Radiation Enteritis: An overview
Summary -
---
-.
-
- -~
.. - -
Tlie clinical and radiological findings in chronic radiation enteritis are described in a group of 18 pat,ients. 'l'he patients presented with inalabsorptioii, diarrhoea, chronic intermittent obstruction or a combination of these signs. Eventually all patients developed an ileiis. The radiologist plays an important role in determining the cause of the clinical signs. The single-contrast barium infusion technique was used. In the ,jejunum no changes were found except bowel dilatation as a sign of an obstruction rnore distally. In the ileum there was evidence of submucosal thickening. adhesions ai-id single or multiple stenoses. These changes are described in relation to the pathogenesis of chronic radiation enteritis. Strahlungsenteritis (Übersicht) -
-
Die klinischen und radiologischen Befunde bei chronischer Strahlungsenteritis werden für eine Patientengnippe von 18 Patienten beschrieberi. Die Untersuchung ergab Malahsorption, Diarrhöe bzw. chronische zeitweilige Obstruktion oder eine Kombination dieser Symptome. Bei allen Patienten entwickelte sich schließlich ein Ileus. Der Radiologe spielt bei der Diagnose der Ursache dieser klinischen Symptome eine besonders wichtige Rolle. Es wurde die EinzelkoiitrastBariumtechnik angewendet. Im Jejuniim wurden keine Veränderungen festgestellt, mit Ausnahme einer Darrndilatation als Zeichen einer mehr distalen Obstruktion. Im Ileum zeigten sich eine submuköse Verdickung, Adhäsionen und vereinzelte oder multiple Stenosen. Diese Veränderungen werden in der Relation zur Pathogenese der chronischen Strahlungsenteritis dargestellt.
Inlroduction -
A well-knowri complication of radiotherapy of the abdomen is the occurrence of clinically significant radiation damage in the digestive tract. This paper only discusses radiation enteritis. but any part of the abdominal gastro-intestinal tract may be damaged. Most frequently enteritis and proctitis (1-3)occur but this appears to reflect P
Fortschr. Röntgeristr. 152.4 (1990)45.1-459 O Cieorg'rhicmc Verlag Stiittgart. New York
I
rather tlie relativrly high frequeiicy of high-dost! irradiation to tlie pelvis than the relative sensitivity of the different gastro-intestinal Segments (3). Diiring radiolherapy an acute form oi' radiation enteritis rnay occur. l'his does not give risc to diagnostic problcrns because the aetiology is clear and trealinent iisiially uiicomplicated. Tho c:hroriic form ofradiation enteritis has been reportcd to oc:cur up to twenty-six years after radiotherapy (4). This does create a diagnostic problem because the Symptoms rnay also be duc to tumor rccurrance. or even have another aetiology. In this problcrn the radiologic examination of the small bowel plays a n important role and, together with the clinical signs, lielps to detcrmine palients managcment. Iri lhis study we describe the clinical and radiological realures of chronic radiation enteritis (CRE) in paticnts who have been treated Tor a pelvic rnalignancy. The cliriical impact ot' the radiologic evaliiation in this group of patients will also be deccrihed. Our results will be coinpared to those oi'previous authors. Patients and Mothods We examincd retrospectively all paticnts who were trented for CKE in oiir tiospital during the periud 1979-- 1988. Thc criteria usrd for paticnt selectiun were: 1 . Rndiotherapy for a rrialignancy in the pelvis.
2. A srnall bowcl single-contrast iniusion examinatiori. 3. Confirmatioii of tha clinical and radiological diagnosis CRE by
surgcry or a correlative rollow-up period ofat Ienst 1 I/, years. Ofan original niimher of 22 patients 18 iriet thesa critcria and were iiicludnd in the study. Thc srnall bowel exairiinations wcrc perforined by the single-contrast small bowcl infusion tecliiiique (entcroclysis) as described by Sellink (5). This method has been stiowri to bc supcrior to tlie convcntional follow-ttirough cxarninatiori i n
demonstrating stenotic segmcnts and mucosal pathology because ofan optimal bowcl distensiori (6).We havc bcen using ttiis techniquc routinely in every patientsiispected oiCRE ror the past 8 years. Only rninor modilications wcrc rnade wheri bowel obstruction was suspected. In thcse cases no drastic oral laxatives were uscd for bowel cleansirig (7). The infusion rate and total arnount orcontrast material wcre also adapted whcn necessary. In thc 18 patients a total of 23 cxaminatioris were performcd. 'l'he radiological fcatures oi the jejunum and ileuni were evaluated scparately. Thiis wc asscssed the nuiiiber of folds per inch. their height and width. ttie rriaximal diarneter and the wall thickncss. 'rhe results wcrc cornpared with normal values obtained frorn a study of 100 riormal cxaminations performcd in nur hospital (8). These values show a good corrclation witli tliose given by Sellink (5) arid I . a ~ . e(9). r
Dieses Dokument wurde zum persönlichen Gebrauch heruntergeladen. Vervielfältigung nur mit Zustimmung des Verlages.
