Our Guarantees Our Quality Standards Our Fair Use Policy

What Makes UK Essays Different?

• We have a verifiable trading history as a UK registered company (details at the bottom of every page).
• Our Nottingham offices are open to the public where you can meet our team of over 40 full-time staff.
• UK Essays partner with Feefo.com to publish verified customer testimonials – both good and bad!

Ask an Expert FREE

Ask an Expert Index Ask a Question Paid Services

About Our Ask an Expert Service

Our totally free “Ask an Expert” Service allows users to get an answer of up to 300 words to any academic question.

• Questions typically answered within 24 hours.
• All answers are researched and written by fully qualified academics in the question’s subject area.
• Our service is completely confidential, only the answer is published – we never publish your personal details.
• Each professional answer comes with appropriate references.

About Us

More About Us

Published: 23, March 2015

Internal organs are considered dose limiting and potential damage to these structures is taken into account with prescriptions to planning and treating techniques to avoid severe toxicities. Toxicities are considered to be acute or late, and side effects of radiation therapy are unavoidable. A debilitating side effect in patients receiving pelvic, abdominal, and rectal radiation therapy is diarrhoea whether acute or chronic affects their quality of life.

Purpose: To perform a literature review on the causes and treatment of radiation induced diarrhoea. This review aims to identify studies performed, review the pathophysiology and discuss similarities and differences within the literature.

Methods: 30 articles were reviewed. Categorized into: trials conducted = 9, literature reviews = 5 and reviews, editorials, reports=16. Publications between 2004 and 2010 were used. Three books were also used for background knowledge and definitions.

Conclusion: Several potential limitations influence the validity and generalization of the data presented. Limitations existed in the sample size and on the amount of studies conducted. Whilst a variety of solutions were discussed and trialed, none have definitive proof of their value. Inconsistencies exist in the literature on treatment of RID. There is insufficient evidence to change current practice which is dependant on toxicity grading. Discrepancies in scoring tool used are of concern. Future research to include targeted therapies, clinical trials and supportive measures to improve patients’ quality of life are key.

Introduction

Professional

Get your grade
or your money back
using our Essay Writing Service!

Essay Writing Service

Diarrhoea is defined as the frequent passage of loose, watery stools(Harris, Nagy, Vardaxis Vardaxis 2009, p. 528). Diarrhea is defined by the World Health Organization (WHO) as having 3 or more loose or liquid stools per day, or as having more stools than is normal for that person (2010). As with other scoring methods each has their own definition as to what diarrhoea is.

Radiation induced diarrhoea (RID) falls into two categories acute and chronic.

Acute toxicities occur within 8 weeks and chronic are from 8 weeks to years after treatment. RID is caused by simple columnar epithelial cells (which are renewed every 4-5 days), of the small and large bowels being shed resulting in a decreased surface ability for the absorption of nutrients, bile salts and Vitamin B12. Motility of the bowel is increased which leads to lactose intolerance exacerbating diarrhoea (Bruner, Haas Gosselin-Acomb 2005, p. 121; Putta Andreyev 2005, p. 472). Late effects may be seen up to 15 years post radiation therapy, as a result of vascular insufficiency due to damaged cells in blood vessels and connective tissue in the bowel wall (Yarbro, Frogge Goodman 2005, p. 302).

RID if not managed early may lead to dehydration, electrolyte imbalance, malnutrition, weight loss, weakness, fatigue, depression, higher risk of infection due to a reduced immune function, bacteria, fungal, viral infections and hospitalisation, therefore increase costs to the community and alterations in patients’ quality of life (QOL) (Cherny 2008, p. 1; Gallagher 1999). Contributing factors in developing diarrhoea from radiation therapy are: site specific, volume, dose, fractionation, treatment technique and protocol of chemotherapy used, as well as age, other co morbidities and vascular disease (Bruner et al, 2005, p. 121). These side effects versus tumor control will be considered as part of the decision making process.

