Diarrhoea induced by chemotherapy in cancer patients is common, causes notable morbidity and mortality, and is Lancet Oncol 2014; 15: e447–60
managed inconsistently. Previous management guidelines were based on poor evidence and neglect physiological Gastrointestinal Unit
causes of chemotherapy-induced diarrhoea. In the absence of level 1 evidence from randomised controlled trials, we (J Andreyev FRCP), Department
of Nutrition and Dietetics
developed practical guidance for clinicians based on a literature review by a multidisciplinary team of clinical
(L Wedlake RD), Department of
oncologists, dietitians, gastroenterologists, medical oncologists, nurses, pharmacist, and a surgeon. Education of Surgery (W Allum FRCS), and
patients and their carers about the risks associated with, and management of, chemotherapy-induced diarrhoea is the Department of Medicine
foundation for optimum treatment of toxic effects. Adequate—and, if necessary, repeated—assessment, appropriate (I Chau MD), Royal Marsden
NHS Foundation Trust London
use of loperamide, and knowledge of fluid resuscitation requirements of affected patients is the second crucial step.
and Surrey, London, UK; Cancer
Use of octreotide and seeking specialist advice early for patients who do not respond to treatment will reduce Services, Guy’s Hospital, Guy’s
morbidity and mortality. In view of the burden of chemotherapy-induced diarrhoea, appropriate multidisciplinary and St Thomas’ NHS
research to assess meaningful endpoints is urgently required. Foundation Trust, London, UK
(P Ross FRCP); Gastrointestinal
and Liver Services, Leeds
Introduction about the optimum approach to treatment. Whilst Teaching Hospital NHS Trust,
Many chemotherapeutic agents used to treat cancer several reviews or guidelines have been published,8–12 Leeds, UK (C Donnellan MRCP);
target rapidly dividing cells, and the effects on such cells most have been written from an oncological rather than University Hospitals
Southampton NHS Foundation
in the epithelium of the gastrointestinal tract can lead to a gastroenterological perspective and have concentrated Trust, Southampton, UK
various gastrointestinal symptoms. Of particular clinical on management of symptoms rather than the underlying (E Lennan RGN); Medical
importance is chemotherapy-induced diarrhoea, which pathophysiology.13 Organic causes of diarrhoea, such as Oncology, Whittington
has been reported as a grade 3–4 serious adverse event bacterial overgrowth, malabsorptive syndromes, and Hospital NHS Trust, London,
UK (P Leonard FRCP); Pharmacy,
with a frequency of 5–47% in randomised clinical trials inflammatory or infectious enteritides, may all be treated Kent and Medway Cancer
(table 1). As well as regimens used to treat gastrointestinal very simply but are undoubtedly frequently missed.13 Network, Chatham, Kent, UK
cancers, those used in patients with tumours at other We have developed multidisciplinary guidance to (C Waters BSc); Cancer Services,
sites—eg, breast cancer treated with docetaxel and facilitate clinical practice, based on an extensive literature University College Hospital,
London, UK (J Bridgewater PhD);
capecitabine or folinic acid antagonists (such as search, which we present in this Review. We have defined Mount Vernon Cancer Centre,
methotrexate)—also raise the risk of chemotherapy- principles of management where possible and outline Northwood, Middlesex, UK
induced diarrhoea. The introduction of tyrosine-kinase research priorities for the future. (R Glynne-Jones FRCR);
inhibitors (TKIs) and epidermal-growth-factor inhibitors Northern Ireland Cancer Trials
Network, Belfast City Hospital,
has also been complicated by a high frequency of Methods Belfast, UK (R Wilson FRCP); and
clinically important diarrhoea (ie, diarrhoea that requires A multidisciplinary working group of five medical Department of Oncology,
intervention and affects the patient’s quality of life so oncologists and one clinical oncologist, two gastro- New Cross Hospital,
Wolverhampton, UK
they stop taking treatment). Treatment, therefore, is enterologists, a nurse consultant, a dietitian, a specialist
(Prof D Ferry FRCP)
frequently compromised, sometimes leads to hospital pharmacist, and a gastrointestinal surgeon was established.