Ry R. E. Weijers. /< .I. ou12 der Jagt. W. ~unseli' I)c:pai.tiii~riis oTI)iagriostic Hadiology iiiid ' (iastro-Eritrl.i~logy. C'nivcrsity t.lospiriil(;ri~riiiigcn. 'fhc Ycthri.liiiidi,
-
454 k o r t s c h r Hontgenstr 152.4
-
R E Weller5 e t al --
P -
Tab. 1
H.K. 38
Cervix adeno Ib Pelvis tumorboost Cervix Pelvis + paraaortic plano ll a-b glands Cervix Cervix plano lb Pelvis Ce~ix Cervix Pelvis plano Ilb Pelvis Cervixinsitu Tumour boost carc. Pelvis till L3-4 Endom. lll Pelvis till L4-5 Endom. Pelvis Endorn I. Pelvis Endorn. lll Abdomen OvarylA? Pelvic boost Ovary III Pelvis + paraaortic glands Pelvic boost Abdomen Ovary
J. P. 58
Ovary lAi
H.S.63 Z.V. 54
Ovarylb 0vary lc
J. B. 32
Retrop. myosarcoma Bladder. carcinoma Gr III
A.M. 48
F.O. 39 M.P. 67 F.V. 58 W. E. 53 B. M. 64 G.P. 79 J.V. 77 K.B. 65 A. B. 6 6
H. W. 65 -
32 16 30
1.8 1.8 2.0
25 13 20
8MeV 8MeV 4MeV
Summaryof radiotherapy data
45 68.2 40
I3'Cs
intracavitary 41.4
38 19 42 37 38 38 25 12 41 9
Ra '"CO 8 MeV 8 MeV 8 MeV 8 MeV 8 MeV 8 MeV 8 MeV 8 MeV 8 MeV @Co
rnoving strip technique
Abdomen Pelvis Abdomen Pelvis Abdomen Turnour boost Bladder 14xl4cm
32 11 47
-
Tab.2
Resultsof radiological nieasurements in thelejunum. ......
thickness J.B. K B. A. B. A.C. W.E. H.K. R.M. A.M. B.M. F.O. G.P. J. P. M.P. H.S. z. V. J.V. F. V. H.W.
,
1 I 1 1 3 1 1 1 1 2-3 1
1 1 1 1 1 1 2
Normal 1-2 values Total of 1 abnormals
n. rn. =not measurable
Fold Pattern height foldslinch rnrn 4 3 4.5 2 5 3 1 3 3 5-6 4-5 7 2 3 4-5 4 6 3 2-6 0
Wc analyst2d 18 patierils, all fernale except for onc: male (H.W.). The riieaii age was 57 years (range: 32-79). The average follow-up time was 5 years (rangc: 2-17). Nine patients (50%) had a history of previous abdominal surgerv: 5 cholecystcctomics. 4 appendectomies and 2 suffcring from gastric bleedirig. N O patieiits were trcatcd for systemic diseases cornrnonly associated with srnall vessel disease. In l'able 1 the primary tumours of thc 18 patients are summarised. All paticnts wcrco treated by surgery and concccritivc radiot,herapy of t.he pelvis. None of the paticnts rccc!ived cherriollierapy. Two patients died within one year afier therapy because of metabolic dysregiilalioii. cacliexia and septicaemia. In a third patient with an extensively infiltrating bladder carcinoma thc caiist: of death was urosepticaemia..
During radiotherapy 15 patients showed signs of ac:ute radialion eiiteritis i n varying degree: diarrhoea. teriesrni, borborygnii. vomitus and rnalaise. All patients except one could be easily treated hy conscrvative measures. Iiospitalisiltion with tcmporary ccssation of the radiotherapy was nccassary in orie case. Alter radiothcrrtpy aII patienls irriproved clinically with only
Dieses Dokument wurde zum persönlichen Gebrauch heruntergeladen. Vervielfältigung nur mit Zustimmung des Verlages.
R. M. 37
-
....
-
.
.-
-
-
.
thick. ness mm
J. B. K. B. A.B. A. C. W.E. H. K . R. M. A.M. B.M. F. 0. G. P. J. P. M.P. H.S. Z.V. J.V. F. V. H.W. ..
2
height folds/ mrn
1-2
2
4
5
2 1
n.m. 2
n.m. 4
jejuno-transversostorny 2 2 8
mm
mm
40 n.m.
+
+ +
32 n. m. 20 32 n. m. 18
1 n. m. n. m. n. m. 2 1
+
30
26
+
48
+
22 28
flocculation,fillingafter hours 2 4 6 4 3 0-1 1 2 4
Normal 1-2 values 1 Totalof abnormals
.
1-3
3-9
2
1
prox. dilatation
-
Tab. 3 Results of radiological measurementsin the ileum.
suspi. cion
60
1 n. m. 2 n. m. n. m.
35 40 60
3 40 40 36 35
14-34
1-3
14-34
..
Fortschr. Röntgenslr. 152.4 455 .---
+
20 28 18
2
mult.
adhesion
.
mm
n. m. n. m. 2 1 2
8
.
