Symptom Management Diarrhea 2

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 defecation habit for the pt.

• Impact: -At best ,annoying -At worst ,life- threatening. • Prevalence: -30-90% of patients on some anti neoplastic agents.

• Causes • Assessment • Pathophysiology • Management

• Can be classified into 6 major categories: Secretory Exudative Dysmotility associated Osmotic Malabsorptive Secondary causes-medication

• Characterized by ↑secretion of fluid & electrolytes. • Associated with carcinoid syndrome & disorders of intestinal inflammation e.g bacteria.

• 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.

• Characterized as a build- up of excess blood, serum proteins , & mucus in the intestinal lumen. • Associated with radiation colitis, infections, & malignancies of the colon.

• Results from improper peristaltic movement throughout the intestines. • Occurs following surgical procedures e.g gastrectomy, ileocecal valve resection.

• 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.

• Results from malabsorption of solutes. • Associated with lactase insufficiency, celiac sprue, whipple’s disease, & short gut syndrome.

• Chemotherapy induces diarrhea e.g 5FU & Irinotecan. • Blood pressure medications. • Digitalis. • Antacids containing Magnesium. • laxatives • Stress.

• 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.

• 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.

• 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.

• 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.

• 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.

• History: What’s normal Description(consistency, frequency, volume, blood, etc.) Onset & duration Weight loss Systemic symptoms Medications(including chemo) Physical Dehydration, fever.

• 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 ↑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

• 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.

• These medications are categorized into : Absorbent agents Prostaglandin inhibitors Opioids Somatostatin inhibitors.

• 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.

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.

• 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.

• 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.

• 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.

• 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.

• Lpoeramide • Diphyenoxylate • Paregoric • Tincture of Opium • Octreotide

• 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.

• 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.

• Low fat diet • Exogenous pancreatic lipase.

• Toxin mediated infection of colon. • Etiology: Gram+ organism Clostridium dificile. • Occur as a complication of antibiotic use (Cephalosporin,Erythromycin,Clindamycin) ,Chemotherapy,intestinal Radiation.

• 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

• Use comprehensive assessment & pathophysiology – based therapy to treat the cause & improve the cancer experience.

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Symptom Management Diarrhea 2

by Al-Sadeel Society on Jan 02, 2010

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