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Background/Objectives: The pathogenesis of enteritis after abdominal radiotherapy (RT) is unknown, although changes in fecal microbiota may be involved. Prebiotics stimulate the proliferation of Lactobacillus spp and Bifidobacterium spp, and this may have positive effects on the intestinal mucosa during abdominal RT. Subjects/Methods: We performed a randomized, double-blind, placebo-controlled trial involving patients with gynecological cancer who received abdominal RT after surgery. Patients were randomized to receive prebiotics or placebo. The prebiotic group received a mixture of fiber (50 inulin and 50% fructo-oligosaccharide), and the placebo group received 6 g of maltodextrin twice daily from 1 week before to 3 weeks after RT. The number of bowel movements and stool consistency was recorded daily. Diarrhea was evaluated according to the Common Toxicity Criteria of the National Cancer Institute. Stool consistency was assessed using the 7-point Bristol scale. Patients’ quality-of-life was evaluated at baseline and at completion of RT using the EORTC-QLQ-C30 (European Organization for Research and Treatment of Cancer quality-of-life Questionnaire C30) test. Results: Thirty-eight women with a mean age of 60.3±11.8 years participated in the study. Both groups (prebiotic ( n =20) and placebo (n =18)) were comparable in their baseline characteristics. The number of bowel movements per month increased in both groups during RT. The number of bowel movements per day increased in both groups. The number of days with watery stool (Bristol score 7) was lower in the prebiotic group (3.3±4.4 to 2.2±1.6) than in the placebo group ( P =0.08). With respect to quality-of-life, the symptoms with the highest score in the placebo group were insomnia at baseline and diarrhea toward the end of the treatment. In the prebiotic group, insomnia was the symptom with the highest score at both assessments, although the differences were not statistically significant. Conclusions: Prebiotics can improve the consistency of stools in gynecologic cancer patients on RT. This finding could have important implications in the quality-of-life of these patients during treatment.

We evaluated whether, and if so to what extent, radiotherapy applied on a series of patients with prostate cancer influenced the patient's bowel habits and anorectal function. Ten consecutive patients participated in the study. The median age of the patients was 74 years (range, 61-71) and the average follow-up period was 22 (range, 15-28) months. Four patients were irradiated using external beam radiotherapy (2 Gy/day for a total of 70 Gy); 6 patients were irradiated with a combination of external beam radiotherapy (50 Gy, 2 Gy/day) and high dose rate brachytherapy (two 10-Gy fractions). Upon interview, patients disclosed characteristic functional disturbances such as urgency with occasional accidents, faecal soiling and spotting of underwear. Involuntary release of gas was another embarrassing problem. One or more of these problems were present in half of the patients. Endoscopy disclosed signs of mild proctitis. Sphincter pressure, rectal capacity and the volume threshold for appreciation of defecation urge were all significantly lower in patients than in 10 age-matched controls. In conclusion, disturbances of anorectal function with imperfection of incontinence still occur so some extent despite improved precision, and reduced margins offered by the modern conformal radiation therapy of prostate cancer. Anal sphincter function, the reservoir capacity of the rectum and its sensory function are adversely affected and radiation proctitis with rectal fibrosis and damage of the extrinsic innervations of the anal sphincters appear to be the principal causative factors. Although conformal radiotherapy together with better positioning may be two substantial improvements of modern radiotherapy, further improvements are needed.

Defecation allows the body to eliminate waste, an essential step in food processing for animal survival. In contrast to the extensive studies of feeding, its obligate counterpart, defecation, has received much less attention until recently. In this study, we report our characterizations of the defecation behavior of Drosophila larvae and its neural basis. Drosophila larvae display defecation cycles of stereotypic frequency, involving sequential contraction of hindgut and anal sphincter. The defecation behavior requires two groups of motor neurons that innervate hindgut and anal sphincter, respectively, and can excite gut muscles directly. These two groups of motor neurons fire sequentially with the same periodicity as the defecation behavior, as revealed by in vivo Ca2+ imaging. Moreover, we identified a single mechanosensitive sensory neuron that innervates the anal slit and senses the opening of the intestine terminus. This anus sensory neuron relies on the TRP channel NOMPC but not on INACTIVE, NANCHUNG, or PIEZO for mechanotransduction. In animals, the final stage in the digestion of food is the removal of waste from the body. Until recently, however, defecation has received less attention than other aspects of digestion such as feeding behavior and nutrition. Fruit flies, also known as Drosophila, are commonly used in research as a model of animal biology. Food is moved through the digestive tract of fruit fly larvae when the muscles that circle the wall of the intestine contract. This process continues until the waste reaches the anus and is expelled from the body. Now Zhang et al. have found that when fruit fly larvae defecate, the muscles at the end of the intestine contract just before the muscles in the anus contract. The nervous system controls these muscles via sequential firing of two sets of nerve cells that connect to the intestine and anus muscles, respectively. Zhang et al. also identified a nerve cell that can sense when the anus is opened and relay this information back to the nervous system. The nerve cell is activated when stretched by the opening of the anus in a process that requires a protein called NOMPC. Problems with defecation can lead to constipation and other diseases. For example, Hirschsprung's disease—a birth defect that affects one in 4000—is caused by abnormal development of the nerve cells that control muscles in the gut. Experiments on fruit flies could help us to understand how defecation works in humans and to develop new treatments for disease.

