The deterioration of radiation proctitis after a course of acute urine retention successfully treated by Argon Plasma Coagulation

Fang-Chin Hsu; Sheng-I Hu; Yi-Chiao Cheng; Chia-Cheng Wen

doi:10.4103/jmedsci.jmedsci_426_20

CASE REPORT

Year : 2022 | Volume : 42 | Issue : 3 | Page : 138-140

The deterioration of radiation proctitis after a course of acute urine retention successfully treated by Argon Plasma Coagulation

Fang-Chin Hsu¹, Sheng-I Hu², Yi-Chiao Cheng³, Chia-Cheng Wen²
¹ Department of General Medicine, Tri-Service General Hospital; School of Medicine, National Defense Medical Center, Taipei, Taiwan
² School of Medicine, National Defense Medical Center; Division of Colon and Rectal Surgery, Department of Surgery, Tri-Service General Hospital; Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
³ School of Medicine, National Defense Medical Center; Division of Colon and Rectal Surgery, Department of Surgery, Tri-Service General Hospital, Taipei, Taiwan

Date of Submission	20-Dec-2020
Date of Decision	01-Jun-2021
Date of Acceptance	16-Jun-2021
Date of Web Publication	20-Aug-2021

Correspondence Address:
Dr. Chia-Cheng Wen
Number 325, Section 2, Chang-gong Rd., Nei-Hu District, 114, Taipei
Taiwan

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jmedsci.jmedsci_426_20

Abstract

Argon plasma coagulation (APC), a nontouch thermoablative therapy, is increasingly recommended as the treatment of choice for radiation proctitis. This paper described a case of recurrent hemorrhagic radiation proctitis after hyperbaric oxygen therapy that deteriorated after a course of acute urine retention successfully treated with APC.

Keywords: Radiation proctitis, acute urine retention, argon plasma coagulation

How to cite this article:
Hsu FC, Hu SI, Cheng YC, Wen CC. The deterioration of radiation proctitis after a course of acute urine retention successfully treated by Argon Plasma Coagulation. J Med Sci 2022;42:138-40

How to cite this URL:
Hsu FC, Hu SI, Cheng YC, Wen CC. The deterioration of radiation proctitis after a course of acute urine retention successfully treated by Argon Plasma Coagulation. J Med Sci [serial online] 2022 [cited 2023 Mar 20];42:138-40. Available from: https://www.jmedscindmc.com/text.asp?2022/42/3/138/324154

Introduction

Radiation proctitis is a well-recognized complication that occurred in 5%–20% of patients following radiotherapy for pelvic malignancy.^[1],[2] A wide variety of interventions have been tried for treating chronic radiation proctitis (CRP) such as sucralfate enemas, hyperbaric oxygen (HBO) therapy, or endoscopic treatment. However, the management of radiation proctitis is challenging because no recommended guidelines are available and only a limited number of studies involving various treatment options are available in the literature.^[3] Argon plasma coagulation (APC), a nontouch thermoablative therapy, is increasingly recommended as one of the treatment options for radiation proctitis.^[4] A case of recurrent hemorrhagic radiation proctitis after HBO therapy that deteriorated after experiencing a course of acute urine retention treated successfully with APC was described.

Case Report

The patient is a 77-year-old male who received radiation therapy for prostate cancer about 40 times. No complications were reported after radiotherapy, and the patient was well. However, the patient presented with a blood stool 9 months after completion of radiotherapy. The patient had no medical history of hemorrhoid, anal fissure, diverticulosis, or colorectal cancer. Telangiectasias over the rectal region were observed through colonoscopy, while no other lesions causing hematochezia were observed through total colonoscopy. Regular sucralfate enema and HBO therapy were arranged. However, the intermittent bloody stool was still observed.

Nevertheless, the patient suffered from acute urinary retention after 40 times of HBO therapy. A Foley catheterization was performed at the emergency department, and 980 mL of urine was drained. In addition, the massive bloody stool was noted after the patient strained to urinate. The initial blood analysis at the emergency department showed a hemoglobin level of 5.4 g/dL, followed by an increased level of 9.6 g/dL in 1 week after transfusion of six units of packed red blood cells. APC therapy was arranged 8 days after the onset of rectal bleeding [Figure 1].

Figure 1: Argon plasma coagulation therapy was arranged 8 days after the onset of rectal bleeding (a). Endoscopic view of the multiple telangiectasias over the rectal region and characteristic of radiation proctitis. (b). Rectal mucosa immediately after argon plasma coagulation

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The patient's condition has significantly improved after APC treatment and less blood was noted after passaging feces. The hemoglobin level increased from 9.6 to 12 g/dL after 1 week and blood transfusion was no longer needed.

Colonoscopy follow-up was arranged 1 month after APC, and the result showed cicatrization of the treated areas with only two oozing bleeders over the lower rectum [Figure 2]. Moreover, snare coagulation was done for hemostasis. The second follow-up colonoscopy was done 2 months after APC, and complete eradication of telangiectasias with two small bleeders was found [Figure 3]. The bloody stool was improved and recovered.

Figure 2: Colonoscopy follow-up 1 month after Argon plasma coagulation (a). Cicatrization of the treated areas. (b) Two oozing bleeders over the lower rectum

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Figure 3: The second follow-up colonoscopy 2 months after Argon plasma coagulation. (a) Eradication of telangiectasias of the treated areas. (b) Two small bleeders over the lower rectum

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Discussion

Different treatment modalities for CRP (e.g., medical, endoscopic, and surgical intervention) have been reported with different pros and cons. Although no comprehensive study of CRP treatment existed, medical treatments are empirically considered first-line therapy.^[3] Endoscopy therapies such as would be applied for patients whose symptoms are resistant or refractory, while surgical intervention would be considered the last step.^[2],[5]

HBO therapy has been reported as a very effective treatment for radiation proctitis.^[6],[7] The number of HBO treatments varies for each patient. Ulrich M. Carl reported that one patient's proctosigmoidoscopy showed a significant improvement after 40 times of HBO therapy. However, the other patient was without subjective changes due to interrupted therapy after 38 times of HBO treatments.^[8] The patient in this study underwent 40 times of HBO therapy, with persisting symptoms and deterioration after a course of acute urine retention.

APC is with the advantage of noncontact ablation, the uniform penetration depth of coagulation, and mobility. Complications attributed to APC have been reported at different rates,^[7] but severe complications such as stricture formation, intestinal perforation, and anal fistula were very low.^[1] Univariate analysis showed ulceration >1 cm² was the only factor significantly associated with severe complications, and telangiectasias are present on >50% of the surface area associated with APC failure.^[9] Thus, single APC treatment will not be recommended to traditionally treat large-scale telangiectasias.

A rectal ulcer is another complication following APC treatment. The occurrence rate may be associated with the power setting and the flow rate of the argon gas.^[2],[10] In previous cases of radiation proctitis treated by APC, an electric power (70 W) and an argon gas flow rate (2.0 L/min) were used.^[1] In the present case, 60 W and argon flow rate of 1.8 L/min were used. No complication was noted during regular colonoscopy follow-ups.

In conclusion, patients with conservatively treated radiation proctitis should be given extra attention if acute urine retention is observed as well. Moreover, APC is recommended as first-line therapy if patients have signs and symptoms of benign prostate hyperplasia. However, a large-scale case accumulation should be considered to validate its variability.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Ethical approval

This study proposal was approved by the Institutional Review Board of Tri-Service General Hospital. TSGHIRB No.: A202005130. Date of Approval: 2020/9/24.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his/her/their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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