Radiation induced diarrhoea is a consequence of pelvic and abdominal radiation therapy, most particularly in those receiving chemotherapy concurrently. Documenting a comprehensive and accurate assessment of these patients leads to an accurate diagnosis which includes: Time of onset and duration of symptoms, the extent of the symptoms and whether blood is visible in the stool. Treatment will vary according to clinical findings.

Ongoing support, assessment and communication with the patient is vital for preventing and managing patient toxicities and has proved to be of benefit in patients completing their course of treatment. Preventative and supportive care through education is important. (Cherny 2008; Yeoh, Horowitz, Russo, Muecke, Robb, Maddox Chatterton 1993). A debilitating condition which affects QOL, diarrhoea as a result of radiation therapy goes unrecognised in many patients as they are too embarrassed to discuss it (Andreyev 2007, p. 739). The table below gives a more comprehensive outline of factors involved.

Table 1 – Symptoms related to gastrointestinal tract dysfunction that can develop after external beam pelvic radiotherapy

Anal ulceration /structuring

Bleeding per rectum

Weight gain (usually from inactivity as feet housebound)

(Andreyev 2007, p. 739)

(Wedlake, Thomas, McGough Andreyev 2008) did an observational study of 37 patients and suggest that loose stools affect up to 80%. Davidson Faithfull (2006) report that over 50% of patients receiving pelvic radiotherapy will develop permanent gastro intestinal symptoms. A Qualitative study of 10 women by Abayomi, Kirwan, Hackett Bagnall (2005), was conducted to investigate women’s experience of radiation enteritis they discussed that chronic RID affected 5-15% of women treated. From the result of these studies it is evident that RID will affect more than half the total patients treated with pelvic, abdominal or rectal radiation therapy. As many patients find discussing their bowel habits embarrassing and late toxicities go undetected due to short follow up time by physicians (Andreyev 2007) it is not surprising that the statistics differ. Therefore, the quality of the data published is questionable and variable (Putta et al. 2005).

Condition and causes

Pre existing co morbidities contribute to RID, especially in the elderly (Andreyev 2007 ;Gallagher 1999). Having a history of previous abdominal surgery, colitis, ileitis, irritable bowel syndrome, vascular disease, anal rectal sphincter impairment, or diabetes predisposes the patient to less tolerance of treatment to the abdomen, pelvis, and rectum (Andreyev 2007; Gallagher 1999; O’Brien 2001). Patient co morbidities also need to be factored into the treatment regime (Davidson and Faithfull 2006, p 419), as severe RID is a dose-limiting factor that may lead to an interruption of the treatment schedule and decreases chance of cure Severe RID may be fatal if not recognised and treated promptly (Putta et al. 2005; Yeoh et al. 1993).

Acute side effect may be seen up to 8 weeks after the completion of treatment. It is caused by radiation therapy damaging the mitotic crypt cells and villi in the intestine effectively denuding it (Hauer-Jensen at al 2003:359). This initiates the release of prostaglandin stimulating an increase in bile secretions, stimulates water and electrolyte emission, influencing peristalsis, causing diarrhoea. An outcome of this process is the mal absorption of vitamin B12, bile salts and lactose(Gallagher 1999; Cherny 2008, p 4). Influences on the severity of toxicity are dose, fractionation, tumour volume, amount of small and large bowel in the treatment field and concomitant chemotherapy (Andreyev 2007, p. 739; Institute 2010); National Cancer Institute 2001). The presence of endotoxins form an overgrowth of bacteria in the gut once in the blood stream stimulate either the central nervous system or neurotransmitters and increase gastric motility causing diarrhoea (Fuccio, Guido, Eusebi, Laterza, Grilli, Cennamo, Ceroni, Barbieri Bazzoli 2009). Huang, Wang, Hsu Sun (2006) conducted a retrospective study of 229 patients for cervical or uterine cancer on the Characteristics and predictive factors of early onset diarrhoea during pelvic irradiation. The conclusion from that study was that rapid small bowel transit time may predispose to early onset diarrhoea in patients who have had previous abdominal surgery and large small bowel volume.

