severe disease. Refractory patients, not responding to formalin or APC, need to be referred for hyperbaric oxygen therapy or surgery. Radio-frequency ablation is a promising modality that needs to be studied further in randomized trials.

Efficacy and complications of argon plasma coagulation for hemorrhagic chronic radiation proctitis

BACKGROUND Chronic radiation proctitis(CRP) is a complication which occurs in 1%-5% of patients who undergo radiotherapy for pelvic malignancies. Although a wide range of therapeutic modalities are available, there is no literature to date showing any particularly appropriate therapeutic modality for each disease stage. Argon plasma coagulation(APC) is currently recommended as the firstchoice treatment for hemorrhagic CRP, however, its indication based on longterm follow-up is still unclear. On the hypothesis that the long-term efficacy and safety of APC are not fully understood, we reviewed APC treatment for patients with hemorrhagic CRP from a single center.AIM To assess the long-term efficacy and safety of APC for hemorrhagic CRP.METHODS This is a retrospective study of consecutive patients treated with APC for hemorrhagic CRP from January 2013 to October 2017. Demographics, clinical variables, and typical endoscopic features were recorded independently. Success was defined as either cessation of bleeding or only occasional traces of bloody stools with no further treatments for at least 12 mo after the last APC treatment.We performed univariate and multivariate analyses to identify factors associated with success and risk factors for fistulas.RESULTS Forty-five patients with a median follow-up period of 24 mo(range: 12-67 mo)were enrolled. Fifteen(33.3%) patients required blood transfusion before APC.Successful treatment with APC was achieved in 31(68.9%) patients. The mean number of APC sessions was 1.3(1-3). Multivariate analysis showed that APC failure was independently associated with telangiectasias present on more than50% of the surface area [odds ratio(OR) = 6.53, 95% confidence interval(CI): 1.09-39.19, P = 0.04] and ulcerated area greater than 1 cm^2(OR = 8.15, 95%CI: 1.63-40.88, P = 0.01). Six(13.3%) patients had severe complications involving rectal fistulation. The only factor significantly associated with severe complications was ulcerated area greater than 1 cm^2(P = 0.035).CONCLUSION The long-term efficacy of APC for hemorrhagic CRP is uncertain in patients with telangiectasias present on > 50% of the surface area and ulceration > 1 cm^2.

Endoscopic treatments for chronic radiation proctitis

Chronic radiation proctitis is a complication that occurs in patients who receive radiation therapy for pelvic malignancies. The common presentation is with rectal bleeding, but also rectal pain, diarrhea, tenesmus and even passage of mucus can occur. The optimal treatment of bleeding due to radiation proctitis remains unclear. Among various therapeutic options, medical management is generally ineffective and surgical intervention has a high incidence of morbidity. Promising advances have been made in endoscopic therapy, including argon plasma coagulation (APC), formalin application as well as new techniques such as radio-frequency ablation and cryoablation. APC is a safe, highly effective and long-lasting therapy in patients with rectal bleeding associated with radiation proctitis. It has been shown that several sessions of APC reduce the rate of bleeding and therefore the blood transfusion requirements. Moreover, the effect of treatment is long lasting. However, best results are achieved in patients with mild to moderate radiation proctitis, leaving space for alternative treatments for patients with more severe disease. In patients with severe or refractoryradiation proctitis intra rectal formalin application is an appropriate treatment option. Radiofrequency ablation and cryoablation have shown efficacy as alternative methods in a limited number of patients with refractory chronic radiation proctitis.

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.

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.

Application of 4% formaldehyde under electronic colonoscope as a minimally invasive treatment of chronic hemorrhagic radiation proctitis

BACKGROUND: To investigate the effectiveness of topical application of 4% formaldehyde as a minimally invasive treatment of rectal bleeding due to chronic radiation proctitis(CRP) under direct vision of electronic colonoscope.METHODS: The clinical data of 13 CRP patients complicated with ≥ grade Ⅱ bleeding admitted to our hospital between January 2003 and December 2018 were retrospectively analyzed. Under the guidance of electronic colonoscope,4% formaldehyde combined with 5-aminosalicylic acid(5-ASA) suppositories was topically applied. Patients were followed up for two months after treatment,and the therapeutic effectiveness was observed and analyzed.RESULTS: The rectal bleeding due to CRP was markedly reduced after topical application of 4% formaldehyde under colonoscope in all 13 patients. The bleeding stopped after one treatment session in 11 patients and after the second session in 2 patients. 5-ASA was also applied along with the use of 4% formaldehyde. The therapeutic effectiveness was satisfactory during the 1-and 2-month follow-up period.CONCLUSION: Topical application of 4% formaldehyde under the direct vision of colonoscope as a minimally invasive treatment for CRB-induced bleeding is a simple,effective,affordable,and repeatable technique without obvious complications,which deserves further exploration and promotion.