-
morph. stenosis single
+ + n.m.
-
-
wall thickness
absence
inch
.-
-.
-
diameter
fold pattern
-
55
9
0 .
-
n. m. = not measurable
slight residual syrnptorns. In 3 cases acute radiatiori enteritis merged imperceptibly into C R E without interveriing irnprovernent. Tlie period ol'lalency varied from 3-38 rnonths (mcan 9 months). Some patieiits receivcd radiotherapy elsewhere arid in thesc cases the data are incoinplete. All relevant available datii are summariscd in Table 1. The turnour dose varied botween 40 and 70Gy except in one patient. After 25 Gy total abdominal irradiation by the nioving strip rnethod she developed a CRE. Two patients receivcd intracavilary irradiatiori as well a s percut.aneous thcrapy. Iri 6 cases the relatioii between the irradiated field and lhe location of thc radiologically diseased bowel could be evaluated. In all cases there was a good correlation. I n the chronic st.age patients dcveloped progressive bowel symptoms: 13 tiad interrnittent subacute srnall bowel obstruclion, 4 combined with malabsorption. Five patients had progressive diarrhoea a s the dominant Symptom. In each case intermittent subacute srnall bowel obstruction developed laler in the Course ofthe illness. Eventually all patients were admitted to hospital with a small bowel ohstructiori. where initially Lliey were treatcd coriservatively. Twelve patients eveiitually iieeded surgery and an cntero-colic bypass was performed. In aII cases the srnall bowel showed typical signs of CRE. In thc other six paticnts conservativc treatment and dictary measures sufficcd; their follow-up for at least two years niakes the diagriosis suficicntly certain. At the moirieiit of writing 3 patients arc absolutely free ol'syrriptoms. 3 patients have a short bowel syndrorne and 9 patients havc mild Symptoms.
Radiological Features
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A Summary of the rcsults of the evaluation of the radiological Features is given in Tables 2 and 3. The ileum of onc patient (J. P.) could not be studied bccause o r a jejuno-transversostomy. In all cases there wcre no abnormalitics iri lold pattcrn, wall thickness or perislalsis in thc a dilatation with a maximum diarno,jejunurn. In 39% tcr of 5 0 m m was present. In thc jejuriuni the dilatation always was associated with a more distal obstruction (Fig. 1). In the ileum an abnormal fold pattern was prc:sent in 71 % (I2/l7). In 47% ('/17) there was atrophy (Fig.2): slightly ragged contours without valvulae conniventes bcing discernible. In the other 2 4 % (4/~7)the mucosal changes were less obvious: an incrcase in height and thickiiess and a decrease in number of the valvulac conniventes (1:ig. 3 nnd 4). In these cases Lhe contours get spiky. 'niese features are the reflection of the submucosal dianges. Thc rnucosal changes were more segmental than local. Uowcl wall thickness was dcfiried as the distance between two adjacent bowel loops rurining parallel for at least 4cm urider compression. In 47% ('/17) of the c:ases the wall thickness could not be riieasured because no pictures wert? available that. met our criteria. In the other 5 3 % ('Y171 no appreciablc increase in wall thickness was found. A possible explanation is the dilutinri of contrast material in some of the cases. At fluoroscopy evidencc of howel wall thickcning was associated with diminishcd or absent peristalsis (Fig. 5). I r i 53% ("YI~) a dilatation 01' the proximal ileum was present with a rnaxiinum diarneter of 6 0 m m
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Radiation h'nterilis: An ovcrview
Fig.2
Mucosal atrophy and dilatationof adherent ileal loops.
Fig. 3 Tickened vaC vulae conniventes cauSe antirnesenterial spiky contour. Also note nodular filling defects on the mesenteric border.
(mean 4 5 mm). 67 % ('YY) showed a n associated dilatation of the jejunum. In 7 7 % ('79) one o r morc stcnoscs wcrc detected. In one casc only the distal ileum w a s dilatated. In a total of 41 % (%7) stenoses were preseril, 1 2 % (2/17) solitary and 29% (5/~7) inultiple. In 18 % (:'/17) the presence 01a c t ~ n o s i was s doubtful. 'l'he aspect of the stenoses varied in length (10-20 m m ) and diameter (8 -12 mm). The delineation w a s always smooth tu slightly raggcd. Thc environment of thc stcnosis showed rnucosal atropliy o r thickeried
Fig. 4 Compression film showing pronounced thickened valvulae Also note the rnucosal atrophy in the two adjacenl bowel loops
valviilae. In 3 0 % mal dilatation.
( 3 / ~ ~ there )
w a s a stenosis without proxi-
Different radiological realures reflect ttie presence of ad hesions. Most commoiily kiiown a r e l h e fixed bowel loops that can only be displaced e n macse by palpation. :2 morc subtile fcaturc is thc "mucosal tacking" associatcd with fi)cal adhosions (4) (Fig. 6). ..2 "pool of bariiim" is described a s "srnall bowel being inseparablo rnattcd
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Fig. 1 Dilatation and rnucosal atrophy of ileal loops, also secondarydilatation of the jejunum.
