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Symptom management
      Diarrhea
  Fatemah Y Abu Abed
   RN, BSN, Msn Environmental Health
• Stool that is looser than normal and/or
  increased in frequency.



• Alteration on consistency and frequency of
  defe...
• Impact:
   -At best ,annoying
   -At worst ,life- threatening.



• Prevalence:
  -30-90% of patients on some anti
  neo...
• Causes

• Assessment

• Pathophysiology

• Management
• Can be classified into 6 major categories:
  Secretory
  Exudative
  Dysmotility associated
  Osmotic
  Malabsorptive
  ...
• Characterized by ↑secretion of fluid &
  electrolytes.



• Associated with carcinoid syndrome &
  disorders of intestin...
• Neuroendocrine tumor arise from hormone –
  producing cells of the GI tract, respiratory tract,
  pancreas,& reproductiv...
• Characterized as a build- up of excess
  blood, serum proteins , & mucus in the
  intestinal lumen.

• Associated with r...
• Results from improper peristaltic
  movement throughout the intestines.



• Occurs following surgical procedures e.g
  ...
• Results from ingestion of oral solutes that
  isn’t
fully absorbed & often follows the ingestion
  of
Fruits, candies , ...
• Results from malabsorption of solutes.



• Associated with lactase insufficiency,
  celiac sprue, whipple’s disease, & ...
• Chemotherapy induces diarrhea e.g 5FU
  & Irinotecan.
• Blood pressure medications.
• Digitalis.
• Antacids containing M...
• Diarrhea also can be classified according
  to duration into:
  Acute: symptoms that are<14 days in
  duration.
  Chroni...
• Chemotherapy: damage intestinal mucosa
  & increased fluid overwhelms large bowel
  capacity.(irinotecan has cholinergic...
• Malabsorption associated with:
• Carcinoma of head of pancreas:
  insufficient pancreatic secretions &
  consequent resu...
• Colectomy: immediately post surgery-total
  or near total, the water in the gut can’t be
  adequately absorbed →ongoing ...
• Diarrhea 2-3 times/day without warning
  suggests anal incontinence.
• Profuse watery stools →colonic diarrhea.
• Sudden...
• History:
  What’s normal
  Description(consistency, frequency,
  volume,
     blood, etc.)
  Onset & duration
  Weight l...
• I s categorized by severity & classified on
  five-point scale.



• Look into table 2 (Grade 0 –Grade 4.
Grade       0          1              2               3             4



Patients    None   ↑of <4 stools ↑ of 4-6 stools ...
• Mild Diarrhea: managed with diet
  ↑oral intake of fluids
  Limit lactulose and fibers
  Avoid gas forming foods
  Incre...
• These medications are categorized into :

 Absorbent agents

 Prostaglandin inhibitors

 Opioids

 Somatostatin inhibito...
• Mythyl cellulose;Citrucel:1-4 /day.

• Synthetic, PO, bulk forming laxatives.

• Mechanism: absorb liquid in GI to
  ↑bu...
Preparations & dose:
Aspirin,300 mg 4 hourly,up to 4g/D
Mesalazine,1.2-2.4g/D
Bismuth subsalicylate,525 mg tab up to 5
mg/...
• Codeine:10-60mg4hourly,duration :4-6h.
• Loperamide:4mg initial,2mg after each
  loose stool up to 16mg/D,duration:8-16h...
• Octreotide:300-600 mcg /24h by SC.

• Mechanism of action:
  Somatostatin is produced in intestinal D cells.
  Act on gu...
• Mild to moderate diarrhea: treated ć
  medic.

• Grade ш and Grade 1V should be
  hospitalized, treated with aggressive ...
• 1st line of TX: Loperamide ,initial 4mg
  followed by 2mg q4h.



• Atropine –diphynoxylate 1-2 tab q6-8h
  may be added...
• Lpoeramide

• Diphyenoxylate

• Paregoric

• Tincture of Opium

• Octreotide
• Aggressive oral rehydration.

