conservative therapies for hemorrhagic radiation proctitis ... · cotti g et al. - conservative...

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From the Department of Gastroenterology,Hospital das Clínicas, Faculty of Medicine,University of São Paulo, São Paulo/SP –Brazil.

Received for publication onMay 26, 2003.

CONSERVATIVE THERAPIES FOR HEMORRHAGICRADIATION PROCTITIS: A REVIEW

Guilherme Cotti, Victor Seid, Sérgio Araujo, Afonso Henrique Silva e Souza Jr.,Desidério Roberto Kiss and Angelita Habr-Gama

COTTI G et al. - Conservative therapies for hemorrhagic radiation proctitis: a review. Rev. Hosp. Clín. Fac. Med. S. Paulo58(5):284-292, 2003.

Chronic radiation proctitis represents a challenging condition seen with increased frequency due to the common use ofradiation for treatment of pelvic cancer. Hemorrhagic radiation proctitis represents the most feared complication of chronicradiation proctitis. There is no consensus for the management of this condition despite the great number of clinical approachesand techniques that have been employed. Rectal resection represents an available option although associated with highmorbidity and risk of permanent colostomy. The effectiveness of nonoperative approaches remains far from desirable, andhemorrhagic recurrence represents a major drawback that leads to a need for consecutive therapeutic sessions and combinationof techniques. We conducted a critical review of published reports regarding conservative management of hemorrhagicchronic radiation proctitis. Although prospective randomized trials about hemorrhagic radiation proctitis are still lacking,there is enough evidence to conclude that topical formalin therapy and an endoscopic approach delivering an argon plasmacoagulation represent available options associated with elevated effectiveness for interruption of rectal bleeding in patientswith chronic radiation proctitis.

DESCRIPTORS: Proctitis. Radiation. Hemmorrhagic. Conservative. Treatment.

Radiotherapy (RDT) techniqueshave become primary treatments forpelvic organ cancer, subsequent to im-provements in these techniques overthe past few decades. After pelvic irra-diation, the rectum is one of the mostcommonly injured organs due to itsfixed position1-3. Its anatomic relation-ships with the uterine cervix and pros-tate make it impossible not to irradi-ate the rectum during RDT regardlessof the target organ4. Radiation procti-tis (RP) is an adverse effect of RDT tothe rectum , and its prevention andtreatment have become topics of de-bate. The main purpose of this reviewis to discuss current therapies for radia-tion-induced injury to the rectum,mainly in its hemorrhagic form.

GENERAL CONSIDERATIONS

Radiation proctitis can be classi-fied as acute or chronic. Acute radia-tion proctitis (ARP) can begin duringor shortly after irradiation but usuallyresolves in up to 6 months. It is char-acterized by diarrhea, intermittentbleeding, nausea, abdominal pain, mu-cous discharge, and constipation oreven urinary symptoms. Histologicalalterations are usually confined to themucosa5, and in general, has a short

duration and improves with conserva-tive measures. However, about 20% ofthe patients with RP require interrup-tion of the treatment for 1 to 2 weeksin order to improve clinical status. Fol-lowing this acute episode most of thepatients remain asymptomatic, but upto 20% of this contingent will developchronic radiation proctitis (CRP)6. Thedevelopment of CRP may take up to2 years and has no relationship withthe occurrence of ARP7.

During the course of radiotherapy,virtually all patients present symptomsrelated to ARP. However, such symp-toms usually subside from 2 to 3months after the end of RDT8. Never-theless, 2% to 10% of the patients de-velop CRP, usually 6 to 24 months af-

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ter RDT, but clinical symptoms mayappear up to 30 years after treat-ment9,10.

Chronic radiation proctitis has sev-eral forms of clinical presentation, in-cluding mucous rectal discharge,diarrhea, urgency, pain, and bleeding.Recto-vaginal fistula, enteric fistula,cutaneous fistula, perforation, and rec-tal stenosis can rarely occur. Histologi-cal alterations are mainly of a vascu-lar nature, such as subintimal fibrosisand platelet thrombi in the arteriolesof the submucosa with fibrosis of con-nective tissue5.