Chronic RID may occur after doses greater than 45Gy (Cherny 2008, p 416) and present 8-12 months and up to 15 years after radiation therapy. Severe problems occur for 5-10% of patients after 10 years after completion of treatment and 10% after 20years (Andreyev 2007). Chronic RID is a result of vascular insufficiency due to damaged of the endothelial and connective tissue in the bowel wall. The volume of small bowel in the field and the total dose of radiation impacts on the incidence of RID (Bruner et al. 2005, p. 121). There appears to be a correlation between the incidence and severity of acute RID and the percentage of patients developing chronic diarrhoea. Clearly then the emphasis on managing chronic or late diarrhea needs to be accurately diagnosed and documented. The lack of supporting evidence becomes obvious when trying to find literature to support side effect management of chronic RID (Davidson and Faithfull 2006, p 419; (Giralt, Regadera, Verges, Romero, de la Fuente, Biete, Villoria, Cobo Guarner 2008).

Tool of assessment

This Essay is

This essay has been submitted by a student. This is not an example of the work written by our professional essay writers.

Examples of our work

Diagnosis of RID becomes problematic when there is inadequately trained staff and no standardized assessment tool available (Muehlbauer, Thorpe, Davis, Drabot, Rawlings Kiker 2009, p. 338). A variety of scoring tools exist, such as World Health Organisation (WHO) Grading System, the National Cancer Institute (NCI), the Common Toxicity Criteria (CTC), the Common Terminology Criteria for Adverse Events (CTCAE) and the Radiation Therapy Oncology Group (RTOG) (Muehlbauer et al. 2009, p. 338).

Implications on practice are that different measurement scales have diverse values and levels which can affect interventions and protocols. An instrument that measures signs and symptoms accurately will guide practitioners in their selection (Muehlbauer et al. 2009, p. 338). The literature recommends the uses of an assessment tool that is valid and reliable, even in the absence of a standardized one. This emphasize the significance of reaching an accurate diagnosis.

Treatment

Management strategies for RID will begin prior to commencing treatment. Health promotion concerning risk factors, through education and early intervention involving referrals to the multi disciplinary team including dietitian are important for these patients in the prevention of exacerbating symptoms and avoiding treatment breaks and any type of infection will significantly impact on the severity of symptoms (O’Brien 2001).

In the treatment of RID a comprehensive and accurate assessment of the whole patient, not solely focusing on the symptom itself. The patient requires frequent (at least weekly) ongoing assessment including weight. Patients receiving adjuvant or concurrent radiation therapy and chemotherapy to the pelvic abdominal and rectal regions will require ongoing support,

assessment and communication with MDT. Developing programmes to promote active self management should be encouraged (Davidson et al. 2006). This is vital for preventing and managing patient side effects (Muehlbauer et al. 2009, p. 338) and has proved to be of benefit in patients completing their course of treatment (Davidson et al. 2006).

Diet.

There is insufficient evidence in support of modifying diets. A study conduct by (McGough, Baldwin, Norman, Frost, Blake, Tait, Khoo, Harrington Andreyev 2006) using nutritional supplements that have been manufactured in their simplest forms referred to as an elemental liquid diet, the end point being improvement in occurrence of RID. Fifty patients were selected and randomised to 1 of 5 groups. Results showed 80% patients experienced gastrointestinal upset after receiving radiation treatment in the pelvic area. No significant difference in toxicity was noted. Conversely, in the literature there continues to be an abundance of recommendations. Gallagher (1999) advises a low residue diet for patients experiencing RID and that cultural and geographic food patterns ought to be considered. He suggests low residue diet guidelines helpful when teaching patients about diet. Bruner et al. (2005, p. 121). and Wedlake et al. (2008) also supports diet modifications in the restriction of product containing: lactose, fatty fried foods, alcohol and caffeine, and avoiding extremes of temperature in food. Patients are encouraged to eat low residue foods and consume adequate fluid replacement such as water and sports drink which containing salt and sugars.