--
Fortschr. Rönlgctistr. 252.4 457
-.
togctlier" and is associa.tcid will1 sliortening of thc moseiitc:ry besides thick and librous adhesions (4). In our series a total of 53 % (y/~,/i71ol'tlie cases showed rcaturcs ofadliesions: In 47 % ( K 7 ) lixed bowel loops. 24% ( - N i ) inucosal tacking and i n on(n case a pool of bariurn i n the pelvic rcgion. A numbt:r ofcases showcd kinkirig of bowel loops. a.ttrihiited by soine authors (2, 5 , 10) to rnesenterial shorteniiig. by olhers (3.4.6)to adliesioiis and wa.ll thick(:nirig.
Fig. 5 Spotfilni without compression. Se. paration of bowel loops due to wall thickening.
Oiily one cnsc showed lliree reprodiicibl(? nodiilar lilliiig defects on tho rneseiiterial side in onc ho\vel scgrnent (Fig. 3). Ketrospectively tlie transit timt! c:ould be dolermined in 65% ("/I, ) of tlie cases. In 73 % I ) it was prolonged varying l'roin 1 I/? tu morc than 24 Iiours. In all cases cvcntually lhere was passagt: irito lhe colon. At. Iluoroscopy peristalsis diminished progressively towards the s(+riousIyclamagcd bowel segments. In snmc cases this was cornbined with progressive dilution of contrasi rnaterial caused by rcsidual bowel fluid. In thrcc cases lhere was also flocculatiori oi' the contrast material. Erosions, ulcers ancl fistula were not observed in our series. Correlation l o Operative- .Fiii(lings ---
-
The radiologic exarninatioris were compai'ed with the operation reports. In every case studied thc extent ol' CRE was undercstirnated on the base of tho radiologic examinalioii.
As is widely knowri, roentgen rays havc tbe rnost deslructive effect. on rapidly dividing cells likt? iri the bowel epithelium. As a corisequence rnany cpittielial cells die during radiotherapy. Besides this directly visible effect, cells in othcr tissues are sublethally darnaged and die off later whcn eriteriiig niitosis. In the case of bowel epitheliiim thc loss ol' cells is cornpensated for by a reduction in th,: length ol'the mitotic cycle a s well as a n enlargement of the slern cell comportrncnt, which originates in the crypts of the rnucosa (1 1). Iri tliis inanner an unstable euuilibrium between los; and production of epithelial cellc created. Sornc? fact,ors Lhat influence this equilibriurn a r e the daily radiatiori dose. total dose. radiation quality. irradiatcd volUrne, vascularisation and iridividual sensitivity (1). A daily dose of 2 Gy can jiist be cnnipensated for (1 1). When the balance is distiirbod, parlial or complctc denudation can occur. Clinically an acute ra.diation eiileritis develops: anorcxia, vnrriiting. crampy diarrhoea and loss of electrolytes; sometirnes haemorrhagc or bacterial infection rnay rosult. Af'tcir discontinuation 01' radiolherapy tl-ie epithelium can recover from the acuto radiation damage. Perrnancni. loss of up to 30% ol' ttie original numbcr »f crypts and villi can rnsur. dcpc?ndiiigon t h ra.diation ~ dose (11).
Rcsides tliese (sub)acut,c oll(:ts, radiation darnage of thc resl of the bowel wall oc:curs a.fler a latent. pt:riod. Those changes are irrcvcrsihle aiid progressive a.nd tlierefore rnucti niore import,arit for the final oiitcornc thari tlie acule effects (1). Th(? late clianges Start will1 llie developnient of an oblii.c?rativeendarteritis willi a tliicken-
Fig. 6 Mucosal tacking.
ing oi'the iritiiiia and thrombosis. This resiilts in undcrperfusion and tissue hypoxia and is a critical factor in the pathogenesis of bowcl darnage. Ederna. fibrin exudation. fibrosis and hyalinisatioii together with signs of chronic inflamrnation occur, initially and prcdorninantly in the submücosit (12). Secondarily, structural and functional changes occur in the miicosa, serosa and mesentery. The rniic:osa lerids to becomc atropliied. leading to malabsorptioii. In the submticosa arid rnuscularis miicosae, fibrosis arid thickening cause segments of bowcl to becorne rigid and rnotionlcss. As a consequence thcrt? is loss ofability to transport intestinal contpnt, rosultirig in functional ohstriict,ioii: "the dysfunctional bowel" (13). In other cases tho I'ormation of stenoscs is iiiore pronounccd, causing morphological obstruction. l'he chronic inflarnniatioii in serosa and rncscntr?ry gives rise to thc hrrnation of adhesions and shorteiiing. 'l'he ultimatc outc:orrie depends upon the dcgroc? of vascular injury. ßccause of the differencc in dcgrce oI'palhological changcs iri tlie different laycrs of'the bowel wall. the clinical katures rnay vary: frorn c:liroiiic irialabsorption to chroriic iiitermittent ilcus witli or without
Dieses Dokument wurde zum persönlichen Gebrauch heruntergeladen. Vervielfältigung nur mit Zustimmung des Verlages.
t
Summary -
---
-.
