1. POSTGRADUATE SCHOOL OF MEDICINE DIARRHOEA
Dr Eliyaz Ahmed and Dr Sarah Smith
MDSC156: Acute Clinical Oncology
A MEMBER OF THE RUSSELL GROUP
CONTINUING PROFESSIONAL DEVELOPMENT

2. 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. 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 % with drugs such as Irinotecan and 5-Flurouracil/Capecitabine
Targeted therapies such as, erlotinib, sorafenib, and cetuximab, may also cause significant CID.

4. Aetiology of Diarrhoea in Cancer Patients
Treatment 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. 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. Grading of Diarrhoea Grade Description 1
National Cancer Institute’s Common Toxicity criteria version 4.0
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 indicated 5
Death

9. Management Patient education Diet Antidiarrhoeals
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. 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. Management of Diarrhoea

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

13. FACULTY OF HEALTH & LIFE SCIENCES – CPD
Institute for Learning & Teaching
Faculty of Health & Life Sciences
Room 2.16A, 4th Floor
Thompson Yates Building
Brownlow Hill
Liverpool
L69 3GB
A MEMBER OF THE RUSSELL GROUP