Diarrhea is a common and potentially life-threatening symptom in cancer patients. It can be caused by the cancer itself or its treatment through chemotherapy, radiation therapy, surgery or bone marrow transplantation. Chemotherapy drugs like capecitabine and irinotecan are common causes. Radiation to the abdomen often results in diarrhea. Diarrhea is classified from grade 1 to 4 based on stool frequency and dehydration risk. For uncomplicated diarrhea, treatments include diet changes, oral rehydration, and anti-diarrheal medications. Complicated diarrhea requiring intravenous fluids and octreotide is defined as high grade, associated with fever or neutropenia, or causing dehydration.

1. Diarrhea in Cancer patients
Presented by
Albino Amum Awin
MD Student in Surgical Oncology at
Faculty of medicine Mansoura University.
Oncology Center Mansoura University(OCMU

2. Diarrhea in cancer patients

3. Definition:
Diarrhea is loose, watery stools three or more times a day, it may be
acute, persistent or chronic, it is not only quite common symptom for
cancer patient, it can also be dangerous enough to threaten the life of
cancer patient.
Etiology:
diarrhea in cancer patients is multifactorial, however, is most commonly
induced by therapy.

4. Causes include:
1-Cancer-related
 Carcinoid syndrome
 Colon cancer
 Lymphoma
 Medullary carcinoma of the thyroid
 Pancreatic cancer, particularly islet cell tumors (Zollinger- Ellison
syndrome)
 Pheochromocytoma

5. 2-Surgery- or procedure-related
 Celiac plexus block
 Cholecystectomy, esophagogastrectomy
 Gastrectomy (dumping), pancreaticoduodenectomy
 Intestinal resection (malabsorption due to short bowel
syndrome)
 Vagotomy

6. 3-Chemotherapy- related:
Chemotherapy damage rapidly dividing cells including
normal cells in mucosa of GIT, leading to a disruption in the
delicate fluid balance.
The absorption of fluids is decreased, followed by increased
secretion of fluids and electrolytes in stools.
 Chemotherapies that cause diarrhea include:
Capecitabine, cisplatin, cytosine arabinoside, cyclophosphamide,
daunorubicin, docetaxel, doxorubicin, 5- fluorouracil, interferon,
irinotecan, leucovorin, methotrexate, oxaliplatin, paclitaxel, topotecan,
lapatinib

7. 4-Radiation therapy–related
Radiation therapy to abdominal, pelvic, lumbar, or para-aortic fields can result in
changes to normal bowel function. Factors contributing to the occurrence and
severity of intestinal complications depend on the following:
 Total dose.
 Fractionation.
 Volume of bowel irradiated.
 Concomitant chemotherapy.
Common manifestations of radiation enteritis include: diarrhea, malabsorption,
bloating & cramping

8. 5-Bone marrow transplantation– related
Graft- versus-host disease after allogeneic bone marrow or
peripheral blood stem cell transplants.
6-Drug adverse effects
Antibiotics (pseudomembranous colitis), magnesium-
containing antacids, antihypertensives, colchicine, digoxin,
lactulose, laxatives, methyldopa, metoclopramide, misoprostol,
potassium supplements, propranolol, theophylline

9. 7-Concurrent disease
Diabetes, hyperthyroidism, inflammatory bowel
disease (Crohn disease, diverticulitis, gastroenteritis,
HIV/AIDS, ulcerative colitis), obstruction (tumor-
related)
8-Infection
Clostridium difficile, Clostridium perfringens, Bacillus
cereus, Giardia lamblia, Cryptosporidium, Salmonella,
Shigella, Campylobacter, Rotavirus

10. 9-Fecal impaction
 Constipation leading to obstruction followed by spurious diarrhea.
10-Diet
 Alcohol, milk, and dairy products (particularly in patients with lactose
intolerance), Caffeine-containing products (coffee, tea, chocolate); specific
fruit juices (prune juice, unfiltered apple juice).
 High-fiber foods (raw fruits and vegetables, nuts, seeds, whole-grain
products, dried legumes); high-fat foods (deep- fried foods, high fat–
containing foods) Lactulose intolerance or food allergies
 Sorbitol-containing foods (candy and chewing gum); hot and spicy foods;
gas-forming foods and beverages (cruciferous vegetables, dried legumes,
melons, carbonated beverages

11. 11-Psychological factors
Through Stress

12. Effects of Diarrhea
⌂ Diarrhea is not only inconvenient side effect of cancer treatment, but
also can be life threatening if not adequately managed, it may lead to:
 Dehydration, Electrolyte imbalance, low immune function, malnutrition; due to
reduced absorption of nutrients: and inflammation, pain and / or bleeding as a
consequence of increased frequency of bowel movement.
 At extreme, diarrhea can lead to hyponatremia, hypokalemia, seizure and coma
 Severely low potassium level cause abnormal heart function or paralytic ileus.