The development of RP is directlyrelated to the dose of radiation, the ir-radiated volume, type of radiation ex-posure, dose fraction regimens, and theinterval between sessions. Smith et al.reported a 20% incidence of RP witha radiation dose up to 7.500 Cgy anda 60% incidence of RP with dosesgreater than 7.500 Cgy11.

Other factors predispose to RP, in-cluding previous abdomino-pelvicsurgery, obesity, diabetes mellitus, hy-pertension, atherosclerosis, and simul-taneous chemotherapy. In 1997,Bertuccelli et al. studied the effect ofthe combination of chemotherapywith RDT in the treatment of rectalcancer and observed an increase in in-cidence of severe diarrhea in the groupthat received RDT plus chemotherapywhen compared to the group that un-derwent RDT alone (20% versus10%)12.

Endoscopic findings of RP are alsovariable. Since 1923, when the first en-doscopic findings were reported, therehave been many attempts to establisha standardized endoscopic approach toits diagnosis13. Paleness, erythema, vas-cular abnormalities, and ulcerations areeasily recognized alterations. However,in order to correlate the clinical pictureto endoscopic findings, Wachter et al.proposed a score for RP based on ter-minology of the World Organization ofDigestive Endoscopy (OMED) and its

5 main alterations, namely telangiecta-sias, congestion, ulcerations, stenosis,and necrosis14.

The prognosis of RP remains ob-scure. Gilinsky et al., in 1983, reportedon 88 patients with RP followed formore than 8 years. Fifty percent pre-sented slight to moderate symptomswith distinct endoscopic findings thatresolved spontaneously in 2 years10.Nevertheless, 17 patients presented re-fractory symptoms. Cho et al. observedthat 19 out of 101 patients developedRP after radiation therapy for prostatecancer15.

Despite the fact that the incidenceof RP tends to increase with time, RPstill lacks research and attention. Itshould be noted that no consensus ex-ists about its clinical and endoscopicevaluation and its natural history. Itsbehavior and prognosis are not com-pletely known.

Rectal bleeding due to RP usuallyrepresents a chronic condition, andanemia is a common finding; some-times bleeding may be severe. Severaltreatments for this presentation havebeen used, and as a result of its high re-currence rate, they were rarely utilizedin a cyclic manner, which makes theirevaluation difficult. We opted to reviewand analyze the results of conservativetreatments of hemorrhagic CRP.

Steroids

In 1976, Goldstein et al. observedclinical improvement of a patient withradiation-induced proctitis who re-ceived salicylazosulfapyridine in com-bination with prednisone16. Subse-quently, other studies were developedin an attempt to evaluate the use ofsteroids as a therapeutic alternative forRP, alone and also in combinationwith other modalities.

In 1984, Ben Bouali et al. demon-strated clinical and endoscopic im-provement in 4 out of 33 patientstreated with daily rectal administration

of 5 mg of betamethasone in combi-nation with diphenoxylate17. In 1977,Pajares et al. also observed a decreaseof rectal bleeding after administrationof prednisone18. More recently,Triantafillidis et al. reported 5 patientstreated for RP with enemas containing5 mg of betamethasone without anyclinical improvement19.

In a prospective randomized study,Kochhar et al. compared the use of en-emas containing prednisolone and 3 gof oral sulfasalazine in 18 patients tothe use of enemas containing sucralfatein combination with an oral placeboin 19 patients for 4 weeks20. Clinicalimprovement was appraised by a scorebased on the number of bowel move-ments, bleeding, and tenesmus.Therapy with sucralfate was more effi-cient, better tolerated, and cheaper.

Another prospective randomizedstudy in mice analyzed administrationof 90 mg of hydrocortisone andshowed endoscopic improvement andbetter tolerance when compared withbetamethasone enemas21.

