DIARRHOEADr Eliyaz Ahmed and Dr Sarah Smith

MDSC156: Acute Clinical Oncology

POSTGRADUATESCHOOL OF MEDICINE

A MEMBER OF THE RUSSELL GROUP CONTINUING PROFESSIONAL DEVELOPMENT

2 Diarrhoea

Diarrhoea

• Diarrhoea is a common toxicity of systemic anticancer treatment

• Can be quite debilitating with volume depletion, electrolyte disturbances

and risk of renal failure

• Can interfere with treatment of malignancy due to dose delays and

reductions and increased hospitalisation

• Assessment is crucial in decision on out-patient vs. in-patient

management

3 Diarrhoea

Chemotherapy Induced Diarrhoea

• Chemotherapy Induced Diarrhoea (CID) can include drugs such

as capecitabine, cisplatin, cyclophosphamide, daunorubicin,

doxorubicin, docetaxel, methotrexate, oxaliplatin, and

paclitaxel.

• Incidence can be as high as 50 -80% with drugs such as

Irinotecan and 5-Flurouracil/Capecitabine

• Targeted therapies such as, erlotinib, sorafenib, and

cetuximab, may also cause significant CID.

4 Diarrhoea

Aetiology of Diarrhoea in Cancer PatientsTreatment related:

Chemotherapy and targeted agents-most common drugs associated with diarrhoea are

5-fluorouracil/Capecitabine and Irinotecan ,Erlotinib, Gefitinib, Sorafenib, Lapatinib and Cetuximab

BMT

Pelvic and abdominal radiotherapy

Disease related:

Neuroendocrine cancers, islet cell tumours , Biliary obstruction

Surgery of GI tract

Whipples, intestinal resection (short bowel)

Drugs: Antibiotics, laxatives, iron etc

Infections : Bacterial (clostridium difficile) , fungal

Dietary factors : High fibre, lactose products, laxatives

5 Diarrhoea

Assessment• History and examination

• Vital signs, skin turgor

• Biochemistry, stool culture

• Complicated vs. uncomplicated

• Complicated diarrhoea

• Grade 3 and 4

• Grade 1 or 2 associated with one or more of the following: nausea/vomiting, Fever and

neutropenia, sepsis, bleeding, dehydration, moderate to severe abdominal cramping,

declining performance status

• Uncomplicated

• Grade 1 and 2

6 Diarrhoea

Grade Description

1 Increase of <4 stools/day over baseline; mild increase in ostomy output compared with baseline

2 Increase of 4–6 stools/day over baseline; moderate increase in ostomy output compared with baseline

3 Increase of ≥7 stools/day over baseline; incontinence; hospitalization indicated; severe increase in ostomy output compared with baseline; limiting self-care ADL

4 Life-threatening consequences; urgent intervention indicated5 Death

Grading of Diarrhoea

• National Cancer Institute’s Common Toxicity criteria version 4.0

7 Diarrhoea

8 Diarrhoea

9 Diarrhoea

Management

• Patient education

• Diet

• Increased fluid intake ( up to 3 L/day)

• Low fibre diet, avoid milk and dairy products and caffeine containing drinks

etc.

• Antidiarrhoeals

• Antimotility agents: Loperamide 4 mg, followed by 2 mg after each unformed

stool with a maximum of 16 mg/day

• Stop chemotherapy/biologicals until complete resolution of symptoms

10 Diarrhoea

Management

Complicated diarrhoea

Hydration: IV fluids and electrolyte replacement

Treat Sepsis

Octroeotide : Starting dose of 100 to 150 ug SC

tid or IV (25 to 50g/h) and consider increasing dose

if diarrhoea is persistent

11 Diarrhoea

Management of Diarrhoea

12 Diarrhoea

Further reading• http://www.oncolink.org/resources/article.cfm?id=1055

• http://

www.cancer.gov/cancertopics/pdq/supportivecare/gastrointestinalcomplications/Health

Professional/page5

• Richardson & Dobish, 2007

• Arnold RJ, Gabrail N, Raut M, et al.: Clinical implications of chemotherapy-induced

diarrhoea in patients with cancer. J Support Oncol 3 (3): 227-32, 2005 May-Jun

• Zidan J, Haim N, Beny A, et al.: Octreotide in the treatment of severe chemotherapy-

induced diarrhea. Ann Oncol 12 (2): 227-9, 2001.

• Benson AB III., Ajani JA, Catalano RB, et al.Recommended Guidelines for the Treatment of

Cancer Treatment-Induced Diarrhoea. J Clin Oncol 2004;22:2918-2926.

A MEMBER OF THE RUSSELL GROUP

FACULTY OF HEALTH & LIFE SCIENCES – CPD

Institute for Learning & TeachingFaculty of Health & Life SciencesRoom 2.16A, 4th FloorThompson Yates BuildingBrownlow HillLiverpoolL69 3GB www.liv.ac.uk/learning-and-teaching/cpd