13. Assessment of diarrhea
Number of stools per day.
Incontinence.
Increase in ostomy output compared with baseline.
The history also includes questions regarding the frequency of bowel
movements during the past 24 hours, the character of the fecal
material, and the time course of the development of diarrhea.
Consistency ranging from well-formed, formed, and semiformed to
loose, very loose, and liquid.

14. Patients are assessed regarding symptoms that might indicate
hemodynamic compromise or the underlying etiology, including:
Dizziness.
 Orthostatic symptoms.
Lethargy.
Cramping.
Abdominal pain.
Nausea.
Vomiting.
Fever.
Rectal bleeding

15. Grades of diarrhea according to America NCI
Grade1: Increase of less than 4 stools a day over baseline
Grade 2: Increase of 4- 6 stools a day over baseline
Grade 3: Increase of greater than 7 stools a day over baseline,
incontinence
Grade 4: Life Threatening consequences including extremely low blood
pressure as a result of severe Dehydration
Grade 5: Death

16. Diarrhea in Cancer patients is classified as complicated or
uncomplicated.
Uncomplicated diarrhea:
Include grade 1 or 2 diarrhea with no other signs or symptoms.
Management is conservative

17. Complicated diarrhea include:
• Grade 1 or 2 diarrhea with any one of the following risk factors:
• Moderate to severe cramping.
• Grade 2 or higher nausea/vomiting.
• Decreased performance status
• Fever.
• Sepsis.
• Neutropenia.
• Frank bleeding.
• •Dehydration.
• Grade 3 or 4 diarrhea is also classified as complicated. Thorough evaluation and
close monitoring is warranted

18. Physical examination:
Includes vital signs and evaluation of skin turgor and oral mucosa to
assess hemodynamic status and dehydration.
 Abdominal examination includes evaluation for rebound
tenderness, guarding, hypoactive or hyperactive bowel sounds, and
stool collection. A rectal exam can rule out fecal impaction

19. Laboratory tests
Laboratory test for diarrhea patient may include:
 Stool cultures for bacterial, fungal, and viral pathogens.
 A complete chemistry panel and hematologic profile can provide
information regarding the effect of diarrhea on kidney function and
electrolytes as well as identify changes in white blood cell count in
response to infection.
 Urinalysis with specific gravity can provide information regarding hydration
status.
 Stool osmolality may also be measured

20. Management of uncomplicated diarrhea
Treat underlying causes, modify or discontinue laxatives.
Dietary modifications include eating small, frequent meals ,
avoiding lactose-containing food, spicy foods, alcohol,
caffeine- containing foods and beverages, certain fruit
juices, gas-forming foods and beverages, high-fiber foods,
and high-fat foods.
For mild cases of diarrhea, the BRAT diet (bananas, rice,
apples and toast) may reduce the frequency of stools.

21. increase clear liquid intake to at least 3 L per day
Administer opioids, e.g Loperamide (Immodium) .
Aspirin may be useful for radiation-induced diarrhea.
Bismuth subsalicylate is believed to have direct antimicrobial effects on
Escherichia coli, hence its prophylactic use in traveler’s diarrhea.
Corticosteroids reduce edema associated with obstruction and radiation
colitis and can reduce hormonal influences of some endocrine tumors

22. Probiotics:
Probiotics are nutritional supplements that contain a defined amount of viable
microorganisms and, upon administration, confer a benefit to the patient. Probiotics
have been promoted for the following:
 Prevention of antibiotic-induced diarrhea and rotavirus.
 Treatment or prevention of inflammatory bowel disease, irritable bowel syndrome,
and gastroenteritis.
 Treatment of necrotizing enterocolitis in premature infants

23. Treatment of Complicated diarrhea
Intravenous (IV) fluids
Octreotide at a starting dose of 100 to 150 μg subcutaneously (SC) 3
times a day or 25 to 50 μg/hour IV with a dose escalation to 500 μg 3
times a day, and administration of antibiotics. This regimen continues
until the patient has been diarrhea free for 24 hours
In severe cases, total parenteral nutrition may be initiated

24. Thanks