Using sucralfate tablets or suspension to make enemas for radiation proctitis

What is sucralfate?

Sucralfate is a medication licensed for the treatment of ulcers or inflammation in the stomach.

Sucralfate is also a very safe and effective treatment for bleeding from the lower bowel.

Why do I need to use sucralfate enemas?

The bleeding you are experiencing has started as a result of the radiation treatment you have been having. After radiotherapy, fragile blood vessels can develop in any part of the bowel exposed to the radiotherapy beam (radiological proctitis). Often these do not cause any problems but some people notice occasional bleeding from the lower bowel and, in a few patients, the bleeding becomes troublesome.

Bleeding is rarely a problem unless you need to strain to open your bowels, open your bowels very frequently or if you take blood thinning medicines such as aspirin or warfarin.

Most patients with troublesome bleeding will notice some improvement after about 1 week from starting treatment with sucralfate.

How do sucralfate enemas work?

Sucralfate forms a protective layer over the bowel wall and protects the fragile blood vessels from breaking. If people use sucralfate enemas for a long time (more than 8 weeks), the sucralfate may also increase the rate that these fragile blood vessels heal and disappear.

At first the treatment may seem strange or difficult but with perseverance it can make a big difference to the bleeding. In trials patients used the sucralfate enemas for at least 4 weeks and were followed up for up to 4 years.

How to administer sucralfate enemas

1. Preparing to use a sucralfate enema

The hospital pharmacy, or your local pharmacy if the prescription is written by your GP, will dispense either the sucralfate tablets (1 gram per tablet) or suspension (1g in 5ml). You will also be supplied with several large ‘bladder syringes’, several ‘soft Foley catheters’ (tubes) for giving the enema and some lubricating jelly.

2. Preparing an enema to use at home

Empty your bladder and bowels before using the enema. Start by washing your hands and clearing a clean surface in your bedroom or bathroom to work on. You may wish to place a towel on the area where you will be lying.

You will need a cup of warm - but not hot - tap water. It is best to set aside a particular cup which you are going to use for your enemas and not to use it for any other purpose such as drinking.

Tablets

• Remove the plunger from the bladder syringe (this can be quite firm to remove) and take two 1 gram tablets from the packaging. Place both tablets in the barrel of the syringe and then push the plunger back into the barrel down to the level of the tablets. There is no need to try to crush the tablets with the plunger.
• Place the nozzle of the syringe in the cup of warm water and draw up about 10 to 15ml of water. Now, holding the syringe with the nozzle pointing up so that no liquid can spill out, gently swirl the syringe until the tablets are fully dispersed.
• While still holding the syringe with the nozzle pointing up, press the plunger to remove the air from the top of the syringe until the water level almost reaches the opening of the nozzle.
• Now put the nozzle of the syringe into the cup of warm water and draw up water until the plunger is at 50mls. Carefully turn the syringe so that the sucralfate fully mixes with the water.

The enema is now ready to use.

Suspension

• Draw up 10ml (2g) of sucralfate suspension (1g in 5ml) into the bladder syringe, and draw up warm water from the cup so that the plunger is at 50ml. Expel any air from the syringe.

The enema is now ready to use.

Put the nozzle of the syringe into the open end of the catheter and apply some lubricating jelly to the other end of the catheter.

3. Giving the enema

• Lie down on your bed on your left side and bend your knees up towards your chest. Holding the prepared enema in one hand, feel for your anus with the other and gently guide the lubricated tip of the catheter into your anus so that 5 to 10 centimetres of the catheter tube has entered the lower bowel.
• Squeeze down the syringe plunger gently so that all the solution goes into your lower bowel.
• You will need to try to hold the solution inside your lower bowel for as long as possible despite it making you feel like you need to open your bowels. At least 15 minutes is ideal. You need to lie down for a lot of this time and roll over several times. Spend at least half the time on your tummy as often the worst bleeding is coming from the front wall of the rectum and lying down and rolling over gives the solution the chance to cover the worst affected parts of the lower bowel.
• Once you have opened your bowels, wash and rinse out the syringe and catheter with warm water. Remember to wash your hands afterwards. The usual recommendation is for you to follow this procedure twice a day for 10 to 14 days after the bleeding has stopped, then just once a day for a further week to make sure the bleeding does not start again. If your doctor has advised differently, then you should follow their directions. We strongly encourage you to continue with treatment for as long as advised. If bleeding starts again, you should consult your doctor for further advice. The doctor may want you to start using the enema again or continue using it for longer. To help heal the blood vessels, your doctor may advise you to continue using a sucralfate enema (usually once a day) even if there is no bleeding.

Additional information

The information on this page is not intended to replace your doctor’s advice.

Store the sucralfate and equipment in a safe place out of the reach of children. If you require more information or have any questions, please contact the pharmacy department:

Gloucestershire Royal Hospital

Tel: 0300 422 6108

or

Cheltenham General Hospital

Tel: 0300 422 3030

Monday to Friday, 9:00 am to 5:30 pm

References

This page is based on information from Basildon and Thurrock University Hospitals and St Mark’s Hospital pharmacy.