A study on rats using lycopene which is red carotene that is found in tomatoes proved successful in the prevention of gastrointestinal toxicities as it acted as a radioprotectant thereby reducing weight loss (Andic, Garipagaoglu, Yurdakonar, Tuncel Kucuk 2009). A randomised trial on rats was conducted using preparations such as Glutamine to prevent acute RID. Evidence suggests the Glutamine has a protective effect on the mucous membrane and diets rich in glutamine will assist in the reduction of mucosal toxicity in RID. Campos FG, Waitzberg DL, Mucerino DR, Gonçalves EL, Logulo AF, Habr-Gama A, Rombeau JL). Glutamine constitutes 53 amino acids in the body. It serves as the principal energy for cells lining the gastrointestinal tract and is used for repairing rapidly dividing cells. Meat, chicken, fish, beans and dairy, wheat, corn, barley and nuts contain glutamine, which are all high protein foods (Hayward Shea 2009). Both studies are encouraging but obviously studies in humans that are larger, randomised and multicentred are required.

Probiotics

Probiotics are live microorganisms that are similar to beneficial microorganism found in the human gut (Medicine 2010). Radiotherapy alters the intestinal flora as does the use of antibiotics and changes in diet which can cause diarrhoea. It also reduces the gastrointestinal motility and allows for colonisation and overgrowth of bacteria. Probiotics can activate and change the function of immune cells. This action induces a secretion of cytokines (soluble proteins produced by many different cells) that suppress the inflammatory response. The function of probiotics includes fermentation of indigestible residue, epithelial cell proliferation, and differentiation, the development of a good immune system and resistance to unwanted microbes (Giralt et al. 2008, p. 1).

Studies on mice with chronic colitis showed improvement after probiotics improved inflammation favouring recovery and homeostasis of the mucosa (Fuccio et al. 2009). Although experiments on animals for the effects of probiotics for the prevention and treatment of RID have shown promise Fuccio et al. (2009) wasn’t convinced of the benefits, as there are few clinical studies available therefore no firm conclusion can be made. Several studies exploring the efficacy of probiotics in humans have been conducted. Delia, Sansotta, Donato, Frosina, Messina, De Renzis Famularo (2007) performed a double blinded placebo controlled study on 490 patients using probiotics VSL #3 in the prevention of RID. Although results were statistically insignificant, a trend was established that VSL#3 was effective in the reduction of bowel motions per day and severity of diarrhoea. Giralt et al. (2008) trialled the effects of probiotic lactobacillus on 85 patients randomised to the Probiotic drink or placebo. The conclusion was that using the probiotic drink containing Lactobacillus casei DN-114 001 does not reduce the incidence of diarrhoea however it did have an effect on stool consistency.

The evidence in the literature suggests that there is insufficient evidence to support the use of probiotics and that further randomized studies be used to evaluate probiotic efficacy and to determine timing of delivery, dosage and strains be conducted (Muehlbauer et al. 2009; Eddins Gray 2008).

Surgery

Surgical interventions are not an ideal for option for chronic radiation enteritis as it carries an increased risk of complication and mortality. One third of patients treated with pelvic irradiation will need to be operated on for an obstruction either by having an intestinal resection or conservative surgical intervention. However, most patients with chronic radiation diarrhoea are treated medically (Regimbeau, Panis, Gouzi Fagniez 2001).

Hyperbaric oxygen

Used in other setting Hyperbaric oxygen has shown efficacy in healing and reduces symptoms but is costly. Currently its value has been subjective in relieving symptoms of chronic radiation induced diarrhoea (Cherny 2008, p. 420). Sixty five patients were treated with 30 daily doses of 100% oxygen over 90 minutes and showed significant improvements in RID (Marshall, Thirlby, Bredfeldt Hampson 2007). Initial results from a study published by (Huddy, Patel, Johnson, Hamilton-Farrell, Ede Sanderson 2006) on Hyperbaric oxygen as a treatment proved hopeful with an initial improvement in symptoms and control of stoma output. Unfortunately, three years after the completion of treatment symptoms returned. (O’Brien 2001) suggests that controlled, larger studies establishing the role of hyperbaric oxygen therapy in the treatment of RID be conducted.

