Conventional treatment

Local corticoids have been rarely studied in this indication. A randomised prospective trial (18 patients) has showed the efficiency of rectal steroids, but sucralfate was superior140.

Two retrospective trials, including 9 patients, conclude that 5-aminosalicylic acid enemas are not effective in the treatment of radiation proctitis141,142.

Rectal sucralfate has improved diarrhoea and bleeding in 3 patients143. In a randomized trial, rectal sucralfate allowed improvement of the symptoms in 94 % of the patients140. A retrospective trial, including 26 patients, showed and improvement in 77% and 92% at 4 and 16 weeks; 22% had recurrence of bleeding. All recurrences responded to the same therapy

(20 ml of 10% rectal sucralfate twice a day)144. Several authors reported the efficiency of sucralfate (enema or oral administration)145,146.

Intra rectal application of formalin (formaldehyde) has been used in retrospective trials. The application can be realized under general anaesthesia or sedation. Rectal bleeding is controlled in 75% to 100% of the cases147-153. Biswal147 presented 16 patients, with bleeding not responding to steroid enemas; formalin stopped bleeding in 81 % of them. In another study, bleeding stopped in 22 of 29 patients (after one application in 17 of them)149. The technique of application must be strict, because formalin can induce colitis150. Formalin seems effective, however randomised trials are necessary.

Local application of short chain fatty acids (SCFA) has been studied154. A first non controlled trial showed a clinical improvement in all 7 patients155. Two randomised trials are contradictory. In 15 patients, SCFA enemas were not more effective than placebo156. In 19 patients, after five weeks, rectal bleeding significantly decreased, and haemoglobin values increased in SCFA treated patients122. Larger trials are necessary to conclude.

Laser (Nd-YAG or Argon) can be used to destruct telangiectasia. An important trial included 47 patients with rectal bleeding; after a median of 2 procedures, bleeding was controlled in 37 of them, with a median follow-up of 14 months157.The efficiency of Nd-Yag laser has been confirmed by retrospective trials158-161. Rectal ulceration, stricture, ileus or fistulae may occur157,158,161. Argon laser has been studied in non controlled trials. In one of the most important trial, a median of three procedures was performed; bleeding stopped in all 14 patients, but recurrent bleeding occurred in 10 patients, requiring maintenance therapy162.

Coagulation of telangiectasia can be realized by bipolar electrocoagulation, heater probe or more recently by argon plasma. Heater probe and bipolar coagulation seem to be equivalent; 12 and 9 patients with bleeding resistant to steroid enema were cured, after a median of 4 procedures163. Argon plasma obtains same results, in non controlled trials164-167.

A phase II trial by the RTOG suggests that proctitis could be managed by pentosanpolysulfate ( 91% of complete and partial response, in 13 patients)168.

The main indications for surgery are rectovaginal or rectovesical fistula and rectosigmoidal stricture93,169,170. The reported mortality in old series varies from 0% to 32%93,169, seems few actually96,170, but surgery must be reserved for the more severe cases, resistant to non surgical treatment. In the series reported by Jao169, 40 of the 62 surgical patients had post operative complications; rectal resection followed by colostomy is correlated with a lower morbidity rate. However coloanal reconstruction with an ileocecal segment is feasible and allows a better anorectal function, and a good

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