Symptom management Diarrhea

Fatemah

Y Abu Abed RN, BSN, Msn Environmental Health

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Stool that is looser than normal and/or increased in frequency.

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Alteration on consistency and frequency of defecation habit for the pt.

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Impact:-At best ,annoying-At worst ,life-

threatening.

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Prevalence:-30-90% of patients on some anti neoplastic

agents.

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Causes

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Assessment

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Pathophysiology

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Management

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Can be classified into 6 major categories:SecretoryExudativeDysmotility associatedOsmoticMalabsorptiveSecondary causes-medication

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Characterized by ↑secretion of fluid & electrolytes.

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Associated with carcinoid

syndrome & disorders of intestinal inflammation e.g

bacteria.

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Neuroendocrine

tumor arise from hormone – producing cells of the GI tract, respiratory tract,

pancreas,& reproductive organs.

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These cells release bradykin

,serotonin , histamine , & prostaglandins.

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Excessive amounts of these hormones result in the development if carcinoid

syndrome.

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Symptoms include flushed face, neck and upper chest, abdominal pain, &diarrhea.

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Characterized as a build-

up of excess blood, serum proteins , & mucus in the intestinal lumen.

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Associated with radiation colitis, infections, & malignancies of the colon.

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Results from improper peristaltic movement throughout the intestines.

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Occurs following surgical procedures e.g gastrectomy, ileocecal

valve resection.

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Results from ingestion of oral solutes that isn’t

fully absorbed & often follows the ingestion of

Fruits, candies , dietetic foods, medications sweetened with non-absorbed

carbohydrates likeFerropel, Antibiotics–Penicillin

&Cephalosporin& pancreatic resection.

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Results from malabsorption

of solutes.

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Associated with lactase insufficiency, celiac sprue, whipple’s

disease, & short

gut syndrome.

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Chemotherapy induces diarrhea e.g

5FU & Irinotecan.

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Blood pressure medications.•

Digitalis.

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Antacids containing Magnesium.•

laxatives

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Stress.

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Diarrhea also can be classified according to duration into:Acute: symptoms that are<14 days in duration.Chronic: symptoms that persists beyond 1 month.

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Majority of diarrhea is acute.

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Chemotherapy: damage intestinal mucosa & increased fluid overwhelms large bowel capacity.(irinotecan

has cholinergic effect -

parasympathatic).•

Laxative therapy: atonic

colon .

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Faecal

impaction: associated with fluid stool which leaks past a faecal

plug or

tumor mass.•

Radiotherapy: involve abdomen or pelvis cause diarrhea in 2nd-3rd

week of therapy.

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Malabsorption

associated with:•

Carcinoma of head of pancreas: insufficient pancreatic secretions & consequent resultant steatorrhoea.

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Gastrectomy: resulting in poor mixing food with pancreatic secretions →steatorrhoea.

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Vagotomy: ↑water secretion into the colon.•

Ileal

resection : ↓the ability of small

intestines to reabsorb bile acids→ fluid in the colon→osmotic

effect.

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Colectomy: immediately post surgery-total or near total, the water in the gut can’t be adequately absorbed →ongoing daily loss of extra water400-1000 ml of gut fluid rectally.

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Colonic or rectal tumors: causing partial bowel obstruction or through ↑

mucus

secretion.

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Diarrhea 2-3 times/day without warning suggests anal incontinence.

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Profuse watery stools →colonic diarrhea.•

Sudden onset of diarrhea after a period of constipation →suspicion of faecal

impaction.

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Alternating diarrhea & constipation →poorly regulated laxative Tx. or impending bowel obstruction.

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Pale or fatty offensive stool →malabsorption

due to pancreatic or ileal

disease.

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History:What’s normalDescription(consistency, frequency, volume,

blood, etc.)Onset & durationWeight lossSystemic symptomsMedications(including chemo)Physical Dehydration, fever.

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I s categorized by severity & classified on five-point scale.

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Look into table 2 (Grade 0 –Grade 4.

43210Grade

Physiologic consequen

ces requiring intensive care or heamodyna

mic collapse.

↑of ≥7 stools / day or incontinenc

e; or need for parenteal

support for dehydration

.

↑

of 4-6 stools /day, or nocturnal stools.

