Radiation enteritis

Below are the CT images of a 60y female patient, post surgery, post chemo-radiotherapy for Ca Rectum 3 months before the CT. 

CT images show 'long segment, contiguous, mild circumferential wall thickening of distal and terminal ileum, measuring length of ~30cm and maximum wall thickness of ~6mm. No peri-enteric fat stranding or lymph node enlargement seen'.  There were no sinuses or fistulae or any features of bowel stricture or obstruction.  

The blue arrows point to the thickened ileal loops. 

Radiation induced enteritis, especially of the small bowel is less often seen even though small bowel is very radiosensitive, because of its relatively increased mobility. Among small bowel the terminal ileum is the most sensitive, as it is more or less fixed. Fixation due to adhesions from a previous surgery or previous inflammation (including PID) can increase the risk of radiation induced bowel damage. Thin habitus, diabetes and hypertension can also influence the post radiation injury. 

Radiation doses >50Gy administered over 6 weeks can produce radiation induced bowel injury, which in 10% of cases might require surgical intervention. ~5-15% patients receiving >45Gy develop chronic radiation enteropathy.

The three stages of radiation enteritis are acute, subacute (2-12 months) and late phase. Acute phase is usually the mucosal inflammation, crypt abscesses, superficial ulcerations. Subacute phase, is a phase of regeneration, arteriolar sclerosis. Late phase is usually due to fibrosis. This phase can result in strictures, obstruction, fistula and sinus formation. 

👉  Point to remember : Keep in mind the differential of radiation induced bowel injury, in cases of bowel wall thickening. Especially in a post op patient, ask for history of radiotherapy.