Correspondence to:
admission, and can be life threatening. Chemotherapy-induced diarrhoea was discussed in a 1 day Dr Jervoise Andreyev,
The true degree of clinically relevant chemotherapy- meeting sponsored by Sanofi-Aventis. The concept Gastrointestinal Unit, The Royal
induced diarrhoea is unknown. In the UK, 75 000 people development, literature review, and writing of the drafts, Marsden, Fulham Road,
receive a regimen including fluorouracil every year, of however, were done independently by the authors. All London SW3 6JJ, UK
J@andreyev.demon.co.uk
whom 15% (950 patients per month) develop grade 3 or members of the working group were allocated topics to
worse diarrhoea, most of whom will require hospital research and wrote the corresponding sections inde-
admission (Ferry D, personal communication). Death pendently. These contributions were edited and the
from fluorouracil-induced diarrhoea is reported in 1–5% resulting paper was reviewed as a whole by all authors.
of patients in clinical trials (8–42 patients per month, There was no input from Sanofi-Aventis into the content
table 1). Although some of these patients also have or writing of this Review.
neutropenia and the contribution of neutropenia-
associated sepsis to diarrhoea and death is unknown, Chemotherapeutic agents frequently associated with
chemotherapy-induced diarrhoea remains an important diarrhoea
complication. Specific causes for the type of gastrointestinal injury,
Despite the effects that diarrhoea has on patients, with each specific agent as far as known, are shown in
carers, health professionals, and health-care resources, panel 1. The drugs most frequently associated with
research and authoritative guidance on management are diarrhoea are fluorouracil (a thymidylate synthase
sparse and there is little agreement among clinicians inhibitor), and irinotecan (a topoisomerase I inhibitor).
new-onset ulcerative colitis or exacerbation of pre-existing complex neurological, hormonal, muscular, immune,
colitis have been reported. Viral-induced colitis has also and enzyme systems. Additionally multiple specialised
been described and might be an important problem. cells contribute diverse cellular and molecular
Cetuximab and panitumumab are monoclonal mechanisms. Dysfunction of different regions of the
antibodies to EGFR with activity in KRAS wild-type gastrointestinal tract might cause completely different
colorectal cancer that may be used alone or in physiological effects in different patients despite
See Online for appendix combination with chemotherapy. These drugs have been symptoms being similar (appendix).50
associated with grade 3–4 diarrhoea in up to 30% of The physiological mechanisms underlying chemo-
patients when combined with a fluoropyrimidine.43 The therapy-induced diarrhoea are likely sometimes to be
licence for a capecitabine combination has been drug dependent, but relevant clinical research is scarce.
withdrawn. The cause for cetuximab-related diarrhoea is Identification of the physiological changes induced by
not known and is managed symptomatically. chemotherapy is of fundamental importance to develop
new treatments. Optimum treatment would reduce the
Chemotherapy combined with other treatments symptom burden on the patient and lessen the
Overlapping, and hence worsened, toxic effects are disruption of adequate oncological treatment.13
important factors to take into account when making The gut epithelium acts as a semipermeable
decisions about combined strategies, such as chemotherapy membrane. Whether some specialist cells or enzyme
with cetuximab43 or aflibercept.44 Additionally, chemo- systems in the gastrointestinal tract are more sensitive to
therapy is increasingly combined with radiotherapy as a chemotherapy than others is unknown. Diarrhoea with
radiosensitiser, but can also sensitise normal tissues to or without steatorrhoea occurs for three principle
toxic effects.45 The severity of acute gastrointestinal reasons: if the lumen contains hypertonic substances,
symptoms during pelvic radiation depends partly on the such as incompletely metabolised components of normal
dose given and volume of bowel treated. Other risk factors diet (osmotic diarrhoea); if there is damage to molecular
for toxic effects include diabetes, inflammatory bowel pumps that control fluid fluxes in and out of enterocytes
disease, collagen vascular disease, HIV, old age, smoking, or across tight junctions or in response to quantities of
and low body-mass index, but are poorly researched.46 inadequately absorbed intraluminal bile (secretory
Acute intestinal side-effects of radiation begin at diarrhoea); and if gastrointestinal motility is altered. The
approximately 10–20 Gy and peak between weeks 3 and 5 known physiological causes of treatment-induced
of treatment. Acute diarrhoea is an independent diarrhoea and steatorrhoea are outlined in table 2.
