HYPERBARIC OXYGEN THERAPY FOR
DELAYED PELVIC AND ABDOMINAL RADIATION DAMAGE

Abdomen and Pelvis
Chronic Radiation Proctitis
Studies of HBOT and Proctitis
Radiation Cystitis
Small Intestine and Gynecological HBOT Applications
HBOT Treatment Protocol for Soft-Tissue Necrosis

    ABDOMEN AND PELVIS

    The digestive tract and reproductive organs all carry similar organ-related risks, from immediate inflammation to a reduction in function. The reactions may be acute, but are often delayed and not visible until years later. Small bowel obstruction and adhesions (things sticking together that don’t belong stuck together), damage to the kidneys and ureters (drainage from the kidneys to the bladder), proctitis (inflammation of the rectum) and subsequent potential for chronic bleeding, fistulas (the development of abnormal ducts), stricture (the narrowing of body passages), and rectal ulcers may be treated by surgery. The results from bowel resectioning (rejoining to bypass defective tissue) or colostomy (connecting the bowel to an opening in abdominal wall) have been discouraging with one study yielding a 65% death rate after resection and 50% and 65% after bypass and colostomy respectively. Other studies show a death rate exceeding 20%.

    Gynecological radiation can lead to accelerated arteriosclerosis, bladder, vaginal, and rectal damage, and potential leg amputations.
    
One study showed that 53% of abdominal radiation patients treated with Hyperbaric Oxygen Therapy (HBOT) showed immediate improvement, with 66% showing long term improvement or cure. Another study showed 87% of HBOT patients experiencing complete symptom resolution after abdominal and pelvic radiation-induced necrosis. A third study of HBOT showed 36% complete resolution and 60% with improvement after radiation treatment resulted in proctitis (rectal inflammation) and enteritis (small bowel inflammation). Whether the damage is to the abdominal wall, groin, perineum, vaginal, or pelvic bones, HBOT provides the potential for complete resolution of injuries.

    RADIATION CYSTITIS

    A rare complication of radiation treatment is hemorrhagic cystitis, where the blood vessels within the bladder swell and leak blood into the urine. This can be fatal. In Sun and Chao’s review of 378 patients treated for cervical cancer, 3.7% died as a result of radiation bladder injury.

    If bladder bleeding is unresolved, it can be life threatening. If putting formalin or alum into the bladder does not stop the bleeding, removal of the bladder (cystectomy) may be required. Treatments may involve inserting drainage tubes into the kidneys or constructing new diversionary loops from segments of the small intestine. Even with these aggressive treatments, four of nine patients (44%) in one study died.

    In contrast, hyperbaric oxygen has provided a 76.3% success rate. In one study, 145 patients out of 190 treated with HBOT healed.
    
In a limited study of post-radiation bladder cancer patients, 30 of 40 patients who had severe urinary bleeding showed no blood in the urine after 20 HBOT sessions and 7 had occasional bleeding. Only 3 showed no change. Long term success (over 76% in another study) of HBOT for post-radiation bladder inflammation is impressive when compared with other treatments which resulted in the death of 44% of patients. Researchers also found that areas of the bladder that were resistant to HBOT quite frequently had tumor recurrence, so analyzing HBOT response was an effective way to determine the presence of diseased tissue.

    In the case of cystitis, prompt treatment is essential to reduce intractible bladder shrinkage.

    CHRONIC RADIATION PROCTITIS

    Injury of the rectum and lower (sigmoid) intestine can result from radiation treatment of the rectum, cervix, uterus, prostate, urinary bladder, and testes. The incidence of the damage can only be expected to increase with increased diagnosis and radiation treatment of prostate cancer.

    Acute injury occurs within six weeks of therapy, with diarrhea, bowel urgency, and occasional bleeding—symptoms that usually resolve spontaneously within two to six months. Butyrate enemas may accelerate healing.

    Chronic radiation proctosigmoiditis (inflammation of the large bowel and/or rectum) may occur 9 to 14 months after treatment, sometimes after more than two years, and rarely, although it does happen, as much as 30 years later. Only 5 to 20 percent of patients experience these chronic post-radiation injuries. The incidence following radiation for specific up to 30 of patients treated for prostate cancer, 12 to 17 percent of patiens with rectal cancer, 16 percent of those with testicular cancer, and 10 percent with rectal cancer.

    This condition is the result of progressive epithelial atrophy (shrinkage of the cells lining the bowel wall), fibrosis (thickening from scar tissue), endarteritis (inflammation of artery walls), and chronic mucosal ischemia (restriction of blood flow to the mucous membranes lining the bowel). When sections of the bowel are subject to restricted blood flow, they form strictures (which can result in bowel obstruction) and can result in bleeding. Diarrhea, rectal pain, urgency, and bowel incontinence are possible symptoms.

    Less obvious symptoms are the result of damage to the genitourinary tract and reduce quality of life in up to 30 percent of patients. Patients may suffer fistulas, small bowel obstruction and bacterial overgrowth, urethral stenosis (narrowing of the urinary elimination passageway), and cystitis (inflammation of the bladder). In one study, 29 of 224 patients (13 percent) treated with radiation for recto-sigmoid cancer suffered small bowel obstruction. The treatent also increased the incidence of secondary cancer more than 10 years after exposure.

    STUDIES OF HBOT AND PROCTITIS

    A wide variety of therapies have been used to treat the bleeding and diarrhea associated with abdominal radiation injury, including hyperbaric oxygen therapy.
    