-
- -~
.. - -
Tlie clinical and radiological findings in chronic radiation enteritis are described in a group of 18 pat,ients. 'l'he patients presented with inalabsorptioii, diarrhoea, chronic intermittent obstruction or a combination of these signs. Eventually all patients developed an ileiis. The radiologist plays an important role in determining the cause of the clinical signs. The single-contrast barium infusion technique was used. In the ,jejunum no changes were found except bowel dilatation as a sign of an obstruction rnore distally. In the ileum there was evidence of submucosal thickening. adhesions ai-id single or multiple stenoses. These changes are described in relation to the pathogenesis of chronic radiation enteritis. Strahlungsenteritis (Übersicht) -
-
Die klinischen und radiologischen Befunde bei chronischer Strahlungsenteritis werden für eine Patientengnippe von 18 Patienten beschrieberi. Die Untersuchung ergab Malahsorption, Diarrhöe bzw. chronische zeitweilige Obstruktion oder eine Kombination dieser Symptome. Bei allen Patienten entwickelte sich schließlich ein Ileus. Der Radiologe spielt bei der Diagnose der Ursache dieser klinischen Symptome eine besonders wichtige Rolle. Es wurde die EinzelkoiitrastBariumtechnik angewendet. Im Jejuniim wurden keine Veränderungen festgestellt, mit Ausnahme einer Darrndilatation als Zeichen einer mehr distalen Obstruktion. Im Ileum zeigten sich eine submuköse Verdickung, Adhäsionen und vereinzelte oder multiple Stenosen. Diese Veränderungen werden in der Relation zur Pathogenese der chronischen Strahlungsenteritis dargestellt.
Inlroduction -
A well-knowri complication of radiotherapy of the abdomen is the occurrence of clinically significant radiation damage in the digestive tract. This paper only discusses radiation enteritis. but any part of the abdominal gastro-intestinal tract may be damaged. Most frequently enteritis and proctitis (1-3)occur but this appears to reflect P
Fortschr. Röntgeristr. 152.4 (1990)45.1-459 O Cieorg'rhicmc Verlag Stiittgart. New York
I
rather tlie relativrly high frequeiicy of high-dost! irradiation to tlie pelvis than the relative sensitivity of the different gastro-intestinal Segments (3). Diiring radiolherapy an acute form oi' radiation enteritis rnay occur. l'his does not give risc to diagnostic problcrns because the aetiology is clear and trealinent iisiially uiicomplicated. Tho c:hroriic form ofradiation enteritis has been reportcd to oc:cur up to twenty-six years after radiotherapy (4). This does create a diagnostic problem because the Symptoms rnay also be duc to tumor rccurrance. or even have another aetiology. In this problcrn the radiologic examination of the small bowel plays a n important role and, together with the clinical signs, lielps to detcrmine palients managcment. Iri lhis study we describe the clinical and radiological realures of chronic radiation enteritis (CRE) in paticnts who have been treated Tor a pelvic rnalignancy. The cliriical impact ot' the radiologic evaliiation in this group of patients will also be deccrihed. Our results will be coinpared to those oi'previous authors. Patients and Mothods We examincd retrospectively all paticnts who were trented for CKE in oiir tiospital during the periud 1979-- 1988. Thc criteria usrd for paticnt selectiun were: 1 . Rndiotherapy for a rrialignancy in the pelvis.
2. A srnall bowcl single-contrast iniusion examinatiori. 3. Confirmatioii of tha clinical and radiological diagnosis CRE by
surgcry or a correlative rollow-up period ofat Ienst 1 I/, years. Ofan original niimher of 22 patients 18 iriet thesa critcria and were iiicludnd in the study. Thc srnall bowel exairiinations wcrc perforined by the single-contrast small bowcl infusion tecliiiique (entcroclysis) as described by Sellink (5). This method has been stiowri to bc supcrior to tlie convcntional follow-ttirough cxarninatiori i n
demonstrating stenotic segmcnts and mucosal pathology because ofan optimal bowcl distensiori (6).We havc bcen using ttiis techniquc routinely in every patientsiispected oiCRE ror the past 8 years. Only rninor modilications wcrc rnade wheri bowel obstruction was suspected. In thcse cases no drastic oral laxatives were uscd for bowel cleansirig (7). The infusion rate and total arnount orcontrast material wcre also adapted whcn necessary. In thc 18 patients a total of 23 cxaminatioris were performcd. 'l'he radiological fcatures oi the jejunum and ileuni were evaluated scparately. Thiis wc asscssed the nuiiiber of folds per inch. their height and width. ttie rriaximal diarneter and the wall thickncss. 'rhe results wcrc cornpared with normal values obtained frorn a study of 100 riormal cxaminations performcd in nur hospital (8). These values show a good corrclation witli tliose given by Sellink (5) arid I . a ~ . e(9). r
Dieses Dokument wurde zum persönlichen Gebrauch heruntergeladen. Vervielfältigung nur mit Zustimmung des Verlages.