prognostic factor of outcome during treatment for
colorectal cancer,47 but more severe acute effects are also Damage to the mucosa
associated with long-term consequences of treatment.38 Nutrients in the diet, such as carbohydrates and proteins,
need to be hydrolysed before absorption and lipids or fats
Prevention of treatment-induced diarrhoea also require emulsification. Damage to the enzyme
Glutamine, celecoxib, probiotics, activated charcoal, systems in the brush border of the gastrointestinal tract
absorbents, and racecadotril have been suggested for the or within the specialist cells responsible for many of
treatment or prophylaxis of chemotherapy-induced these metabolic processes might contribute to diarrhoea.
diarrhoea, but evidence of efficacy is lacking for all. The Malabsorption of carbohydrate and fat are particularly
options are reviewed in guidelines published by the important. Protein malabsorption might occur in
Multidisciplinary Association for Supportive Care in patients undergoing chemotherapy for solid tumours but
Cancer.39 No pharmacological strategies effectively prevent has never been described.
radiotherapy-induced diarrhoea. Oral glutamine,48
sucralfate, sulfasalazine, or subcutaneous and intra- Carbohydrate malabsorption
muscular octreotide49 have been tested in randomised Chemotherapy-induced lactose intolerance, which is due
controlled trials but none decreased or prevented to decreased functional expression of the enzyme lactase
diarrhoea during therapeutic pelvic irradiation. in the brush border, is seen in 10% of patients receiving
fluorouracil52,53 and is described in children after various
Mechanisms underlying diarrhoea chemotherapy regimens.54,55 Diarrhoea associated with
Although the risk factors contributing to direct toxic lactase insufficiency is frequently accompanied by pain,
effects in the gastrointestinal tract are starting to be bloating, and wind.
understood, why diarrhoea happens remains unclear. Other brush-border enzymes with roles in final
Many lesions might occur in the gastrointestinal tract hydrolysis of carbohydrates to monosaccharide units
without causing any unusual symptoms, but lesions probably affect monosaccharide transport proteins on
become relevant when they lead to changes in normal the luminal side of gut enterocytes. This mechanism has
gastrointestinal physiology. never been studied, but the D-xylose absorption test has
Maintenance of the secretory, absorptive, and been reported to be abnormal in various groups of
propulsive functions of the gastrointestinal tract relies on patients receiving chemotherapy,54,55 which implies that
malabsorbed, treatment with a simple diet that excludes Malabsorption of non-lactose disaccharides ? ?
these disaccharides should abolish gastrointestinal Bile acid malabsorption ? 50%
symptoms, including diarrhoea. Small bowel bacterial overgrowth ? 25%
Reduced transit time ? 100%
Fat malabsorption Viral infection (eg, cytomegalovirus) ? ?