Steroids have been used for manyyears in the treatment of RP despitethe absence of larger and well-de-signed studies22. Moreover, steroidswere not able to achieve sustainedresolution of symptoms for patientswith CRP.

Aminosalicylates

Derivatives of 5-aminosalicylicacids (5ASA), also known as amino-salicylates, have been the object of re-search in treatment of RP since thestudies of Menie et al. in 1975 showedefficiency of the 5-aminosalicylic aciddrugs versus placebo in the preventionof diarrhea in patients undergoing pel-vic RDT, as well as studies for theirprevious use in the management of in-flammatory proctitis. Aminosalicylatesact in reducing the production ofprostaglandins in the intestinal mu-cosa20.

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Goldstein et al. demonstrated theeffectiveness of oral sulfasalazine incombination with steroid enemas in 1patient16. Bem Bouali et al. demon-strated that administration of sulfa-salazine, in oral or enema form, pro-vided clinical and endoscopic im-provement in 60% of patients17. In1989, Ladas et al. demonstrated thatadministration of sulfasalazine in com-bination with sucralfate enemas waseffective in controlling rectal bleedingand promoted endoscopic improve-ment in 1 patient with CRP.23

On the other hand, in 1989, Baumet al. showed that daily administrationof enemas containing 5ASA for a pe-riod of 2 to 6 months was not able toinduce clinical, endoscopic, or histo-logical improvement in 4 patients withCRP24. Another study of 5 patientsperformed by Triantafillidis et al. dem-onstrated no improvement over 5ASAenemas.19

We believe that multicenter pro-spective randomized studies of amino-salicylates are needed to confirm theirrole in the management of RP, butavailable evidence suggests that theyare not effective.

Sucralfate

Sucralfate is an aluminum salt thatadheres to the mucous membrane, pro-moting the formation of a protectivebarrier that has been used for manyyears in the treatment of peptic ulcers.Its possible effectiveness for inflamma-tory proctitis and for colonic bleedingafter endoscopic polypectomy is alsounder investigation.

The cytoprotective action of su-cralfate seems to be derived from theproduction of prostaglandins and pro-motion of epithelial cell proliferation.In animal models of colitis in mice,rectal administration of sucralfate in-duced high E2-prostaglandin levelsand increased cellularity of the co-lonic mucosa25.

The best route for sucralfate ad-ministration remains controversial. In1988, Kochhar et al. used enemas con-taining 2 g of sucralfate in 4 patientswith hemorrhagic RP and demon-strated reduced bleeding26. A previousstudy by Henriksson et al. in 1987showed the usefulness of oral sucralfateadministered for 2 to 6 weeks afterRDT in the reduction of bowel move-ments, mucous discharge, and rectalbleeding after 1 year27. Another studyby Kochhar in 1991 demonstrated thesuperiority of topical sucralfate oversteroid enemas administered in combi-nation with sulfasalazine20.

In 1996, Stockdale and Biswas re-ported that administration of enemascontaining 2 g of sucralfate in a patientwith hemorrhagic RP resulted in long-term control of CRP as revealed from 4years of follow-up28. Again in 1996, Tadaet al. demonstrated endoscopic improve-ment of CRP in 6 out of 7 patientstreated with 2 g sucralfate enemas.29

In 1997, O’Brien et al. publishedthe negative effect of a sucralfate sus-pension for prevention of ARP30. Inthis multicenter Australian study, 86patients were randomized into 2groups: 1 group received 3 g sucralfateenemas and the other group receiveda placebo. Enemas were administeredonce daily for a period of 2 weeks af-ter RDT. Sucralfate enemas did not re-duce symptoms associated with ARPand therefore should not be recom-mended in clinical practice.