Ry R. E. Weijers. /< .I. ou12 der Jagt. W. ~unseli' I)c:pai.tiii~riis oTI)iagriostic Hadiology iiiid ' (iastro-Eritrl.i~logy. C'nivcrsity t.lospiriil(;ri~riiiigcn. 'fhc Ycthri.liiiidi,
-
454 k o r t s c h r Hontgenstr 152.4
-
R E Weller5 e t al --
P -
Tab. 1
H.K. 38
Cervix adeno Ib Pelvis tumorboost Cervix Pelvis + paraaortic plano ll a-b glands Cervix Cervix plano lb Pelvis Ce~ix Cervix Pelvis plano Ilb Pelvis Cervixinsitu Tumour boost carc. Pelvis till L3-4 Endom. lll Pelvis till L4-5 Endom. Pelvis Endorn I. Pelvis Endorn. lll Abdomen OvarylA? Pelvic boost Ovary III Pelvis + paraaortic glands Pelvic boost Abdomen Ovary
J. P. 58
Ovary lAi
H.S.63 Z.V. 54
Ovarylb 0vary lc
J. B. 32
Retrop. myosarcoma Bladder. carcinoma Gr III
A.M. 48
F.O. 39 M.P. 67 F.V. 58 W. E. 53 B. M. 64 G.P. 79 J.V. 77 K.B. 65 A. B. 6 6
H. W. 65 -
32 16 30
1.8 1.8 2.0
25 13 20
8MeV 8MeV 4MeV
Summaryof radiotherapy data
45 68.2 40
I3'Cs
intracavitary 41.4
38 19 42 37 38 38 25 12 41 9
Ra '"CO 8 MeV 8 MeV 8 MeV 8 MeV 8 MeV 8 MeV 8 MeV 8 MeV 8 MeV @Co
rnoving strip technique
Abdomen Pelvis Abdomen Pelvis Abdomen Turnour boost Bladder 14xl4cm
32 11 47
-
Tab.2
Resultsof radiological nieasurements in thelejunum. ......
thickness J.B. K B. A. B. A.C. W.E. H.K. R.M. A.M. B.M. F.O. G.P. J. P. M.P. H.S. z. V. J.V. F. V. H.W.
,
1 I 1 1 3 1 1 1 1 2-3 1
1 1 1 1 1 1 2
Normal 1-2 values Total of 1 abnormals
n. rn. =not measurable
Fold Pattern height foldslinch rnrn 4 3 4.5 2 5 3 1 3 3 5-6 4-5 7 2 3 4-5 4 6 3 2-6 0
Wc analyst2d 18 patierils, all fernale except for onc: male (H.W.). The riieaii age was 57 years (range: 32-79). The average follow-up time was 5 years (rangc: 2-17). Nine patients (50%) had a history of previous abdominal surgerv: 5 cholecystcctomics. 4 appendectomies and 2 suffcring from gastric bleedirig. N O patieiits were trcatcd for systemic diseases cornrnonly associated with srnall vessel disease. In l'able 1 the primary tumours of thc 18 patients are summarised. All paticnts wcrco treated by surgery and concccritivc radiot,herapy of t.he pelvis. None of the paticnts rccc!ived cherriollierapy. Two patients died within one year afier therapy because of metabolic dysregiilalioii. cacliexia and septicaemia. In a third patient with an extensively infiltrating bladder carcinoma thc caiist: of death was urosepticaemia..
During radiotherapy 15 patients showed signs of ac:ute radialion eiiteritis i n varying degree: diarrhoea. teriesrni, borborygnii. vomitus and rnalaise. All patients except one could be easily treated hy conscrvative measures. Iiospitalisiltion with tcmporary ccssation of the radiotherapy was nccassary in orie case. Alter radiothcrrtpy aII patienls irriproved clinically with only
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R. M. 37
-
....
-
.
.-
-
-
.
thick. ness mm
J. B. K. B. A.B. A. C. W.E. H. K . R. M. A.M. B.M. F. 0. G. P. J. P. M.P. H.S. Z.V. J.V. F. V. H.W. ..
2
height folds/ mrn
1-2
2
4
5
2 1
n.m. 2
n.m. 4
jejuno-transversostorny 2 2 8
mm
mm
40 n.m.
+
+ +
32 n. m. 20 32 n. m. 18
1 n. m. n. m. n. m. 2 1
+
30
26
+
48
+
22 28
flocculation,fillingafter hours 2 4 6 4 3 0-1 1 2 4
Normal 1-2 values 1 Totalof abnormals
.
1-3
3-9
2
1
prox. dilatation
-
Tab. 3 Results of radiological measurementsin the ileum.
suspi. cion
60
1 n. m. 2 n. m. n. m.
35 40 60
3 40 40 36 35
14-34
1-3
14-34
..
Fortschr. Röntgenslr. 152.4 455 .---
+
20 28 18
2
mult.
adhesion
.
mm
n. m. n. m. 2 1 2
8
.
