3.radiation Inj

Surgery
Dr. Faruq Lec: -3-

17-Oct-06
Radiation inj.of intestine

• Radiation Therapy-a component of multimodality therapy for many intra-
abdominal & pelvic cancers,such as those of cervix, endomertrium, ovary,
bladder, prostate &rectum.
• An undesired S.E of radiation therapy is radiation inj. To intestine, which can
present as 2 distinct syndromes;
• 1-Acute radiation enteritis
• Chronic radiation enteritis.
Acute radiation enteritis
• Transient condition
• Occurs in approximately 75% of patients.
• Main effects on mucosa
• Radiation induces cellular inj directly & via the generation of free radicals.
• Clinical presentations; nausea,vomiting,diarrhea & crampy abd. Pain.
• Dx. Obvious, & the condition is transient
Chronic Radiation enteritis(CRE)
• Inexorable.
• Develops in approximately 5-15 % .
• There is a progressive occlusive vasculitis---that leads to chronic ischemia &
fibrosis, that affects all layers of intestinal wall--- these changes ---strictures,
abscesses & fistula formation.
CRE( Presentations)
• Usually become evident within 2 years.
• Terminal ileum most commonly affected.
• Partial small bowel obstruction-Nausea ,vomiting,intermittent abd.
Distension, crampy abd. Pain & wt loss.
• Complete bowel obstrcution.
• Acute or ch. Intestinal haemorrhage.
• Abscess or fistula formation.
1
CRE( Dx)
• Enteroclysis-contrast radiograph of small intestine:1-widely separated loops of
small bowel.2- luminal narrowing.3-loss of mucosal folds.4-ulcerations.
• CT scan to exclude recurrent cancer.
Rx
• Acute RE- self limited. Supportive Rx
• CRE-Surgery- very difficult with high M&M.( M.R=10%)
• Surgery indicated for;high grade obstruction. Haemorrhage.Intra-abd. Abscess
& fistulas.
• Limited resection + anatamosis
Intestinal Fistulas
(Epidemiology)
• Definition- a fistula- abnormal communication bet.2 epithelialized surface.
• Internal fistulas- communications bet.2 parts of GIT( enterocolic F.), or bet.
GIT a & adjacent organ ( colovesicular F).
• External F.( enterocutaneous F., or rectovaginal F.)involves the skin or another
ext.surface epithelium.
• Low-output F-drains <500ml/d.
• High-output F- drains >500ml /d
• 80% iatrogenic inj.( complications), as a result of enterotomies or intestinal
anastamotic dehisence.
• Spontaneous F—Crohn’s dis, Cancer,CRE
Aetiology
A- Congenital –patent vitello-intestinal duct
B-acquired- most common causes are:

• 1-anastomotic leakage
• 2-inflam. Bowel disease
• 3-malignancy
• 4-radiotherapy
• 5-trauma
2
Pathophysiology
• Enteroenteric F-››››malabsorption syndrome.
• Enterovesical F- Recurrent UTI
• Enterocutaneous F– skin excoraition.
• High-output F.—dehydration, electrolyte abnormalities & malnutrition
• Fistulas have the potential to close spontaneously.
• Factors inhibiting spontaneous closure are:malnutrition,sepsis, Inflam. Bowel
dis, cancer,radiation, distal obstruction, F.B,high-output, & epithelialization of
fistula
Clinical presentations
• Iatrogenic enterocutaneous F. clinically evident bet 5th & 10th postoperative

days.
• Initial signs :.
Fever. Leukocytosis. Prolonged ileus, abdominal tenderness & wound infection
• Dx- becomes obvious,when drainage of enteric material viaabd. Wound or
existing drains occur. These fistulas are often ass. With intra-abd. Abscesses.
Dx
• Enhanced CT scan
• Small bowel series- enteroclysis
• Fistulogram
Rx
Step 1(Stabilization)
• Fluid & electrolyte resuscitation.

