Rectal Bleeding After Pelvic Radiation

A 48-year-old woman was hospitalized following 10 days of rectal bleeding. One year earlier, she had undergone combined external-beam radiation and brachytherapy for stage IIIA carcinoma of the cervix. The patient was orthostatic and pale on admission, and her hemoglobin level was 6 g/dL. After receiving a transfusion of packed red cells, she underwent colonoscopy. Several telangiectases were seen in the rectum, the mucosa was friable, and blood oozed from one of the lesions (A).

Severe rectal bleeding of 3 days' duration resulted in hospitalization of a 68-year-old man with a history of prostate cancer. He had received external-beam radiation for this condition 11 months earlier. The patient was pale, and rectal examination showed frank blood. After bowel cleansing, he underwent colonoscopy, which disclosed prominent telangiectases in the rectum and rectosigmoid junction. Several ectatic vessels (spiders) were seen, surrounded by areas of pallor (B).

Dr Klaus E. Mnkmller of Birmingham, Ala, writes that radiation-induced proctosigmoiditis is the most common clinically apparent form of colonic damage after pelvic irradiation. Such injury presents in two different ways:

• Acute injury occurs in up to half of the patients; it appears within 6 weeks after completion of radiation therapy and is manifested by diarrhea, tenesmus, discharge, and pain.
• Chronic injury presents with symptoms related to strictures, fistulas, or telangiectases.

Telangiectases, as seen in these two patients, are manifested by bleeding that can be massive. Therapies used to manage these lesions include corticosteroid and sulfasalazine enemas, hyperbaric oxygen, laser cautery, electrocoagulation, sclerotherapy, and endoscopic application of formalin. Most of these methods are somewhat successful in diminishing the amount of rectal bleeding, but most of them do not eliminate the vascular malformations and recurrent bleeding.