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Radiotherapy to the pelvis (for prostate, bladder, cervix, womb, rectal or anal cancer) can change how the bowel works for months or years: urgency, loose stools, wind, leakage or bleeding. Most of it has a cause that can be found and treated, often more than one, so ask for a proper assessment rather than being told it is just something to live with.
The reference is the 2015 Frontline Gastroenterology guidance (Andreyev et al.), the algorithm used in the ORBIT randomised trial, in which an algorithmic approach helped and trained nurses managed patients as well as a gastroenterologist; 65 clinicians reviewed it and agreed 27 of 28 sections. Its principles: patients can have many symptoms at once, each with more than one cause, so investigate systematically and order all first-line tests at the first visit; irritable bowel syndrome is rarely the right diagnosis here; endoscopy or surgery in irradiated tissue carries more risk, and irradiated areas are not biopsied. Common treatable causes are bile acid malabsorption (SeHCAT; a sequestrant for moderate or severe), small intestinal bacterial overgrowth (breath test or aspirate), carbohydrate intolerance, exocrine pancreatic insufficiency after para-aortic fields, and pelvic floor dysfunction (at least six weeks of exercises). Faecal calprotectin is not recommended in this group. Bleeding from telangiectasia usually starts 6 to 12 months after treatment and settles by 8 to 10 years: reassure if it is not affecting life; otherwise stop anticoagulants if possible and consider sucralfate enemas, then hyperbaric oxygen (RCT support; MASCC/ISOO suggests it, level II), formalin or thermal ablation such as argon plasma coagulation, which the guidance says is absolutely contraindicated after brachytherapy. The ASGE (2019) found argon plasma coagulation and other endoscopic methods effective from small observational studies. MASCC/ISOO suggests Lactobacillus probiotics to prevent radiation diarrhoea (level III).
Why: People often have several symptoms at once, and words like 'diarrhoea' mean different things to different people.
“Tools such as a Bristol Stool Chart can often clarify exactly what patients mean.”
Frontline Gastroenterology (BMJ and British Society of Gastroenterology; Andreyev et al.) 2015
Why: These point to causes that can be treated, such as fat malabsorption, and are easily missed.
“Patients and clinicians alike often miss the presence of intermittent steatorrhoea—ask:”
Frontline Gastroenterology (BMJ and British Society of Gastroenterology; Andreyev et al.) 2015
Why: Each symptom can have more than one cause; testing everything at once means treatment can start sooner and fewer visits are needed.
“Arranging all investigations at the first consultation reduces follow-up and allows directed treatment at all causes for symptoms at the earliest opportunity.”
Frontline Gastroenterology (BMJ and British Society of Gastroenterology; Andreyev et al.) 2015
Why: In people who have had pelvic radiotherapy, specialist units almost always find a specific cause instead.
“Specialist centres only very rarely reach a new diagnosis of ‘irritable bowel syndrome’ in this patient group.”
Frontline Gastroenterology (BMJ and British Society of Gastroenterology; Andreyev et al.) 2015
Why: It is too unspecific after radiotherapy to guide care.
“Note: faecal calprotectin as a marker for bowel inflammation is too non-specific and hence not recommended in this population.”
Frontline Gastroenterology (BMJ and British Society of Gastroenterology; Andreyev et al.) 2015
Why: Radiotherapy can damage the part of the small bowel that reabsorbs bile, and the bile then causes diarrhoea; binding it often helps a great deal.
“For severe BAM developing after radiotherapy, most patients need a bile acid sequestrant and advice about long-term reduction in dietary fat intake.”
Frontline Gastroenterology (BMJ and British Society of Gastroenterology; Andreyev et al.) 2015
Why: Long-term malabsorption and sequestrant treatment can leave people short of vitamins and minerals.
“Many patients with moderate/severe BAM will be deficient in trace elements and fat-soluble vitamins. These should be checked periodically and supplemented as appropriate.”
Frontline Gastroenterology (BMJ and British Society of Gastroenterology; Andreyev et al.) 2015
Why: Radiotherapy weakens the muscles and stiffens the rectum; exercises and firmer stools reduce urgency and leakage.
“Pelvic floor and toileting exercises (page 18)—min. 6 weeks.”
Frontline Gastroenterology (BMJ and British Society of Gastroenterology; Andreyev et al.) 2015
Why: The bleeding is usually from small fragile vessels the radiotherapy has caused, but other causes must be ruled out; biopsy of irradiated tissue can cause ulcers or fistulas that do not heal.
“Do not biopsy irradiated areas.”
Frontline Gastroenterology (BMJ and British Society of Gastroenterology; Andreyev et al.) 2015
Why: Radiation bleeding usually starts 6 to 12 months after treatment, is worst at about 4 years and has gone by 8 to 10 years.
“If bleeding is not staining clothes, causing anaemia or interfering with daily activities, reassure and do nothing.”
Frontline Gastroenterology (BMJ and British Society of Gastroenterology; Andreyev et al.) 2015
Why: Sucralfate coats and protects the lining of the rectum; stopping blood thinners lets it heal.
“If bleeding affects quality of life, stop anticoagulants if possible and consider sucralfate enemas ± metronidazole 400 mg tds for 4 weeks.”
Frontline Gastroenterology (BMJ and British Society of Gastroenterology; Andreyev et al.) 2015
Why: Each option has trade-offs: hyperbaric oxygen has trial support but takes eight weeks of daily sessions; heat treatments are simple but can cause ulcers that do not heal in irradiated tissue.