Steatorrhoea is excess fat (more than 6 g per day) in the Bacterial infection (eg, Clostridium difficile) ? ?
stool. Clinicians and patients frequently mistakenly Parasitic or opportunistic infection ? ?
diagnose this disorder as diarrhoea. It may be constant or Pancreatic insufficiency ? ?
intermittent. In the UK measurement of stool fat cannot Drug related (non-chemotherapy) ? ?
be requested and, unless microscopy is done and identifies Other (eg, hormone secretion, changes in neural pathway signalling, ? ?
the presence of fat globules, diagnosis relies on clinical stress)
expertise. Patients might report pale stools that splatter, are *Pelvic radiotherapy.13,51
difficult to flush away, have an offensive smell, or, most
usefully of all, are associated with an oily film in the Table 2: Acute physiological changes in normal gastrointestinal function that cause diarrhoea
lavatory water.
Fat malabsorption triggered by chemotherapy has two neuroendocrine tumour dedifferentiates into a
likely causes: small bowel bacterial overgrowth and bile functioning tumour) might all result in diarrhoea or
acid malabsorption. Small bowel bacterial overgrowth is steatorrhoea of varying severity.
difficult to diagnose definitively,56 but immunosuppressed
patients are at higher risk of developing pathological Effects on delivery of cancer treatments
levels of colonic bacteria growing in the small bowel than Whether dose reduction because of toxic effects leads to
are non-immunocompromised patients. The rates of adverse outcomes is controversial. Early data suggested
bacterial overgrowth have not been systematically no benefit from maintaining the dose intensity of
studied, but clinical experience and animal data suggest fluoropyrimidine,65,66 but the importance of dose
that it is a frequent problem in patients undergoing intensity and optimum management of toxic effects has
chemotherapy.57–60 Appropriate antibiotic therapy given been emphasised as a guiding principle for the delivery
for a few days should be curative.61 of adjuvant therapies.67 Circumstantial data indicate
No data are available on chemotherapy-induced bile that dose reductions lead to more severe toxic effects
acid malabsorption. Clinical experience suggests that this than no dose reductions, but are likely to improve
effect is common. It sometimes causes severe symptoms outcomes.67 The guidelines of the American Society of
and is generally responsive to treatment with bile acid Clinical Oncology favour maintaining dose intensity.68
sequestrants, dietary fat reduction, or both. That bile acid A randomised study that included 280 patients with
malabsorption causes a substantial proportion of metastatic colorectal cancer showed significantly
chemotherapy-induced secretory diarrhoea, steatorrhoea, improved response rates (33% vs 18%, p=0·0004) and
or both, would not be surprising. The definitive diagnostic non-significant improvement in overall survival
test for bile acid malabsorption is the 23-seleno-25-homo- (median 22 months vs 16 months) with pharma-
tauro-cholic acid (SeHCAT) scan, but is available in only cokinetically guided fluorouracil dosing compared with
eight European countries, Canada, and Australia. standard dosing.69 Furthermore, the frequency of toxic
Consequently, this disorder is seldom considered. An effects, particularly grade 1–4 diarrhoea, was reduced
alternative test is the C4 (7α-hydroxy-4-cholesten-3-one) from 60% to 16% and grade 3–4 from 18% to 4%.
blood test. Although slightly less sensitive than the Therefore every effort should be made to manage toxic
SeHCAT scan, it is a useful way to screen for bile acid effects without compromising clinical efficacy.
malabsorption.
Less frequently, fat malabsorption occurs for other Effects of diarrhoea on patients
reasons. Pancreatic insufficiency is described after Diarrhoea can have a notable effect on performance
conditioning regimens that precede stem cell status and the ability to perform daily activities. Patients
transplantation.62–64 Whether other chemotherapy may become housebound because of embarrassment,
regimens predispose to pancreatic insufficiency is fatigue, dehydration, and abdominal, rectal, and
unknown. Intestinal lymphatic obstruction from perianal pain, excoriation or discomfort, and the fear of
tumour infi ltration, previous small bowel resection needing to defecate suddenly. Thus, chemotherapy-
causing malabsorption of free fatty acids, radiotherapy- induced diarrhoea can result in social isolation, time off
induced intestinal lymphangiectasia, excessive use of work, relationship difficulties, and psychological
somatostatin analogues, or hormone secretion from distress. Some individuals doubt their ability to
tumours (usually when a previously non-functioning complete treatment.70
The role of patients in management medication to confirm the severity and whether face-to-
If patients do not present in a timely manner with face assessment is required. Alternatively, patients should
potentially serious symptoms, optimum management speak to their oncology team or covering staff immediately.