In Warren, Feehan, Slade, and Cianci’s 1997 study, eight of fourteen (57 percent) of patients treated with HBOT experienced complete symptom resolution along with visible improvement of the rectal mucosa. One patient, although not “cured,” had substantial improvement.

    
In Woo, Joseph, and Oxer’s study that same year over half of patients treated at the Freemantle Hyperbaric Oxygen Unit expeienced partial or complete resolution of proctitis symptoms.

    
Mayer, Klemn, Quehenberger, Sankin, Mayer, Hackl, and Smolle-Juettner reported their study on the use of hyperbaric oxygen therapy in 18 men previously treated with radiation for prostate cancer. Bleeding ceased in five of five patients with proctitis and six of eight with cystitis.

    
Nakabayashi, Beard, Kelly, Carr-Locke, and Oh found HBOT resolved a deep anorectal ulcer which resulted from treatment for prostate cancer. Nine months later, the symptoms had not recurred.

    
Feldmeier and Hampson reported that 36 percent of 114 cases of radiation proctitis reported symptom resolution, and 60 percent saw improvement after HBOT treatment. For patients with other symptoms—pain diarrhea, weight loss, fistulas, and obstruction—58 percent improved with HBOT. The response rate for rectal disease was 65 percent, with improvement of other proximal sites at 73 percent.

    SMALL INTESTINE, BLADDER, AND GYNECOLOGICAL HBOT APPLICATIONS

    Radiation treatment of the lower abdomen can result in radiation enteritis (inflammation of the small bowel) or proctitis (inflammation of the anus), often after a latent, asymptomatic period of several months to a year. Either of these conditions can result in hemorrhage, infection or fistulas—abnormal connections between different parts of the intestines, the bowel and the bladder, the rectum and vagina, or the rectum and the exterior skin. Fistulas result in bowel contents draining to the skin, the bladder, or the vagina, with the potential for life-threatening infection.

    Of 114 patients reported in nine publications, forty-one (36%) experienced complete resolution of proctitis, and 68 (60%) improved after hyperbaric oxygen treatment. Feldmeier reported the resolution of fistulae in six of eight patients, with only three requiring surgical intervention. He also reported that only seven of twenty-six patients required surgical debridement (removal of dead tissue), flaps, or grafts.

    In Feldmeier’s study of thirty-one patients who experienced radiation injuries to the abdominal wall, groin, perineum, vagina, or pelvic bones, twenty-six (84%) had complete resolution of symptoms after twenty hyperbaric treatments. In this group, six patients suffered vaginal necrosis, which was completely healed. Williams reported that thirteen of fourteen patients with vaginal necrosis experienced complete resolution of their condition with HBOT, although one required two courses of treatment. Farmer reported he had success in using HBOT to resolve a single case of vaginal necrosis. Overall, forty of forty-six patients experienced complete success with hyperbaric oxygen treatment of radiation-induced pelvic and abdominal injuries.
    
In Marshall, Thirlby, Bredfeldt, and Hampson’s study of 65 patients treated with HBOT for chronic radiation enteritis (small bowel inflammation), 68 percent responded, with complete healing in 43 percent. The most common initial cancers in these 37 male and 28 female patients were prostate (27 patients), endometrial, uterine, and cervical (15 patients) and colorectal (12 patients). Damaged areas included the rectum (54 percent), other proximal sites (stomach duodenum, small bowel, and colon—four patients had damage to both the rectum and proximal sites. Fifty-four patients (83%) suffered bleeding, with 16 of those serious enough to require transfusion before or during HBOT treatment. Of those 16, 75 percent responded to HBOT and did not require additional blood transfustions after treatment. Overall, bleeding was reduced in 70 percent of the cases.


    
In Sidik, Hardjodisastro, Setiabudy and Gondowiardjo’s study of 32 gynecological patients undergoing post-radiation HBOT treatment against 33 controls, the HBOT group showed both decreased acute and late side effects as well as improved quality of life. Fink, Chetty, Lehm, Marsden, and Hacker reported that 10 of 14 (71 percent) patients with delayed gynecological radiation symptoms either healed completely or had significant (over 50 percent) improvement after 20 HBOT treatments.

    HBOT TREATMENT PROTOCOL FOR SOFT-TISSUE NECROSIS

    Hampson and Corman concluded that soft tissue radionecrosis of the gastrointestinal tract or bladder is:

    
  1. Effectively treated with HBOT
  2. Requires at lesat 30 treatments to optimize response rates
  3. Equally responsive, whether treatment is 3, 7, or more times per week

    
Theoretically, HBOT reduces bacterial growth; preserves tissue which, untreated, may have an inadequate oxygen supply; and inhibits the production of toxins. It increases tissue oxygenation, stimulates tissue repair, and promotes the development of blood vessels into irradiated tissue-- the re-vascularization restores irradiated tissue oxygenation to 80 percent of normal. This is significant.

    
TStudies suggest that an increase in the development of new blood vessels may result from increased HBOT treatment pressure. Longitudinal studies (over 4 years) indicate that this repair of blood vessels is permanent. Of note is that the duration of symptoms and the amount of time between radiation treatment and HBOT does not seem to affect the response rate.
    Many of the effects of radiation treatment are not seen for years. It may be difficult to diagnose which symptoms are caused by recurrence of the tumor, metastasis (spreading of the original tumor to new sites), new malignant growths, or damage caused by the radiation so many years before.

©2008 Florida Oxygen