Xerostomia Head and Neck

necessary depending on the underlying cause of the edema and the severity. ENT evaluation and hospitalization may be required for more com- plicated cases. Adolescent patients should be advised against smoking during and after RT as it has been reported to lead to persistent hoarse- ness in adults with glottic tumors Chopra and Bogart 2009 .

13.6 Gastrointestinal

Complications The stomach and small bowel are often inciden- tally irradiated when treating upper GI tract, infe- rior lung, retroperitoneal, and pelvic tumors. Acute gastrointestinal RT-induced side effects include nausea, vomiting, and anorexia immedi- ately after treatment as well as dysphagia, esopha- gitis, dyspepsia, ulceration, bleeding, enteritis GI mucositis manifesting as cramping, diarrhea, and malabsorption, and proctitis within the fi rst few weeks of therapy Kavanagh et al. 2010 ; Michalski et al. 2010 . Late small bowel obstruction due to RT-induced fi brosis and secondary adhesions as well as chronic dyspepsia, ulceration, diarrhea, fi stula, perforation, bleeding, strictures, and chronic radiation proctitis must be considered but are beyond the scope of this chapter. RT dose- volume constraints for the stomach and small bowel are diffi cult to determine as partial volume irradiation is usually undertaken; ≥45 Gy for the whole stomach and for partial small bowel 195 mL are thresholds that have been published for adult patients Kavanagh et al. 2010 .

13.6.1 Dysphagia and Esophagitis

Radiation to the oropharynx can lead to pharyn- geal edema as well as dysphagia while RT to the thorax can lead to esophagitis. Adult patients receiving chemoradiation or hyperfractionated RT have been noted to have a 15–25 risk of severe acute esophagitis with symptoms peaking 4–8 weeks after the commencement of RT Werner-Wasik et al. 2010 . Of note, esophageal infections such as oroesophageal OE candidiasis or herpes simplex esophagitis can lead to similar symptoms and must be ruled out; additionally, preexisting gastroesophageal refl ux GER can worsen esophagitis and should be treated Werner- Wasik et al. 2010 . If infection is a concern, patients should undergo diagnostic endoscopy unless the level of symptoms contradicts such a procedure; in such cases empiric therapy e.g., fl u- conazole for OE candidiasis may be required. Radiation doses 40–50 Gy in adults have been shown to correlate with increased risk of acute esophagitis Werner-Wasik et al. 2010 . Data in the pediatric population are lacking. Amifostine has shown some potential benefi t in non-small cell lung cancer patients, but the reports are inconsistent, and recommendation for its use is also not uniform Keefe et al. 2007 ; Hensley et al. 2009 ; Peterson et al. 2011 . No other agent has been well studied; oral sucralfate has been utilized, but data are confl icting, and it is not recommended in consensus guidelines for RT-induced esophagitis Bradley and Movsas 2004 . General treatment strategies include treat- ment of underlying GER with an H 2 blocker or proton pump inhibitor, ruling out and treating infectious etiologies for esophagitis, and prescrib- ing viscous lidocaine and analgesics for pain. Promotility agents such as metoclopramide can also be tried. Patients should be advised to avoid acidic and spicy foods as well as alcohol and cof- fee. Nutritional status should be closely moni- tored, and patients at risk for malnutrition should receive oral supplementation, nasogastric feeds, PEG placement if with a head and neck tumor, or TPN, depending on the underlying clinical sit- uation; see Chap. 12 for more details. Pediatric patients with a history of chemoradiation- induced esophagitis are at risk for esophageal stricture and should be monitored for this potential late compli- cation Mahboubi and Silber 1997 .

13.6.2 Nausea, Vomiting and Anorexia

Radiation-induced nausea and vomiting RINV has been reported to occur in 50–80 of adult patients dependent on the radiation fi eld, RT dose,