might not be possible. The National Confidential Enquiry Many studies have indicated that patients are reluctant
into Perioperative Death audit into deaths within 30 days to take medicines. For chemotherapy-induced diarrhoea
of receiving systemic anticancer therapy71 confirmed that the most important drug is loperamide. Patients should
substantial numbers of patients did not recognise toxic be told that this drug is not absorbed into the body and is
effects or seek advice appropriately. Additionally, the excreted in the faeces and, in contrast to the commonly
audit noted that patients do not want to bother health accepted advice associated with this drug’s use for
professionals. Therefore, clinicians delivering chemo- travellers’ diarrhoea, risk of overdose in this clinical
therapy must educate patients and carers about the setting is unlikely. How much to take, how often, and
optimum management of potentially life-threatening when in relation to meals patients can take antidiarrhoeal
effects before chemotherapy is started. The information medication must be made clear. Importantly, if the first
should be reiterated at every clinical meeting throughout doses of loperamide do not work, patients should be
treatment. informed that it is likely that they have not taken enough.
All patients must be given a regimen-based information After starting loperamide, patients need to know when
sheet outlining potential side-effects, written in simple they must contact their chemotherapy unit and when
language. The use of visual aids, such as the Bristol stool they can delay contact; generally, patients should make
chart (appendix), might improve understanding. Self- contact if taking eight 2 mg tablets in 24 h has had no
assessment tools to assess bowel function might also effect. The possible need for intravenous fluids and other
give patients the confidence to seek help. treatments because of diarrhoea must be explained.
Before chemotherapy is started, clinicians must
establish what each individual patient’s normal bowel Clinical assessment
function was before and whether it changed after their Patients with early signs of acute toxic effects might need
cancer was diagnosed, and discuss how function could adjustment or even discontinuation of chemotherapy or
change in the future with treatment. Patients can be breaks in radiotherapy. The seriousness of diarrhoea is
encouraged to self-medicate but should keep a record of frequently defined with the Common Terminology
their drug use. Antidiarrhoeal tablets should be provided Criteria for Adverse Events (panel 2).73 The most important
for patients to keep at home and carry with them if they decision is whether the patient can be managed as an
go out should diarrhoea start. The National Chemotherapy outpatient or needs admission for fluid resuscitation, and
Advisory Group report72 states that health professionals is dependent on the risk of adverse outcomes. Patients
should rehearse with patients when to start treatment and with grade 1–2 diarrhoea without worrying clinical
give instructions about continuation. If an acute oncology features and test results can usually be managed at home.
helpline is available, patients should be encouraged to Those with grade 3–4 diarrhoea generally need immediate
telephone for advice after starting antidiarrhoeal admission unless clinical review suggests the patient is
well hydrated, has not yet had any antidiarrhoeal
medication, and can be reviewed daily (figure).
Panel 2: Common Terminology Criteria for Adverse Events
grades of diarrhoea73 Warning signs
• Grade 1: increase to two to three bowel movements per Several features should alert clinicians to the fact that
day additional to number before treatment or mild diarrhoea is clinically worrying. These include abdominal
increase in stoma output cramps not relieved by loperamide, an inability to eat,
• Grade 2: increase to four to six bowel movements per day increasing fatigue, increasing weakness, chest pain,
additional to number before treatment, moderate nausea not controlled by antiemetics, vomiting,
increase in stoma output, as well as moderate cramping dehydration accompanied by reduced urine output, fever
or nocturnal stools (temperature higher than 38·5°C), gastrointestinal
• Grade 3: increase of seven to nine bowel movements per bleeding, and previous admission for diarrhoea.