Refractory Ulcerative Proctitis—A Brief Review

Ulcerative proctitis (UP) is a common condition in adult patients and can be very dif-ficult to treat. This review considers critically the definition of this entity, its epidemi-ology and course, and the modes of therapy currently available. Therapies currently in development are considered as well.

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.

Qingchang suppositry(清肠栓)induced remission in patients with mild-to-moderate ulcerative proctitis:a multicenter,prospective,randomized,parallel-controlled clinical trial

OBJECTIVE:To evaluate the efficacy and safety of Qingchang suppository(清肠栓,QCS),a preparation of Chinese herbal medicine,in the induction of remission in patients with mild-to-moderate ulcerative proctitis(UP).METHODS:We performed a multicenter,prospective,randomized,parallel-controlled trial to evaluate the efficacy of QCS induction therapy in 140 adult patients with mild-to-moderate UP and TCM syndrome of dampness-heat in large intestine.The patients were randomized to receive QCS(study group)or Salicylazosulfapyridine(SASP)suppository(control group)one piece each time,twice a day,per anum for 12 weeks.Mayo score and main symptoms score were evaluated at weeks 0,2,4,8 and 12,rectosigmoidscopy was taken at weeks 0,4,8 and 12,Geboes score,erythrocyte sedimentation rate(ESR),C-reactive protein(CRP)and safety indexes were assessed at weeks 0 and 12.The primary efficacy endpoint is clinical remission rate,the secondary efficacy endpoints are clinical response rate,mucosa healing rate,Geboes score,the remission rates of the main symptoms,the median day to the remission of the symptom,etc.RESULTS:There were no statistical difference in the clinical remission rates,the clinical response rates,the mucosa healing rates,Geboes score,ESR and CRP between the two groups.The remission rates of tenesmus and anal burning sensation of the study group were significantly higher than those of the control group(76.5%vs 25.0%,P=0.009;74.51%vs 29.63%,P=0.003).The median day to the remission of purulent bloody stool of the study group was significantly less than that of control group[11(1,64)vs 19(2,67),P=0.007].The patients receiving QCS had a significantly higher mucosa healing rate at week 4 than the patients receiving SASP suppository(71.42%vs 52.85%,P=0.023).No adverse event occurred in the study group while the adverse events incidence of the control group was 5.7%(P=0.049).CONCLUSIONS:QCS could induce the remission of UP as effectively and safely as SASP suppository,and was superior to SASP suppository in relieving the symptoms of tenesmus,anal burning sensation and purulent bloody stool and the time to reach mucosa healing.

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...

Near obstructing painful anorectal mass and facial rash in a man with monkeypox: A case report

BACKGROUND Monkeypox(MPX)is a zoonotic infection that is endemic in Western and Central Africa along the Congo River basin.It has a high case fatality rate especially in younger age groups.It belongs to the virus family orthopoxvirus like smallpox.It is transmitted from wild animals to humans but human to human transmission has been established.It is often a self-limited infection in endemic regions.Recently,attention has been given to MPX with the spread of infection to Europe and the United States of America(USA).There is currently sporadic infection of MPX in the USA especially amongst men who have sex with men(MSM).It is a serious life-threatening infection in human immunodeficiency virus/acquired immunodeficiency syndrome co-infected individuals especially those who are treatment naïve with severe immunosuppression.CASE SUMMARY We report a 38-year old man who presented with rectal pain,and anal,torso,and facial rash.Abdominal computed tomography scan showed a near obstructive rectal mass with peri-anal fistula.MPX was positive.He was started on tecovirimat(TPOXX)and HAART therapy.Additional treatment provided included vaccinia immunoglobulin following his clinical deterioration.CONCLUSION This case highlights a rare presentation of MPX with peri-anal fistula and near obstructive rectal mass,and the significance of MPX as a differential diagnosis in proctitis in MSM in addition to other sexually transmitted infection like gonorrhea and chlamydia.

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.

Gastrointestinal radiation injury:Symptoms,risk factors and mechanisms

Ionising radiation therapy is a common treatment modality for different types of cancer and its use is expected to increase with advances in screening and early detection of cancer.Radiation injury to the gastrointestinal tract is important factor working against better utility of this important therapeutic modality.Cancer survivors can suffer a wide variety of acute and chronic symptoms following radiotherapy,which significantly reduces their quality of life as well as adding an extra burden to the cost of health care.The accurate diagnosis and treatment of intestinal radiation injury often represents a clinical challenge to practicing physicians in both gastroenterology and oncology.Despite the growing recognition of the problem and some advances in understanding the cellular and molecular mechanisms of radiation injury,relatively little is known about the pathophysiology of gastrointestinal radiation injury or any possible susceptibility factors that could aggravate its severity.The aims of this review are to examine the various clinical manifestations of post-radiation gastrointestinal symptoms,to discuss possible patient and treatment factors implicated in normal gastrointestinal tissue radiosensitivity and to outline different mechanisms of intestinal tissue injury.