Purpose Pelvic radiotherapy may lead to changes of anorectal function resulting in incontinence-related complaints. The aim of this study was to systematically review objective findings of late anorectal physiology and mucosal appearance after irradiation for prostate cancer. Methods MEDLINE, EMBASE, and the Cochrane library were searched. Original articles in which anal function, rectal function, or rectal mucosa were examined ≥3 months after EBRT for prostate cancer were included. Results Twenty-one studies were included with low to moderate quality. Anal resting pressures significantly decreased in 6 of the 9 studies including 277 patients. Changes of squeeze pressure and rectoanal inhibitory reflex were less uniform. Rectal distensibility was significantly impaired after EBRT in 7 of 9 studies (277 patients). In 4 of 9 studies on anal and in 5 of 9 on rectal function, disturbances were associated with urgency, frequent bowel movements or fecal incontinence. Mucosal changes as assessed by the Vienna Rectoscopy Score revealed telangiectasias in 73 %, congestion in 33 %, and ulceration in 4 % of patients in 8 studies including 346 patients, but no strictures or necrosis. Three studies reported mucosal improvement during follow-up. Telangiectasias, particularly multiple, were associated with rectal bleeding. Not all bowel complaints (30 %) were related to radiotherapy. Conclusions Low to moderate quality evidence indicates that EBRT reduces anal resting pressure, decreases rectal distensibility, and frequently induces telangiectasias of rectal mucosa. Objective changes may be associated with fecal incontinence, urgency, frequent bowel movements, and rectal bleeding, but these symptoms are not always related to radiation damage.

Postnatal behavior as measured by activity and elimination in the open field, activity in exercise wheels, and hoarding performance, was followed in mice of the ENA strain that had been exposed to 300 R on the day of birth. Long-lasting effects of neonatal irradiation were evidenced by changes in several characteristics. Irradiated mice weighed only 87% as much as controls at 7 weeks of age. Neonatal irradiation was found to decrease elimination scores, activity in wheels, and hoarding scores, but was not found to have a significant effect on open-field activity. Additional studies examined the relationship between locomotion in the open field and different levels of neonatal irradiation in three genotypes of mice. In general, locomotion was observed to decrease with increasing levels of irradiation in the three genotypes, with all three genotypes showing a marked decrease after receiving 300 R. Comparison of present results with those of other studies has demonstrated that strain differences may influence the type of behavioral response observed after neonatal irradiation.

Objective To systematically evaluate the guidelines for the diagnosis and treatment of radioactive enteritis, compare their differences and reasons and provide some reference for updating them. Methods This study used guidelines related to radiation enteritis by searching a database. Four independent reviewers used the AGREE II evaluation tool to evaluate the quality of the included guidelines, collate their main recommendations, and analyze the highest evidence supporting the main recommendations. Results Six diagnostic and therapeutic guidelines for radiation enteritis were included in this study, one of which, the American Society for Gastrointestinal Endoscopy guidelines, had an overall score of over 60%, which is worthy of clinical recommendation. In the diagnosis and treatment of radioactive rectal injury, the recommendations for hemorrhagic endoscopic treatment are mature and mainly include (I) argon plasma coagulation; (II) formalin treatment; (III) bipolar electrocoagulation; (IV) heater probe; (V) radiofrequency ablation; and (VI) cryoablation. Conclusion The methodological quality of radioactive enteritis guidelines is unequal; even in the same guidelines, different domains have a large difference. For radioactive rectal damage diagnosis, a type of endoscopic treatment recommendation is more mature, but the overall diagnosis and treatment of radioactive enteritis still lacks high-quality research evidence. Key point This article reviews the diagnosis and treatment guidelines for radiation enteritis in order to promote further update of the guidelines.

Introduction: A total of 60–80% of patients undergoing rectal resection (mostly as a treatment for rectal cancer) suffer from a variety of partly severe functional problems despite preservation of the anal sphincter. These patients are summarized under the term low anterior resection syndrome (LARS). Preoperative radiotherapy, vascular dissection and surgical excision of the low rectum and mesorectum lead, alone or all together, to a significant impairment of colonic and (neo-) rectal motility. This results in a variety of symptoms (multiple defecation episodes, recurrent episodes of urge, clustering, incontinence, etc.) which are associated with severe impairment of quality of life (QOL). Methods: This narrative review summarizes the present state of knowledge regarding the pathophysiology of LARS as well as the evidence for the available treatment options to control the symptoms resulting from this condition. Results: A review of the literature (Medline, Pubmed) reveals a variety of treatment options available to control symptoms of LARS. Medical therapy, with or without dietary modification, shows only a modest effect. Pelvic floor rehabilitation consisting of muscle exercise techniques as well as biofeedback training has been associated with improvement in LARS scores and incontinence, albeit with limited scientific evidence. Transanal irrigation (TAI) has gained interest as a treatment modality for patients with LARS due to an increasing number of promising data from recently published studies. Despite this promising observation, open questions about still-unclear issues of TAI remain under debate. Neuromodulation has been applied in LARS only in a few studies with small numbers of patients and partly conflicting results. Conclusion: LARS is a frequent problem after sphincter-preserving rectal surgery and leads to a marked impairment of QOL. Due to the large number of patients suffering from this condition, mandatory identification, as well as treatment of affected patients, must be considered during surgical as well as oncological follow-up. The use of a standardized treatment algorithm will lead to sufficient control of symptoms and a high probability of a marked improvement in QOL.