day additional to number before treatment,
incontinence, or severe increase in stoma output, as well History taking
as severe cramping or nocturnal stools, that interfere Gastrointestinal symptoms are frequently manifestations
with activities of daily living of pathologies outside the gastrointestinal tract, such as
• Grade 4: increase to more than ten bowel movements per chest or urinary sepsis. Reviewing systems in detail,
day additional to number before treatment, grossly therefore, is always required. If a patient is taking
bloody diarrhoea, need for parenteral support, or a unfamiliar drugs, especially biological agents, urgent
combination of these features review of the drug information sheets is mandatory.
• Grade 5: death What constituted normal bowel function before the
onset of diarrhoea must be established before any new
treatment is started, to understand how much bowel diarrhoea not associated with chemotherapy. Diarrhoea
function has really changed. Guidance in the UK on the is so common with chemotherapy that all patients should
management of gastrointestinal side-effects of cancer be provided with stool-culture bottles before the start of
therapies emphasises three crucial factors: whether the treatment to enable collection of a sample as soon as they
patient is being woken from sleep to defecate; whether feel changes in bowel function. This approach avoids
there is any steatorrhoea; and whether there is urgency of delays in obtaining samples if admission to hospital is
defecation or any faecal incontinence. If any of these required.
factors is present, an urgent gastroenterological Evidence from oncological studies to guide the choice
assessment is mandated. If the first two are present, an of investigations is limited. Therefore, the suggestions
organic cause is always indicated that should, if we make here are based on the best available alternative
identified, be treatable. A positive answer to the third sources, which, notwithstanding differences in
question means the presence of symptoms that are pathophysiology, are three peer-reviewed UK guidance
particularly disabling for patients. documents: the UK Inflammatory Bowel Disease
Five other important factors to consider are the degree guidelines,76 the British Society of Gastroenterology
of fatigue, changes in medication, diet, other guidelines on the management of chronic diarrhoea,77
chemotherapy-induced toxic effects, and whether the and guidance on managing acute and chronic
patient is presenting with overflow diarrhoea. gastrointestinal symptoms in cancer treatments.13
The intensity of fatigue correlates with the severity of
diarrhoea at 3 weeks.74,75 Fatigue can also be associated Immediate laboratory investigations
with a significant decrease in albumin concentrations in Patients with acute grade 3–4 diarrhoea admitted to
serum (p<0·001).75 Recent changes to medication (within hospital require urgent stool culture for microscopy
the previous 10–14 days) should be taken into account, as
the introduction of proton-pump inhibitors, non-
Patient has chemotherapy with or without radiotherapy
steroidal anti-inflammatory drugs, laxatives, or antibiotics
particularly can lead to diarrhoea. When assessing diet, it
should be established whether patients are eating very
Grade 1 diarrhoea Grade 2 diarrhoea Grade 3 and 4 diarrhoea
little or excessive amounts of fibre. Foods containing
lactose might trigger diarrhoea and should be suspected, and
especially if the diarrhoea is accompanied by marked Start self-medicating with 4 mg loperamide followed by
bloating. Other causes to consider are excessive alcohol 2 mg up to every 2 h
Physical assessment
Physical assessment must include the standard Low risk High risk
observations of temperature, pulse, blood pressure (lying Well hydrated, no vomiting Dehydrated, vomiting,
neutropenic, abdominal pain
and standing), respiratory rate, oxygen saturation,
peripheral perfusion, capillary refill, urine analysis, and
full physical examination. If the patient has neutropenia, Admit to hospital
avoidance of rectal examination was suggested in
previous guidelines, but there is almost no evidence to
Resuscitate and continue
support this recommendation. Unless rectal examination loperamide at least every 2 h
causes severe anal pain, it should be done together with with or without prophylactic
quinolones and consider
gentle perianal palpation to exclude the possibility of a adding octreotide
local sepsis as the cause for diarrhoea.