• Nutrition, usually parentral route initially.
• Sepsis is controlled- Ab, localisation & drainage.
• Skin- care & protection with ostomy appliances or fitula drains.
3
Step 2 ( Investigation)
Definition of anatomy
• Anatomy of fistula is defined using:
• CT scan
• Small bowel series
• Fistulogram
Step 3(Rehabilitation)
Carrying out the definitive procedure
(where necessary)
• Probability of spontaneous closure is maximized.
• Nutrition & time are the key components
• Most patients will require TPN, however, a trial of oral or entral nutrition
should be attempt in low-output fistulas, originating from distal ileum.
• Octreotide- somatotatin analogue;reduces the volume of fistula output & may
accelerate the rate of closure.
• 2 to 3 months are allowed for spontaneous closure, after that they are unlikely
to do so.
• Surgery-remove of fisltua tract + the involved segment of bowel from which
the fistula originated
OUTCOME
• M.R- 10-15 %- mostly related to sepsis or underlying disease.

• Overall 50% close spontaneously
• FRIEND- a useful mnemonic designates factors that inhibit spontaneous
closure
• F.B. Radiation enteritis. Infection/inflammation at the fistula
origin.Epithelialization of the fistula tract.Neoplasm at the fistula origin.Distal
obstruction of the intestine.
• Surgery for fistulas is associated with >50%MR, including a 10 % recurrence
rate.
4
Mesenteric ischemia
1-Acute.Causes
• 1-Arterial embolus-
• 2-arteial thrombosis
• 3-Vasospasm( also known as ;nonocclusive mesenteric ischemia, or NOMI)
• 4-venous thrombosis
Art.Embolism
• Most common cause of art.Emb.>50% of cases
• Source of Emboli- usually-Heart.95% LA,or ventricular or valvular lesions.
• SMA- embolism 50% of cases.
Art.thrombosis
• Usually superimposed on pre-existing atherosclerotic lesions
NOMI
The result of vasospasm & usually diagnosed in critically –ill-patients who are
receiving vasopressor agents
Mesenteric venous thrombosis
• Accounts for 5-15% of cases of acute mesenteric ischemia.

• Involves the SM vein in 95% of cases.
• IMV- only rarely involved.
• Classified as primary-if no etilogic factor is identifiable, or as sec.if an etilogic
factor, such as heritable or acquired coagulation disorders, is identified
Regardless of the cause:

Acute mesenteric ischemia can---
• Intestinal mucosal sloughing within 3 hours of onset
• Full- thickness intestinal infarction by 6 hours.
5
2-Chronic mesenteric ischemia
• Develops insidiously, allowing for development of collat. Circulation.
• Rarely leads to intestinal infarction
• Ch.mesent. Art. Ischemia- from atherosclerosis in the main splanchnic
art.s(caeliac, SMA, IMA)
• Chronic form of mesenteric venous thrombosis can involve the portal or
splenic veins—portal HT
Clinical presentation
• The hallmark of acute Mesent. Isch is :Severe abd. Pain out of proportion to
the degree of tenderness O/E .
• The pain – colicky & most severe in the mid-abd
• Associated symptoms can include; nausea,vomiting & diarrhea.
• Physical exam.- characteristically absent early in the course of ischemia.
• With onset of bowel infarction;abd. Distension, peritonitis &passage of bloody
stools occur
Presentation
( Chronic mesent. Isch)
• -presents insidiously.
• Postprandial abd. Pain- the most prevalent symptom, producing a
characteristic aversion to food (food-fear) & wt. loss.
• Often thought to have malignancy & suffer a prolonged period of symptoms
before the correct Dx is made.
(Ch. Mesent. Venous thrombosis)