Changes to XRT

Total dose, fractionation of external radiation therapy, dose rate, techniques and patient factors all influence rectal morbidity (O’Brien 2001). In a study conducted between 1988-2000 of 1571 patients by Zelefsky, Levin, Hunt, Yamada, Shippy, Jackson Amols (2008), it was noted that the incidence of late rectal and urinary toxicity was significantly reduced the risk of gastrointestinal toxicity serious late toxicities were unusual, using Intensity Modulated Radiotherapy (IMRT), compared with conventional 3D conformal radiation therapy. The literature also reflects the opinion that IMRT has advanced without randomised trials examining their effects on toxicity.

Medications

Diarrhoea as a RT side effect was welcomed by pts taking opioids was a letter written by (Harris, Doyle, Barnes, Sinclair, Danjoux, Barbera Chow 2006), confirming that patients with chronic constipation due to opioid use were relieved of their constipation after completing a course of radiation therapy for their cancer. A detailed study would have been more reliable than this letter.

Loperamide is regularly used to achieve control of diarrhea as it reduce the frequency and urgency of motions by slowing gastointestinal peristalsis which increase gastointestinal transit time and promotes water rehabsorption(Gallagher 1999) (Bruner et al. 2005, p. 123)

Severe diarrhea can be treated with Octreotide (sandostatin: a natural hormone) which inhibits: gastrointestinal motility, serotonin, gastrin, insulin, glucagons (10. Cherny (Cherny 2008, p. 419) inhibits intestinal absorption. Another study by Yavus et al (2002p195-202) also conducted a randomized study of octreotide versus conventional anti-diarrhoeal agents. Results indicated a complete resolution of diarrhea in 61% of patients treated with Octreotide compared with 14% of those treated with the conventional agent, within the three day course of administration. Conversely to this (Martenson, Halyard, Sloan, Proulx, Miller, Deming, Dick, Johnson, Tai Zhu 2008) conducted a Phase III double blinded study of Depot Octreotide (sandostatin) versus placebo in 125 patients randomly selected. Their conclusion was that Octreotide did not decrease diarrhoea, infact some gastrointestinal symptoms were worse and did not recommend its use treating RID.

By accurately assessing and diagnosing RID, individual treatment plans can be developed. A variety of intervention can be utilized in the treatment of RID depending on the severity. Encouraging increased oral intake for less severe cases is the first option. Intravenous therapy as a means of rehydration with or without hospitalisation may be necessary in severe cases Benson et al (2004:2924). Other drugs such as anticholinergics, and antispasmodic agent to relieve cramping may be necessary. Antidiarrhoeals and mucosal prostaglandin inhibitors such as aspirin or sulfasalazine may be offered in preventing RID Rauch et al (cited in Kilic et al 2000, 128). However, (O’Brien 2001) reports that sucralfate given twice daily as an enema was more effective than oral sulfasalazine. Narcotics are also used to relieve symptoms associated with diarrhea. (Institute 2010). Metronidazole (Flagyl) an antibiotic drug used against an overgrowth of anaerobic bacteria may also assist in reducing diarrhoea (Cherny 2008, p. 420).

Conclusion

Developing a care plan is essential to assess risk of RID and to start preventative measures prior to commencement of treatment. Radiation induced diarrhoea essentially goes undiagnosed especially as anti diarrhoeal preparations can be brought over the counter. The importance of having a standardised score tool has been emphasised. This review has highlighted that RID it is poorly managed. At its severest RID can be life threatening. It is evident from the literature that many of the treatments outlined have not proven to be effective on the majority of patients. Treatment options are limited but diet and medication appear to be the most practical and cost effective options. One treatment has not proved superior over the other and in many patients has not proven to be effective. Clearly multicentred, randomised trails in humans are required. Targeted therapies, which address the prevention of RID, is the way of the future, as prevention is better than cure.

World Health Organisation (2010), Diarrhoea [Online], Available: who.int/topics/diarrhoea/en/ [29th April 2010].

Request Removal

If you are the original writer of this essay and no longer wish to have the essay published on the UK Essays website then please click on the link below to request removal:

More from UK Essays