↑of <4 stools /day over pretreatment

NonePatients without colostomy

Physiologic consequen

ces requiring intensive care or heamodyna

mic ll

Severe ↑

in loose watery colostomy output compared ć

pretreatme nt

i t f i

moderate ↑

in loose watery colostomy output compared ć

pretreatment but not interfering

ith l

mild ↑

in loose watery colostomy output compared to pretreatment

NonePatients with a colostomy

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Mild Diarrhea: managed with diet↑oral intake of fluidsLimit lactulose and fibersAvoid gas forming foodsIncrease bulkAttapulgite could be given(clay like powder med can↓ absorption of benztropine,usedfor short tx of diarrhea).Bismuth salts can be given(chelatingagent used to mobilize toxic metals from human tiisues-it’s main metabolite of Disulfiram.

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These medications are categorized into :

Absorbent agents

Prostaglandin inhibitors

Opioids

Somatostatin inhibitors.

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Mythyl

cellulose;Citrucel:1-4 /day.

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Synthetic, PO, bulk forming laxatives.

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Mechanism: absorb liquid in GI to ↑bulk→↑peristalsis.

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Advantages vs

disadv.: not metabolized.

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Pt with PKU should avoid the sugar –free preparation as it contains aspartame.

Preparations & dose:Aspirin,300 mg 4 hourly,up to 4g/DMesalazine,1.2-2.4g/DBismuth subsalicylate,525 mg tab up to 5 mg/D

Mechanism: antiinflammatory, antioxidant .

Advantage vs disadv.: PO & PR available.Careful monitoring for renal & liver impaired,Risk for bleeding & bruising.

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Codeine:10-60mg4hourly,duration :4-6h.•

Loperamide:4mg initial,2mg after each loose stool up to 16mg/D,duration:8-16h.

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Mechanism: opioid receptor agonist•

Act peripherally on µ-opioid receptors in large intestines.

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Decrease activity of intestinal myenteric plexus →↓gut motility→↑water

absorption.

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Adv. Vs dis. : always R/O infectious etiology pre use.

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Octreotide:300-600 mcg /24h by SC.

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Mechanism of action: Somatostatin is produced in intestinal D cells.Act on gut epithelial receptor s to inhibit secretion & peristalsis.It acts as inhibitor of growth hormone ,Glucagon,& Insulin.Treat refractory diarrhea & Carcinoid syndrome, bowel obstruction, vasoactive intestinal peptide –secreting tumors.

Advantages vs Dis advantages:Can be given once a month.

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Mild to moderate diarrhea: treated ć medic.

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Grade ш

and Grade 1V should be hospitalized, treated with aggressive fluids ,electrolyte repletion plus medication.

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Refractory diarrhea should be treated with continuous hydration plus medication.

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1st

line of TX: Loperamide

,initial 4mg followed by 2mg q4h.

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Atropine –diphynoxylate

1-2 tab q6-8h may be added to Loperamide

for Grade 1

& Gџ.

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Lpoeramide

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Diphyenoxylate

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Paregoric

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Tincture of Opium

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Octreotide

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Aggressive oral rehydration.

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Expectant management:Loperamide4mg then 2mg q2h till diarrhea free for 12 hr.Octreotide for refractory diarrhea.Admit for severe diarrhea ,nausea ,vomiting, fever, sepsis, or bleeding.

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Symptoms improved with addition of Somatostatin

analogs & Interferon.

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Short acting preparation should be used first like Sandostatin(Octreotide),SC

,1*3/D .

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Opioids for mild cases & Cholestyramine(bile acid sequestrant).

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Long acting preparation can be given every 2-4 weeks depending on response &control of s&s

like: Octreotide LAR ,20 mg ,IMQ4 weeks.Lanreotide LA 30 mg IM Q2weeks.Lanreotide Autogel,60mgIM Q4weeks.

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Low fat diet

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Exogenous pancreatic lipase.

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Toxin mediated infection of colon.

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Etiology: Gram+ organism Clostridium dificile.

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Occur as a complication of antibiotic use (Cephalosporin,Erythromycin,Clindamycin)

,Chemotherapy,intestinal

Radiation.

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S&S: ↑WBC, low grade fever progress to high fever, watery diarrhea to bloody, abdominal cramp ,dehydration

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Complication: toxic megacolon, peritonitis, perforation.

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DX: sigmoidscopy.

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TX: Metranidazole+ Vancomycin

• Use comprehensive assessment

& pathophysiology – based therapy to treat the cause &improve the cancer experience.