Management of Intestinal Complications in Patients With Pelvic Radiation Disease  Lorenzo Fuccio, Alessandra Guido, H. Jervoise N. Andreyev  Clinical Gastroenterology and Hepatology  Volume 10, Issue 12, Pages 1326-1334.e4 (December 2012) DOI: 10.1016/j.cgh.2012.07.017 Copyright © 2012 AGA Institute Terms and Conditions

Figure 1 Telangiectasias that developed in a patient after radiotherapy for prostate cancer. The patient reported occasional bleeding (1 episode per week) without anemia or a decrease in quality of life. The patient was reassured and no treatment was proposed. Clinical Gastroenterology and Hepatology 2012 10, 1326-1334.e4DOI: (10.1016/j.cgh.2012.07.017) Copyright © 2012 AGA Institute Terms and Conditions

Figure 2 A flowchart for the management of patients with rectal bleeding. Outcomes will improve if patients with bleeding are managed in a sequential and logical way. This diagram indicates the steps that a clinician should consider in managing patients with radiation-induced bleeding. Clinical Gastroenterology and Hepatology 2012 10, 1326-1334.e4DOI: (10.1016/j.cgh.2012.07.017) Copyright © 2012 AGA Institute Terms and Conditions

Supplementary Figure 1 Cell and molecular pathways to radiation injury. Acute changes occur during the first 12 weeks after radiation therapy and result from an inflammatory reaction. Chronic changes are the indirect result of inflammation and included fibrosis of the intestinal wall and vascular sclerosis. The pathologic changes are shown on the left side, and the known cellular and cytokine changes are shown on the right side. In 2002, Denham and Hauer-Jensen16 compared radiotherapy injury with a chronic wound and proposed 3 primary effects that lead to long-term toxicity. First, radiation kills cells when an adequate dose is delivered. Second, radiation has many indirect effects or responses to radiation-induced injury in other cells or tissues. Third, there are functional effects from radiation on different intracellular and extracellular molecules and changes in gene expression in irradiated cells. Clinical Gastroenterology and Hepatology 2012 10, 1326-1334.e4DOI: (10.1016/j.cgh.2012.07.017) Copyright © 2012 AGA Institute Terms and Conditions

Supplementary Figure 2 The referral pathway for patients with pelvic radiation disease. The diagram shows referral pathways used by a multidisciplinary, gastroenterology-led, late-effects clinic that has been established for 12 years and sees approximately 500 new patients per year. All patients are managed based on comprehensive gastroenterological assessments and careful, nurse-led, holistic-needs assessments. The support services that are needed by this patient group are indicated. Clinical Gastroenterology and Hepatology 2012 10, 1326-1334.e4DOI: (10.1016/j.cgh.2012.07.017) Copyright © 2012 AGA Institute Terms and Conditions