Radiation enteritis leading to intestinal failure: 1994 patient-years of experience in a national referral centre.

BACKGROUND/OBJECTIVES: Chronic radiation enteritis (RE) has been reported in up to 20% of patients receiving pelvic radiotherapy and can lead to intestinal failure (IF), accounting for 3.9% of new registrants for home parenteral nutrition (HPN) in the UK annually. Our aim is to report nutritional and survival outcomes for patients with RE referred to a national IF unit. SUBJECTS/METHODS: A retrospective study of all new admissions over a 13-year period at the Intestinal Failure Centre, Manchester, UK. Data are presented as median (range). RESULTS: Twenty-three (3.8%) of 611 patients were admitted with IF secondary to RE. The primary site of malignancy was genitourinary in 17 (74%) patients. Radiotherapy was administered 9.5 (1-42) years previously. Patients underwent 2 (1-5) laparotomies prior to intestinal failure unit (IFU) admission. Twelve (52%) patients were admitted with intestinal obstruction and 11 (48%) with intractable weight loss and/or high output fistulae/stomas. Additional conditions contributing to IF were noted in 11 (48%) patients. Twenty-two (96%) patients had 2 (1-5) laparotomies prior to IFU referral. At discharge, 5 (22%) patients resumed oral diet without the need for artificial nutrition support, 3 (13%) required enteral feeding and 13 (56%) commenced HPN. The 10-year survival of the patient cohort was 48.2%. CONCLUSIONS: Surgical intervention is infrequently required, whereas the majority of patients with IF secondary to RE require long-term HPN. The judicious use of surgery in selected patients, coupled with an aggressive medical strategy to detect and treat contributing factors, and optimal enteral feeding may allow a modest proportion of patients with IF secondary to RE to achieve independence from PN.

Chronic radiation enteritis.

Chronic radiation enteritis is an increasing problem, as more patients receive radiotherapy as part of their cancer therapy and as the long-term survival of these patients improves. This review addresses the causes, investigation, treatment and prevention of this disease. A review of published studies was carried out using a variety of search terms, including radiation enteritis, investigation, treatment and prevention. Chronic radiation enteritis has been reported in up to 20% of patients receiving pelvic radiotherapy, although this may underestimate its true prevalence, as not all patients with gastrointestinal symptoms after radiotherapy will seek medical attention. Predisposing factors to chronic radiation enteritis include a low body mass index, previous abdominal surgery and the presence of co-morbid conditions; the radiation dose, fractionation and technique, as well as the concomitant use of chemotherapy, may also play a role. Clinical features of chronic radiation enteritis are multiple as the disease can affect any part of the gastrointestinal tract. Moreover, symptom aetiology within any one patient may be multifactorial and therefore it is important to adopt a structured approach when planning investigations. The evidence base for current therapies is limited, but nutrition, anti-diarrhoeals, anti-inflammatories, antibiotics, probiotics, pentoxifylline, tocopherol, cholestyramine, hyperbaric oxygen, endoscopic and surgical therapies have all received attention. Given the significant morbidity and mortality associated with chronic radiation enteritis, current available preventative strategies are reviewed, including tissue-sparing radiotherapy techniques. In conclusion, the evidence base for therapeutic and preventative strategies in treating chronic radiation enteritis is limited, but adopting a structured approach to investigating gastrointestinal symptoms after radiotherapy should allow better targeting of current therapies. Closer collaboration between oncologists and gastroenterologists will facilitate a more structured approach, not only in managing individual patients, but also in establishing clinical and research networks for this expanding disease, in order to improve the evidence base for its management.

Review article: minimizing tuberculosis during anti-tumour necrosis factor-alpha treatment of inflammatory bowel disease.

BACKGROUND: Tumour necrosis factor (TNF)-alpha inhibitors are a major advance in the management of inflammatory bowel disease but increase the risk for tuberculosis (TB). AIM: To examine the reasons for the increase in the risk for TB and the strategies to reduce it. METHODS: PubMed searches were performed using search terms that included TB and each of the current anti-TNF-alpha biological agents and also TB and Crohn's disease. RESULTS: Increased susceptibility to TB, often with extrapulmonary or disseminated disease, occurs following treatment with all anti-TNF-alpha biological agents and amounts to a four- to 20-fold increased risk with infliximab. TB usually occurs shortly after anti-TNF-alpha initiation suggesting reactivation of latent infection. Animal studies show that TNF-alpha inhibition impairs inflammatory cell trafficking and granuloma formation. Currently recommended screening for latent TB typically, risk assessment, tuberculin skin testing and chest radiograph used prior to anti-TNF-alpha treatment can reduce TB rates by up to 90% but newer screening interferon gamma assays may enhance screening efficacy. Patients positive on screening who are treated with isoniazid and subsequently receive anti-TNF-alpha treatment still have approximately 19% risk for TB. CONCLUSIONS: Tuberculosis following treatment with TNF-alpha inhibitors usually results from reactivation of latent disease. Screening reduces the risk substantially but does not completely eliminate it.