Case 7: An 83-Year Old Man with Palliative Prostate Cancer
This 83-year-old man was diagnosed with prostate cancer 3 years ago, which was treated with a transurethral resection of the prostate (TURP) and palliative radiation. Today, he presents to the ED with weakness, anemia, and a two week history of bright red blood per rectum. He undergoes a colonoscopy, revealing erythematous, friable mucosa in the proximal sigmoid colon, between 31 and 34 cm from the anal verge. What explains these endoscopic findings?
This patient has chronic radiation proctitis. Radiation proctitis is one of the most common complications of pelvic radiation, and is a result of damage to the rectal epithelium from ionizing raditation. While acute radiation proctitis occurs within the first 3 months following radiation, chronic radiation proctitis has a delayed onset, occuring typically beyond 9-14 months, or even decades post-radiation.
Patients with acute radiation proctitis can present with diarrhea, cramping, tenesmus, urgency, mucous discharge, and minor bleeding. Chronic radiation proctitis can have these same symptoms, in addition to features such as malabsorption, severe bleeding, strictures, perforations, and fistulas.
Endoscopically, acute radiation proctitis can appear as erythematours, bleeding mucosa, while chronic radiation proctitis can have telangiectasias, as seen in this patient:
Source: Dahiya DS, Kichloo A, Tuma F, Albosta M, Wani F. Radiation Proctitis and Management Strategies. Clin Endosc. 2022;55(1):22-32. doi:10.5946/ce.2020.288. Available from https://pubmed.ncbi.nlm.nih.gov/34788934/
While acute radiation proctitis is typically self-limiting and can be managed supportively, chronic radiation proctitis typically requires treatment, with on average two sessions of argon plasma coagulation (APC) to control bleeding. This patient was treated with APC, and was discharged from hospital after his rectal bleeding resolved:
Four weeks later, he represented to hospital with recurrent rectal bleeding. Repeat endoscopic assessment demonstrated recurrent bleeding from his chronic radiation proctitis, which was again treated with APC:
