Diarrhea
Background
Diarrhea, a common symptom among patients with CRC and characterized by frequent, watery stools, impairs quality of life, can lead to other complications, and may even be life threatening. Diarrhea occurs in 6% of hospitalized patients with cancer, up to 10% of patients with advanced cancer, 20%–49% of patients undergoing abdominopelvic irradiation, 50%–87% of patients receiving fluoropyrimidines (5-fluorouracil [5-FU]) and topoisomerase inhibitors (irinotecan), and 80% of patients with carcinoid tumors. 2
Types of diarrhea include:3
- Osmotic
- Malabsorptive
- Secretory
- Exudative
Assessment Tools
1 |
2 |
3 |
4 |
| Increase of < 4 stools per day over baseline; mild increase in ostomy output compared with baseline | Increase of 4–6 stools per day over baseline; IV fluids indicated < 24 h; moderate increase in ostomy output compared with baseline |
Increase of > 7 stools per day over baseline; incontinence; IV fluids > 24 h; hospitalization; severe increase in ostomy output compared with baseline; interfering with ADLs
|
Life-threatening consequences (eg, hemodynamic collapse)
|
ADLs = activities of daily living.
National Cancer Institute Cancer Therapy Evaluation Program, CTCAE v 3.04
Cancer-Related Diarrhea: Criteria for Optimal Assessment
- Stool consistency determined by grading scale using graphic illustrations
- Liquid stool measured by volume rather than number of episodes
- Onset and duration of diarrhea in relation to potential causative factors (eg, food or liquid intake, medication, radiation therapy, activity)
- Identification of accompanying symptoms (eg, tenesmus, urgency, abdominal pain or cramping, bloating, fever, bleeding)
- Presence of perianal or peristomal skin alteration graded according to severity
- Patient report of self-care interventions and efficacy of interventions
- Effect on performance levels and functional ability (eg, ability to work, assume responsibilities, participate in interpersonal and sexual relationships.
Data from: Kornblau et al.5
Patients with refractory diarrhea, which does not resolve with medication or dietary changes, should be evaluated by stool culture for enteric bacterial or parasitic infections and intestinal obstruction. Typhlitis, also called necrotizing enterocolitis, is a rare complication of cancer therapy but can be life-threatening condition if not recognized and treated emergently. Typhlitis may present as bloody diarrhea accompanied by right lower quadrant abdominal pain and fever. The pathogenesis of typhlitis generally requires (1) mucosal injury by chemotherapy or other means think mucositis); (2) altered gut flora, leaving the patient vulnerable to microorganism invasion of the gut; and (3) profound neutropenia.6 Several case reports have been published concerning CRC patients on 5FU/LV therapy.7 Necrotizing enterocolitis has been reported in patients taking capecitabine, an oral fluoropyrimidine.8 Workup for necrotizing enterocolitis/typhlitis should include a CT of the abdomen and pelvis.
Management of diarrhea
Nonpharmacologic management of diarrhea should include dietary modifications, avoiding foods that trigger diarrhea such as fruit, highly sweetened beverages, beverages containing aspartame, and fatty foods. If the patient is experiencing grade 2-3 watery diarrhea or has abdominal cramping, pharmacologic intervention may be required. There are several antidiarrheal agents available that work through various mechanisms of action:
Table 1. Antidiarrheal agents2
Generic Name |
Trade Name |
Mechanism of Action |
| loperamide octreotide paregoric codeine psyllium kaolin pectate/pectin activated charcoal |
Imodium AD Sandostatin/Sandostatin LR |
Intestinal transit inhibitor Antisecretory agent Anticholinergic Anticolinergic Proabsorptive agent Proabsorptive agent Proabsorptive agent Proabsorptive agent |
Clinical Practice Guidelines
The National Cancer Institute
Click here for a comprehensive review of all chemotherapy-induced GI complications.
National Oncology Alliance (NOA)
Diarrhea management begins with the initial work-up through follow-up. Link to http://www.noainc.com, click on Treatment Guidelines on the Scroll Bar.
Patient Care Management Protocols/Algorithms
References
- Hogan CM, The nurse’s role in diarrhea management. Oncol Nurs Forum. 1998; 25:879-886.
- Benson AB, Ajani JA, Catalano R, Engelking C, et al. Recommended guidelines for the treatment of cancer treatment-induced diarrhea. J Clin Oncol. 2004;22:2918-2926.
- Rutledge DN, Engelking C. Cancer-related diarrhea: selected findings of a national survey of oncology nursing experiences. Oncol Nurs Forum. 1998;25:861-873.
- National Cancer Institute Cancer Therapy Evaluation Program. Common terminology criteria for adverse events v3.0. Available at: http://ctep.cancer.gov/reporting/ctc_v30.html.
- Kornblau S, Benson AB, Catalano R, Engelking C, et al. Management of cancer treatment-related diarrhea: issues and therapeutic strategies. J Pain Symptom Manage. 2000;19:118-129. [ Pub Med ]
- Song LM, Marcon NE. Up to Date: Necrotizing enterocolitis (typhlitis) in adults. Available here.
- Hayes, D, Leonardo JM. Neutropenic enterocolitis in a woman treated with 5-fluorouracil and leucovorin in colon carcinoma. NCMedJ. 2002:53:132-134.
- Roche Laboratories, Inc. Xeloda package insert, page 17. Available at: http://www.rocheusa.com/products/xeloda/pi.pdf.
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