-
morph. stenosis single
+ + n.m.
-
-
wall thickness
absence
inch
.-
-.
-
diameter
fold pattern
-
55
9
0 .
-
n. m. = not measurable
slight residual syrnptorns. In 3 cases acute radiatiori enteritis merged imperceptibly into C R E without interveriing irnprovernent. Tlie period ol'lalency varied from 3-38 rnonths (mcan 9 months). Some patieiits receivcd radiotherapy elsewhere arid in thesc cases the data are incoinplete. All relevant available datii are summariscd in Table 1. The turnour dose varied botween 40 and 70Gy except in one patient. After 25 Gy total abdominal irradiation by the nioving strip rnethod she developed a CRE. Two patients receivcd intracavilary irradiatiori as well a s percut.aneous thcrapy. Iri 6 cases the relatioii between the irradiated field and lhe location of thc radiologically diseased bowel could be evaluated. In all cases there was a good correlation. I n the chronic st.age patients dcveloped progressive bowel symptoms: 13 tiad interrnittent subacute srnall bowel obstruclion, 4 combined with malabsorption. Five patients had progressive diarrhoea a s the dominant Symptom. In each case intermittent subacute srnall bowel obstruction developed laler in the Course ofthe illness. Eventually all patients were admitted to hospital with a small bowel ohstructiori. where initially Lliey were treatcd coriservatively. Twelve patients eveiitually iieeded surgery and an cntero-colic bypass was performed. In aII cases the srnall bowel showed typical signs of CRE. In thc other six paticnts conservativc treatment and dictary measures sufficcd; their follow-up for at least two years niakes the diagriosis suficicntly certain. At the moirieiit of writing 3 patients arc absolutely free ol'syrriptoms. 3 patients have a short bowel syndrorne and 9 patients havc mild Symptoms.
Radiological Features
-
A Summary of the rcsults of the evaluation of the radiological Features is given in Tables 2 and 3. The ileum of onc patient (J. P.) could not be studied bccause o r a jejuno-transversostomy. In all cases there wcre no abnormalitics iri lold pattcrn, wall thickness or perislalsis in thc a dilatation with a maximum diarno,jejunurn. In 39% tcr of 5 0 m m was present. In thc jejuriuni the dilatation always was associated with a more distal obstruction (Fig. 1). In the ileum an abnormal fold pattern was prc:sent in 71 % (I2/l7). In 47% ('/17) there was atrophy (Fig.2): slightly ragged contours without valvulae conniventes bcing discernible. In the other 2 4 % (4/~7)the mucosal changes were less obvious: an incrcase in height and thickiiess and a decrease in number of the valvulac conniventes (1:ig. 3 nnd 4). In these cases Lhe contours get spiky. 'niese features are the reflection of the submucosal dianges. Thc rnucosal changes were more segmental than local. Uowcl wall thickness was dcfiried as the distance between two adjacent bowel loops rurining parallel for at least 4cm urider compression. In 47% ('/17) of the c:ases the wall thickness could not be riieasured because no pictures wert? available that. met our criteria. In the other 5 3 % ('Y171 no appreciablc increase in wall thickness was found. A possible explanation is the dilutinri of contrast material in some of the cases. At fluoroscopy evidencc of howel wall thickcning was associated with diminishcd or absent peristalsis (Fig. 5). I r i 53% ("YI~) a dilatation 01' the proximal ileum was present with a rnaxiinum diarneter of 6 0 m m
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Radiation h'nterilis: An ovcrview
Fig.2
Mucosal atrophy and dilatationof adherent ileal loops.
Fig. 3 Tickened vaC vulae conniventes cauSe antirnesenterial spiky contour. Also note nodular filling defects on the mesenteric border.
(mean 4 5 mm). 67 % ('YY) showed a n associated dilatation of the jejunum. In 7 7 % ('79) one o r morc stcnoscs wcrc detected. In one casc only the distal ileum w a s dilatated. In a total of 41 % (%7) stenoses were preseril, 1 2 % (2/17) solitary and 29% (5/~7) inultiple. In 18 % (:'/17) the presence 01a c t ~ n o s i was s doubtful. 'l'he aspect of the stenoses varied in length (10-20 m m ) and diameter (8 -12 mm). The delineation w a s always smooth tu slightly raggcd. Thc environment of thc stcnosis showed rnucosal atropliy o r thickeried
Fig. 4 Compression film showing pronounced thickened valvulae Also note the rnucosal atrophy in the two adjacenl bowel loops
valviilae. In 3 0 % mal dilatation.
( 3 / ~ ~ there )
w a s a stenosis without proxi-
Different radiological realures reflect ttie presence of ad hesions. Most commoiily kiiown a r e l h e fixed bowel loops that can only be displaced e n macse by palpation. :2 morc subtile fcaturc is thc "mucosal tacking" associatcd with fi)cal adhosions (4) (Fig. 6). ..2 "pool of bariiim" is described a s "srnall bowel being inseparablo rnattcd
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Fig. 1 Dilatation and rnucosal atrophy of ileal loops, also secondarydilatation of the jejunum.