• Mostly asymptomatic bec. Of collat.
• Usually discovered as an incidental finding on imaging studies.
• Some patients- present with bleeding from esophagogastric varices
6
Dx
• Lab.tests abnormalities, such as leukocytosis,acidosis, Increase in amylase are

late findings.
• Patients suspected of having acute mesent. Ischemia & who have physical
findings suggestive of peritonitis should undergo emergent laparotomy
• CT Scanning- sensitive in 64-82% . If negative & the case suspicious Do
angio
• Angiography-sensitivity of 74-100% & specificities approaching 100%
• Angiography- is invasive, time-consuming & costly
Rx(imp. Considerations in selecting Rx options)

• The presence or absence of signs of peritonitis
• The presence or absence of ischemic but viable intestine
• The general condition of the patient
• The specific vascular lesions lesion causing mesenteric ischemia
Signs of peritonitis -detected

• Emergent laparotomy .
• Assess the viability of bowel
• Resection& anastamosis
• Sec look laparotomy
Embolus or thrombus-induced ischemia

• 1-Standard Rx-surgical revascularization:
• Embolectomy
• Thrombectomy
• Mesenteric bypass
• B- C.I to these op. are:
• 1-if most bowel supplied by the affected art. Infarcted 2-unstable patients
Chronic radiation inj of the intestine

(Epidemiology)
• May occur in any patient who has radioRx to the abdomen or pelvis.
• Most patients –young or middle –aged women treated for pelvic malign.
• Occurs in elderly men with ca. prostate.
• Occurs in adolescents treated for testicular tumors
7
Aetiology
• The intestine is radiosensitive , particularly the small intestine with its rapid
mucosal cell turnover cycle.
• Inj- directly related to total radiation dose
• Possible factors – previous abd. Op.
previous pelvic sepsis
Atherosclerosis
D.M
Concomitant chemoRx
Pathology
• Progressive ischemia- any part, usually the distal ileum & rectosigmoid region
• Gross-appearance- bowel –white ,telangectasia, thickened,indurated &
narrowed. adhesion, fistulas to vagina, bladder, or other loops of bowel
• Microscopic-thickening of submucosa by fibrosis.Obliterative vasculitis in
arterioles & venules. Infiltration of the bowel wall with lymphocytes & bizarre
fibroblasts
Clinical features
Essential to the Dx-is past Hy of irradiation, therapeutic or otherwise.

1-Strictures—Partial I.O-symptoms—intermittent.
2-Necrosis---free perforation or fistulas
3-Ulceration-may cause haemorrhage
4-Malabsorption-wt loss
5-Urinary symptoms-freq.,dysuria or hematuria-(radiation cystitis).
6-Defecatory symptoms-loss of compliance of rectum-urgency, frq, & tenesmus
NOMI
• Standard Rx-infusion of vasodilator
• papaverine
8
Acute mesenteric venous thrombosis
• Standard Rx- Anticoagulation
• Heparin
Outcome
• MR- acute art.mesenteric isch—59-93%
• MR- mesenteric venous thrombosis-20-50%
• MR- of surgery-0-16%
• Recurrent rate after surgery < 10%
Prepared by:
Rand Aras Najeeb

3.radiation Inj

Uploaded by

Copyright:

Available Formats

3.radiation Inj

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

3.radiation Inj

Uploaded by

Copyright:

Available Formats

Surgery

Dr. Faruq Lec: -3-

Radiation inj.of intestine

Acute radiation enteritis

Chronic Radiation enteritis(CRE)

B-acquired- most common causes are:

• Iatrogenic enterocutaneous F. clinically evident bet 5th & 10th postoperative

• Fluid & electrolyte resuscitation.

• M.R- 10-15 %- mostly related to sepsis or underlying disease.

Mesenteric venous thrombosis

• Accounts for 5-15% of cases of acute mesenteric ischemia.

Regardless of the cause:

(Ch. Mesent. Venous thrombosis)

• Lab.tests abnormalities, such as leukocytosis,acidosis, Increase in amylase are

Rx(imp. Considerations in selecting Rx options)

Signs of peritonitis -detected

Embolus or thrombus-induced ischemia

Chronic radiation inj of the intestine

Essential to the Dx-is past Hy of irradiation, therapeutic or otherwise.

You might also like