tumors of the pelvis are increasingly being irradiated for local treatment benefit , with the subsequent complication of anorectal injury .
tumors inside the pelvic cavity are suited to receiving radiotherapy as the exposure to healthy tissue can be minimized and high doses can be delivered to the target tumor .
however , the proximity of the rectum to the back of the prostate , the cervix and the uterus makes it anatomically impossible for the rectum not to receive radiation while irradiating these neighbor organs .
the term radiation enteritis refers to radiation injury of the colon and small intestine mucosa characterized by telangiectasias , pallor and friability , while the injury or the rectum due to that cause is referred to as radiation proctitis .
radiation proctitis is usually a result of pelvic irradiation for malignancies of the prostate , cervix , uterus , anus , rectum or urinary bladder and can be subdivided into two types : acute and chronic .
chronic colitis typically presents within 912 months with rectal bleeding or obstructed defecation due to strictures .
in addition , these patients seem to be at increased risk of developing rectal cancer . historically , treatment of rectal strictures has been limited to surgery with a high morbidity and mortality .
therefore , a less invasive therapeutic approach for benign rectal strictures , endoscopic balloon dilation with or without intralesional steroid injection , has become a common method of treatment .
we present a case of benign post - radiation rectal stricture treated successfully with balloon dilation and adjuvant intralesional triamcinolone injection .
a 70-year - old woman presented to the emergency room complaining of 2 weeks of diarrhea and meteorism .
she had been operated for adenocarcinoma of the uterus 11 years before and radiation therapy had been performed for 1 month post - hysterectomy .
she had also been operated for breast cancer 9 years earlier . the regular post - operation follow - up with thorax ,
she also suffered from type 2 diabetes , hypertension and hyperlipidemia and was receiving oral medication ( glimepiride 4 mg once daily 1  1 , sitagliptin ( 50 mg ) + metformin ( 1,000 mg ) 1  1 , perindopril arginine 5 mg 1  1 , nebivolol 5 mg 1  1 , and simvastatin 20 mg 1  1 ) . on physical examination
the patient was mildly dehydrated with a blood pressure of 155/85 mm hg and a heart rate of 98/min .
a stricture was palpated 10 cm from the anus into the rectum at digital rectal examination .
complete blood count revealed a normal leukocyte count ( white blood cells 8,200/l ) with mild neutrophilia ( 80.1% ) , hemoglobin 13 g / dl , hematocrit 39.6% , and platelets 305,000/l .
serum biochemical profile revealed hyperglycemia ( 277 mg / dl ) , normal renal function ( urea 40 mg / dl , creatinine 0.6 mg / dl ) and a c - reactive protein level of 1.35 mg / dl .
colonoscopy revealed a stricture 10 cm from the anus , reducing the rectal lumen to 5 mm in diameter , not allowing the endoscope to pass ( fig .
afterwards , multiple endoscopic biopsies were obtained from the stricture ; a deflated 17 mm guidewire - bearing dilating balloon , 5.5 cm long ( rigiflex , boston scientific , nattick , mass . ,
usa ) , was passed through the endoscope and was advanced through the stricture over the guidewire under direct endoscopic guidance .
the balloon was inflated to maximum pressure according to the manufacturer 's instructions ( fig .
after the dilation , the endoscope could be advanced through the stricture , which was 6 cm .
after satisfactory dilation had been achieved , triamcinolone ( 2 ml of 40 mg / ml diluted to 10 ml with normal saline ) was injected quadrantically into the stricture using a varix injection catheter with a 5 mm needle .
the procedure was uneventful ; the post - procedure abdominal x - ray was negative for pneumoperitoneum and the patient was discharged after 24 h without any treatment .
histologic examination of the biopsies revealed non - specific inflammatory changes of the rectal mucosa and no specific changes of the mucosa due to radiation .
the patient is stricture - free 12 months post - treatment as confirmed by repeated flexible endoscopy .
rectal strictures are chronic narrowings of the intestinal lumen by abnormal tissue , resulting in complete or partial bowel obstruction . this tissue may be scar tissue resulting from chronic rectal or anal inflammation , trauma , foreign bodies , prior surgery , perianal fistulas or pelvic irradiation . '
radiation enteritis ' refers to injury of the colon and small intestine after radiation and can be subdivided into acute and chronic . for radiation injuries of the rectum , the term  radiation proctitis is used . in acute radiation enteritis , histopathological changes of intestinal mucosa are inflammatory cell infiltrate , reduced crypt micro - abscesses , epithelial denudation and ulceration .
patients with acute radiation enteritis or proctitis present diarrhea , abdominal pain or rectal bleeding shortly after a course of radiotherapy , but can be presented within 3 months .
histologic features of chronic radiation enterocolitis are obliterative endarteritis , lymphatic dilation , tissue ischemia and necrosis , submucosal fibrosis and collagen deposition , which can lead to severe transmural fibrosis and formation of strictures or fistulas .
chronic radiation colitis has been reported in up to 20% of patients receiving radiation in the pelvis , and the rate of intestinal obstruction due to strictures is referred to as 115% .
there are also patient and treatment factors which may increase the risk of developing chronic radiation colitis .