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Fortschr. Rönlgctistr. 252.4 457
-.
togctlier" and is associa.tcid will1 sliortening of thc moseiitc:ry besides thick and librous adhesions (4). In our series a total of 53 % (y/~,/i71ol'tlie cases showed rcaturcs ofadliesions: In 47 % ( K 7 ) lixed bowel loops. 24% ( - N i ) inucosal tacking and i n on(n case a pool of bariurn i n the pelvic rcgion. A numbt:r ofcases showcd kinkirig of bowel loops. a.ttrihiited by soine authors (2, 5 , 10) to rnesenterial shorteniiig. by olhers (3.4.6)to adliesioiis and wa.ll thick(:nirig.
Fig. 5 Spotfilni without compression. Se. paration of bowel loops due to wall thickening.
Oiily one cnsc showed lliree reprodiicibl(? nodiilar lilliiig defects on tho rneseiiterial side in onc ho\vel scgrnent (Fig. 3). Ketrospectively tlie transit timt! c:ould be dolermined in 65% ("/I, ) of tlie cases. In 73 % I ) it was prolonged varying l'roin 1 I/? tu morc than 24 Iiours. In all cases cvcntually lhere was passagt: irito lhe colon. At. Iluoroscopy peristalsis diminished progressively towards the s(+riousIyclamagcd bowel segments. In snmc cases this was cornbined with progressive dilution of contrasi rnaterial caused by rcsidual bowel fluid. In thrcc cases lhere was also flocculatiori oi' the contrast material. Erosions, ulcers ancl fistula were not observed in our series. Correlation l o Operative- .Fiii(lings ---
-
The radiologic exarninatioris were compai'ed with the operation reports. In every case studied thc extent ol' CRE was undercstirnated on the base of tho radiologic examinalioii.
As is widely knowri, roentgen rays havc tbe rnost deslructive effect. on rapidly dividing cells likt? iri the bowel epithelium. As a corisequence rnany cpittielial cells die during radiotherapy. Besides this directly visible effect, cells in othcr tissues are sublethally darnaged and die off later whcn eriteriiig niitosis. In the case of bowel epitheliiim thc loss ol' cells is cornpensated for by a reduction in th,: length ol'the mitotic cycle a s well as a n enlargement of the slern cell comportrncnt, which originates in the crypts of the rnucosa (1 1). Iri tliis inanner an unstable euuilibrium between los; and production of epithelial cellc created. Sornc? fact,ors Lhat influence this equilibriurn a r e the daily radiatiori dose. total dose. radiation quality. irradiatcd volUrne, vascularisation and iridividual sensitivity (1). A daily dose of 2 Gy can jiist be cnnipensated for (1 1). When the balance is distiirbod, parlial or complctc denudation can occur. Clinically an acute ra.diation eiileritis develops: anorcxia, vnrriiting. crampy diarrhoea and loss of electrolytes; sometirnes haemorrhagc or bacterial infection rnay rosult. Af'tcir discontinuation 01' radiolherapy tl-ie epithelium can recover from the acuto radiation damage. Perrnancni. loss of up to 30% ol' ttie original numbcr »f crypts and villi can rnsur. dcpc?ndiiigon t h ra.diation ~ dose (11).
Rcsides tliese (sub)acut,c oll(:ts, radiation darnage of thc resl of the bowel wall oc:curs a.fler a latent. pt:riod. Those changes are irrcvcrsihle aiid progressive a.nd tlierefore rnucti niore import,arit for the final oiitcornc thari tlie acule effects (1). Th(? late clianges Start will1 llie developnient of an oblii.c?rativeendarteritis willi a tliicken-
Fig. 6 Mucosal tacking.
ing oi'the iritiiiia and thrombosis. This resiilts in undcrperfusion and tissue hypoxia and is a critical factor in the pathogenesis of bowcl darnage. Ederna. fibrin exudation. fibrosis and hyalinisatioii together with signs of chronic inflamrnation occur, initially and prcdorninantly in the submücosit (12). Secondarily, structural and functional changes occur in the miicosa, serosa and mesentery. The rniic:osa lerids to becomc atropliied. leading to malabsorptioii. In the submticosa arid rnuscularis miicosae, fibrosis arid thickening cause segments of bowcl to becorne rigid and rnotionlcss. As a consequence thcrt? is loss ofability to transport intestinal contpnt, rosultirig in functional ohstriict,ioii: "the dysfunctional bowel" (13). In other cases tho I'ormation of stenoscs is iiiore pronounccd, causing morphological obstruction. l'he chronic inflarnniatioii in serosa and rncscntr?ry gives rise to thc hrrnation of adhesions and shorteiiing. 'l'he ultimatc outc:orrie depends upon the dcgroc? of vascular injury. ßccause of the differencc in dcgrce oI'palhological changcs iri tlie different laycrs of'the bowel wall. the clinical katures rnay vary: frorn c:liroiiic irialabsorption to chroriic iiitermittent ilcus witli or without
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t