In 1998, Sasai et al. published 3cases of patients with hemorrhagic RPwho had undergone previous sulfa-salazine and steroid treatment withoutsuccess. They experienced significantimprovement of rectal bleeding afterdaily administration of 4 g of su-cralfate during 1 to 2 months31. Theauthors emphasized the advantages oforal sucralfate, which include goodtolerance and few side effects associ-ated with control of the symptoms fora long period.

More recently in 1999, Kochhar etal. demonstrated that topical sucralfateproduced sustained resolution ofsymptoms, in agreement with previousauthors32. Stockdale and Biswas 28

studied 26 patients with hemorrhagicRP that were treated with 2 g sucralfateenemas twice daily. The patients wereexamined every 4 weeks in the first 16weeks of treatment and after that at aninterval of 8 to 12 weeks. Twenty pa-tients had a significant reduction ofbleeding in the first 4 weeks of treat-ment, as did another 4 patients after 16weeks. At a mean of 45 weeks, 7 pa-tients had some kind of symptomaticrecurrence. However, bleeding ceasedsoon after the sucralfate treatment wasreintroduced.

Short-Chain Fatty Acids (SCFA)

During the past few years, manystudies have been performed on short-chain fatty acids (SCFA) so that knowl-edge regarding these substances hasincreased. Short-chain fatty acids areorganic acids containing from 1 to 6carbons that are a product of bacterialmetabolism of some carbohydrates inthe colon; they are the main source ofenergy for colonocytes. Butyrate is themost important SCFA and is preferen-tially metabolized by colonic mucosawhen compared to propionate and ac-etate. The dependence of the colon re-lated to the oxidation of SCFA in-creases towards the rectum, and 70%of the oxygen consumed by the co-lonic epithelial cells is used in the oxi-dation of SCFA33.

The effect of SCFA on rectal andcolonic mucosa has been tested in pa-tients with RP in an attempt to obtainhealing of mucous lesions33,34. In 1999,Pinto et al. in a double-blind rando-mized placebo-controlled trial studied19 patients with CRP35. They demon-strated a beneficial effect from admin-istration of 2 daily enemas with 60mmol SCFA for 5 weeks in compari-

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son with the administration of an isot-onic solution. There was a significantdecrease of rectal bleeding with SCFAas well as an endoscopic improvement.In 1995, Mamel et al. also demon-strated the efficacy of enemas contain-ing 60 mL of SCFA twice daily for 4weeks in the improvement of 6 pa-tients with CRP36. In 1996, AlSababagh et al. using the same solu-tion described in the previous studiesachieved clinical, endoscopic, and his-tological improvement in 7 patientswith hemorrhagic RP37.

These results were not reproducedby Chen et al. in a prospective study,where they evaluated the evolution of12 patients with hemorrhagic CRP for2 weeks and did not find any signifi-cant difference in clinical, endoscopic,and histological aspects of patientstreated with SCFA38.

More recently, Talley et al. com-pared daily administration of 2 enemaswith 60 mL of butyrate in a concen-tration of 40 mmol to placebo for 2weeks in a randomized double-blindstudy of 15 patients with CRP. Theyfound no benefit from SCFA39.

In 1998, Cook and Sellin per-formed a literature review about SCFAin the management of colitis33. Regard-ing RP, the authors observed that stud-ies showed early reduction of bleedingepisodes, but SCFA had no influencein other symptoms such as chronicpain and tenesmus.

In spite of the great progress in theknowledge of the structure, metabo-lism, and action of SCFA, there is stillneed for additional data to confirm itseffectiveness. Because of these con-flicting data, there are no commercialpreparations available for clinical use.

Formalin

The use of formalin in the manage-ment of RP emerged from its use in thetreatment of bleeding tumors of thebladder and radiation cystitis40,41, 2.

