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A case of PR Bleeding

A 73 year-old lady complained of fresh rectal bleeding and passing mucus for 10 days. She suffered from endometrical carcinoma one year ago and underwent total abdominal hysterectomy. She had finished adjuvant total pelvic radiotherapy and brachytherapy within 2 months after the operation.

1. Question: What is the provisional diagnosis?
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Answer 1 : The provisional diagnosis is chronic radiation procititis. Rectal bleeding is the prominent symptom in this condition. It usually manifests between 8 to 13 months after radiotherapy.
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2. Question: How would you manage this patient?
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Answer 2 : The principle of management includes differentiating radiation injury from other conditions, localizing the extent of involvement and grading the severity and general fitness of patient for treatment. Clinical assessment including detailed questioning of history of radiation treatment, any associated symptoms, impact of disease on patient¡¦s life, is therefore extremely important for subsequent decision making.
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3. Question: What investigation would you arrange?
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Answer 3 : Colonoscopy and biopsy is helpful to assess the extent and severity of radiation injury, and excludes other colorectal conditions. A computed tomography of abdomen and pelvis may be necessary if tumour recurrence or metastasis is suspected.
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4. Question: Describe the endoscopic finding in the rectum.

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Answer 4 : The diagram shows prominent telangiectasia and erythema. There is a distinct margin between normal and abnormal tissue that is related to the edge of radiation field. Contact bleeding and ulceration may be also present in other cases.
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5. Question: The slide showed a piece of rectal mucosa. Describe the finding.

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Answer 5 : This slide shows significant mucosal ulceration and crypt distortion. Submucosal layer was infiltrated by inflammatory cells. There was excess collagen deposits in submucosal layer, suggesting fibrosis. ¡@
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6. Question: How would you treat this patient?

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Answer 6 : The principle of treatment is symptomatic relief. The predominant symptom in this case is rectal bleeding. Her treatment option includes local application of topical steroid, sucralfate , 5-aminosalicylates enemas.
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7. Question: How would you manage this lady? What other treatment options do you consider?
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Answer 7 : Patient suffered from severe radiation proctitis and anaemia. She is indicated for blood transfusion. Endoscopic argon plasma coagulation is effective in controlling more resistant case. On average, patient needs 2 to 4 sessions of treatment.
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8. Question: What are the complications of topical formalin?
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Answer 8 : Perianal skin ulceration and fissure due to formalin spill onto anus has been reported. Other complications include worsening of radiation stricture and ulceration. Therefore, patient should be carefully counseled before the procedure.
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9. Question: When would you consider surgery?
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Answer 9 : Surgery is the last resort and is usually contemplated only in complicated conditions, such as rectal strictures or fistulae. Resection carries a high risk of fistula, intra-abdominal sepsis, wound dehiscence and bowel obstruction as the surgical plane has been greatly distorted and tissue is ischaemic after radiation.
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Acknowledgement: This case scenario was prepared by Dr. Eva Chau, Specialist in Surgery, Department of Surgery, PYNEH.
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Reference :
1)
Chronic radiation proctitis
Tagkalidis P and Tjandra J
Volume 71(4) pp 230-237
ANZ J Surg
2)
Non surgical interventions for late radiation proctitis in patients who have received radical radiotherapy to the pelvis
Denton A, Forbes A, Andreyev J, Maher EJ
Cochrane Database of systematic reviews (1) CD003455,2002



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