Early treatment and prevention of the radiation proctitis—composite enemas containing sodium butyrate

Abstract

Dear Editor: With interest, we read the paper by Pironi et al. "Chronic radiation-induced proctitis: the 4 % formalin application as non-surgical treatment" considering the problem of proctitis induced by chronic radiation.Radiation-induced proctitis is a very important problem in irradiated patients. The frequency of radiation proctitis, presented in publications, mostly affects severe cases with clear clinical symptoms. It is estimated from 5 % to more than 50 %, and depends on knowledge of doctors treating patients and criteria used for evaluation the symptoms. Main factors determining those criteria are different radiation protocols, observation period, and standard of diagnosis.Evaluation of proctitis starts from some mucosal lesions, which are mostly asymptomatic and can be detected only in proctoscopy and histological examination of the mucosal specimen. This phase, called acute endoscopic proctitis, can lead, in most cases, into acute clinical proctitis with diarrhea, rectal bleeding, mucoid discharge, rectal pain, tenesmus, changes in bowel movements frequency, urgency, and continence problems. Severe symptoms, with bleeding leading to anemia, occur in patients with chronic clinical proctitis. Surgery is avoided in most of the cases so the nonsurgical treatment in those patients is indicated. Effective and popular methods are endoscopic treatment with argon plasma coagulation, laser therapy, application of the low concentration of formalin, or hyperbaric oxygen therapy. These techniques may cause some complications and side effects. Their effectiveness, as well as time of recurrence of symptoms, varied in different publications.Multiple experiments confirmed indication and effectiveness for the prevention of radiation proctitis. In our opinion, there are three main steps to reduce the frequency and severity of the proctopathy after radiation:1. Early prevention of proctitis starting even before radiation: This may be achieved by anti-inflammatory treatment, usage of the physiological agents and promotion of colonocytes renewal. The therapy can be administered Z. Stojcev

Butyric acid – a well-known molecule revisited

“…Sodium butyrate was shown to have an ability to reduce inflammation, as confirmed by clinical and endoscopic assessment. A key aspect related to sodium butyrate which appears to be of great relevance for this challenging and treatment-resistant form of proctitis is a multifaceted mechanism of action of butyrate which prevents inflammation, stimulates proliferation and normalizes the profile of secreted mucus [ 38 ].…”

Sodium butyrate alleviates experimental autoimmune prostatitis by inhibiting oxidative stress and NLRP3 inflammasome activation via the Nrf2/HO‐1 pathway

“…The anti‐inflammatory effects of NaB have been verified in animal models of multiple inflammatory diseases, including pancreatitis, 14 allergic rhinitis, 15 sepsis, 13 and acute lung injury 16 . The safety and efficacy of NaB has been proven in clinical applications, including treatment of ulcerative colitis, 17 diverticulitis, 18 irritable bowel syndrome, 19 shigellosis, 20 and radiation proctitis 21 . These studies suggested that NaB has good safety prospects and great potential for clinical application.…”

“…16 The safety and efficacy of NaB has been proven in clinical applications, including treatment of ulcerative colitis, 17 diverticulitis, 18 irritable bowel syndrome, 19 shigellosis, 20 and radiation proctitis. 21 These studies suggested that NaB has good safety prospects and great potential for clinical application. However, the effects of NaB on the pathogenesis and development of CP have not yet been elucidated.…”

Therapeutics in Radiation-induced Proctopathy: A Systematic Review

“…Secondary symptoms, such as abdominal pain, nausea, vomiting, malabsorption, tenesmus, hematochezia, and constipation, occur after three months. 22 Rectal bleeding is the most common symptom, and refractory bleeding is a common problem that sometimes requires transfusion. 9,23 Based on the severity of the symptoms, proctitis can be graded from 0 to 4 according to the classifications of the Radiation Therapy Oncology Group (RTOG) and the European Organization for Research and Treatment of Cancer (EORTC) 5 (►Table 2).…”

“…The best strategy to prevent its occurrence is by reducing the radiation dose and the irradiated area. Still, some studies support measures that could contribute to the reduction in the frequency and severity of radiotherapy-induced proctopathy: 22 1. Use of anti-inflammatories and agents that promote the renewal of colonies such as probiotics, which produce short chain fatty acids (SCFAs).…”