In 1986, Rubinstein et al. success-fully used a rectal wash with formalinfor the first time in the treatment ofRP42. The authors reported a 71-year-old patient irradiated for bladder can-cer who developed diffuse hemor-rhagic RP. The patient underwent gen-eral anesthesia and the rectum was ir-rigated with two liters of 3.6% forma-lin for 15 minutes, followed by irriga-tion with saline. An insufflated vesicalprobe was used in order to protect thesigmoid colon. The procedure was re-peated after 2 weeks and after 3months. Bleeding episodes immedi-ately ceased and the patient wasasymptomatic after 14 months.

After these results, many authorsinitiated treatments of hemorrhagicCRP with formalin. In 1993, Seow-Choen et al. used formalin in 8 pa-tients with hemorrhagic CRP refrac-tory to steroids and with a constantneed for blood transfusions43. In thisstudy, a 4% solution-soaked gauze wasapplied to the rectum through a recto-scope. Patients underwent regionalanesthesia and had their perianal skinprotected to avoid direct contact withthe formalin. Contact between thegauze and rectal mucosa was main-tained until the bleeding stopped(from 2 to 3 minutes). Bleeding ceasedin 7 patients after a single session,while another patient needed an addi-tional application.

In 1995, the same authors con-firmed the effectiveness of direct ap-plication of formalin solution soaked

gauze in 29 patients followed for 12months44. In this study, rectal bleedingceased right after application in 17 pa-tients. Four patients needed a secondapplication (72% success rate). The 5remaining patients obtained only par-tial improvement.

The instillation technique pro-posed by Rubinstein et al. was modi-fied by 2 groups. One of them used rec-tal instillation with 4% formalin afterplacement of a Foley catheter in orderto delineate the superior limit of theinstillation and protect the normal in-testine in 14 patients resistant to ster-oid and/or sulfasalazine treatment45.Treatment was well tolerated, and 11patients needed 2 applications whileother 3 patients needed 3 sessions. Af-ter 6 months, 9 patients were asymp-tomatic (64%), 3 patients had incom-plete resolution of symptoms, and 2had no improvement. Saclarides et al.reported a study in which aliquots of50 mL of 4% formalin were instilledinto the rectum for 30 seconds each,with a total of 400 to 500 mL per ses-sion in 16 patients. They achievedcomplete symptom control in 81% ofafter 1 or 2 applications46. Four pa-tients developed fissures in the analverge and 1 developed tenesmus.

The technique of soaked gauzeproposed by Seow-Choen was revisedby 5 groups, with a total of 41 patients.Complete success rate ranged from80% to 100% after 1 to 4 sessions (Ta-ble 1)43,47-51.

Recently, in an Australian study, a

Table 1 - Summarized results of patients with hemorrhagic radiation proctitistreated with formalin instillation.

Author Number of patients Follow-up (months) Response

Seow-Choen et al.43, 1993 8 4 88%

Biswal et al.47, 1995 16 11 81%

Isenberg et al.48, 1994 2 3 100%

Salvati et al.49, 1996 10 Not reported 100%

Roche et al.50, 1996 6 12 100%

Faragher et al.51, 1997 7 10 100%

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combination of formalin and Nd:YAG(neodymium yttrium-aluminum-garnet)laser was used in 14 patients52. First, thepatients underwent an endoscopicNd:YAG laser procedure and then weretreated with a formalin application asdescribed by Seow-Choen. A single ses-sion was enough for 9 patients, 2 ses-sions were necessary for3 patients, and3 sessions forthe other 2 patients. Aftera 3-year follow-up, 10 (71%) patientshad no rectal bleeding, and another onehad a significant decrease in bleedingepisodes. Two patients required an op-eration to manage their symptoms.

After these first published serieswith formalin as a therapeutic alterna-tive for hemorrhagic RP, investigatorshave been trying to determine the bestconcentration and form of its applica-tion as well as its side effects. In lowconcentrations, formalin is not toxic.However, high concentrations can resultin severe toxic effects. Additionally, thenutritional state and smoking can alterblood levels of formalin. The only re-ported case of intoxication after rectalirrigation occurred due to accidentalinfusion of 100 mL of 10% formalin.The patient developed chronic colitisthat resolved after 2 months53.