• Expectant management:
  Loperamide4mg then 2mg q2h till diarrhea
  free for 12 hr.
  Oct...
• Symptoms improved with addition of
  Somatostatin analogs & Interferon.
• Short acting preparation should be used first ...
• Low fat diet

• Exogenous pancreatic lipase.
• Toxin mediated infection of colon.

• Etiology: Gram+ organism Clostridium
  dificile.

• Occur as a complication of ant...
• S&S: ↑WBC, low grade fever progress to
  high fever, watery diarrhea to bloody,
  abdominal cramp ,dehydration

• Compli...
• Use comprehensive
  assessment
 & pathophysiology – based
 therapy to treat the cause &
 improve the cancer experience.
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Transcript of "Symptom Management Diarrhea 2"

  1. 1. Symptom management Diarrhea Fatemah Y Abu Abed RN, BSN, Msn Environmental Health
  2. 2. • Stool that is looser than normal and/or increased in frequency. • Alteration on consistency and frequency of defecation habit for the pt.
  3. 3. • Impact: -At best ,annoying -At worst ,life- threatening. • Prevalence: -30-90% of patients on some anti neoplastic agents.
  4. 4. • Causes • Assessment • Pathophysiology • Management
  5. 5. • Can be classified into 6 major categories: Secretory Exudative Dysmotility associated Osmotic Malabsorptive Secondary causes-medication
  6. 6. • Characterized by ↑secretion of fluid & electrolytes. • Associated with carcinoid syndrome & disorders of intestinal inflammation e.g bacteria.
  7. 7. • Neuroendocrine tumor arise from hormone – producing cells of the GI tract, respiratory tract, pancreas,& reproductive organs. • These cells release bradykin ,serotonin , histamine , & prostaglandins. • Excessive amounts of these hormones result in the development if carcinoid syndrome. • Symptoms include flushed face, neck and upper chest, abdominal pain, &diarrhea.
  8. 8. • Characterized as a build- up of excess blood, serum proteins , & mucus in the intestinal lumen. • Associated with radiation colitis, infections, & malignancies of the colon.
  9. 9. • Results from improper peristaltic movement throughout the intestines. • Occurs following surgical procedures e.g gastrectomy, ileocecal valve resection.
  10. 10. • 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 like Ferropel, Antibiotics–Penicillin &Cephalosporin & pancreatic resection.
  11. 11. • Results from malabsorption of solutes. • Associated with lactase insufficiency, celiac sprue, whipple’s disease, & short gut syndrome.
  12. 12. • Chemotherapy induces diarrhea e.g 5FU & Irinotecan. • Blood pressure medications. • Digitalis. • Antacids containing Magnesium. • laxatives • Stress.
  13. 13. • Diarrhea also can be classified according to duration into: Acute: symptoms that are<14 days in duration. Chronic: symptoms that persists beyond 1 month. • Majority of diarrhea is acute.
  14. 14. • Chemotherapy: damage intestinal mucosa & increased fluid overwhelms large bowel capacity.(irinotecan has cholinergic effect - parasympathatic). • Laxative therapy: atonic colon . • 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.
  15. 15. • Malabsorption associated with: • Carcinoma of head of pancreas: insufficient pancreatic secretions & consequent resultant steatorrhoea. • Gastrectomy: resulting in poor mixing food with pancreatic secretions →steatorrhoea. • Vagotomy: ↑water secretion into the colon. • Ileal resection : ↓the ability of small intestines to reabsorb bile acids→ fluid in the colon→osmotic effect.
  16. 16. • 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. • Colonic or rectal tumors: causing partial bowel obstruction or through ↑ mucus secretion.
  17. 17. • Diarrhea 2-3 times/day without warning suggests anal incontinence. • Profuse watery stools →colonic diarrhea. • Sudden onset of diarrhea after a period of constipation →suspicion of faecal impaction. • Alternating diarrhea & constipation →poorly regulated laxative Tx. or impending bowel obstruction. • Pale or fatty offensive stool →malabsorption due to pancreatic or ileal disease.
  18. 18. • History: What’s normal Description(consistency, frequency, volume, blood, etc.) Onset & duration Weight loss Systemic symptoms Medications(including chemo) Physical Dehydration, fever.
  19. 19. • I s categorized by severity & classified on five-point scale. • Look into table 2 (Grade 0 –Grade 4.
  20. 20. Grade 0 1 2 3 4 Patients None ↑of <4 stools ↑ of 4-6 stools ↑of ≥7 Physiologic without /day over /day, or stools / day consequen colostomy pretreatment nocturnal or ces stools. incontinenc requiring e; or need intensive for care or parenteal heamodyna support for mic dehydration collapse. . Patients None mild ↑ in moderate ↑ in Severe ↑ in Physiologic with a loose watery loose watery loose consequen colostomy colostomy colostomy watery ces output output colostomy requiring compared to compared ć output intensive pretreatment pretreatment compared ć care or but not pretreatme heamodyna interfering nt mic
  21. 21. • Mild Diarrhea: managed with diet ↑oral intake of fluids Limit lactulose and fibers Avoid gas forming foods Increase bulk Attapulgite could be given(clay like powder med can↓ absorption of benztropine,used for short tx of diarrhea). Bismuth salts can be given(chelating agent used to mobilize toxic metals from human tiisues-it’s main metabolite of Disulfiram.
  22. 22. • These medications are categorized into : Absorbent agents Prostaglandin inhibitors Opioids Somatostatin inhibitors.
  23. 23. • Mythyl cellulose;Citrucel:1-4 /day. • Synthetic, PO, bulk forming laxatives. • Mechanism: absorb liquid in GI to ↑bulk→↑peristalsis. • Advantages vs disadv.: not metabolized. • Pt with PKU should avoid the sugar –free preparation as it contains aspartame.
  24. 24. Preparations & dose: Aspirin,300 mg 4 hourly,up to 4g/D Mesalazine,1.2-2.4g/D Bismuth 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.
  25. 25. • Codeine:10-60mg4hourly,duration :4-6h. • Loperamide:4mg initial,2mg after each loose stool up to 16mg/D,duration:8-16h. • Mechanism: opioid receptor agonist • Act peripherally on µ-opioid receptors in large intestines. • Decrease activity of intestinal myenteric plexus →↓gut motility→↑water absorption. • Adv. Vs dis. : always R/O infectious etiology pre use.
  26. 26. • Octreotide:300-600 mcg /24h by SC. • 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.
  27. 27. • Mild to moderate diarrhea: treated ć medic. • Grade ш and Grade 1V should be hospitalized, treated with aggressive fluids ,electrolyte repletion plus medication. • Refractory diarrhea should be treated with continuous hydration plus medication.
  28. 28. • 1st line of TX: Loperamide ,initial 4mg followed by 2mg q4h. • Atropine –diphynoxylate 1-2 tab q6-8h may be added to Loperamide for Grade 1 & Gџ.
  29. 29. • Lpoeramide • Diphyenoxylate • Paregoric • Tincture of Opium • Octreotide
  30. 30. • Aggressive oral rehydration. • 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.
  31. 31. • Symptoms improved with addition of Somatostatin analogs & Interferon. • Short acting preparation should be used first like Sandostatin(Octreotide),SC ,1*3/D . • Opioids for mild cases & Cholestyramine(bile acid sequestrant). • 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.
  32. 32. • Low fat diet • Exogenous pancreatic lipase.
  33. 33. • Toxin mediated infection of colon. • Etiology: Gram+ organism Clostridium dificile. • Occur as a complication of antibiotic use (Cephalosporin,Erythromycin,Clindamycin) ,Chemotherapy,intestinal Radiation.
  34. 34. • S&S: ↑WBC, low grade fever progress to high fever, watery diarrhea to bloody, abdominal cramp ,dehydration • Complication: toxic megacolon, peritonitis, perforation. • DX: sigmoidscopy. • TX: Metranidazole+ Vancomycin
  35. 35. • Use comprehensive assessment & pathophysiology – based therapy to treat the cause & improve the cancer experience.
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