Damage to the gastrointestinal system

Survivors of childhood cancer sometimes develop fibrosis (excessive formation of scar tissue) or chronic enterocolitis (inflammation of the intestines).

Fibrosis can occur anywhere in the GI system, from the esophagus to the rectum, causing thickening of the inner walls that can lead to strictures (narrowing) or obstructions (blockages). Fibrosis can also occur outside of the GI tract in the form of adhesions (bands of scar tissue that cause surfaces of structures that are usually separate to stick together).

Fibrosis, strictures, and chronic enterocolitis can be caused by the following:

• Radiation (3,000 cGy or higher) and if the colon received > 45Gy

• Abdominal surgery

• Chemotherapy (with radiation)

• Chronic GVHD

• Infection

Fibrosis and chronic enterocolitis can cause adhesions, obstructions, ulcers, diarrhea, constipation, lactose intolerance, and malabsorption problems. Intestinal damage can appear months to decades after treatment ends. The colon and rectum are more often damaged by radiation than the stomach and small intestine.

Survivors who received low doses of radiation have a very low incidence of GI damage, while those who had multiple abdominal surgeries and higher radiation doses are at higher risk.

Another problem that can develop is slow emptying of the stomach and reflux (backflow) of food into the esophagus. These effects can occur after radiation or in survivors who had long-term problems with severe vomiting while in treatment. Reflux is a chronic problem. Barrett’s esophagus (changes in the cells of the esophagus) can occur in association with reflux in those whose GI tracts were irradiated. For more information about late effects to the esophagus, see Chapter 12, Head and Neck.

The role of chemotherapy drugs in the development of GI late effects is not well understood. Certain drugs (i.e., dactinomycin, Adriamycin^®, daunorubicin) are known to increase the effects of radiation and thus may increase the likelihood of GI problems.

Signs and symptoms of damage to the stomach and intestines:

Signs and symptoms of damage to the stomach and intestines:

• Chronic diarrhea

• Chronic constipation

• Nausea and vomiting

• Persistent or severe abdominal pain or cramping or bloating

• Blood in the stool

• Anemia

• Loss of appetite

• Problems gaining weight or loss of weight

• Failure to grow or thrive

Failure to grow and thrive is the primary symptom of malabsorption or difficulty in the digestion or absorption of nutrients from food. It often is accompanied by persistent diarrhea. This problem usually begins during treatment and persists. Malabsorption does not suddenly occur years after treatment.

Small bowel obstructions (obstructions of the small intestine) generally begin abruptly. The signs and symptoms include abdominal pain, nausea, vomiting, and loss of appetite. The pain is sometimes described as “crampy.” It may be in one specific area but is more commonly generalized. If the obstruction is complete, you cannot pass gas or have a bowel movement. Vomiting is caused by the increased pressure from the obstruction. The abdomen will become distended (enlarged) and if tapped will sound like a drum. If this happens, it is a medical emergency and you need to get medical attention right away because it can be life-threatening.

Screening and detection for damage to stomach and intestines

Your annual follow-up appointment should include a thorough physical examination and health history. You are at risk if you had one or more abdominal surgeries, abdominal radiation, or chronic GVHD after a stem cell transplant.

If you haven’t reached your full adult growth, your height and weight should be plotted on a growth chart. Your healthcare provider should ask about your diet, any stomach or abdominal pains, and whether you have chronic diarrhea or constipation. If you have persistent symptoms, you should be referred to a gastroenterologist for further evaluation.

Certain abnormalities can be detected only with laboratory tests. A complete blood count (CBC) will show if you have anemia. Some clinics for cancer survivors test serum total protein and albumin levels every couple of years to check for liver and kidney disease and nutritional deficiencies.

Medical, surgical, and nutritional management of GI problems

Diet and nutrition. Many GI problems require low-fat, gluten-free, lactose-free, or low-residue diets. These are best undertaken under the guidance of a gastroenterologist and nutritionist.