Evidence suggests that formalin isvery effective in the treatment ofhemorrhagic CRP, mainly in cases inwhich the 2 distal thirds of the rectumare affected. Other advantages of for-malin application are low cost, low in-cidence of side effects, availability, andits easy manipulation.

Endoscopic

Endoscopic management of CRP isbased on endoscopic coagulation in-duced by Nd:YAG laser, electrocoagu-lation, or argon plasma coagulation(APC).

The first description of Nd:YAG la-ser use in CRP was published byLeuchter in 1982. The author reportedthe success of this technique for the

control of rectal hemorrhage after 4applications in 1 patient in which heused 30 shots driven to the endoscopi-cally identified vascular alterations54.

The effectiveness of the Nd:YAGlaser was confirmed by other authorsin series with a total of 98 patients.One of the most important was pub-lished by Viggiono et al. in 1993 re-porting on 47 patients. After an aver-age of 2 sessions (7950 joules each), a79% control rate of rectal bleedingwas achieved55.

In 1998, Swaroop et al. describedthe technique for therapy with aNd:YAG laser56. Initially, the patientshould undergo a complete colo-noscopy to determine the extent of thelesion. With an initial energy of 40 Wand a maximum pulse duration of halfa second, the laser is applied withoutdirect contact to the mucosa, but withits tip less than 1 cm away from it. Allvisible lesions should be coagulatedin the distal direction. A white clotshould be obtained as a final effect,avoiding cavities in the intestinal mu-cosa. Complications of Nd:YAG lasertherapy include tenesmus, abdominalpain, rectal stenosis, prostatitis, andrecto-vaginal fistula55,57.

Laser therapy for hemorrhagic CRPwas supplanted by argon plasma co-agulation (APC) because it is morereadily available, cheaper, and requiresfewer safety precautions, while stillyielding excellent results. Argonplasma coagulation is a diathermymethod in which there is no directcontact between the electrode and thepatient, and high frequency energy is

applied to the tissue through the ion-ized argon. This technique is very suit-able for coagulation of large bleedingsurfaces and features the advantage oflimited penetration (2 to 3 milli-meters), minimizing the risks of perfo-ration, stenosis, and fistulization. Thechar generated with APC promotes aninterruption of the current passingthrough the tissue while Nd:laser con-tinues to penetrate the tissue until itis switched off.

Since the first use of APC with aflexible endoscope described byGrund et al.58 in 1994, it has gained awide popularity. Silva et al. in a studyof 28 patients obtained good results59

and emphasized the possibility of ap-plication of the argon plasma in anydirection, resulting in excellent accessto vascular lesions. Gas flow eliminatesoxygen from the coagulation area,avoiding carbonization of the tissueand smoke production. Moreover,light produced by gas ionization pro-motes good visual control of the pro-cedure. Those authors also propose theuse of 50 W of energy and a 1.5 L/minflow for the procedure. Fantin et al.demonstrated the effectiveness of APCin 7 patients after 2 to 4 applications,using as parameters an energy of 60 Wand a flow of 3 L/min60.

Other authors have also obtainedgood results with APC. Taylor et al.used APC in 14 patients with hemor-rhagic CRP61. Bleeding episodesceased in 10 patients (71%), althoughthey needed complementary applica-tions. The summarized series are re-ported in table 261-63.

Table 2 - Series and summarized results of patients with hemorrhagic radiationproctitis treated with argon plasma coagulation.

Author Number of Follow-up Complete Partialpatients (months) Response Response

Buchi et al.62, 1987 3 7 66% 100%

Taylor et al.63, 1993 14 35 50% 50%

O’Connor et al.64, 1989 5 5 100% -

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Argon plasma coagulation hasproven beneficial in almost all avail-able studies. Use of argon plasma tech-nology for other applications espe-cially in surgery increases the useful-ness of the equipment.

