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Grand Round on Symptopms Management:Diarrhea

Presented by
Holystic Group:Abeer Manea, Andrin Antony, Annamma Varghese, Bency Abraham, Jenitha Selvam, Neena Chacko
Thursday May 18th, 2017
Outline
Case presentation
Video
Description of the symptom
Classifications of diarrhea
Impact on patients quality of life
Pathophysiology underlying the symptom
Pharmacological therapies
Complementary therapies
Patient and family education
Case Presentation
CB is a 68 year old man with a history of small cell lung cancer with bony
metastasis.
He reports the symptom of diarrhea post chemotherapy with cisplatin and
etoposide along with radiation therapy and irinotecan a week ago.
He stated diarrhea started with in the past couple of days and has gotten
progressively worse, over past 12 hours 4 to 6 episode of explosive diarrhoea.
Sometimes, he passes small amount of stool, but the urge to go to the bathroom
comes quickly and strongly.
Video
https://www.youtube.com/watch?v=zhNGkXVsSEU
Describe the symptom
Describe the symptoms ? How common is this symptom in cancer patients? What is the impact of the
symptom on the quality of life?

Diarrhea is defined as an abnormal increase in both the liquidity and the frequency of stools
Diarrhea could be due to the general toxicity of chemotherapy.
Chemotherapy induced diarrhea is not only highly prevalent but also not tolerable and can be life
threatening, if left untreated.
Radiation induced diarrhea, can cause damage to intestinal mucosa, this damage induces
prostaglandin release and bile salt malabsorption which leads to increased intestinal peristalsis and
causes diarrhea.

(Muehlbauer & Lopez, 2014)


National Cancer Institute Common Terminology for Adverse Events
(CTCAE), Diarrhea Grades.
Grade Description
1 Increase of <4 stools per day over baseline; mild increase in ostomy output
compared to baseline
2 Increase of 4 - 6 stools per day over baseline; moderate increase in ostomy output
compared to baseline
3 Increase of >=7 stools per day over baseline; incontinence; hospitalization
indicated;
severe increase in ostomy output compared to baseline; limiting self care ADL

4 Life-threatening consequences; urgent intervention indicated


5 Death
(Muehlbauer & Lopez, 2014)
(Stein, Voigt, & Jordan, 2010)
Classifications of Diarrhea
In addition to the increase in number of stool per
day, diarrhea is further classified by the length of
time it persists, acute or chronic, as well as its
severity.

Acute diarrhea resolve with in 14 days and chronic


diarrhoea persists longer than 14 days.

Patients are classified as uncomplicated or


complicated diarrhea on the basis of clinical
features.

Uncomplicated diarrhea patients with 1or 2 grade


diarrhoea with no other complicating signs and
symptoms.

(Muehlbauer & Lopez, 2014)


Classifications of Diarrhoea

Complicated diarrhea is grade 3 or 4 with other


symptoms which include abdominal cramping,
nausea, vomiting, decreased performance
status, fever, sepsis, neutropenia, frank
bleeding, and dehydration.

Complicated diarrhea can be life threatening due


to loss of fluid and electrolyte imbalance,
dehydration, renal insufficiency.

(Muehlbauer & Lopez, 2014)


(Stein, Voigt, & Jordan, 2010)
How common is this symptom in cancer patients?

About 1 out of every 10 people (10%) have diarrhoea during their illness
Diarrhea is a common symptom in cancer patients with chemotherapy
- 50-80% of patients treated with chemotherapy report diarrhea as a side effect
Mr. CB was on Irinotican which can cause acute diarrhea or delayed diarrhea.

(Stein, Voigt, & Jordan, 2010)


(Cancer Research UK, 2014)
Impact on Patients Quality of Life

Diarrhea may have Acute diarrhea leads Chronic diarrhea can


impact on patients to fatigue, weakness, cause significant
quality of life. lethargy, and fluid fatigue, malnutrition,
loss. changes in skin
integrity, sleep
disturbances,
anxiety, isolation
and discomfort.

