放射治疗(简称放疗)相关肠毒性常见表现为腹泻、腹痛、吸收不良与体重下降,可降低生活质量并影响放疗连续性与剂量强度。本文聚焦放疗肠毒性的临床表型与急慢性连续谱,强调感染、药物相关腹泻及胆汁酸吸收不良、胰腺外分泌功能不全、小肠细菌过度生长等可逆机制的诊断与鉴别诊断,并在此基础上提出肠内营养治疗建议。短肽/半元素配方以水解蛋白为主要氮源,脂肪常富含中链甘油三酯,适作为中重度肠毒性、持续喂养不耐受或明确/高度怀疑吸收不良患者的短期过渡方案;对多数肠功能基本完整或可恢复的患者,整蛋白配方在依从性与成本效益方面更具优势,适合长期维持。现有证据不支持短肽配方在临床结局上优于整蛋白配方,因此,建议采取问题导向的个体化策略:在必要时升级使用短肽配方,并适时降阶回整蛋白基础营养。该过程应与病因评估、对症及对因治疗同步进行,避免单纯依赖更换配方而忽视全面的诊断与综合管理。
Abstract
Radiotherapy-related intestinal toxicity commonly presents with diarrhea, abdominal pain, malabsorption, and weight loss, impairing quality of life and potentially compromising radiotherapy delivery. This review focuses on clinical phenotypes across the acute-to-chronic spectrum and highlights diagnostic and differential diagnostic considerations, including infectious and medication-related diarrhea as well as reversible malabsorptive mechanisms such as bile acid malabsorption, exocrine pancreatic insufficiency, and small intestinal bacterial overgrowth. Based on this, enteral nutrition recommendations are proposed. Short-peptide/semi-elemental formulas, which use hydrolyzed protein as the primary nitrogen source and are often rich in medium-chain triglycerides, are suitable as short-term transitional regimens for patients with moderate-to-severe intestinal toxicity, persistent feeding intolerance, or confirmed/strongly suspected malabsorption. For most patients with essentially intact or recoverable bowel function, whole-protein formulas offer advantages in terms of compliance and cost-effectiveness and are appropriate for long-term maintenance. Current evidence does not support the superiority of short-peptide formulas over whole-protein formulas in clinical outcomes. Therefore, a problem-oriented, individualized strategy is recommended: upgrade to short-peptide formulas when necessary and step back to whole-protein-based nutrition in a timely manner. This process should be carried out alongside etiological assessment, symptomatic treatment, and disease-specific management, avoiding overreliance on formula switching at the expense of comprehensive diagnosis and integrated care.
关键词
放射治疗 /
肠毒性 /
肠内营养 /
放射性肠炎 /
短肽配方 /
个体化策略 /
营养管理 /
吸收不良
Key words
Radiotherapy /
Intestinal toxicity /
Enteral nutrition /
Radiation enteritis /
Peptide-based formula /
Individualized strategy /
Nutritional management /
malabsorption
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参考文献
[1] HAUER-JENSEN M, DENHAM J W, ANDREYEV H J N. Radiation enteropathy pathogenesis, treatment and prevention [J]. Nat Rev Gastroenterol Hepatol, 2014, 11(8):470-479.
[2] ANDREYEV H J N, MULS A C, NORTON C, et al. The practical management of the gastrointestinal symptoms of pelvic radiation disease guidance [J]. Frontline Gastroenterol, 2015, 6(1):53-72.
[3] BOSSI P, ANTONUZZO A, CHERNY N I, et al. Diarrhoea in adult cancer patients ESMO Clinical Practice Guidelines [J]. Ann Oncol, 2018, 29(Suppl 4):iv126-iv142.
[4] DEMERS M, DAGNAULT A, DESJARDINS J. A randomized, double-blind, placebo-controlled trial Impact of probiotics on diarrhea in patients treated with pelvic radiation [J]. Clin Nutr, 2014, 33(5):761-767.
[5] REN H, WU Q, SUN Z, et al. Research progress and treatment of radiation enteritis and gut microbiota [J]. Radiat Oncol J, 2023, 41(2):61-68.
[6] VITZTHUM L, YUAN J, JONES D, et al. Reducing prolonged chemoradiation treatment times for cervical cancer [J]. BMJ Open Qual, 2019, 8(3):e000516.
[7] ANDREYEV J, ADAMS R, BORNSCHEIN J, et al. British Society of gastroenterology practice guidance on the management of acute and chronic gastrointestinal symptoms and complications as a result of treatment for cancer [J]. Gut, 2025, 74(7):1040-1067.
[8] MUSCARITOLI M, ARENDS J, BACHMANN P, et al. ESPEN practical guideline clinical nutrition in cancer [J]. Clin Nutr, 2021, 40(5):2898-2913.
[9] ZOELLER S, BECHTOLD M L, BURNS B, et al. Dispelling myths and unfounded practices about enteral nutrition [J]. Nutr Clin Pract, 2020, 35(2):196-204.
[10] WEDLAKE L, SHAW C, MCNAIR H, et al. Randomized controlled trial of dietary fibre for prevention of radiation-induced gastrointestinal toxicity during pelvic radiotherapy [J]. Am J Clin Nutr, 2017, 106(3):849-857.