Gastrointestinal radiation injury:Prevention and treatment

With the recent advances in detection and treatment of cancer,there is an increasing emphasis on the efficacy and safety aspects of cancer therapy.Radiation therapy is a common treatment for a wide variety of cancers,either alone or in combination with other treatments.Ionising radiation injury to the gastrointestinal tract is a frequent side effect of radiation therapy and a considerable proportion of patients suffer acute or chronic gastrointestinal symptoms as a result.These side effects often cause morbidity and may in some cases lower the efficacy of radiotherapy treatment.Radiation injury to the gastrointestinal tract can be minimised by either of two strategies:technical strategies which aim to physically shift radiation dose away from the normal intestinal tissues,and biological strategies which aim to modulate the normal tissue response to ionising radiation or to increase its resistance to it.Although considerable improvement in the safety of radiotherapy treatment has been achieved through the use of modern optimised planning and delivery techniques,biological techniques may offer additional further promise.Different agents have been used to prevent or minimize the severity of gastrointestinal injury induced by ionising radiation exposure,including biological,chemical and pharmacological agents.In this review we aim to discuss various technical strategies to prevent gastrointestinal injury during cancer radiotherapy,examine the different therapeutic options for acute and chronic gastrointestinal radiation injury and outline some examples of research directions and considerations for prevention at a pre-clinical level.

Chronic radiation proctopathy: A practical review of endoscopic treatment

Chronic radiation proctopathy(CRP) is a troublesome complication of pelvic radiotherapy. The most common presentation is rectal bleeding. CRP symptoms interfere with daily activities and decrease quality of life. Rectal bleeding management in patients with CRP represents a conundrum for practitioners. Medical therapy is ineffective in general and surgical approach has a high morbidmortality. Endoscopy has a role in the diagnosis,staging and treatment of this disease. Currently available endoscopic modalities are formalin,potassium titanyl phosphate laser,neodymium:yttrium-aluminum-garnet laser,argon laser,bipolar electrocoagulation(BiCAP),heater probe,band ligation,cryotherapy,radiofrequency ablation and argon plasma coagulation(APC). Among these options,APC is the most promising.

Evaluation of enterochromaffin cells and melatonin secretion exponents in ulcerative colitis

AIM: To study an assessment of the number of enterochromaffin cells and expression of hydroxyindole-Omethyltransferase in colonic mucosa and urine excretion of 6-sulfatoxymelatonin in patients with ulcerative colitis. METHODS: The study included 30 healthy subjects (groupⅠ-C), 30 patients with ulcerative proctitis [group Ⅱ-ulcerative proctitis (UP)] and 30 patients with ulcerative colitis [group Ⅲ-ulcerative colitis (UC)] in acute phases of these diseases. The number of enterochromaffin cells (EC) was estimated in rectal and colonic mucosa. Bioptates were assembled from many different parts of the large intestine. Immunorective cells collected from various parts of the colon were counted according to the Eurovision DAKO (Dako A/S, Copenhagen, Denmark) System in the range of 10 fields in each bioptate at × 200 magnification. The level of mRNA expression of hydroxyindole-O-methyltransferase (HIOMT) in colonic mucosa was estimated with RT-PCR. Urine 6-sulfatoxymelatonin (6-HMS) excretion was determined immunoenzymatically using an IBL (IBL International GmbH, Hamburg, Germany) kit (RE 54031). RESULTS: The number of EC cells in healthy subjects (C) was 132.40 ± 31.26. In patients of group Ⅱ (UP) and group Ⅲ (UC) the number of these cells was higher 225.40 ± 37.35 (P < 0.001) and 225.24 ± 40.50 (P < 0.001) respectively. Similar differences were related to HIOMT expression, which was 1.04 ± 0.36 in group C, 1.56 ± 0.56 (P < 0.01) in group UP and 2.00 ± 0.35 (P < 0.001) in group UC. Twenty-four hour 6-HMS urinary excretion was as follows: C 16.32 ± 4.95 μg/24 h, UP 26.30 ± 7.29 μg/24 h (P < 0.01), UC 42.30 ± 12.56 μg/24h (P < 0.001). A correlation between number of EC cells and 6-HMS excretion was noted in all groups: r = 0.766 in patients with UP, r = 0.703 with UC and r = 0.8551 in the control group; the correlation between the results is statistically significant. CONCLUSION: In the acute phases of both UP and UC, proliferation of EC cells and high expression of HIOMT and urine excretion of 6-HMS is noted. These changes may represent a beneficial response in the anti-inflammatory and defense mechanism.