Refractory Hemorrhagic Radiation Proctitis Managed With Sequential Endoscopic, Topical, and Hyperbaric Oxygen Therapy

Chronic radiation proctitis is a recognized late complication of pelvic radiation therapy and may present with rectal bleeding, urgency, altered bowel habits, ulceration, and transfusion-requiring anemia. Management can be challenging when bleeding persists despite standard endoscopic therapy. We present the case of a 72-year-old man with a history of prostate cancer treated with radiation therapy in 2016 who developed refractory hemorrhagic radiation proctitis in 2023. He initially underwent three sessions of argon plasma coagulation (APC) for rectal bleeding but was later hospitalized with acute blood loss anemia requiring transfusion. Colonoscopy demonstrated post-treatment rectal ulcers with visible vessels, which were treated with bipolar electrocautery. He subsequently received compounded sucralfate enemas with improvement in bleeding, followed by repeat endoscopic treatment of residual radiation proctitis with APC. Due to persistent symptoms, mesalamine suppositories and rectal radiofrequency ablation were used. Ongoing bleeding ultimately prompted referral for hyperbaric oxygen therapy, with completion of 30 sessions over seven weeks and resolution of rectal bleeding. Follow-up flexible sigmoidoscopy showed resolution of radiation proctitis with one clean-based rectal ulcer. Biopsies were negative for cytomegalovirus (CMV), herpes simplex virus (HSV), and dysplasia. This case highlights the stepwise and often multimodal management required for refractory chronic radiation proctitis and supports consideration of hyperbaric oxygen therapy when bleeding persists despite topical and endoscopic interventions.