University of Rochester Medical Center, Strong Memorial Hospital Rochester, NY, United States
Timothy J. Lee, MD1, Matthew S. Berger, MD1, Colin D. Donahoe, PA-C2, Hong Zhang, MD, PhD2, Howard N. Langstein, MD2, Brandon Sprung, MD1 1University of Rochester Medical Center, Strong Memorial Hospital, Rochester, NY; 2University of Rochester Medical Center, Rochester, NY
Introduction: Argon plasma coagulation (APC) is an effective treatment for hemorrhagic chronic radiation proctitis (CRP) due to its superficial treatment effect. Ischemic complications of APC such as rectal ulcers are uncommon and usually self-limiting. Persistent post-APC ulcers and their treatment in this population is seldomly reported. We present a case of CRP with APC induced rectal ulceration and its response to various therapies including hyperbaric oxygen therapy (HBOT).
Case Description/Methods: An 80-year-old male with a history of prostate cancer s/p external beam radiation therapy two years prior presented with hematochezia.
Colonoscopy revealed friable radiation proctitis and oozing radiation-associated vascular ectasias without ulceration in the distal rectum (Fig.1A). APC was applied with excellent cautery effect noted. Three weeks later, hematochezia recurred prompting initiation of pharmacologic measures including bulking fiber supplements, hydrocortisone suppositories, and pentoxifylline. Symptoms persisted and reevaluation with flexible sigmoidoscopy revealed a large deep ulcer with adherent clot in the distal rectum (Fig.1B). Ulcer pathology showed ulcer/granulation tissue, vascular fibrinoid necrosis, and findings suggestive of radiation proctitis without dysplasia or malignancy. MRI pelvis was negative for fistula or abscess. Despite addition of mesalamine suppositories, symptoms continued and repeat flexible sigmoidoscopy showed persistent ulceration.
Due to pharmacologic treatment failure, HBOT was recommended. He underwent 45 treatments of HBOT that consisted of compression to 2.5 atmosphere absolute in 100% oxygen. Treatment resulted in resolution of hematochezia. Four months after last HBOT treatment, flexible sigmoidoscopy showed significant healing of the distal rectal ulcer with only small residual ulceration and granulation tissue remaining (Fig.1C).
Discussion: This case demonstrates a rare deep ulcerative complication from APC treatment for CRP and the beneficial role of HBOT when pharmacologic measures fail. While APC treatment depth is generally limited to the mucosal surface, it is thought that deeper structures are more susceptible when the submucosa contains fibrotic and ischemic tissue, as is seen with CRP. HBOT may allow for healing of deeper injuries by reducing local hypoxia to promote wound healing. Clinicians utilizing APC for treatment of superficial vascular lesions in the setting of CRP should be aware of the potential for such complications and its management.
Figure: Figure 1. A) Radiation proctitis prior to APC B) Distal rectal ulcer following APC, prior to HBOT C) Distal rectal ulcer following 45 treatment sessions of HBOT
Timothy Lee indicated no relevant financial relationships.
Matthew Berger indicated no relevant financial relationships.
Colin Donahoe indicated no relevant financial relationships.
Hong Zhang indicated no relevant financial relationships.
Howard Langstein indicated no relevant financial relationships.
Brandon Sprung indicated no relevant financial relationships.
Timothy J. Lee, MD1, Matthew S. Berger, MD1, Colin D. Donahoe, PA-C2, Hong Zhang, MD, PhD2, Howard N. Langstein, MD2, Brandon Sprung, MD1. P2583 - Successful Treatment of an Argon Plasma Coagulation-Induced Rectal Ulcer With Hyperbaric Oxygen Therapy, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.