Radiation enteritis - Forum

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Billroth

Radiation enteritis - Ärzteforum

Post#1 »

40 year old female had hysterectomy followed by radiotherapy for cervical carcinoma 10 years ago. presented with diarrhoea, urgency and finally total incontinence to faeces. Endoscopic and radiological investigation of both small and large bowel normal. Stool culture and parasitology negative. Anal sphincters normal tone and squeeze pressures. Presumed diagnosis of radiational enteritis. Patient commenced on codeine phosphate dosage increased to 1.5 maximum no response. Lomotil then imodium added no response. As you can imagine patient is unable to go anywhere without incontinence pads. Unable to continue in her executive job. after long discussion agrees to undergo end colostomy. Initially well pleased despite frequent and large volume loose colostomy output. but 2 months later develops skin ulceration and persistent ulcers at colostomy site. Conservative measures fail to stop or reverse local peri-colostomy excoriation. it becomes impossible to fix colostomy bags on skin. Decision taken to fashion an end ileostomy with a 'longer' spout. Uneventful procedure barring minimal adhesion. Ileostomy output initially settles to <1 litre daily (with codeine phosphate 240 mg daily). goes home only to return after a week severely dehydrated. Intra venous rehydration successful but ileostomy output averages 5-6 litres daily more anti- diarrhoea no response. In desperation commenced on somatostatin 50 then 100 mg tds. output down to 4 litres. Needs continuos i.v. fluids to replace losses and therefore hospital bound.

Apart from re-operating and closing the ileostomy and refashioning a colostomy which we plan to do. Any ideas where do we go from here ? any suggestions welcome.


Avicenna

Re: Radiation enteritis - Ärzteforum

Post#2 »

I don'n understand why the patient is incontinence if her sphincters are normal. Is it due only to massive diarrhea with perfectly normal sphincters. In that case I would persue nonoperative managment with maximum use of antidiarrheal medication and diet modification. If her sphincters are uselss then she is a canidate for neosphincter.

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Surgeon

Re: Radiation enteritis - Ärzteforum

Post#3 »

Here are a few less often thought of treatments for diarrhea that occasionally work:

1. Calcium channel blockers such as diltiazem--one of our internists ordered this on one of my patients with intractable diarrhea and it was almost instantly effective
2. Tricyclic anti-depressants such as amitryptyline--also quite constipating and worth a try in intractable dehydrating diarrhea

Of course, any med may just wash on through with such high volume diarrhea and not have any effect.

I wonder if an intractable diarrhea patient like this might be a candidate for a small bowel transplant--of course, the success rate of these is still low and the patient would probably die if the small bowel transplant failed.

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A Doctor

Re: Radiation enteritis - Ärzteforum

Post#4 »

I am struck that a basic question has not been asked. What is the cause of the diarrhea. The assumption was made that this is XRT induced. Perhaps something else is involved. Is it secretory (does it remain despite fasting??)? You've already shown, eloquently, that it is "small bowel" and not of colonic origin. Is there malabsorption?? Are we missing an endocrine tumor?

Before further surgical endeavors, I think that this type of evaluation must be completed. Use XRT enteritis as a Dx of last resort. You need to do 72 hr fecal (chyme?) fats, Serum and fecal electrolytes/osmolality, response to in hospital fasting, hormones (serotonin, 5HIAA, Gastrin, VIP, etc.), small bowel bx, search for seripiteous laxative use, etc.

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Billroth

Re: Radiation enteritis - Ärzteforum

Post#5 »

It was felt that even though we have not exhausted the diagnostic possibilities almost all pharmacological manipulation of the ileostomy output was doomed to failure. As you correctedly pointed out - any med may just wash on through with such high volume diarrhea and not have any effect. Even with the patient on minimal oral intake and Total Parentral Nutrition ileostomy poured out approx 4 litres daily. we reasoned that she probably needs her colon in circuit to minimize diarrhea so she underwent closure of the ileostomy and formation of a ' long spout colostomy'. Difficult operation due to dense adhesions (unlike previous surgery) the ileostomy end excised and sent for histological examination. hopefully this will prevent skin problems and may provide histological diagnosis. We have almost tried all your list of medications to maximum dosages, except fruit pectin and Calcium channel blockers. Malak Bokhari you missed the problem which is failure of dietrary modification and antidiarrheal medication, tried over 2 years, to control her symptoms which progressed to complete incontinence. Douglas, your suggestions are quite valid.However I would have thought that an endocrine cause would at least be partially controlled by somatostatin. Will look up the review paper you mentioned. Will keep you all posted of her progress.

Paranoid

Re: Radiation enteritis - Ärzteforum

Post#6 »

Just a note of warning -- most of the small bowel diseases that cause diarrhea (other then Crohn's) are proximal diseases. They will be missed on illeal bx. (my once in a lifetime case of Whipples disease had been missed on illeal bx, but was obvious on proximal small bowel bx. Sprue will effect the proximal SB selectively, etc.) However, as she doesn't slow down with being NPO, you are dealing with a secretory diarrhea, which probably is not of mucosal origin. This assumes that this is not due to seripitous self medication with diarrhea-genic substances (a primary psychiatric disease).

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