Endoscopic treatment throughelectrocoagulation is simple, widelyavailable, and cheap. Bipolarelectrocoagulation may be safer thanmonopolar. Electrocoagulation andheater probes are readily available atmost hospitals without significantadditional cost. Because of its readyavailability, it is one of our firstoptions for hemorrhagic CRP. Distaltelangiectasias can be treatedconveniently by this method. Allvisible lesions should be treated in asingle session. The most importanttechnical aspect of telangiectasiasablation is to use the smallest possibleamount of energy for coagulation,avoiding formation of deep ulcers.After the initial session of coagulation,an interval should be intervene beforereexamination, since coagulated areasneed time for healing.

CONCLUSIONS

Many alternative techniques andresearch with other possible therapeu-tic agents for the treatment ofhemorrhagic CRP, the most frequentchronic complication of radiation in-jury to the rectum, are currently underinvestigation71-73. The effectiveness ofmany therapeutic options has still notbeen shown with solid scientific evi-dence from controlled trials, and basicresearch may open a new perspective.Nowadays, the best alternatives formanagement of hemorrhagic CRPseem to be topical formalin and APC.

Despite all therapeutic strategiesavailable for the management of CRP,the best one remains its prevention.Use of more advanced radiation tech-niques in the past few decades and in-troduction of less toxic regimens aregood examples that may contribute toa decrease in incidence of CRP. How-ever, the prevalence of CRP may in-crease as result of widespread use ofradiotherapy for cancer treatment.

Hyperbaric Oxygen Therapy

Hyperbaric oxygen (HBO) has beenused in the treatment of the RP afterprevious experiences with other radia-tion-induced lesions (cystitis and der-matitis) with satisfactory results.

Its mechanism of action is basedon the decrease of tissue hypoxia withconsequent acceleration of healingprocess, restoration of local anti-infec-tious defenses, and directly toxic ef-fects to bacteria.

Four publications reported excellentresults with the use of HBO in 8 patientswith hemorrhagic RP64-67. However, 2 re-cent studies demonstrated more modestresults. The first of these obtained a 56%rate of good results for 18 patients68. Theother was able to achieve 64% good re-sults in 14 patients69. These studies wereretrospective with controversial results.There may be recurrences, and it maytake a long period of treatment for symp-toms to resolve. In addition to the lackof scientific support, HBO is an expen-sive technique that is still restricted tospecialized centers.

RESUMO

COTTI G e col. - Tratamento conser-vador da retite actínica hemor-rágica: uma revisão. Rev. Hosp.Clín. Fac. Med. S. Paulo 58(5):284-292, 2003.

A retite actínica crônica é uma con-dição cada vez mais freqüentementeobservada como resultado do crescen-te emprego da radioterapia no trata-mento do câncer de órgãos pélvicos.A manifestação hemorrágica da retiteactínica é a complicação mais comumdessa doença e seu tratamento é desa-fiador. Diversas técnicas foram empre-

gadas para o tratamento dessa condi-ção e não há evidência satisfatóriaacerca da melhor forma de controlar osepisódios de sangramento de formaeficaz e duradoura. A necessidade dese realizar múltiplas sessões de trata-mento conservador bem como a asso-ciação de técnicas freqüentemente ob-servada no manejo desses pacientes di-ficulta a interpretação dos resultados.O objetivo dessa revisão foi avaliar asegurança e a eficácia das alternativasclínicas mais freqüentemente emprega-das no controle da retite actínicahemorrágica. Ainda que a falta de es-

tudos prospectivos e randomizadoscomparando duas ou mais alternativasterapêuticas impeça uma conclusãomais definitiva, concluímos que exis-te suficiente evidência acerca de ele-vada eficácia e segurança associadasao emprego da formalina tópica e dacoagulação por plasma de argônio nocontrole do sangramento em pacientescom retite actínica crônica.

DESCRITORES: Retite. Actínica.Hemorrágica. Tratamento. Conser-vador.

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