these factors include low body mass index , co - morbid conditions ( diabetes , hypertension , collagen vascular diseases , inflammatory bowel disease ) , smoking , volume of bowel inside the radiation field , radiotherapy dose , radiotherapy technique and simultaneous chemotherapy .
the clinician should have chronic radiation colitis in mind while evaluating patients with bowel obstruction after radiation therapy , especially in the pelvis .
patients affected by post - radiation strictures display obstructing symptoms , including diarrhea or tenesmus often producing narrow ribbons of feces or no feces at all . abdominal pain and
vomiting may occur in response to a stricture , but combined with a history of weight loss can also occur secondary to recurrent neoplasia .
the importance of this was presented by andreyev et al . , who reported the incidence of new or recurrent neoplasia with gastrointestinal symptoms 2 years after radiation of the pelvis in around 12% of patients , making this a common diagnosis .
patients with colonic symptoms must be investigated with colonoscopy , while patients with non - specific gastrointestinal symptoms should be investigated with ct with or without enteroclysis , looking for a tumor . in our patient ,
ct was unremarkable , while histopathology of biopsy specimens from the stricture during colonoscopy revealed inflammatory mucosal changes , compatible with but not specific for chronic radiation colitis , and was negative for malignancy .
traditionally , surgical techniques , such as line rectal pull - through , myotomy or stricturoplasty , have been performed to manage rectal strictures .
however , post - operative complications can occur in up to 30% , around half of the patients will require more than one surgery , and one third of them die in hospital .
surgery in these patients is complicated because of the extensive fibrosis and adhesions in the pelvis and should be avoided if possible .
endoscopy has recently gained an important role in chronic radiation colitis , with therapeutic options such as argon plasma coagulation for angiodysplastic lesions and balloon dilation for management of intestinal strictures .
endoscopic placement of self - expanding metallic stents has been used for management of malignant strictures , alternatively to surgery .
the success rate was extremely high ( < 92% ) and reported a complication rate < 5% .
there is also a case report in which a radiation stricture of the rectosigmoid was successfully treated with self - expanding metallic stents , and obstructing symptoms were relieved in a patient who lived without any complications for 4 months until he died of sepsis due to pneumonia and bedsores .
endoscopic balloon dilation is effective for managing both surgical anastomotic strictures and inflammatory disease strictures , with an up to 97% success rate and major complications < 3% . in a systematic review , hassan et al .  
presented the results of 13 studies enrolling 347 patients treated with balloon dilation due to post - surgical anastomotic crohn 's strictures .
it is reported that 58% of the patients avoided surgery until 36 months of follow - up , while 59% of them needed a single session , 22% required 2 sessions , and 19% required more than 2 sessions with range from 3 to 18 .
presented the results of 17 patients who underwent balloon dilation due to pharyngoesophageal strictures caused by radiotherapy of the head and neck .
clinical success was achieved in 64.7% of patients with mean range of 2.4 sessions ( range 17 sessions ) . moreover
, intralesional steroid injection has been used together with balloon dilation to treat patients with colorectal anastomotic strictures or strictures secondary to crohn 's disease .
adjuvant intralesional steroid injection is safe and only adds a few minutes in procedure time .
, in a study of dermal keloids , reported that triamcinolone seems to inhibit collagen formation , enhance collagen breakdown and prevent cross - linking of collagen that results in scar contracture .
intralesional use of triamcinolone appears to enhance the effect of balloon dilation and even prolong the relapse interval .
post - radiation stricture is a rare complication after pelvis irradiation , but must be in the mind of the clinician evaluating a lower gastrointestinal obstruction .
endoscopic balloon dilation with adjuvant intralesional steroid injection can be a minimally invasive , safe and effective treatment option for the management of post - radiation benign rectal strictures .
the procedure appears to have a high success rate and a very low complication rate .
an alternative treatment option is the endoscopic placement of a metallic stent in the stricture area , and last choice surgery , a procedure with very high morbidity and mortality rates .
 post - radiation stricture is a rare complication after pelvis irradiation , but must be in the mind of the clinician evaluating a lower gastrointestinal obstruction . 
 endoscopy has gained an important role in chronic radiation proctitis with several therapeutic options for management of intestinal strictures . 
 the treatment of rectal strictures has been limited to surgery with high morbidity and mortality . 
 therefore , a less invasive therapeutic approach for benign rectal strictures , endoscopic balloon dilation with or without intralesional steroid injection , has become a common treatment modality . 
 we present a case of benign post - radiation rectal stricture treated successfully with balloon dilation and adjuvant intralesional triamcinolone injection . a 70-year - old woman presented to the emergency room complaining for 2 weeks of diarrhea and meteorism , 11 years after radiation of the pelvis due to adenocarcinoma of the uterus . 
 colonoscopy revealed a stricture at the rectum and multiple endoscopic biopsies were obtained from the stricture . 
 the stricture was treated with endoscopic balloon dilation and intralesional triamcinolone injection . 
 the procedure appears to have a high success rate and a very low complication rate . 
 histologic examination of the biopsies revealed non - specific inflammatory changes of the rectal mucosa and no specific changes of the mucosa due to radiation . 
 all biopsies were negative for malignancy . 
 the patient is stricture - free 12 months post - treatment . 
Introduction
Case Report
Discussion
Conclusion
Disclosure Statement