(Muehlbauer & Lopez, 2014)


(Stein, Voigt, & Jordan, 2010)
Causes of the Symptom Experienced by this Patient

The causes of the symptom experienced by CB is due to the side effects of chemotherapy with
cisplatin and etoposide along with radiation therapy and irinotecan treatment. CBs diarrhea is a
common side effect for patients with advanced cancer.
Chemotherapy causes damage to both cancer cells and to normal, rapidly dividing interstitial
crypt cells.
Thus, the epithelial lining of the intestinal tract is susceptible to damage from the chemotherapy.

(Muehlbauer & Lopez, 2014)


(Stein, Voigt, & Jordan, 2010)
Causes of the Symptom Experienced by this Patient

Fluid reabsorption into the body from the GI tract decreases and fluid and electrolyte
secretion into stool increases resulting in watery bowel movement that can lead to severe
diarrhea.
An additional cause of diarrhea in the oncology population is colonization with
infectious agents. Patients receiving chemotherapy are at a higher risk of CDAD
(Clostridium deficile associated diarrhea) even without antibiotic therapy.
Diarrhea can be due to Irinotecan, which is unique. It is associated with early and
delayed phase diarrhea. Regardless of its schedule for administration ,myelosuppression
and delayed type diarrhea are the most common side effects.
(Muehlbauer & Lopez, 2014)
(Stein, Voigt, & Jordan, 2010)
Pathophysiology

Diarrhea is identified by its underlying causes: many times, there


is more than one contributing mechanism. In normal digestion the
small intestine and the colon absorb 99% of fluid from oral
secretions and intake daily which is roughly equal to 9-10 liters.

A small reduction of intestinal (1%) absorption or an


increase in gastrointestinal secretion may be enough to
cause diarrhea.

The pathophysiology of CID (Chemotherapy induced diarrhea) is


complex .The rapidly dividing crypt cells throughout the intestinal
epithelium are damaged by chemotherapy, altering the absorptive
and secretory capacity within the gut. When the chemotherapy
affects the absorptive capacity , there is increase of solutes in the
intestinal lumen. This causes an osmotic shift of water into the
lumen, resulting in diarrhea.
(Muehlbauer & Lopez, 2014)
Pathophysiology

A disruption in the intestinal epithelium may also cause exudative


diarrhea that results from the leakage of water, electrolytes,
mucus, proteins and red and white blood cells into the intestinal
lumen.

Current literatures focus on the pathophysiologic


mechanism of CID.

Osmotic diarrhea is the result of increased intake or decreased


absorption of water soluble solutes that remain in the bowel and
retain water.

Other causes include chemotherapy induced and


radiotherapy induced enteritis, mucosal damage, or fat
reabsorption also may cause diarrhea. (Muehlbauer & Lopez, 2014)
(Muehlbauer et al., 2009)
Pharmacological Therapies

Uncomplicated chemotherapy induced diarrhoea is treated by:


- The alteration of diet
- Administration of anti-diarrheal drugs such as loperamide, octotide and tincture of opium.

Complicated diarrhea needs high dose of antidiarrheal administration and


hospitalization.

Loperamide is an opioid which functions by decreasing intestinal motility by directly affecting


the smooth muscle of the intestine.

Loperamide is given 4 milligram loading dose followed by 2 milligram every 4


hours. This can be discontinued when patient is diarrhea free for 12 hours.

(Muehlbauer & Lopez, 2014)


Pharmacological Therapies

Deodorised Tincture of Opium is another drug used for chemotherapy induced diarrhea. Opium
tincture contains morphine which is an opioid pain reliever and can reduce gastrointestinal
motility.

Patients who are not responding to Loperamide after 48 hours can use Octreotide as a
second line of treatment.

(Muehlbauer & Lopez, 2014)


Side Effects
Loperamide increases paralytic ileus and abdominal distension.
Octreotide causes heartburns, constipation, stomach pain,
vomiting, headache and nausea.
Deodrised Tincture of Opium cause nausea, vomiting, euphoria,
painful urination.