“Any thermal therapy (eg, APC): Advantages: easily available and simple; disadvantages: significant risk of non-healing ulceration/perforation as the tissue is ischaemic and unproven efficacy in heavy bleeding. Absolutely contraindicated in patients treated with brachytherapy.”
Frontline Gastroenterology (BMJ and British Society of Gastroenterology; Andreyev et al.) 2015
Why: Some findings need same-day action rather than the routine pathway.
“Where it is stated that ‘this is an emergency’, the user of this guide must discuss the issue with a suitably qualified person for immediate action.”
Frontline Gastroenterology (BMJ and British Society of Gastroenterology; Andreyev et al.) 2015
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
The 2015 Frontline Gastroenterology guidance (Andreyev et al.), the algorithm tested in the ORBIT randomised trial, is the most complete readable protocol: systematic investigation of every symptom with all first-line tests at the first visit, active search for bile acid malabsorption, bacterial overgrowth, carbohydrate intolerance, pancreatic insufficiency and pelvic floor dysfunction, no biopsy of irradiated tissue, and a stepped approach to bleeding (reassure, stop anticoagulants, sucralfate enemas, then ablation). On ablation the sources differ in emphasis: the guidance prefers hyperbaric oxygen for its randomised evidence and warns that thermal therapy such as argon plasma coagulation risks non-healing ulceration and is absolutely contraindicated after brachytherapy, while the ASGE (2019) found argon plasma coagulation, bipolar electrocoagulation, heater probe and radiofrequency ablation effective from small observational studies. MASCC/ISOO 2020 suggests hyperbaric oxygen for radiation proctitis (level II).
Frontline Gastroenterology (BMJ and British Society of Gastroenterology; Andreyev et al.) 2015 · MASCC and ISOO (Cancer; Elad et al.) 2020 · American Society for Gastrointestinal Endoscopy (Gastrointestinal Endoscopy) 2019
Where it differs: Treats bleeding radiation proctopathy with argon plasma coagulation or another endoscopic method as the usual first ablative step.
Evidence: ASGE 2019 (abstract read): from mostly small observational studies, argon plasma coagulation, bipolar electrocoagulation, heater probe and radiofrequency ablation were effective; the evidence was limited by a lack of controlled and comparative trials. The UK guidance warns of non-healing ulceration and perforation, and contraindicates thermal therapy after brachytherapy.
American Society for Gastrointestinal Endoscopy (Gastrointestinal Endoscopy) 2019 · Frontline Gastroenterology (BMJ and British Society of Gastroenterology; Andreyev et al.) 2015
Where it differs: About eight weeks of daily sessions in a pressure chamber for bleeding or other late radiation damage.
Evidence: MASCC/ISOO 2020 suggests it for radiation proctitis in pelvic cancers (level II). The UK guidance notes randomised evidence and possible benefit for urinary symptoms, against time, cost and travel.
MASCC and ISOO (Cancer; Elad et al.) 2020 · Frontline Gastroenterology (BMJ and British Society of Gastroenterology; Andreyev et al.) 2015
Where it differs: Gives a probiotic containing Lactobacillus during treatment to prevent acute radiation diarrhoea.
Evidence: MASCC/ISOO 2020 suggests (level III) that probiotics containing Lactobacillus may help prevent diarrhoea from radiotherapy or chemoradiotherapy in pelvic cancers.
Bowel problems lasting months or years after radiotherapy to the pelvis are common and often treatable once their causes are found. In a randomised trial, a trained nurse following a step-by-step plan helped as much as a specialist doctor, and both helped more than a self-help booklet. Specialist services exist in some places and not others.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Agreement with the guidance sections (defined as 60% or more of panellists agreeing) “Consensus (defined prospectively as 60% or more panellists selecting ‘strongly agree’ or ‘agree’) was reached for 27 of the original 28 sections in the guide, with a median of 75% of panellists agreeing with each section.” | Consensus reached for 27 of 28 sections | Frontline Gastroenterology (BMJ and British Society of Gastroenterology; Andreyev et al.) 2015 |
| An algorithmic approach helps and trained nurses can manage patients as well as a gastroenterologist “A recent randomised trial suggested that an algorithmic approach to investigating and managing gastrointestinal symptoms of pelvic radiation disease (PRD) is beneficial and that specially trained nurses can manage patients as effectively as a gastroenterologist.” | One randomised trial (ORBIT), as described by the guidance | Frontline Gastroenterology (BMJ and British Society of Gastroenterology; Andreyev et al.) 2015 |
| Hyperbaric oxygen to treat radiation proctitis in pelvic cancers “The panel suggests that hyperbaric oxygen is an effective way to treat RT‐induced proctitis in patients with pelvic malignancy.” | II (suggestion) | MASCC and ISOO (Cancer; Elad et al.) 2020 |
| Lactobacillus probiotics to prevent radiation diarrhoea in pelvic cancers | III (suggestion) | MASCC and ISOO (Cancer; Elad et al.) 2020 |
One technology page on OnCo cites this paper by its DOI; this record gives the citation a page of its own so a reader can follow it without leaving OnCo. Read the abstract above alongside the citing page listed under Related; the record was created automatically from the Europe PMC entry and its figures have not been checked by hand.
One technology page on OnCo cites this paper by its DOI; this record gives the citation a page of its own so a reader can follow it without leaving OnCo. Read the abstract above alongside the citing page listed under Related; the record was created automatically from the Europe PMC entry and its figures have not been checked by hand.
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