Radiation proctitis other diagnostic studies
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:
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Overview
Other diagnostic studies such as colonoscopy, tissue biopsy and histological analysis can help with the diagnosis of radiation proctitis.
Other Diagnostic Studies
Colonoscopy
Colonoscopic findings can help differentiate ulcerative colitis and Crohn's disease. Involvement of the colon and rectum and the absence of fistulas are findings that favor the diagnosis of ulcerative colitis. The best test for diagnosis of ulcerative colitis remains endoscopy. Full colonoscopy to the cecum and entry into the terminal ileum is attempted only if diagnosis of UC is unclear. Otherwise, a flexible sigmoidoscopy is sufficient to support the diagnosis. The physician may elect to limit the extent of the exam if severe colitis is encountered to minimize the risk of perforation of the colon.
- Loss of the vascular appearance of the colon
- Erythema (or redness of the mucosa) and friability of the mucosa
- Superficial ulceration, which may be confluent
- Pseudopolyps
Ulcerative colitis is usually continuous proximally from the rectum, with the rectum almost universally being involved. There is rarely peri-anal disease, but cases have been reported. The degree of involvement endoscopically ranges from proctitis or inflammation of the rectum, to left sided colitis, to pancolitis, which is inflammation involving the ascending colon.
Biopsy sample (H&E stain) that demonstrates marked lymphocytic infiltration (blue/purple) of the intestinal mucosa and architectural distortion of the crypts. - By User:KGH - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=510530
Colonoscopy is usually avoided in the acute radiation induced proctitis due to the risk of bleeding.However it can be done to confirm the diagnosis,to determine the extent and severity of chronic radiation proctitis, rule out other causes of inflammation and to treat bleeding.Endoscopic findings in Radiation proctitis include the following:
- edematous, dusky red rectal mucosa with friability and telangiectasias in case of acute injury
- pale and noncompliant rectum with telangiectasias associated with strictures, ulcerations, fistulas, and areas of mucosal hemorrhage. in case of chronic radiation proctitis
Tissue Biopsy
Biopsy shows absence of deep tissue involvement in case of ulcerative colitis. A biopsy of a patient with ulcerative colitis shows continuous involvement of the colon, lacks abscesses and granulomas.
Histologic
Histological findings include:
- eosinophilic infiltrates,
- epithelial atypia,
- Atrophy of the overlying mucosa
- Obliterative arteritis
- fibrosis, and
- capillary telangiectasia
Biopsies of the mucosa are taken to definitively diagnose UC and differentiate it from Crohn's disease, which is managed differently clinically. Microbiological samples are typically taken at the time of endoscopy. The pathology in ulcerative colitis typically involves distortion of crypt architecture, inflammation of crypts (cryptitis), frank crypt abscesses, and hemorrhage or inflammatory cells in the lamina propria. In cases where the clinical picture is unclear, the histomorphologic analysis often plays a pivotal role in determining the management.
Rectal biopsy is usually avoided as they is no role in diagnosis of chronic radiation proctopathy.However it can be done if any malignancy is suspected.