Investigations
Outpatient management Recovery Urgent multidisciplinary
If the patient is tachycardic or dehydrated or if sepsis is involvement and
suspected, fluid resuscitation should be started and 4 mg investigations
loperamide given before investigations are done.
Investigations should be done early to rule out causes of Figure: Flow diagram of action required for managing chemotherapy-induced diarrhoea
and testing for Clostridium difficile. Blood samples alternative. Patients should, however, be reviewed by an
should be tested for full blood count, urea and experienced gastrointestinal surgeon at the earliest
electrolytes, liver function, glucose, thyroid function, opportunity.
and C-reactive protein. If a patient is hypotensive or If symptoms have not settled within 24 h of intensive
tachycardic, acid base balance and lactate concentrations therapy with loperamide and octreotide,47 biochemistry
should also be measured in blood. Abdominal and full blood count should be repeated and endoscopy
radiography should be done and frequency of defecation should be done that includes duodenal biopsy and
and type of stool passed should be recorded on a aspirate. Biopsy should be done of any small ulcers or
stool chart. erosions seen in the upper gastrointestinal tract, as these
If at any time a patient shows signs of peritonism might indicate viral infection, especially cytomegalovirus
(guarding, rebound tenderness), CT of the abdomen is infection.13 Aspirate should be assessed to exclude small
required to assess the extent of involvement of the small bowel bacterial overgrowth and parasite infection.
and large bowel, exclude the possibility of neutropenic Platelet infusion should be available for patients with
enterocolitis, and detect complications (eg, perforation, platelet counts lower than 50–80 000 cells per μL in case
abscess, and pancreatitis). Surgery for these of severe bleeding from biopsy sites. Endoscopy of the
complications carries a high risk and should be lower gastrointestinal tract is contraindicated if there is
performed only in exceptional cases when there is no any suggestion of neutropenic enterocolitis (also known
as typhlitis).13 In these patients CT scanning should be pancreas or has a history of excessive alcohol intake.
done instead. If there is no typhlitis, flexible A SeHCAT scan will exclude bile acid malabsorption.
sigmoidoscopy should be done at the same time as the Alternatively, a bile acid sequestrant can be tried
upper-gastrointestinal endoscopy. The pathologist empirically. Small bowel bacterial overgrowth should be
should be asked to comment specifically on the biopsy investigated, for instance with a glucose hydrogen
samples taken with reference to the possibility of methane breath test, or empirical antibiotics and a trial
infection with cytomegalovirus and C difficile. C difficile- of lactose-free diet considered.
toxin-negative colitis might be difficult to detect as
neutrophils are needed to produce typical pseudo- Management
membranes, and numbers of neutrophils are low in Acute fluid resuscitation
neutropenic paients.13 If ulceration is substantial, PCR Patients frequently become dehydrated because of
for cytomegalovirus could be requested or empirical diarrhoea with or without vomiting. Assessment of fluid
anticytomegalovirus therapy could be started.76 balance is crucial, but is often done poorly. Physiological
If symptoms have not settled within 48 h, CT scanning requirements must be established before and reviewed
of the abdomen is required, after which the patient regularly after replacement of fluids is started. Patients
requires review by a gastroenterologist. Additional with severe chemotherapy-induced diarrhoea can lose up
investigations, such as amylase concentrations in serum to 4–6 L of diarrhoea per day. Consequently, patients
or pancreatic elastase-1 in the stool, should be considered might be severely hypovolaemic, which can make
to exclude pancreatic insufficiency, particularly if the exclusion or differentiation from sepsis difficult (they
patient has had previous radiotherapy or surgery to the might coincide).
SeHCAT=23-seleno-25-homo-tauro-cholic acid. C4=7-α-hydroxy-4-cholesten-3-one. *Intravenous administration is rarely required for prophylaxis. †Licenced dose. ‡Avoid use of 5% dextrose in hypovolaemic
patients.
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