(Muehlbauer & Lopez, 2014)


Complementary Therapies

Chinese herbal medicine

Diet modification

Probiotics

(Qi et al., 2010)


(Morturano, 2012)
Chinese Herbal Medicines
Herbs are used in a combination with chemo-or-radiation therapy:
- Enhance the efficacy
- Minimize the side effects and its complication
Examples: astragalus, turmeric, ginseng
PHY906: it is a four-herbs formula used for patients who are receiving chemo-or-
radiotherapy (Scutellariae baicalensis, Paeonia lactiflora, Ziziphus jujuba and Glycyrrhiza
uralensis)
In a study done in 2011 in 24 cancer patients, after 14 days of using PHY906 the result
showed significant reduction of gastrointestinal side effects especially diarrhea.
(Qi et al., 2010)
(Morturano, 2012)
PHY906

Scutellariae baicalensis Paeonia lactiflora Ziziphus jujuba Glycyrrhiza uralensis


Diet Modification
The goal is to eat food that build up consistency but it should be low in fibers.
Food high in potassium such as bananas (to avoid hypokalemia).
Lactose-free diet (Lactase alterations could not break lactose down and cause
additional GI problems).
Food should be in room temperature to reduce peristalsis.
Increase fluid intake.
Avoid alcohol, spicy food, caffeinated beverages.

Probiotics
Probiotics are living microorganisms (Bacteria) used for diarrhea
management (nutritional supplements).
(Qi et al., 2010)
(Morturano, 2012)
What Should the Nurse Teach the Patient about
Managing Diarrhea?
Explain to CB and family that
diarrhea is a side effect of
chemotherapy and radiation. Record number of stools.

Encourage to consume bland diet. Report any fever ,dizziness,


abdominal pain, fecal incontinence.
Avoid dairy product, spicy food,
alcohol, caffeine containing product,
Educate CB about the importance
food high in fiber or fat and orange
of perineal skin hygiene to avoid
juice.
skin break down and infection.
Encourage to drink 8-10 glasses of
clear liquid per day. Avoid excessive cold or hot food.
Consume high potassium food such
as banana and potatoes. (Muehlbauer & Lopez, 2014)
Discussion
Questions?
References
Cancer Research UK. (2014). Coping with cancer. Retrieved from http://www.cancerresearchuk.org/about-
cancer/coping/physically/bowel-problems/types/diarrhoea/symptoms
Morturano, R. (2012). Management of chemotherapy-induced diarrhea. Retrieved from
https://www.oncolink.org/healthcare-professionals/o-pro-portal/articles-about-cancer-treatment-and-
medications/management-of-chemotherapy-induced-diarrhea
Muehlbauer, P. M., Arlene Davis, R. N., CNSD, R., Rawlings, B. L., & Elizabeth Kiker, R. N. (2009). Putting evidence
into practice: Evidence-based interventions to prevent, manage, and treat chemotherapy-and radiotherapy-
induced diarrhea. Clinical journal of oncology nursing, 13(3), 336.
Muehlbauer, P. M., Lopez, R. C. (2014). Diarrhea. In: Yarbro, C. H., Wujcik, D., Gobel, B. Hcancer (Eds). Symptom
Management. (4th ed., 185-212). Burlington, MA: Jones &Bartlett Learning.
Qi, F., Li, A., Inagaki, Y., Gao, J., Li, J., Kokudo, N., ... & Tang, W. (2010). Chinese herbal medicines as adjuvant
treatment during chemo-or radio-therapy for cancer. Bioscience trends, 4(6), 297-307.
Stein, A., Voigt, W., & Jordan, K. (2010). Chemotherapy-induced diarrhea: pathophysiology, frequency and guideline-
based management. Therapeutic Advances in Medical Oncology, 2(1), 5163.
doi.org/10.1177/1758834009355164

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