Inpatient Wards Case Presentation – A Look at Some New Technology in the GI Lab Dean Keller, M.D.

1. Inpatient Wards Case Presentation – A Look at Some New Technology in the GI Lab Dean Keller, M.D. January 28, 2004

2. 78 yo male seen in outpatient clinics with a swollen right leg for 2 days.Ultrasound verified DVT in the femoral and the popliteal segment and he was admitted for further evaluation. Two weeks prior he had taken a long car ride to Minneapolis. Denied pleuritic pain, dyspnea, hemoptysis. No history of clotting problems in patient or in his family. Review of systems positive for BRBPR on toilet paper with history of hemorrhoids.

3. Past Medical History • Stage 2a Prostate cancer diagnosed in 1/2001. S/P hormonal treatment with Zoladex, also radiation therapy to total dose 73 Gray. Last PSA 0.4. Meds- none • Colonoscopy one year ago “diverticulosis”

4. Physical Exam Afebrile RR12, 146/78 HR 80 No acute distress 2+ edema RLE, 3cm differential in calf circumference Stool guaiac +, no masses, anoscopy showed friable internal hemorrhoids The patient did pass blood clots with anoscopy or rectal exam.

5. Laboratory WBCs 8.4, Hgb and Hct 15/45, platelets 216, MCV 90, INR 1.1, PSA 0.4, Chem 7 normal Hct decreased to 37 next 4 days Tagged RBC scan was negative Colonoscopy findings

6. Objectives: -Understand the clinical presentation of chronic radiation proctitis -Review treatment options with an emphasis on Argon Plasma Coagulation (APC)

7. Chronic Radiation Proctitis Clinical Presentation: Setting – Pelvic radiation for cervical, uterine, ovarian, or prostate cancer Incidence – 5 to 20% in published series (suggest need > 50 Gray) Symptoms – Bleeding, bleeding, bleeding (tenesmus, diarrhea, rectal pain, and obstruction are much less likely)

8. Time frame – At least 3-6 months after radiotherapy completed, can be seen years later. Endoscopy Findings – Not inflammation such as is seen in ACUTE (less than 6 weeks) Radiation injury, but prominent telegectasia, neovascularity and friability is the hallmark of CHRONIC radiation proctitis.

9. Treatment -No large controlled trials, experience is derived mostly from case reports and small clinical trials. -Pharmacotherapy is generally ineffective, whereas surgical treatment is associated with high morbidity and mortality. -Endoscopic treatments are preferred - (APC) argon plasma coagulation, bipolar electrocoagulation, heat probe coagulation.

10. Argon Plasma Coagulation (APC) – becoming the standard of care? -Noncontact electrocoagulation in which high frequency energy is delivered to the tissue through ionized argon gas -Limited depth penetration, 2-3 mm -Brushwork like application provides quick and uniform coagulation of large bleeding surfaces.

11. -Can be applied in axial direction, radially, and around bends -1 to 3 treatments are standard -$25,000 for the Erbe APC 300 -A complete bowel lavage is safest!

12. Dr. Reichelderfer: “Argon has the advantage of being a noncontact, superficial treatment with little risk of perforation. Ideal therefore for telangiectasia-neovascularity which is what this is rather than inflammation. This ‘late’ disease only responds to cautery in my experience.”

13. References: American Society of Gastrointestinal Endoscopy, (2002). The Argon Plasma Coagulator. Gastrointestinal Endocscopy, 55(7), p807-810. Tjandra, J., (2001). Argon Plasma Coagulation is an Effective Hemorrhagic Treatment for Refractory Radiation Proctitis. Dis. Colon Rectum, 44(12), p1759-1763. Siva, R., et al., (1999). Argon Plasma Coagulation Therapy for Hemorrhagic Radiation for Proctsigmoiditis. Gastrointestinal Endoscopy, 50(2), p221-224. Babb, R. (1996). Radiation Proctitis: A Review. American Journal of Gastroenterology, 91(7), p1309-1311.