[11] ROSLI D, SHAHAR S, MANAF Z A, et al. Randomized controlled trial on the effect of partially hydrolyzed guar gum supplementation on diarrhea frequency and gut microbiome count among pelvic radiation patients [J]. JPEN J Parenter Enteral Nutr, 2021, 45(2):277-286.
[12] PARADA-VENEGAS D, DE LA FUENTE M K, LANDSKRON G, et al. Short chain fatty acids mediated gut epithelial and immune regulation and its relevance for inflammatory bowel diseases [J]. Front Immunol, 2019, 10:277.
[13] YE F, NING J, FARDOUS Z, et al. Citrulline, a potential biomarker of radiation-induced small intestine damage [J]. Dose Response, 2020, 18(3):1559325820962341.
[14] LUTGENS L C H W, DEUTZ N E P, GRANZIER-PEETERS M, et al. Plasma citrulline concentration a surrogate end point for radiation-induced mucosal atrophy of the small bowel A feasibility study in 23 patients [J]. Int J Radiat Oncol Biol Phys, 2004, 60(1):275-285.
[15] BRYDON W G, NYHLIN H, EASTWOOD M A, et al. Serum 7 alpha-hydroxy-4-cholesten-3-one and selenohomocholyltaurine (SeHCAT) whole body retention in the assessment of bile acid induced diarrhoea [J]. Eur J Gastroenterol Hepatol, 1996, 8(2):117-123.
[16] BRYDON W G, CULBERT P, KINGSTONE K, et al. An evaluation of the use of serum 7-alpha-hydroxycholestenone as a diagnostic test of bile acid malabsorption causing watery diarrhea [J]. Can J Gastroenterol, 2011, 25(6):319-323.
[17] SPAMPINATO S, TANDERUP K, BARCELLINI A, et al. Impact of the Common Terminology Criteria for Adverse Events (CTCAE) evolution on toxicity scoring in gynaecological radiotherapy [J]. Radiother Oncol, 2025, 207:110881.
[18] SHAH N D, LIMKETKAI B N. The use of medium-chain triglycerides in gastrointestinal disorders [J]. Pract Gastroenterol, 2017, 41(2):20-28.
[19] PARRISH C R, MCCRAY S. Enteral feeding dispelling myths [J]. Pract Gastroenterol, 2003, 27(9):33-50.
[20] BOULLATA J I, CARRERA A L, HARVEY L, et al. ASPEN safe practices for enteral nutrition therapy [J]. JPEN J Parenter Enteral Nutr, 2017, 41(1):15-103.
[21] LIN S, SHEN Y. The efficacy and safety of probiotics for prevention of chemoradiotherapy-induced diarrhea in people with abdominal and pelvic cancer a systematic review and meta-analysis based on 23 randomized studies [J]. Int J Surg, 2020, 84:69-77.
[22] SADOWSKI D C, CAMILLERI M, CHEY W D, et al. Canadian association of gastroenterology clinical practice guideline on the management of bile acid diarrhea [J]. Clin Gastroenterol Hepatol, 2020, 18(1):24-41.e1.
[23] PIMENTEL M, SAAD R J, LONG M D, et al. ACG clinical guideline small intestinal bacterial overgrowth [J]. Am J Gastroenterol, 2020, 115(2):165-178.
[24] BERNTSSTON H, THIEN A, HIND D, et al. Interventions for managing late gastrointestinal symptoms following pelvic radiotherapy a systematic review and meta-analysis [J]. Clin Oncol (R Coll Radiol), 2024, 36(5):318-334.
[25] WHELAN K, MARTIN L D, STAUDACHER H M, et al. The low FODMAP diet in the management of irritable bowel syndrome an evidence-based review of FODMAP restriction reintroduction and personalisation in clinical practice [J]. J Hum Nutr Diet, 2018, 31(2):239-255.
[26] WHITCOMB D C, BUCHNER A M, FORSMARK C E. AGA clinical practice update on the epidemiology, evaluation, and management of exocrine pancreatic insufficiency expert review [J]. Gastroenterology, 2023, 165(5):1292-1301.
[27] ARENDS J, BACHMANN P, BARACOS V, et al. ESPEN guidelines on nutrition in cancer patients [J]. Clin Nutr, 2017, 36(1):11-48.
[28] CARTERON L, SAMAIN E, WINISZEWSKI H, et al. Semi-elemental versus polymeric formula for enteral nutrition in brain-injured critically ill patients a randomized trial [J]. Crit Care, 2021, 25(1):31.
[29] CURRY A S, CHADDA S, DANEL A, et al. Early introduction of a semi-elemental formula may be cost saving compared to a polymeric formula among critically ill patients requiring enteral nutrition a cohort cost-consequence model [J]. Clinicoecon Outcomes Res, 2018, 10:293-300.
[30] HOLM M O, FALKMER U, YILMAZ M K, et al. The effect of nutritional interventions in acute radiation-induced diarrhoea in patients with primary pelvic cancer a systematic review [J]. Crit Rev Oncol Hematol, 2023, 188:104038.
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