Background Low anterior resection syndrome (LARS) is a frequent problem after rectal resection. Transanal irrigation (TAI) has been suggested as an effective treatment in patients who have developed LARS. This prospective RCT was undertaken to evaluate the effect of TAI as a prophylactic treatment to prevent symptoms of LARS. Methods Patients who had undergone ultralow rectal resection were randomized to start TAI on a daily basis, or to serve as a control with supportive therapy only after ileostomy closure. All patients were seen after 1 week, 1 month and 3 months, and the maximum number of defaecation episodes per day and night documented during follow‐up. Wexner score, LARS score and Short Form 36 questionnaire responses were evaluated in both groups. Results Thirty‐seven patients could be evaluated according to protocol (TAI 18, control 19). The maximum number of stool episodes per day and per night was significantly lower among patients who underwent TAI at 1 month (median 3 versus 7 episodes/day in TAI versus control group, P = 0·003; 0 versus 3 episodes/night, P = 0·001) and 3 months (3 versus 5 episodes per day, P = 0·006; 0 versus 1 episodes/night, P = 0·002). LARS scores were significantly better in the TAI group after 1 month (median 16 versus 32 in control group; P = 0·044) and 3 months (9 versus 31; P = 0·001). A significantly better result in terms of Wexner score was seen in the TAI group after 3 months (median 2 versus 6 in controls; P = 0·046). Conclusion Prophylactic TAI led to a significantly better functional outcome compared with supportive therapy for up to 3 months. Registration number: DRKS00011752 ( http://apps.who.int/trialsearch/). Low anterior resection syndrome is a frequently encountered disorder following rectal resection that strongly affects patients' quality of life. In this randomized multicentre trial, prophylactic application of transanal irrigation (after closure of the protective ileostomy) resulted in a significant improvement in functional outcome compared with that in a control group with supportive therapy only.

Purpose of Review Low anterior resection syndrome is a highly prevalent condition that can develop after anal sphincter-sparing surgery for rectal cancer and impair quality of life. In this review, we summarize the major features and pathophysiology of this syndrome and discuss treatment approaches. Recent Findings Quality of life correlates significantly with severity of low anterior resection syndrome. Prompt assessment and initiation of therapy are essential to rehabilitating damaged mechanical and neural structures. Anorectal manometry demonstrates a global decrease in sphincteric function postoperatively, though in many patients, function does recover. Transanal irrigation, pelvic floor rehabilitation, and biofeedback are the mainstays of the treatment of major LARS. Definitive stoma can be considered in therapy refractory LARS > 2 years. Summary The development of low anterior resection syndrome likely involves an interplay between mechanical and neural pathways. Clinically, patients present at varying levels of severity, and scoring systems are available to help assess patient symptoms and guide therapy. Treatment approaches range from conservative therapies to biofeedback and sacral nerve stimulation. Future randomized controlled trials aimed at risk stratification of patients and development of severity-based treatment algorithms are warranted.

Despite the experimental evidence that certain dietary compounds lower the risk of radiation-induced damage to the intestine, clinical data are missing and dietary advice to irradiated patients is not evidence-based. We have previously identified 28 intestinal health-related symptoms among 623 gynaecological-cancer survivors (three to fifteen years after radiotherapy) and 344 matched population-based controls. The 28 symptoms were grouped into five radiation-induced survivorship syndromes: defecation-urgency syndrome, fecal-leakage syndrome, excessive mucus discharge, excessive gas discharge and blood discharge. The grouping was based on factor scores produced by Exploratory Factor Analysis in combination with the Variable Cutoff Method. Frequency of food intake was measured by a questionnaire. We evaluated the relationship between dietary intake and the intensity of the five syndromes. With the exception of excessive mucus discharge, the intensity of all syndromes declined with increasing intake of citrus fruits. The intensity of defecation-urgency and fecal-leakage syndrome declined with combined intake of vegetables and citrus fruits. The intensity of excessive mucus discharge was increased with increasing intake of gluten. In this observational study, we found an association between a high intake of citrus fruits and vegetables and a lower intensity of the studied radiation-induced cancer survivorship syndromes. Our data suggest it may be worthwhile to continue to search for a role of the diet before, during and after radiotherapy to help the cancer survivor restore her or his intestinal health after irradiation.